Exercise in the elderly

Author(s): David Z. Prince, MD

Originally published:09/20/2014

Last updated:09/20/2014

1. DISEASE/DISORDER:

Definition

The definition of exercise is “a physical activity that is done in order to become stronger and healthier or a particular movement or series of movements done to become stronger and healthier.” There are unique considerations that should be taken into account when prescribing and advisin golder adults regarding exercise, and the physiatrist is the ideal professional to evaluate and council older adults regarding exercise.

Etiology

The study of exercise physiology is not new; however, more recently there has been increased interest in elucidating how exercise specifically affects older adults. Classic human physiology data sets regarding response to exercise were derived from studying young, healthy, and disease-free individuals; therefore, extrapolation to older individuals is not always simple and may lead to flawed conclusions. Understanding the geriatric response to exercise has become an increasing area of interest, especially as the population ages.1,2

Epidemiology including risk factors and primary prevention
The aging of American society and impact on the American health care system has been well described.In a recent longitudinal study of physical activity levels in older women, numerous factors had an effect on the participants’ ability to maintain physical activity levels as they aged, including obesity, mobility disability, low self-efficacy, and disease burden.3 However, despite the well-known benefits of exercise, up to 75% of older Americans do not exercise at a high enough intensity to improve their health at all, and only 16% of individuals between the ages of 65 and 74 years comply with the current recommendation of 30 minutes or more of moderate physical activity on 5 or more days a week.4,5 A 2013 analysis of generational cohorts from the National Health and Nutrition Examination Survey database shows that regular exercise is significantly less frequent in the baby boomer generation than in the previous generation, and more than half of baby boomers reported no regular physical activity at all.6 These compelling epidemiologic data suggest that without a significant change in the overall physical activity level of the baby boomer generation, an epidemic of sedentarism-related disease burdens in our society will increase exponentially.

Pathoanatomy/physiology

Osteoarthritis is the most common pathoanatomic challenge that faces an older adult participating in an exercise program. Cardiopulmonary impairment affects work capacity, safe intensity thresholds, and duration of conditioning; however, osteoarthritis of the major weight-bearing joints is common and can cause significant pain while exercising or following overexertion. Steadily decreasing cardiopulmonary reserve combined with skeletal muscle sarcopenia reduces the intensity at which older adults can execute a fitness program. Decreased range of motion, chronic restrictions, and contractures can become exacerbated by inactivity caused by underlying medical disease and progress rapidly in older adults. These musculoskeletal changes put older adults at risk for muscle sprains and acute inflammation (eg tendinitis, bursitis), especially when beginning or intensifying an existing exercise program. To avoid potential complications, any older individual should ideally undergo a full physiatric evaluation before implementing a new exercise program.

Disease progression: natural history, disease phases/stages, and disease trajectory

The chronic progressive changes that lead to a decrease in exercise capacity are summarized as follows:

  1. Decreased cardiac output and heart rate response to exercise
  2. Decreased pulmonary function (maximal oxygen consumption, forced expiratory volume in 1 second, vital capacity, carbon monoxide diffusing capacity)
  3. Decreased joint motion and cartilage synthesis
  4. Decreased balance
  5. Decreased postural control with increased response time to positional challenges
  6. Decreased thermo-regulation
  7. Decreased protein metabolism
  8. Increased body fat/lean muscle ratio

Although these changes represent normative aging, the rate of progression can be greatly altered by engaging in a regular exercise program.7

Specific secondary or associated conditions and complications

The most common musculoskeletal conditions that are exacerbated by exercise become the most common complications of exercise and include the following:

  1. Upper extremity pain: impingement, tendonitis, bursitis
  2. Low back pain: exacerbation of chronic pain from all causes (mechanical, radicular)
  3. Knee pain: osteoarthritis
  4. Hip pain: osteoarthritis

Thorough evaluation prior to exercise with careful counseling and possible referral to physical therapy prior to vigorous physical activity can prevent injury in many cases.

2. Essentials of Assessment

History

Obtaining a detailed and focused exercise history is essential to properly council exercising patients and functionally optimize sedentary patients prior to exercise. Older patients will often over report their actual activity level stating that they are active, whereas a detailed medical history will reveal a truly sedentary lifestyle. For this reason, objective measurement tools (eg, Duke Activity Status Index,8 Physical Activity Scale for the Elderly9,10) are helpful in determining actual baseline energy expenditure. Additionally, these tools can give insight into the patient’s ability to perform functional activities. These instruments can be efficient tools to augment physiatric history and can facilitate focused history taking when completed prior to the medical visit.

Physical examination

The physical examination of an older adult who is either actively exercising or considering beginning an exercise program should emphasize range of motion;however, there is no absolute consensus on whether geriatric inactivity causes decreased range of motion.11 A careful evaluation of joint function and stability will alert the provider to potential injuries that can arise following increased physical activity. Patients are often unaware to what degree they have reduced range of motion, especially when these restrictions develop over time.

Functional assessment
A thorough functional assessment, including gait analysis, is indicated in all older adults considering beginning an exercise program and who are actively exercising. Evaluation of fall risk and discussion of safe activities should take place prior to any exercise program or new athletic activity for the regularly exercising older adult. Patients with faster gait may overestimate their ability to participate in higher-risk activities12 and should be scrupulously counseled regarding safe activities, optimal footwear, and fall prevention. Counseling based on objective assessment will be better received and likely have more utility in independent and potentially overconfident geriatric exercisers.

Laboratory studies
Exercise stress testing is recommended by the American College of Sports Medicine for all sedentary or minimally active older adults who plan to begin an intense exercise program; however, walking is generally accepted as safe.4 No other laboratory studies or diagnostic testing are required; however,patient compliance with exercise may be increased if serial lipid testing and hemoglobin A1C demonstrate an improvement attributable to exercise.

Supplemental assessment tools
The use of accelerometers to objectively determine physical activity has been validated in older adults and used for more than 15 years.13 Their use can be helpful in patients who cannot objectively report their current physical activity level. Improvement in objective parameters (eg, accelerometer activity) can be highly motivational for some patients.Pedometer use can also be cost-effective and may result in significant improvement in leisure-time walking.14

Environmental
Olderexercisers have increased sensitivity to extremes of temperature caused by impaired ability to regulate core temperature in both hot and cold environments.15 All physically active older people should be educated regarding the options for indoor exercise during extreme heat and cold. Mall-walking, seasonal gym membership, and home exercise equipment may be preferred, especially with increasing age. Another advantage of indoor exercise during warm weather is free access to water, essential important in preventing heatstroke.

Social role and social support system
Patients who are primary caregivers are less likely to exercisebecause of the demands placed on them by occupying a position of responsibility within their family structure. Although women do not exclusively serve this role, it is more common for women, especially over the age of 65 years, to be primary caregivers for a geriatric partner. The ability to exercise regularly will depend on the degree of social support a participant has within their overall social system (immediate family and community). As in many areas of medicine,sex disparities even exist in cardiac rehabilitation,16,17 a setting where motivation and social support for regular exercise is high. Helping patients identify additional resources where possible and emphasizing the medical importance of a regular exercise program can help all patients prioritize their exercise programs.

3. Rehabilitation Management and Treatments

Available or current treatments
Rehabilitation professionals are uniquely qualified to optimize older patients prior to exercising and address the musculoskeletal concerns that can arise from increased physical activity.

Coordination of care
When a rehabilitation provider is unaware of their patient’s risk for cardiovascular disease, the older patient should see a cardiologist prior to vigorous physical activity. Exercise-related symptoms (shortness of breath, chest pain, sudden nausea, sudden sweating) may be initially reported to a rehabilitation provider and should prompt a follow-up visit with either the primary care provider, cardiologist, or both.Patients with a known history of coronary artery disease will often ignore recurrent symptoms and not report them to a cardiologist for fear of triggering further diagnostic testing.

Patientand family education

It is important to educate all patients regarding safety issues that are relevant to the older members of the population. Fall prevention, temperature regulation, hydration, and adequate protein intake may all be a concern for older patients who are engaged in active exercise programs. Encouraging family members to exercise with their older relatives can improve compliance and surveillance of the vulnerable person’s physiologic response to exercise. Additionally, older patients may have limited ability to travel to malls for walking, gyms for exercise, or rehabilitation clinics for therapy. Educating family members on the important role that physical activity and physical therapy play in the continued health of their older family member will highlight the importance of addressing barriers that can prevent exercise from taking place.

Emerging/unique intervention
In the outpatient setting, most older adults come to physiatrists for exacerbation of musculoskeletal conditions, often acute on chronic conditions. Pain control and referral to physical therapy is standard practice in this setting; however, physiatrists are well positioned to oversee the institution of a new exercise program following successful graduation from physical therapy. If the clinical emphasis is restoration of function followed by increasing physical activity, patients will have better outcomes over time.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

NA

5. Gaps in the Evidence-Based Knowledge

The medical literature continues to demonstrate the clinical effects and benefits of exercise in older adults. Although clinical studies have explored the effect of exercise on the oldest old, basic science exploration relating to exercise in older adults has largely focused on skeletal muscle physiology and sarcopenia. Clinical inferences based on interpretation of molecular biology findings take place; however, large clinical studies correlating the molecular biologic effects of exercise and functional status in geriatric populations are needed. Only then will physiatrists be able to prescribe evidence-based and highly specific exercise programs that can directly address the functional impairments of theirolder patients.

REFERENCES

1. Fiatarone MA, O’Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people.N Engl J Med.1994;330(25):1769-1775.

2. Frontera WR, Hughes VA, Fielding RA, Fiatarone MA, Evans WJ, Roubenoff R. Aging of skeletal muscle: a 12 year longitudinal study.J Appl Physiol.2000;88(4):1321-1326.

3. Xu QL, Bandeen-Roche K, Mielenz TJ, et al. Patterns of 12-year change in physical activity levels in community-dwelling older women: can modest levels of physical activity help older women live longer?Am J Epidemiol. 2012;176(6):534-543.

4. Nied RJ, Franklin B. Promoting and prescribing exercise for the elderly.Am Fam Physician. 2002;65(3):419-426.

5. United States Department of Health and Human Services.Healthy People 2010: Understanding and Improving Health. Washington, DC: US Government Print Office; 2000.

6. King DE, Matheson E, Chirina S, Shankar A, Broman-Fulks J. The status of baby boomers’ health in the United States: the healthiest generation?JAMA Intern Med.2013;173(5):385-386.

7. Burke TN, Franca FJ, Ferreira de Meneses SR, Cardoso VI, Marques AP. Postural control in elderly persons with osteoporosis: efficacy of an intervention program to improve balance and muscle strength: a randomized controlled trial.Am J Phys Med Rehabil. 2010;89(7):549-556.

8. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity the Duke Activity Status Index.Am J Cardiol. 1989;64(10):651-654.

9. Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation.J Clin Epidemiol.1993;46(2):153-162.

10. Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA. The Physical Activity Scale for the Elderly (PASE): evidence for validity.J Clin Epidemiol.1999;(52):643-651.

11. Frankel JE, Bean JF, Frontera WR. Exercise in the elderly: research and clinical practice.Clin Geriatr Med.2006;22(2):239-256.

12. Cress ME, Schechtman KB, Mulrow CD, Fiatarone MA, Gerety MB, Buchner DM. Relationship between physical performance and self-perceived physical function.J Am Geriatr Soc.1995;43(2):93-101.

13. Kochersberger MD, McConnell E, Kuchibhatla M, Pieper C. The reliability, validity, and stability of a measure of physical activity in the elderly.Arch Phys Med Rehabil. 1996;77(7):793-795.

14. Kolt GS, Schofield GM, Kerse N, Garrett N, Ashton T, Patel A. Healthy Steps trial: pedometer-based advice and physical activity for low-active older adults.Ann Fam Med.2012;10(3):206-212.

15. Kenney WL, Munce TA. Invited review: aging and human temperature regulation.J Appl Physiol. 2003;95(6):2598-2603.

16. Sutton EJ, Rolfe DE, Landry M, Sternberg L, Price JA. Cardiac rehabilitation and the therapeutic environment: the importance of physical, social and symbolic safety for programme participation among women.J Adv Nurs.2012;68(8):1834-1846.

17. Allen JK, Scott LB, Stewart KJ, Young DR. Disparities in women’s referral to and enrollment in outpatient cardiac rehabilitation.J Gen Intern Med.2004;19(7):747-753.

Author Disclosure

David Z. Prince, MD
Nothing to Disclose

Related Articles