Clinical epidemiologist aims to help ailing older adults stay active

A surprise gift arriving in the mail. A grandchild's photo on the bedside table. The memory of a long-ago college graduation. Could such small pleasures contribute to big differences in the health and exercise habits of the sickest elderly patients?

Dr. Janey Peterson is betting that they can. And two leading organizations in the field of aging research are putting their money on it too, by funding her study on interventions that can help older adults with multiple chronic illnesses become more physically active, thereby improving their health and overall well-being.

Dr. Peterson is an associate professor of clinical epidemiology in medicine, cardiothoracic surgery, and integrative medicine who is trained as a registered nurse. She has gained attention from both her peers and the mainstream media for her work as a clinical epidemiologist and behavioral scientist on issues affecting older patients, from financial exploitation of the elderly to later-life pain management. In 2013, she became the only registered nurse to receive a Beeson Career Development Award in Aging Research, just 200 of which have been given over the past 20 years.

Dr. Peterson is now using the more than $720,000 she garnered from the award (which is funded by the National Institute on Aging and the American Federation for Aging Research and supports investigations by outstanding junior faculty at medical schools nationwide) to apply lessons she has learned from her past work on motivating healthy behaviors to help a population typically excluded from clinical studies and exercise recommendations because of the complexity and seriousness of their health issues. "As people age, they often have multiple chronic conditions such as diabetes, congestive heart failure, or a history of heart attack," Dr. Peterson explains. "Physicians prescribe exercise to only about a third of older adults, and research demonstrates that doctors lack training in how to offer exercise recommendations to this high-risk group. Older adults who have a high number of chronic illnesses have a two to three times greater risk of becoming disabled over just a few years — but physical activity can both prevent disability and improve function in older adults who have early disability."

To take advantage of that window of opportunity, Dr. Peterson and her team motivate physical activity through an intervention she has named Positive Affect Induction for Regular Exercise, or PAIRE. Positive affect — a feeling of happiness and well-being — has been shown in non-clinical studies to promote self-efficacy, flexible thinking, and healthy behaviors, among other benefits. To induce it, Dr. Peterson uses small surprises — like the gift of an inexpensive blanket — to make patients feel good and reflect on their participation in the study. Through brief, scripted phone calls, she also encourages patients to induce positive affect on their own by thinking pleasant thoughts or looking at pictures of loved ones whenever they need motivation.

Dr. Peterson's ultimate goal is to find out how much — or how little — exercise will make a difference for older adults facing complex health issues. She notes that for the nation, the socioeconomic stakes are high: 32 percent of Medicare beneficiaries suffer from two to three chronic illnesses, 23 percent have four to five, and 14 percent are struggling with six or more. And while the Surgeon General recommends at least 150 minutes of moderate to intense physical activity a week for adults, Dr. Peterson believes that much smaller amounts of regular activity can help patients with chronic conditions avoid disability and major morbidity and mortality. "People underestimate the value of regular physical activity," she says. "My pilot data suggests that if we can get older adults with chronic disease walking just a little bit and they can sustain it, they have significant reductions in morbidity and mortality." Moreover, Dr. Peterson notes that regular exercise can increase hippocampal mass by 2 percent over a year — meaning that new neurons are being generated in the brains of older adults — while those who don't exercise lose 1.4 percent of their hippocampal mass. Recent work has also shown that exercise enhances DNA methylation in muscle cells, which helps explain the mechanisms by which exercise reduces the risk of disease. "My work in this area won't be finished," she says, "until we translate our data into clinical guidelines for physicians to use when prescribing physical activity for older adults with chronic disease."

Dr. Peterson points to projections that more than 20 percent of Americans will be 65 or older by 2040. She believes that guidelines and interventions to promote exercise can help older adults take better control of their own health — and ease the national burden of caring for chronically ill patients who go on to become disabled, in large part through inactivity. Her colleagues and research partners in fields as varied as oncology, cardiology and urology share her sense of urgency. "As the population ages, we need to find new strategies to help patients change behaviors and manage complications from serious conditions," says Dr. John Leonard, associate dean for clinical research, the Richard T. Silver Distinguished Professor of Hematology and Medical Oncology, and one of Dr. Peterson's collaborators. "By applying a scientific approach to the development and assessment of such strategies, Dr. Peterson is making a major contribution to the field."

Dr. Leonard notes that the implications of Dr. Peterson's research go beyond geriatric medicine; for example, she has studied how cancers such as lymphoma affect mindset and behavior. Her current focus, on helping older adults, was inspired in part by caring for her own parents. "The more I learn from my family's experiences and the more I work with this population, the more passionate I become," Dr. Peterson says. "Our country is growing older and older. Every hole in the safety net, every gap in the research, is an opportunity to advance care for older adults."

— C. A. Carlson

This story first appeared in Weill Cornell Medicine,Vol. 14, No. 1.

Exercise is key to improving health outcomes for patients who suffer from cardiovascular disease and depression, according to new research findings from Weill Cornell Medical College investigators.

Previous research has shown that patients who have both cardiovascular disease and depression have as much as a two times greater risk for adverse events, such as heart attacks and death, and frequently present with other chronic diseases, though the biological reasons behind this are not fully understood. With recent scientific literature suggesting that physical inactivity may be at the root of that increased risk, the Weill Cornell investigators set out to see if exercise would tangibly improve these patients' health.

Dr. Janey Peterson. Photo credit: Faye Osgood

Their findings, published Nov. 13 in the journal Clinical Therapeutics, shed light on the biological mechanics of those improved health outcomes, and offers a threshold for just how much physical activity is needed to reduce risk.

"This study allowed us to dig deep into the biological mechanisms underlying why exercise helps decrease morbidity and mortality," said first author Dr. Janey Peterson, an associate professor of clinical epidemiology in medicine, in cardiothoracic surgery and in integrative medicine. "That's what is so exciting about this."

Researchers have recognized the connection between cardiovascular disease and depression in increasing the risk of adverse health outcomes for three decades, but previous attempts to improve clinical outcomes in this population have proven disappointing, Dr. Peterson said. Scientists have examined several strategies to treat these patients, such as using antidepressants to improve depressive symptoms and thereby reduce morbidity and mortality, but none of them have ultimately been successful, Dr. Peterson said.

In their study, the Weill Cornell investigators enrolled 242 patients who had recently undergone a non-surgical procedure to open narrow or blocked coronary arteries — 89 of whom had high levels of depressive symptoms — in a randomized, 12-month clinical trial evaluating the efficacy of exercise on this population. A subset of 54 patients agreed to participate in a biological measures sub-study.

Patients' physical activity, demographic, psychosocial characteristics and depressive symptoms were evaluated at the beginning of the trial to establish a baseline; patients in the biological study also gave blood. Participants were asked to increase their physical activity to the equivalent of walking about 4.2 miles per week.

While all of the patients were given an educational workbook about cardiovascular disease and how to live with it, half of the participants received an induction of positive affect intervention. Positive affect, a feeling of happiness and wellbeing, has been shown in non-clinical studies to enhance positive feelings, lead to higher self-efficacy, increase intrinsic motivation and promote flexible thinking and healthier behaviors. Weill Cornell investigators are credited as the first group to translate and develop induction of positive affect for use in clinical patient groups, which Dr. Peterson and her colleagues have recently employed to successfully motivate physical activity and other health behaviors, such as medication adherence.

Patients receiving induction of positive affect received small, unexpected gifts in the mail, such as fleece blankets or umbrellas. Researchers followed up with patients by phone at bimonthly intervals during the year; staff induced positive affect for patients in the intervention group at the end of each call.

Investigators found that patients who walked 4.2 miles or more per week for a year, regardless of what group they were in, had lower rates of cardiovascular morbidity and mortality. Patients with high depressive symptoms who achieved that physical activity benchmark were nearly nine times less likely to experience a major cardiac complication or death over the course of the study.

The biological study seems to confirm these findings. Researchers compared blood samples taken at baseline and at the end of the trial, measuring the amounts of a peptide (interleukin-6) and protein (C-reactive protein) that are implicated in inflammation and also examining activity in the parasympathetic branch of the autonomic nervous system, which is tasked with restraining a person's stress response. Higher activity is associated with reduced inflammation and better cardiovascular health.

Patients who met the physical activity benchmark had an increased ability to respond to stressors in a healthy way, a decrease in the biological markers of inflammation, interleukin-6 and C-reactive protein, Dr. Peterson said.

"The biological study provides strong evidence as to why physical activity works so well," she said. "We now have longitudinal data that we didn't have before. We can now show in a structural equation model, from baseline to a year later, how important physical activity benchmark is for patients with cardiovascular disease and the mechanisms."