Exercise can be defined as a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediate objective the improvement or maintenance of physical fitness1. Unfortunately, there is no adequate, consistent definition of the word “elderly”, however it is generally referring to the population above age 65. There are unique considerations that should be taken into account when prescribing and advising older adults regarding exercise, and a physiatrist is the ideal professional to evaluate and counsel older adults regarding exercise.
Worldwide, the number of people over the age of 65 is expected to increase from approximately 900 million in 2015 to over a trillion in 20302. Becoming familiar with the unique biomechanical and physiologic changes associated with elderly patients will allow the Physiatrist to adequately increase physical fitness levels safely. Frailty is often considered a physical disability in the elderly and often mistaken for a normal part of the aging process3. This state is characterized by weakness, weight loss, exhaustion, a decrease of daily activity and accumulation of co-morbidities 3. The majority of the evidence shows that physical activity or exercise is highly recommended as a means to modify frailty and its adverse outcomes4.
Epidemiology including risk factors and primary prevention
The aging of American society and impact on the American healthcare system has been well described. Despite clear benefits of exercise, 27.5% of US adults over the age of 50, approximately 31 million persons, self reported as “inactive” 5. The prevalence of inactivity increased with advancement in age: adults aged 50-64 (25.4%), 65-74 (26.9%) and 75 years and older (35.3%)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. There are numerous studies demonstrating the positive effects on cardiovascular, metabolic, endocrine, psychological health and delay decline in the elderly population.
There are multiple physiologic and structural changes that occur within the organ and musculoskeletal systems as we age. Cardiopulmonary impairment affects work capacity, safe intensity thresholds, and duration of conditioning. Steadily decreasing cardiopulmonary reserve combined with skeletal muscle sarcopenia reduces the intensity at which older adults can execute a fitness program. These musculoskeletal changes put older adults at risk for muscle sprains and acute inflammation (e.g. tendinitis, bursitis), especially when beginning or intensifying an existing exercise program. Almost all elderly persons can benefit from an exercise program and few contraindications exist to implementation of physical activity. To avoid potential complications, assess current functional abilities and design a safe exercise program, any sedentary older individual should ideally undergo a full Physiatrist evaluation before implementing a new exercise regimen.
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:
- Decreased peak cardiac output and maximum heart rate response to exercise.
- Cardiac aging is associated with progressive loss of myocytes and compensating mild hypertrophy; reduced sensitivity to sympathetic stimuli compromises myocardial contractility in older adults7
- Decrease in maximal aerobic capacity presented by peak exercises oxygen consumption regardless of physical activity level7
- Increased left ventricle and systolic volume and decreased ejection fraction during exercising7
- Decrease in muscle mass and protein metabolism
- Decreased number of myofibrils and concentration of mitochondrial enzymes. Decrease in muscle strength by 15% per decade after age 50 and 30% per decade after age 708. Aging leads leads to increased percentage of type I muscle fibers due to type II muscle fiber atrophy9,10
- Decreased pulmonary function (maximal oxygen consumption, forced expiratory volume in 1 second (decreased consistently 30cc/year), vital capacity, carbon monoxide diffusing capacity, maximum minute ventilation). Increase in residual lung volume and functional residual capacity.
- Decreased baroreceptor sensitivity associated with orthostatic hypotension
- Decreased articular cartilage cellularity, matrix composition and mechanical changes19
- Decreased proprioception, gait velocity, stride length and balance11. Increased base of stance
- Decreased postural control with increased response time to positional challenges
- Impaired thermo-regulation with decreased autonomic vasomotor control
- Decreased protein metabolism
- Decrease in basal metabolic rate. Increased body fat/lean muscle ratio
- Higher risk of dehydration due to changes in secretion of ADH, decreased sense of thirst and physiologic changes related to renal concentrating ability12.
Although these changes represent normative aging, the rate of progression can be greatly altered by engaging in a regular exercise program.13
Specific secondary or associated conditions and complications
Most commonly seen complications of exercise are almost always due to exertional or overuse injuries, comprising 70-85% of total injuries, in the elderly14. Appropriate training programs, use of safe and familiar equipment, careful warming up and cooling down, multiphasic training (including balance, coordination and reaction time) are essentials to prevent injuries14. Regular follow-ups with a physiatrist throughout the patient’s participation in an exercise program can help prevent and mitigate these injuries. Other more commonly seen exacerbation of chronic conditions such as osteoarthritic joint pain and decreased range of motion, impingement, bursitis and tendonitis, all can discourage and limit adherence to exercise programs.
ESSENTIALS OF ASSESSMENT
Obtaining a detailed and focused exercise history is essential to properly counsel exercising patients and functionally optimize sedentary patients prior to exercise. A thorough review of past medical history and medications can help guide the physiatrist when designing an exercise program, such as the use of beta-blockers and anticholinergic medications. Additionally, it is important to understand a patient’s motivation for initiating an exercise regime so that it can be tailored to the patient. Identifying barriers to exercise is also key as it can affect exercise adherence 15. Musculoskeletal pain is a common barrier to exercise and one that is particularly amenable to intervention by a physiatrist.
The physical examination of an older adult should be comprehensive with focused examination of the systems primarily involved in exercise. The heart and peripheral vasculature should be assessed to garner information about aerobic exercise capacity as well as identifying pathologies that may limit aerobic exercise tolerance such as peripheral vascular disease. Underlying cardiovascular disease may also be identified such as uncontrolled hypertension, unstable angina, third degree heart block or acute heart failure which would be contraindicated to exercise initiation in older adults16. The respiratory system should also be examined, namely to identify any pulmonary disorders such as chronic bronchitis, emphysema or restrictive lung diseases. The musculoskeletal examination involves examination of the axial and appendicular skeleton, with an attention to posture, muscle bulk, joint range of motion and strength testing. Gait assessment should also be performed and an evaluation of static balance and fall risk may be assessed using the Berg Balance scale16. Neurological testing should include vision assessment, sensation, proprioception and a mini-mental examination. Psychological testing should also be assessed to provide insight on exercise motivation and goals and to identify patients with underlying mood disorders (Geriatric Anxiety and Depression Scales) 17,18. An exercise-focused physical examination allows the physician to identify conditions that may impact exercise in the elderly but also can be used to track the beneficial changes of an exercise program.
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. For this reason, objective measurement tools (e.g., Timed Up and Go Test, Duke Activity Status Index,19 Physical Activity Scale for the Elderly17,18) are helpful in determining actual baseline energy expenditure. Additionally, these tools can give insight into the patient’s ability to perform functional activities. Discussion of patient’s independence levels during Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) can be used to determine the patient’s physical functional level. Counseling based on objective assessment will be better received and likely have more utility in independent and potentially overconfident geriatric exercisers.
There are no routine laboratory studies that are recommended in older adults prior to initiating a new exercise program. The use of routine electrocardiogram is not indicated either. According to the guidelines set forth by the American College of Sports Medicine in 2018, older adults who do not engage in regular exercise but would like to and do not have any signs or symptoms and current cardiovascular, renal or metabolic diseases may engage physical activity without medical clearance. Older adults who do have known cardiovascular, renal or metabolic disease or show signs of them it is recommended they obtain medical clearance 23.
Supplemental assessment tools
Exercise and Physical Activity Tracking Tool worksheets are simple ways for older patients to track exercise and activity levels with samples available online on the National Institute of Aging website 24. Pedometers are low cost tools that track the number of steps a person takes during a day and can classify an older adult as highly active (more than 10 000 steps/day), moderately active (less than 10 000 steps/day but more than 5 000 steps/day) or inactive (less than 5 000 steps/day) 25,26,27. Data for two to three days in an older adult reflects the usual daily physical activity of an individual 25. Accelerometers provide information about exercise frequency, intensity and duration of various movements in a given day 25. New technological devices such as smart watches have these tools integrated with heart rate monitors that allows individuals to track activity levels in a live format.
Proper footwear and clothing is recommended for older adults during physical activity which should match the exercise type that is performed 28. Walking is the preferred mode of physical activity in older adults and so options such as mall walking or indoor gym facilities may facilitate participation in older adults. Environmental factors such as hills, stairs, uneven walking surfaces and weather have been identified as barriers to exercise 29. Generally, access to parks, recreational facilities, safe footpaths and areas free from crime have been known to influence physical activity levels in all age exercisers 25. It is important to consider ambient temperature in exercise with older adults as there is an attenuated ability to dissipate heat with age thus subjecting older individuals to increased risk of heat-related illness during exercise in heat 30.
Social role and social support system
Group exercise in the elderly provides an opportunity for social support for individuals as a lack of company was the second most cited reason for not exercising in older adults 31. Community-based group exercise programs increase physical activity levels and improve adherence rates in older adults. Those who join have an improved sense of well being, quality of life and expanded social network32. This has an impact on overall health as older adults with appropriate social relationships have a greater likelihood of survival compared to those with limited social support 32,33. Participating in regular group exercises increases social connectedness and a sense of security in the community through peer support 34. Community-based exercise programs, the Silver Sneakers and EnhanceFitness are exercise programs designed for older adults that provide this opportunity and should be suggested prior to initiating an exercise regimen.
REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatments
Physiatrists should be aware of the current exercise recommendations for older adults to maximise health benefits. As outlined by the American College of Sports Medicine, older adults should strive to perform at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity in combination with a resistance program targeting major muscle groups at least two days a week followed by flexibility exercises 23. In addition, older adults should perform balance training three or more days per week. It is also important to discuss the components of an exercise prescription which includes: exercise mode, frequency, intensity and duration with older adults. Aerobic exercise programs should target 50-60% of VO2max which is equivalent to 2.5 to 5.5 METs (metabolic equivalents) for a total of 30 minutes with a 5-10 minute warm up and cool down period. Vigorous aerobic exercise should be performed at greater than 6 METs 16. Resistance training should begin with low intensity (40-50% of 1 repetition max (RM)) and eventually progress to moderate (60-70% of 1 RM) and then to high intensity (80% of 1 RM) with a goal of 10-15 repetitions for 2-3 sets 16. Core and hip muscles should be strengthened to prevent falls. Also, high speed power training in older adults increases speed related performances and may also benefit in fall prevention 35. Flexibility exercises are recommended for 10-30 seconds for static stretching and repeating the stretch 2-4 times in a session 16. Balance exercises aim to progressively decrease the base of support with dynamic movements that work postural muscles or reduce sensory input 16. Tai chi and yoga incorporate such movements with varying lengths of duration per session. If older adults are unable to achieve the prescribed exercises due to chronic conditions or pain, they may make modifications as any amount of exercise is superior to being sedentary.
Coordination of care
Physiatrists can coordinate with other allied health professionals in order to prepare patients for exercise activities. For older adults not accustomed to performing exercises, working with a fitness trainer may be an option. Patients with gait impairments may benefit from attending physical therapy sessions prior to engaging in exercise programs 25. Occupational therapy sessions may also aid a patient with balance issues to work on postural stability as well as energy conservation and safety techniques 16. Patients may also require dietary consultation due to changes in energy expenditure especially those with chronic diseases such as diabetes, COPD and cancer.
Patient and family education
It is important to educate both the patient and family members about the health benefits of exercise activity in elderly adults. Involving family members may also help with exercise program compliance and adherence and ensure elderly adults have access to safe exercise environments. The benefits of the aerobic exercise components includes improvement in VO2max which leads to lower heart rate at rest and during submaximal exercise, smaller increases in blood pressure, improved glycemic control and improved postprandial lipid metabolism 16. Resistance training in the elderly leads to an increase in fat-free body mass, a decrease in total body fat and counteracts sarcopenia. There is also an increase in motor unit recruitment and discharge rates as well as muscular endurance 16. The combination of aerobic and resistance training in elderly adults without disabilities results in increased functional independence. Flexibility training in elderly adults has been shown to increase range of motion especially in the lumbar back region and knee flexors which allows for faster recovery from a perturbation, hence decreasing the likelihood of suffering a fall 16. Flexibility exercises have also been shown to reduce pain. Balance exercise programs are designed to improve neuromotor control of the lower extremities and improve the vestibular component which reduces the likelihood of falling 16. Together, these various components promote physiologic changes in an elderly adult. However, an added benefit to a physically active elderly person is improving feelings of well being, mood and improved quality of life which lowers the risk of dementia and cognitive decline 25.
With technological advances, access to exercise programs has improved in all age categories with the use of smartphone apps and internet-based subscriptions with live classes. This may be an option for elderly patients who have difficulty with transportation or mobility impairments to attend outside facilities for exercise classes. Tele-exercise group classes are effective ways to improve balance in elderly patients 36. The goal of the physiatrist is to guide elderly patients on initiating, maintaining an exercise program to restore function with a positive impact on their quality of life.
CUTTING EDGE CONCEPTS AND PRACTICE
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.
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Original Version on the Topic
David Z. Prince, MD. Exercise in the elderly. 9/20/2014
Joe Mendez, MD
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Melissa Mafiah, MD
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