Essentials of Assessment
Rehabilitation Management and Treatments
Available or current treatments
Physiatrists should be aware of the current exercise recommendations for older adults in order to maximize 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 followed by flexibility exercises at least two days a week.1,2 In addition, older adults should perform balance training three or more days per week. It is also important to educate older adults on the components of an exercise prescription which includes exercise mode, frequency, intensity and duration. Aerobic exercise programs should target 50-60% of VO2max which is equivalent to 2.5 to 5.5 metabolic equivalents (METs) 3 or more days per week 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.3 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) performed 2-3 times per week with a goal of 10-15 repetitions for 2-3 sets.3 Core and hip muscles should be strengthened to prevent falls. Additionally, high speed power training in older adults has been associated with increased speed related performances and may also benefit in fall prevention.4 Flexibility exercises are recommended for 10-30 seconds for static stretching and repeating the stretch 2-4 times in a session.3 Balance exercises aim to progressively decrease the base of support with dynamic movements that work postural muscles or reduce sensory input.3 Tai chi and yoga incorporate such movements with sessions of varying duration. Low-intensity aerobic training programs in the aquatic environment has also been shown to be effective in the treatment of depression by reducing anxiety, decreasing oxidative stress, and improving functional anatomy.4 If older adults are unable to achieve the prescribed exercises due to chronic conditions or pain, they may need the assistance of a physiatrist for making functional modifications. Any amount of exercise or physical activity is preferable to a sedentary lifestyle and studies have shown improvements in balance and fall prevention in the elderly.5
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.6 Occupational therapy sessions may also aid a patient with balance issues to work on postural stability as well as energy conservation and safety techniques.3 Patients may also require dietary consultation due to changes in energy expenditure especially those with chronic diseases such as diabetes, COPD and cancer. Comprehensive geriatric assessment (CGA) programs are a multidisciplinary diagnostic process that evaluates medical, functional, psychological, and social capabilities of frail or vulnerable elderly persons in various clinical and community settings. These programs help develop a coordinated plan to maximize health with aging, and include improving physical function.7
Patient and family education
It is important to educate both the patient and family members about the health benefits of exercise in elderly adults. Involving family members may also help with exercise program compliance and ensure elderly adults have access to safe exercise environments. The benefits of aerobic exercise include improvement in VO2max which leads to lower heart rate at rest and during submaximal exercise, reduced increase in blood pressure, improved glycemic control and superior postprandial lipid metabolism.3 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.3 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.3 Flexibility exercises have also been shown to reduce pain. Balance exercise programs are designed to improve neuromotor control of the lower extremities and enhance the vestibular component which reduces the likelihood of falling.3 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.6
With technological advances, access to exercise programs has improved in all age categories due to 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 which prevents them from attending outside facilities for exercise classes. Tele-exercise group classes are also effective for improving balance in elderly patients.8 The goal of the physiatrist is to guide elderly patients towards initiating and maintaining an exercise program in order to maintain and improve their function and quality of life.
Cutting Edge Concepts and Practice
- With more evolving research on the positive effects of exercise, studies have focused on determining the most beneficial type of exercise for elderly patients specifically. Recently, resistance type exercise has demonstrated increased levels of insulin-like growth factors and superior effects in limiting age-related muscle atrophy compared to aerobic exercise.9
- It is widely recognized that with the aging process, there is a typical decline in bone mass in both men and women. Not all exercise regimens are equal in their effects on bone remodeling in the elderly. While walking alone is not enough to modify the loss of bone mineral density, it has been previously understood that optimal bone mineral maintenance is through a multicomponent training: weight-bearing aerobic training with high intensity and speed, strength training, progressive resistance training, and simulated functional tasks. There are new arising technologies such as physiotherapy interventions of high frequency mechanical stimuli generated by a vibrating platform that activates mechanoreceptors of bone-favoring osteogenesis (Whole Body Vibration).10
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 elderly, basic science research relating to exercise in older adults has largely focused on skeletal muscle physiology and sarcopenia. Clinical inferences based on interpretation of molecular biology findings has occurred; however, large clinical studies correlating the molecular biologic effects of exercise and functional status in geriatric populations are needed.
- Riebe D, Ehrman JK, Liguori G, Magal M. American College of Sports Medicine’s guidelines for exercise testing and prescription. 10th ed. Philadelphia, PA.Wolters Kluwer; 2018.
- Larsen RT, Wagner V, Korfitsen CB, et al. Effectiveness of physical activity monitors in adults: systematic review and meta-analysis. BMJ. 2022;376:e068047. Published 2022 Jan 26. doi:10.1136/bmj-2021-068047
- Galloza, J, Castillo B, Micheo W. Benefits of Exercise in the Older Population. Phys Med Rehabil Clin N Am. 2017;28(4):659-669.
- Sayers SP, Gibson K. High-speed power training in older adults: A shift of the external resistance at which peak power is produced. J Strength Cond Res. 2014 March ; 28(3): 616-621.
- Thomas E, Battaglia G, Patti A, et al. Physical activity programs for balance and fall prevention in elderly: A systematic review. Medicine (Baltimore). 2019;98(27):e16218. doi:10.1097/MD.0000000000016218
- Taylor D. Physical activity is medicine for older adults. Postgraduate Medical Journal 2014;90:26-32.
- Lee H, Lee E, Jang IY. Frailty and Comprehensive Geriatric Assessment. J Korean Med Sci. 2020 Jan 20;35(3):e16. doi: 10.3346/jkms.2020.35.e16. PMID: 31950775; PMCID: PMC6970074.
- Wu G, Keyes LM. Group tele-exercise for improving balance in elders. Telemed J E Health. 2006 Oct;12(5):561-570.
- Lai X, Bo L, Zhu H, et al. Effects of lower limb resistance exercise on muscle strength, physical fitness, and metabolism in pre-frail elderly patients: a randomized controlled trial. BMC Geriatr. 2021;21(1):447. Published 2021 Jul 30. doi:10.1186/s12877-021-02386-5
- Benedetti MG, Furlini G, Zati A, Letizia Mauro G. The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients. Biomed Res Int. 2018;2018:4840531. Published 2018 Dec 23. doi:10.1155/2018/4840531
Original Version on the Topic
David Z. Prince, MD. Exercise in the elderly. 9/20/2014
Previous Revision(s) on the Topic
Joe Mendez, MD, Melissa Mafiah, MD, Alexandre Mazar, MD. Exercise in the elderly. 8/20/2020
Jason Do, DO
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Alex Vertes, MD
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Simron Gill, MD
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Haris Choudry, MD
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Derek Ho, DO
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