Exercise in elderly

Exercise in elderly
DR Doha Rasheedy
Assistant Professor of Geriatric
Medicine
Ain Shams University

• Regular exercise provides a myriad of health
benefits in older adults, including improvements in
blood pressure, diabetes, lipid profile,
osteoarthritis, osteoporosis, and neurocognitive
function. Regular physical activity is also
associated with decreased mortality and age-
related morbidity in older adults.
up to 75 percent of elderly are
insufficiently active to achieve these health
benefits.
However,

Cardiovascular risks
• The relative risk (RR) for cardiovascular
disease caused by sedentary living has been
estimated to be 1.9, compared with other
modifiable risk factors such as hypertension
(RR = 2.1) and cigarette smoking (RR = 2.5),
but it occurs at a much higher prevalence.
• Fewer than 10 percent of women over age 75
smoke cigarettes while greater than 70
percent are insufficiently active
Dishman RK. Advances in exercise adherence. Champaign, Ill.: Human Kinetics, 1994:215.
Jones DA, Ainsworth BE, Croft JB, Macera CA, Lloyd EE, Yusuf HR. Moderate leisure-time physical activity: who is
meeting the public health recommendations? A national cross-sectional study. Arch Fam Med 1998;7:285-9.

• Aerobic capacity, muscle mass, and strength
decline with age:
1. Aerobic capacity declines at about 1 percent
per year from mid-life forward and at one-
half that rate among habitually active
persons.
2. Loss of muscle mass and strength are also
thought to accelerate after mid-life. Lean-
mass loss was about 1 percent per year.

Benefits of Exercise
• Improvements in cardiovascular, metabolic,
endocrine, and psychological health.
• Up to one third of the age-related decline in
aerobic capacity (V°O2 max) can be reversed with
prolonged (six months or more) aerobic training
leading to decrease in all- cause mortality and
morbidity.(even if started after age 75).
Thus, it is never too late for patients
to benefit from physical activity

Benefits of Exercise in Older Adult in
different systems
Cardiovascular:
1. Improves physiologic parameters (V°O2 max,
cardiac output, decreased submaximal rate-
pressure product)
2. Improves blood pressure
3. Decreases risk of coronary artery disease
4. Improves congestive heart failure symptoms and
decreases hospitalization rate
5. Improves lipid profile

Diabetes mellitus, type 2;
1. Decreases incidence
2. Improves glycemic control
3. Decreases hemoglobin A1C
levels
4. Improves insulin sensitivity
Osteoporosis
1. Decreases bone density loss in
postmenopausal women
2. Decreases hip and vertebral
fractures
3. Decreases risk of falling
Other
1. Decreases all-cause mortality
2. Decreases all-cause morbidity
3. Decreases risk of obesity
4. Improves symptoms in
peripheral vascular occlusive
disease
Osteoarthritis;
1. Improves function
2. Decreases pain
Neuropsychologic health
1. Improves quality of sleep
2. Improves cognitive function
3. Decreases rates of depression,
improves Beck depression
scores.
4. Improves short-term memory
5. Increase self-esteem
Cancer
• Potential decrease in risk of
colon, breast, prostate, rectum
• Improves quality of life and
decreases fatigue

social benefits
• Empowering older individuals
• Enhanced social integration
• Widened social networks
• Enhanced intergenerational activity

Risks of exercise
Cardiovascular
• intense exercise can
cause venous thrombosis
• Isometric Exercises cause
rise in blood pressure
• unaccustomed
vigorous physical exertion
can trigger Acute
myocardial infarction and
sudden cardiac death
Musculoskeletal
• Strain
• Discomfort
• pain
Less common;
• hyperthermia in warmer
weather, hypoglycemia in
diabetics,
• electrolyte imbalances, and
dehydration.
• hemoglobinuria, hematuria
and rhabdomyolysis in
vigorous activity.

DETERMINANTS OF PHYSICAL
ACTIVITY

Determinants for initiation
Knowledge, beliefs
Habits
Perceived health
Motivation
Self efficacy
Stress, anxiety, depression
Perceived availability of time
Accessibility
Cognition
Functional independence
Determinants for Maintenance
Perceived discomfort
Activity characteristics
Peer reinforcement
Self efficacy
Stress, anxiety, depression
safety

• Age should not limit exercise training however,
experts recommend a more gradual approach in
older patients
• Before arranging for an exercise program,
physicians should consider social preferences
(e.g., solitude or socialization), cultural norms,
exercise history, instructional needs, readiness,
motivation, self-discipline, short- and long-term
goals, and logistics

Physiological Factors
• Cognition
• General health
• Functional independence
• Exercise induced discomfort

Psychosocial Factors
1. Characteristics such as motivation, stress tolerance, social
adequacy, and independence can affect physical activity
levels.
2. Affective disorders such as anxiety and depression tend to
be inversely associated with physical activity participation
at any age.
3. self-efficacy, or confidence in one's abilities, is a factor
strongly associated with both the adoption and adherence
to physical activity.
4. Long-life habits and behavior
5. Knowledge and beliefs.
6. Social influences on physical activity patterns. Peer
reinforcement is especially important to physical activity
patterns
7. Perceived available time

Environmental Factors
• Safety
• accessibility

Activity characteristics
• Intensity
• Type
• Frequency

Considerations in planning exercise program
• Important components to consider in an
exercise program include aerobic exercise,
muscular strength, flexibility, and balance.
• Preventive, therapeutic goals consideration
• Exercise must meet individual and group needs
and expectations.
• Exercise should be relaxing and enjoyable.
• Have fun!
• Exercise should be regular, if possible daily.

Steps of exercise program
• Pre-participation Screening
• Plan the regimen
• Initiate
• Periodic evaluation for maintain, Progress, or
Discontinuation

A self-guided screening for physical
activity program
• easy-to-use screening tools to guide adults
through the process of initiating an exercise
program with no input or supervision from an
exercise or health/ fitness professional.
• Not applicable alone for elderly due to
comorbidities, increased cardiovascular risk.
• E.g. Physical Activity Readiness (PAR-Q) Form
(A Questionnaire for People Aged 15 to 69)

HISTORY AND PHYSICAL EXAMINATION
• Target at identifying cardiac risk factors, exertional
signs/symptoms, and any physical limitations.
• Other social, and psychological limitation should be
addressed at the office visit.
• There are few contraindications to aerobic exercise
or resistance training. See later
• Even patients with these conditions can safely
exercise at low levels once appropriate evaluation
and treatment have been initiated

Pre-exercise Evaluation
History(geriatrician)
• Current and past exercise habits (mode, frequency, intensity, duration)
• Current motivation and barriers to exercise
• Preferred forms of physical activity
• Beliefs about benefits and risks of exercise
• Risk factors for heart disease (hypertension, diabetes mellitus,
hyperlipidemia,
• smoking, family history of heart disease before 55 years of age)
• Physical limitations precluding certain activities
• Exercise-induced symptoms
• Concurrent disease (cardiac, pulmonary, musculoskeletal, vascular,
psychiatric, etc)
• Social support for exercise participation
• Time and scheduling considerations
• Medication profile

Potential Contraindications to Aerobic Exercise
and Resistance Training
Absolute
1. Recent acute myocardial infarction
2. Unstable angina
3. Ventricular tachycardia and other
dangerous dysrhythmias
4. Dissecting aortic aneurysm
5. Acute congestive heart failure
6. Severe aortic stenosis
7. Active or suspected myocarditis or
pericarditis
8. Thrombophlebitis or intracardiac
thrombi
9. Recent systemic or pulmonary
embolus
10. Acute infection
Relative
1. Complex ventricular ectopy
2. Moderate Valvular heart disease
3. Cardiomyopathy
4. Moderate aortic stenosis
5. Severe subaortic stenosis
6. Supraventricular dysrhythmias
7. Ventricular aneurysm
8. Uncontrolled metabolic disease
(diabetes, thyroid disease, etc) or
electrolyte abnormality
9. Chronic or recurrent infectious
disease (malaria, hepatitis, etc)
10. Neuromuscular, musculoskeletal or
rheumatoid diseases that are
exacerbated by exercise

• Certain medications interfere with heart rate,
blood pressure and exercise capacity and may
potentially cause cardiovascular or respiratory
insult ( appendix)

Recommended pre-exercise program
investigations
1. ECG
2. EXERCISE STRESS TESTING

ECG
• A resting office-based electrocardiogram (ECG)
has limited use in preparticipation screening
• Bradycardia, minor ST-wave changes, and
atrial and ventricular complexes can be
normal variants in older persons and are
nonspecific for coronary artery disease.

EXERCISE STRESS TESTING
Indications
1. The American College of Sports Medicine recommends exercise
stress testing for all sedentary or minimally active older adults
who plan to begin exercising at a vigorous intensity.
2. Men ≥45 years and women ≥55 years who plan to exercise at ≥60
percent V°O2 max
3. Known coronary artery disease or cardiac symptoms
4. Two or more coronary artery disease risk factors*
5. Diabetes
6. Known or major signs/symptoms of pulmonary or metabolic
disease
7. Symptoms of Cardiovascular Disease
8. Patients with cardiac rhythm disorders: Evaluation of exercise-
induced arrhythmia and response to treatment, Evaluation of
rate-adaptive pacemaker setting

**Symptoms of Cardiovascular Disease
• 1. Pain, discomfort (or anginal equivalent) in the chest,
jaw, arms, or other areas that may be ischemic
• 2. Shortness of breath (SOB) at rest or with mild
exertion
• 3. Dizziness or syncope
• 4. Orthopnea or paroxysmal nocturnal dyspnea
• 5. Ankle edema
• 6. Palpitations or unexplained tachycardia
• 7. Intermittent claudication
• 8. Known heart murmur
• 9. Unusual fatigue or SOB with usual activities

Prescription should include
• FITT – PRO
1. Frequency
2. Intensity
3. Type
4. Time
5. progress

There are four main types
1. Endurance, or aerobic, activities increase your
breathing and heart rate. Brisk walking or jogging,
dancing, swimming, and biking are examples.
2. Strength exercises make your muscles stronger.
Lifting weights or using a resistance band can
build strength. (resistance, weight lifting exercise)
3. Balance exercises help prevent falls
4. Flexibility exercises stretch your muscles and can
help your body stay limber

Aerobic exercise
• Exercise that involves repetitive motions, uses
large muscle groups, increases heart rate for
an extended period, and raises core body
temperature (e.g., walking, dancing,
swimming). must be sustained for a minimum
of 10 minutes.

Strength Training (resistance training)
• Muscle strength declines by 15 percent per decade
after age 50 and 30 percent per decade after age 70.
greater degree in older women than men.
• Resistance training can result in 25 to 100 percent, or
more, strength gains in older adults through muscle
hypertrophy and, presumably ,increased motor unit
recruitment.
• Strength training also improves nitrogen balance and
can, combined with adequate nutrition, prevent
muscle wasting in institutionalized elderly persons.

Exercise regimen
• Initially, sedentary patients should begin at a very low level and
gradually progress to a goal of moderate activity.
• More simply, patients should exercise at the maximal intensity at
which they are still able to comfortably carry on a conversation
(the “talk test”)
• Warm-up and cool-down periods consisting of five to 10 minutes
of less intense activity (e.g., slow walking, stretching) should be
included to decrease the risk of hypotension, and
musculoskeletal and cardiovascular complications.
• A combination of aerobic activity, strength training, and flexibility
exercises, plus increased general daily activity
• An exercise prescription should include the following
components: Frequency, Intensity, Type, Time, and Progression
(FITT-PRO)
• The duration of whole program shouldn’t last > 1hour to
minimize dropout

• The activities and intensity levels should depend
on the patient’s daily health and energy needs,
• the training routine should vary to maintain
interest and promote optimal gains.
• Chair- and bed-based exercise should be
considered as a starting point and used by frail
patients.
• periodic evaluation of the program to maintain
the desired therapeutic effect

Aerobic exercise
• Exercise that involves repetitive motions, uses large muscle
groups, increases heart rate for an extended period, and raises
core body temperature (e.g., walking, dancing, swimming).
• 20 to 60 minutes of continuous or intermittent exercise
(minimum of 10 minutes per episode), three to seven days per
week Frequency depends on intensity; seven days per week is
preferred
• Moderate intensity.
• Increase the length of the exercise session every few weeks
without altering intensity.
• Next, maintain session length but increase intensity
intermittently for a brief time (e.g., increase the pace for 20
steps, then return to a comfortable pace for three minutes,
repeat).

Progressive resistance
training
• Exercise that requires muscles to generate force to
move or resist weight, with the intensity increasing as
physical capacity improves (e.g., strength training)
• The following regimen should be performed two or
three non consecutive days per week; and should
target 8 to 10 major muscle groups (abdomen,
bilateral arms, legs, shoulders, and hips).
– One set of 10 to 15 repetitions of low intensity weight
– One set of eight to 10 repetitions of moderate-intensity
weight
– One set of six to eight repetitions of high-intensity weigh

• Weight intensity:
– Low: 40 percent of 1-RM§
– Moderate: 41 to 60 percent of 1-RM§
– High: greater than 60 percent of 1-RM§
Repetition maximum is the most weight that
can be lifted through a full range of motion, in
good form, for one repetition.

Safety considerations for older adults
during resistance exercise• Ensure that the muscles to be exercised are warmed up for at least
10 min prior to the resistance-training component
• Begin with low resistance levels and gradually add repetitions, sets,
and intensity
• Encourage movement through a full but pain-free range of motion
• Discontinue any resistance exercise that causes pain: lower the
resistance or find an alternative exercise for the targeted muscle
group that can be performed without pain
• Instruct the older adult in correct breathing techniques: exhalation
during the effort phase and inhalation during the relaxation phase
• Teach the older adult client how to perform a resistance exercise
without hyperextending or locking the joints
• Allow at least a 48-hour rest interval between resistance-training
sessions that require the same muscle groups

TIPS for elderly
• The initial weight should be one that an individual can lift about eight times. This
weight should be maintained until he/she can easily lift the weight 10 to 15 times,
then increased to a weight that again he/she can only lift eight times, continuing
with this gradual approach to progression. If a weight cannot be lifted eight times,
it is too heavy and should be dropped down.
• Breathing should be normal while lifting weights, exhaling as the weight is lifted.
• Movements should be slow through a repetition: two to three seconds to lift,
hold for one second, and three to four seconds to return to the starting position.
• Avoid locking the joints in a tightened position.
• Patients should be advised that muscle soreness is normal at first and should
subside in a few weeks. For individuals with painful chronic conditions, muscle
strengthening activities should not exacerbate pain. More gradual incremental
strengthening is advised for patients with chronic pain to maximize tolerance and
their longterm commitment to a strengthening program.
• Muscle strengthening can also be performed at home, using exercise bands,
dumbbells, or homemade weights such as soup cans, water bottles, or empty milk
jugs filled with water or sand.

Flexibility training
• Exercise that lengthens muscles to increase a joint’s capacity to move
through a full range of motion. Stretches can be static (assume
position, hold stretch, then relax); dynamic (fluid motion [e.g., tai
chi]); active (balance while holding stretch, then moving [e.g., yoga]);
or a combination (proprioceptive neuromuscular facilitation).
• The following regimen should be performed two or three times per
week:
• Three or four repetitions for each stretch; rest briefly between
stretches (30 to 60 seconds).
• Hold static stretches 10 to 30 seconds
• Include static and dynamic techniques to stretch all major muscle
groups.
• Hold stretch in a position of mild discomfort.
• Add new stretches to the routine, progress from static poses to
dynamic moves, or reduce reliance on balance support.

Some tips for implementing a
flexibility program for older adults are
as follows:
• Flexibility exercises should be performed twice a week
for at least 10 minutes.
• Stretching is best performed after aerobic or
strengthening activities when the body is warmed up.
• Patients should breathe normally while stretching and
avoid bouncing into a stretch.
• It is best to slowly stretch into the desired position and
hold each stretch for 10 to 30 seconds.
• Patients should feel a slight pull but should not stretch
to the point of pain.

Balance training
• Exercise that helps maintain stability during
daily activities and other exercises, preventing
falls. It can be static (e.g., stand on one leg) or
dynamic (e.g., walk a tightrope), with hand
support as needed

• balance is important to help you perform
many of your daily activities and prevent falls.
Research has shown that tai chi can
significantly reduce the risk of falls among
older people. In tai chi, which is sometimes
called "moving meditation," you work to
improve your balance by moving your body
slowly, gently, and precisely, while breathing
deeply.

Lifestyle Exercise
Use opportunities in a person’s daily routine to increase
energy expenditure (e.g., manually open doors, carry
groceries, use stairs) and substitute active for sedentary
leisure time
1. taking the stairs
2. parking in a space furthest from the door
3. bicycling to work –
4. walking during your lunch
5. walking your dog
6. walking to the train or bus stop
7. raking the leaves
8. vacuuming the house

Rate of Progression
• emphasis is placed first on increasing frequency, second
on increasing duration, and lastly, on increasing
intensity.
• Progression
• Initial Conditioning Phase
– Duration – 4 to 6 weeks
– Goal is to increase frequency
• Improvement Conditioning Phase
– Duration – 4 to 6 months
– Goal is to increase duration and intensity
• Maintenance Conditioning Phase
– Occurs after 6 months of regular exercise
– Goal is to maintain cardiorespiratoy fitness

3 phases during progression:
• The initial conditioning phase lasts approximately 4 to 6
weeks. During this phase, training effects should be
appreciated. These are a decrease in resting heart rate, more
rapid recovery of resting heart rate following physical
activity, and the ability to increase duration and intensity
without increasing fatigue.
• The improvement conditioning phase lasts approximately 4
to 6 months. Patients can be progressed to reach target
heart rates or desired duration of physical activity. It is best
to first increase the duration of activity to the desired length
and then increase the intensity. The patient will continue to
enhance cardiorespiratory fitness resulting in improve
endurance and resistance to early fatigue.
• the maintenance conditioning phase after 6 months of
regular exercise. Individuals will have obtained the desired
level of cardiorespiratory fitness and do not need to increase
their duration or intensity of exercise

Discontinuation
• Patients should be counseled to discontinue
exercise and seek medical advice if they
experience major warning signs or symptoms
(e.g., chest pain, palpitations, or
lightheadedness).

Intensity
• For younger adults, intensity of effort is assessed in absolute
terms by estimating the metabolic equivalent (MET) of a given
activity.
• Typically, METs are determined by measurement of oxygen
consumption during a given activity; METs levels for a wide
range of physical and occupational activities are published,
but these have largely been derived from measurement
among younger adults
• By contrast, older adults have a reduced range of functional
capacity and tremendous heterogeneity of fitness levels.
Thus, the use of absolute MET values for estimating intensity
of effort is inappropriate because an activity that requires four
METS of energy expenditure may be low for one older adult
but near maximum capacity for another. Thus, for older
adults, intensity of effort is best based on a relative scale.

• A good rule of thumb for moderate to
vigorous aerobic activity is that the individual
should be able to carry on a conversation
during activity
• Moderate: „Walking briskly, water aerobics,
ballroom dancing, and general gardening „
• Vigorous: „Race walking, jogging, running,
swimming laps, jumping rope, and hiking
uphill or with a heavy backpack

MET Values of Common Physical Activities
Classified as Light, Moderate, or Vigorous
Intensity
• Light (<3 METs)
• Moderate (3–6 METs)
• Vigorous (>6 METs)

Intensity Using Heart Rate
• Target Heart rate „Maximal heart rate = 220
Maximal heart rate = 220-age
• „Based on level of intensity a heart rate range is
selected.
1. very light = <50 % of maximal heart rate
2. Light = 50-63 % of maximal heart rate
3. „Moderate 64-76 % of maximal heart rate „
4. Vigorous = 77-93 % of maximal heart rate „
5. Very Hard = >94 % of maximal heart rate „
6. Maximal = 100% of maximal heart rate

VO2max / VO2R
• The aerobic intensity can be expressed as a
percentage of a person’s maximal oxygen
uptake/aerobic capacity (VO2max) or oxygen
uptake reserve (VO2R), which could be
estimated by exercise tests (3)
• Light 20-39
• Moderate 40-59
• Vigorous 60-84

“Median” Shape of the
Dose-Response Curve

THE BENEFITS OF EXERCISE AS
ANTIAGING (MOLECULAR BASIS)
Molecular explanation of anti-ageing properties of Exercise

Physical activity has an anti-aging effect at the
cellular level
Potential mechanisms
prevented shortening
of telomeres
Anti-inflammatory
effects sestrins
Prevent Genomic
instability induces autophagy
epigenetic
modifications

• Exercise certainly cannot reverse the aging
process, but it does attenuate many of its
deleterious systemic and cellular effects.

1. 5-month aerobic exercise program prevented
mitochondrial DNA (mtDNA) instability in multiple tissues,
thereby reducing multisystem pathology and preventing
premature mortality.
2. there is increasing evidence supporting an association
between habitual physical exercise, particularly aerobic
exercise, and longer leukocyte telomere length.
3. exercise seems to induce epigenetic modifications that can
help attenuate age-deregulations and several mechanisms,
such as metabolic adaptations and transient hypoxia
conditions, have been proposed recently. Regular aerobic
exercise can modify genome-wide DNA methylation
4. aerobic exercise induces autophagy in:The brain,heart,
muscle by modulating IGF-1, Akt/mTOR, and Akt/Forkhead
box O3A (FoxO3a) signaling, thereby preventing loss of
muscle mass/strength

Regular Exercise as a Means of
Reducing Age-related Inflammation
CRP levels were inversely related to physical
activity levels
While contradictory data exists regarding ,
IL-6 and TNF-α
data suggests that CRP may be more responsive to
physical activity levels than either IL-6 or TNF-α, though
the data in this regard are not entirely consistent.
Other factors may complicate this association e.g.
gender, obesity, antioxidants supplements

• There is evidence that exercise can both cause and
attenuate inflammation.
• Acute, unaccustomed exercise can cause muscle and connective
tissue damage, especially if done at high intensities and for
prolonged durations. This typically manifests as delayed onset
muscle soreness which is preceded by microstructural skeletal
muscle damage (e.g. streaming z disks), inflammatory cell
infiltration and elevation of muscle-specific creatine kinase
isoforms.
• This damaging response is attenuated if exercise is done repeatedly
as the tissue adapts to the new overload stress.
• Indeed, blocking the inflammatory response using broad spectrum
anti-inflammatory drugs can reduce muscle adaptation and,
ultimately, increases in muscle performance induced by the exercise

Potential mechanisms of exercise training-induced
reductions in inflammation in the aged
1. loss of adipose tissue, as visceral fat, of obese humans produces pro-
inflammatory cytokines that contribute in a large way to systemic
inflammation.
2. Acute exercise increases muscle production of IL-6 and while IL-6 has been
associated with inflammation, it also may have anti-inflammatory properties
3. regular exercise reduces oxidative stress by up-regulating endogenous anti-
oxidant defense systems
4. aerobic exercise training may increase efferent vagus nerve activity, and this
increased activity may contribute to the anti-inflammatory effect of exercise,
as parasympathetic nervous system suppress the release of proinflammatory
cytokine
5. Acute exercise activates the hypothalamic-pituitary-adrenal axis and
sympathetic nervous systems. Cortisol is known to have potent anti-
inflammatory effects and catecholamines can inhibit pro-inflammatory
cytokine production
6. exercise training can down regulate toll-like receptor 4, ligation of which
activates pro-inflammatory cascades

Sestrins
• Sestrins prevent sarcopenia, insulin resistance,
diabetes, and obesity.
• They also extend life span and health span
through activation of AMPK, suppression of
mTORC1, and stimulation of autophagic signaling.
• Recently, a possible role of the AMPK-modulating
functions of sestrins was proposed in the benefits
produced by exercise in older subject

osteoarthritis
1. Focus on improving functionality through cross-training; functional
exercises include sitting and standing and stair climbing.
2. Start with repeated short bouts of low-intensity exercise every day,
progressively increasing the duration.
3. Exercise affected joints using a pain-free range of motion for
flexibility training.
4. PRT should begin using the patient’s pain threshold as an intensity
guide; begin with as little as two or three repetitions and work up to
10 to 12 repetitions, two or three days per week.
5. Cardiovascular exercise initially should be brief (10 minutes), adding
five minutes per session until 30 minutes is reached;
6. cardiovascular exercises may be weight bearing (walking) or
nonweight bearing (cycling, hydrotherapy).
• Icing the affected area for 10 minutes following physical activity will
provide symptom relief and can prevent inflammation

• Contraindications
1. Avoid vigorous, repetitive exercises that use unstable
joints;
2. Avoid overstretching
3. avoid morning exercise if rheumatoid arthritis–
related stiffness is present.
4. Avoid exercising joints during flare-ups.
5. Discontinue exercise if patient has unusual or
persistent fatigue, increased weakness, or decreased
range of motion, or if joint swelling or pain lasts for
more than one hour after exercise.

Deconditioning, frailty
• "start low and go slow“
• strength and balance training should start
before beginning aerobic exercise in
deconditioning management.
•

Obesity
• Special considerations
1. Focus on daily activities that use large muscle groups
and increase total energy expenditure.
2. Patients should exercise 45 to 60 minutes, five to
seven days per week.
3. Initial intensity should be 40 to 60 percent VO2
reserve with an emphasis on increased duration and
frequency; progression to 50 to 75 percent VO2
reserve will help the patient expend calories faster; a
4. vigorous program may not be necessary if moderate
activities such as walking are preferred and will
promote compliance.

• The mechanism for weight-reduction is through
increased total energy expenditure, preservation
of lean body mass, and changes in metabolism.
• The most recent ACSM guidelines suggest
exercise programs conducted 3 times per week
that expend 250 to 300 kilocalories per exercise
session. This generally will require at least 30 to
45 minutes of exercise per session in an
individual of average fitness.

• To prevent orthopedic injury, aerobic intensity
and duration may be maintained at or below
usual recommendations and modified as needed;
• nonweight-bearing aerobic activities or frequent
rotation of modalities may be required.
• Equipment modifications may be required,
because treadmills have weight limits and cycle
or rowing seats may be too small; free weights
may be used instead of weight machines, if
needed.
• Because risk of hyperthermia during exercise is
increased in patients who are obese, hydration
and proper attire should be emphasized.

CAD
• Activity should be individualized with exercise
prescription by qualified personnel.
• ECG and blood pressure monitoring:
Continuous during exercise sessions until
safety is established, usually in 6 to 12 session
or more.
• Medical supervision during all exercise
sessions until safety is established.

Hypertension
• Focus on aerobic activities that use large muscle groups.
• Patients should exercise 30 to 60 minutes, three to seven
days per week to effectively lower blood pressure; daily
exercise may be most effective.
• Intensities of 40 to 70 percent 1-RM† appear to be as
effective as higher intensities in lowering blood pressure.
• PRT should be combined with aerobic activity using lower
resistance and more repetition;
• Patients should follow proper form and breathing to
prevent Valsalva maneuver.
• Beta blockers may attenuate heart rate response and
reduce exercise capacity, and other medications may impair
thermoregulation; therefore, patients should cool down
gradually after exercise to prevent hypotension.

Diabetes
• Special considerations
1. Aim to expend at least 1,000 kcal per week (equivalent to
walking 10 miles). If weight loss is a goal, aim for more than
2,000 kcal per week.
2. PRT should include lower resistance (40 to 60 percent of 1-
RM†) and lower intensity; use major muscle groups;
repetition goal should be 15 to 20,
3. focusing on proper form and breathing to prevent Valsalva
maneuver.
4. Before beginning an exercise program, patients should
undergo a medical evaluation to assess cardiovascular,
nervous, renal, and visual systems and the risk of diabetic
complications.

• Intense PRT may cause an acute hyperglycemic effect;
basic PRT may cause postexercise hypoglycemia,
especially in patients taking insulin or oral hypoglycemic
agents.
• Patients with diabetes and concomitant retinopathy and
overt nephropathy may have reduced exercise capacity.
• Peripheral neuropathy may be associated with gait and
balance abnormalities; consider limiting weight-bearing
exercises and addressing patient foot care.
• With autonomic neuropathy, emphasize the Borg RPE‡;
monitor patient for heart rate and blood pressure
response to exercise, thermoregulation, signs of silent
ischemia, and postexercise plasma glucose levels.
• Polyuria may contribute to dehydration and
compromised thermoregulation.

Prevention of Hypoglycemia or
HyperglycemiaBefore Exercise
• Estimate intensity, duration, and energy expenditure of exercise
• Eat a meal 1-3 hours before exercise
• Insulin:
– Administer insulin more than 1 hour before exercise
– Administer insulin in abdomen and avoid extremity injections
– Decrease insulin that has peak activity coinciding with exercise period (may not be required)
• Assess metabolic control:
– If blood glucose < 100 mg/dL, take supplemental pre-exercise snack
– If blood glucose > 250 mg/dL or serum ketones are positive, delay exercise
During Exercise
• Supplement calories with carbohydrate feedings (30-40 grams for adults, every 30 minutes
during extended, strenuous exercise
• Replace fluid losses adequately
• Monitor blood glucose during exercise of long duration
After Exercise
• Monitor blood glucose, especially if exercise is not consistent
• Increase calorie intake for 12-24 hours after activity, according to intensity and duration of
exercise
• Reduce insulin, which peaks in the evening or night, according to intensity and duration of
exercise (may not be required)

Pulmonary disease
• The minimum frequency goal should be three to five days per
week; those with impaired functional capacity may benefit
most from daily exercise;
• patients should initially exercise intermittently for 10 to 30
minutes per session until they progress to 20 to 30 minutes of
continuous exercise.
• An exercise subspecialist should monitor initial training
sessions, and modifications should be made in response to
symptoms; patients may be taught to use a heart rate or a
dyspnea scale to assess intensity.
• Walking is strongly recommended; stationary bicycling may be
an alternative.
• PRT with emphasis on shoulder girdle and inspiratory and
upper extremity muscles is important.

EIA
• The guidelines are to inhale a beta-agonist 15
minutes before exercise.
• If symptoms develop during exercise, on-demand
beta-agonist therapy should be repeated.
• Cromolyn sodium is the second most commonly
used medication used for treatment of Exercise
Induced Asthma.
• Avoid exercising at the coldest times of the day
(early morning or evening). Also, don’t exercise
when pollution or allergens are at their highest.
Instead, exercise indoors. Watch out for irritants
such as smoke or allergens there, too

• Warm up for 10 minutes before you exercise. This can reduce the
duration and severity of an attack during and after exercise.
• Cool down for 10 minutes after your exercise.
• If you have been inactive for a long time, start with short sessions
(10 to 15 minutes). Add five minutes to each session, increasing
every two to four weeks. Gradually build up to being active at
least 30 minutes a day for most days of the week.
• Drink plenty of fluids before, during, and after exercise.
• Don’t exercise at an intensity that is too high for you. Doing so
might provoke an attack and temporarily prevent exercising. It
also increases the risk of injury.
• Avoid holding your breath when lifting. This can cause large
changes in blood pressure. That change may increase the risk of
passing out or developing abnormal heart rhythms.
• If you have joint problems or other health problems, do only one
set for all major muscle groups. Start with 10 to 15 repetitions.
Build up to 15 to 20 repetitions before you add another set

Components of the COPD Exercise
Prescription

Osteoporosis
• Focus should be on improving balance and functionality.
• Frequency should include weight-bearing aerobic activities
four days per week; PRT two or three days per week;
flexibility five to seven days per week; and functional
exercise (e.g., chair stand,stair-climbing, vigorous walking).
• Intensity should be 40 to 70 percent VO2 reserve for
aerobic activities; PRT (Borg RPE‡ at 13 to 15) should
include one or two sets of eight to 10 repetitions.
• Pain status will dictate the exercise plan; patients severely
limited by pain should consult a physician before initiating
an exercise program.
• Avoid explosive movements and high-impact loading (e.g.,
jumping, jogging) and dynamic abdominal exercise with
excessive trunk flexion and twisting (e.g., sit-ups, golf
swing, bending while picking up objects).

Peripheral arterial disease
• Because patients with peripheral arterial
disease are at a high risk of cardiovascular
disease, an exercise stress test should be
performed before the physician creates an
exercise prescription; many patients are
extremely deconditioned

Promoting Physical Activity
• identifying and overcoming barriers to activity
• setting specific goals,
• recruiting spouse/family support, and
providing positive reinforcement.
• individualized counseling because of specific
physical limitations, multiple comorbidities, or
both.

Overcoming Barriers to Exercise
Self-efficacy Begin slowly with exercises that are easily accomplished; advance
gradually; provide frequent encouragement.
Attitude Promote positive personal benefits of exercise; identify enjoyable activities.
Discomfort Vary intensity and range of exercise; employ crosstraining; start slowly;
avoid overdoing.
Disability Specialized exercises; consider personal trainer or physical therapist.
Poor balance/
ataxia
Assistive devices can increase safety as well as increase exercise intensity.
Fear of injury Balance and strength training initially; use of appropriate clothing,
equipment, and supervision; start slowly.
Habit Incorporate into daily routine; repeat encouragement; promote active
lifestyle.
Fixed income Walking and other simple exercises; use of household items; promote active
lifestyle.
Environmental factors Walk in the mall; use senior centers; promote active lifestyle.
Cognitive decline Incorporate into daily routine; keep exercises simple
fatigue Use a range of exercises/intensities that patients can match to their varying
energy level

Example of Exercise Prescription
Lifestyle modification 1. Brisk dog walk: 15 minutes each morning and evening, regardless of
weather, seven days per week with wife; Borg RPE* at 13 to 14
2. Take the stairs: One flight up, two flights down
3. Park at perimeter of parking lots: Walk to entrances
4. Yard work: One day per week, weather permitting
Aerobic exercise 1. Brisk dog walk: See above
2. Group circuit training class: 50 minutes, two mornings per week of
bicycle or elliptical training at the local senior center
Flexibility training 1. Balance ball: Stretch back, chest, hamstrings, gastrocnemius, and Achilles
tendon for five minutes each morning and 10 minutes each evening, seven
days per week using physician-provided, illustrated handouts with
stretch variations
2. Introductory yoga video: 60 minutes each Sunday morning for one month,
then reassess with physician
Progressive
resistance training
1. Group circuit training class: 50 minutes, two mornings per week of total
body strength and range-of-motion training at the local senior center;
Borg RPE* at 12 to 15
2. Balance ball: Core muscle training (abdominal curls and back extensions)
every other day while watching television: one set of 10 repetitions for
each exercise

A 71-year-old man who has moderately well-controlled
hypertension, and osteoarthritis of the knees bilaterally
and right hip. He is active in two bowling leagues and
enjoys walking; however, both activities are becoming
limited by pain in his knees. He will benefit from
increasing the level of activity and incorporating
resistance training into his exercise routine. The patient
began cross training with non–weight-bearing activities
of swimming and biking three times per week. He was
encouraged to wear good athletic shoes and may benefit
from bracing, orthotics, nonsteroidal anti-inflammatory
medication, or viscosupplementation. A twice-weekly,
resistance training program was initiated focusing
initially on lower extremity strength using light weights
on a multipurpose machine.

An 85-year-old woman who lives alone has a previous history
of a minor stroke and has hypertension controlled with a beta
blocker. She does not have known osteoporosis or a history of
fracture and is currently sedentary. On examination, this
patient had some difficulty with eyes-closed balance and was
unable to stand from a chair without using both armrests,
indicating fairly significant leg weakness. She began her
exercise program by focusing on balance and strength with a
simple home routine based on chair exercises, 12 oz soup
cans, and balancing on one leg while holding the kitchen
counter. Because she is asymptomatic for coronary artery
disease, she can begin a low-intensity aerobic program
without further testing. Because of the cold weather, the
patient chose to begin walking the ground floor of her large
apartment building, adding time and distance as she gains
endurance.

Strength exercise: Toe stand
• This exercise will help make walking easier
by strengthening your calves and ankles.
For an added challenge, you can modify
the exercise to improve your
balance.Stand behind a sturdy chair, feet
shoulder-width apart, holding on for
balance. Breathe in slowly.
• Breathe out and slowly stand on tiptoes,
as high as possible.
• Hold position for one second.
• Breathe in as you slowly lower heels to the
floor.
• Repeat 10 to 15 times.
• Rest; then repeat 10 to 15 more times.
• As you progress, try doing the exercise
standing on one leg at a time for a total of
10 to 15 times on each leg.

Strength exercise: Arm curl
• After a few weeks of doing this exercise
for your upper arm muscles, lifting that
gallon of milk will be much easier.
• Stand with your feet shoulder-width
apart.
• Hold weights* straight down at your
sides, palms facing forward. Breathe in
slowly.
• Breathe out as you slowly bend your
elbows and lift weights toward chest.
Keep elbows at your sides.
• Hold the position for one second.
• Breathe in as you slowly lower your arms.
• As you progress, use a heavier weight and
alternate arms until you can lift the
weight comfortably with both arms.

Strength exercise: Chair dip
• This pushing motion will strengthen
your arm muscles even if you are not
able to lift yourself up off the chair.
• Sit in a sturdy chair with armrests
with your feet flat on the floor,
shoulder-width apart.
• Lean slightly forward; keep your back
and shoulders straight.
• Grasp arms of chair with your hands
next to you. Breathe in slowly.
• Breathe out and use your arms to
push your body slowly off the chair.
• Breathe in as you slowly lower
yourself back down.
• Rest; then repeat 10 to 15 more
times.

Strength exercise: Back leg raise
• This exercise strengthens your buttocks and
lower back. For an added challenge, you can
modify the exercise to improve your balance.
• Stand behind a sturdy chair, holding on for
balance. Breathe in slowly.
• Breathe out and slowly lift one leg straight
back without bending your knee or pointing
your toes. Try not to lean forward. The leg
you are standing on should be slightly bent.
• Breathe in as you slowly lower your leg.
• Repeat 10 to 15 times with other leg.
• Repeat 10 to 15 more times with each leg.
• As you progress, you may want to add ankle
weights

Strength exercise: Chair stand
• This exercise, which strengthens your
abdomen and thighs, will make it easier to
get in and out of the car. If you have knee or
back problems, talk with your doctor before
trying this exercise.
• Sit toward the front of a sturdy, armless chair
with knees bent and feet flat on floor,
• Lean back with your hands crossed over your
chest. Keep your back and shoulders straight
throughout exercise. Breathe in slowly.
• Breathe out and bring your upper body
forward until sitting upright.
• Extend your arms so they are parallel to the
floor and slowly stand up.
• Breathe in as you slowly sit down.
• People with back problems should start the
exercise from the sitting upright position.

Strength exercise: Wall push-up
• These push-ups will strengthen your arms,
shoulders, and chest. Try this exercise during
a TV commercial break.
• Face a wall, standing a little farther than
arm's length away, feet shoulder-width apart.
• Lean your body forward and put your palms
flat against the wall at shoulder height and
• Slowly breathe in as you bend your elbows
and lower your upper body toward the wall
in a slow, controlled motion. Keep your feet
flat on the floor.
• Breathe out and slowly push yourself back
until your arms are straight.

Strength exercise: Overhead arm raise
• This exercise will strengthen your shoulders
and arms. It should make swimming and
other activities such as lifting and carrying
grandchildren easier.
• You can do this exercise while standing or
sitting in a sturdy, armless chair.
• Keep your feet flat on the floor, shoulder-
width apart.
• Hold weights* at your sides at shoulder
height with palms facing forward. Breathe in
slowly.
• Slowly breathe out as you raise both arms up
over your head keeping your elbows slightly
bent.
• Breathe in as you slowly lower your arms.
• As you progress, use a heavier weight and
alternate arms until you can lift the weight
comfortably with both arms.

Strength exercise: Side leg raise
• This exercise strengthens hips, thighs, and
buttocks. For an added challenge, you can
modify the exercise to improve your balance.
• Stand behind a sturdy chair with feet slightly
apart, holding on for balance. Breathe in
slowly.
• Breathe out and slowly lift one leg out to the
side. Keep your back straight and your toes
facing forward. The leg you are standing on
should be slightly bent.
• Breathe in as you slowly lower your leg.
• Repeat 10 to 15 times with other leg.
• Repeat 10 to 15 more times with each leg.
• As you progress, you may want to add ankle
weights.

Flexibility exercise: Back
• This exercise is for your back muscles. If
you've had hip or back surgery, talk with your
doctor before trying this stretch.
• Sit securely toward the front of a sturdy,
armless chair with your feet flat on the floor,
• Slowly bend forward from your hips. Keep
your back and neck straight.
• Slightly relax your neck and lower your chin.
Slowly bend farther forward and slide your
hands down your legs toward your shins.
Stop when you feel a stretch or slight
discomfort.
• Hold for 10 to 30 seconds.
• Straighten up slowly all the way to the
starting position.
• Repeat at least three to five times.
• As you progress, bend as far forward as you
can and eventually touch your heels.

Flexibility exercise: Calf muscles and
Achilles tendon
• Because many people have tight calf
muscles, it's important to stretch them.
• Stand facing a wall slightly farther than arm's
length from the wall, feet shoulder-width
apart.
• Put your palms flat against the wall at
shoulder height and shoulder-width apart.
• Step forward with right leg and bend right
knee. Keeping both feet flat on the floor,
bend left knee slightly until you feel a stretch
in your left calf muscle. It shouldn't feel
uncomfortable. If you don't feel a stretch,
bend your right knee until you do.
• Hold position for 10 to 30 seconds, and then
return to starting position.
• Repeat with left leg.
• Continue alternating legs for at least three to
five times on each leg.

Flexibility exercise: Chest
• this exercise, which stretches the
chest muscles, is also good for your
posture.
• You can do this stretch while standing
or sitting in a sturdy, armless chair.
• Keep your feet flat on the floor,
• Hold arms to your sides at shoulder
height, with palms facing forward.
• Slowly move your arms back, while
squeezing your shoulder blades
together. Stop when you feel a
stretch or slight discomfort.
• Hold the position for 10 to 30
seconds.
• Repeat at least three to five times

Flexibility exercise: Shoulder and
upper arm
• This exercise to increase flexibility in your
shoulders and upper arms will help make it
easier to reach for your seatbelt. If you have
shoulder problems, talk with your doctor
before trying this stretch.
• Stand with feet shoulder-width apart.
• Hold one end of a towel in your right hand.
• Raise and bend your right arm to drape the
towel down your back. Keep your right arm
in this position and continue holding on to
the towel.
• Reach behind your lower back and grasp the
towel with your left hand.
• To stretch your right shoulder, pull the towel
down with your left hand. Stop when you
feel a stretch or slight discomfort in your
right shoulder.
• Reverse positions, and repeat at least three
to five times

Flexibility exercise: Shoulder
• This exercise to stretch your shoulder
muscles will help improve your posture.
• Stand back against a wall, feet shoulder-
width apart and arms at shoulder height.
• Bend your elbows so your fingertips point
toward the ceiling and touch the wall behind
you. Stop when you feel a stretch or slight
discomfort, and stop immediately if you feel
sharp pain.
• Hold position for 10 to 30 seconds.
• Let your arms slowly roll forward, remaining
bent at the elbows, to point toward the floor
and touch the wall again, if possible. Stop
when you feel a stretch or slight discomfort.
• Alternate pointing above head, then toward
hips.

Flexibility exercise: Thigh (standing)
• Here's an exercise that stretches your thigh
muscles. If you've had hip or back surgery,
talk with your doctor before trying this
stretch.
• Stand behind a sturdy chair with your feet
shoulder-width apart and your knees
straight, but not locked.
• Hold on to the chair for balance with your
right hand.
• Bend your left leg back and grab your foot in
your left hand. Keep your knee pointed to
the floor. If you can't grab your ankle, loop a
resistance band, belt, or towel around your
foot and hold both ends.
• Gently pull your leg until you feel a stretch in
your thigh.
• Repeat at least three to five times with your
right leg.

Balance exercises: Balance walk
• Good balance helps you walk safely
and avoid tripping and falling over
objects in your way.
• Raise arms to sides, shoulder height.
• Choose a spot ahead of you and
focus on it to keep you steady as you
walk.
• Walk in a straight line with one foot
in front of the other.
• As you walk, lift your back leg. Pause
for one second before stepping
forward.
• Repeat for 20 steps, alternating legs.
• As you progress, try looking from side
to side as you walk, but skip this step
if you have inner ear problems.

Balance exercises: Heel to toe walk
• Having good balance is
important for many everyday
activities, such as going up and
down stairs.
• Position the heel of one foot
just in front of the toes of the
other foot. Your heel and toes
should touch or almost touch.
• Choose a spot ahead of you
and focus on it to keep you
steady as you walk.
• Take a step. Put your heel just
in front of the toe of your
other foot.
• Repeat for 20 steps.

Balance exercise: Stand on one foot
• You can do this exercise while
waiting for the bus or standing in
line at the grocery. For an added
challenge, you can modify the
exercise to improve your balance.
• Stand on one foot behind a sturdy
chair, holding on for balance.
• Hold position for up to 10
seconds.
• Repeat 10 to 15 times with other
leg.
• Repeat 10 to 15 more times with
each leg.

To summarize
Aerobic:
 ≥30 min or three bouts of ≥10 min/day
 ≥5 days/week
 Moderate intensity = 5 to 6 on a 10-point scale (where 0 = sitting, 5 to 6 =
"can talk," and 10 = all-out effort)
 In addition to routine ADLs
Strength:
 8 to 10 exercises (major muscle groups), 10 to 15 repetitions
 ≥2 nonconsecutive days/week
 Moderate to high intensity = 5 to 8 on a 10-point scale (where 5 to 6 =
"can talk" and 7 to 8 = short of breath)
Flexibility/balance:
 ≥10 min ≥2 days/week
 Flexibility to maintain/improve range of motion (ie, stretching of major
muscle/tendon groups, yoga)
 Balance exercises for those at risk for falls (ie, tai chi, individualized
balanced exercises)
Prevention:
 Create a single physical activity plan that integrates preventive and
therapeutic treatment of chronic conditions

Sample endurance (walking) and strength plan
Weeks
Walking
 Strength
Weeks 1 to 2:
Introduction and
acclimatization
1. Walk 10 minutes
2. Three days/week
3. Intensity level = 5 to 6
on a 10-point scale
 Four to five exercises for major muscle groups
using weightbearing calisthenics, elastic bands,
free weights, or weight machines
 One set of 10 to 15 repetitions on two
nonconsecutive days/week
 Intensity level = 5 to 8 on a 10-point scale
Weeks 2 to 6:
Begin progression
 First increase to five
days/week
 Gradually increase
time to either 20
minutes or two bouts
of 10 minutes/day
 Gradually add four to five exercises, totaling 8 to
10 major muscle group exercises
 One set of 10 to 15 repetitions on two
nonconsecutive days/week
 Intensity level = 5 to 8 on a 10-point scale
Weeks 6+:
Continued
progression and
exercise routine
refining
 Progress time to meet
guideline of at least 30
minutes, in at least 10-
minute bouts
 Five or more
days/week
 Add a third nonconsecutive day/week
 Increase resistance by 2 to 10 percent depending
on patient's progress and comfort level
 Emphasize pain-free exercising

your role as a geriatrician
• Assess current physical activity (type, frequency, duration,
intensity)
• Advise benefits relative to medical history
• Tailor realistic plan (consider chronic illness, current physical
activity level, functional limits, and preferred activities)
• Specify what to do where and when
• Look for barriers and strategize solutions
• Encourage social support: who and how
• Confirm patient is "very sure" of physical activity success
• Chart plan and give written physical activity prescription to
patient
• In follow-up, revise physical activity plan to enhance progress
• Reinforce positive behavior and activity documentation
• Reaffirm that more physical activity enhances benefits

METHODS FOR ASSESSING AEROBIC
INTENSITY

it is important to understand how aerobic
physical activity levels and intensity are measured.
1. One frequently used method of calculating intensity of physical
activity or exercise is the metabolic equivalent (MET) value, which
is an indicator of energy expenditure. One MET is roughly
equivalent to the energy expended during quiet sitting.
https://sites.google.com/site/compendiumofphysicalactivities/
2. Perceived rate of exertion: a simple scale of intensity based on a
self-perceived rate of exertion is used. It is scaled from 0–10 with
5–6 being moderate-intensity exercise and 7–8 being vigorous-
intensity exercise.
3. Intensity Using Heart Rate (see before)
4. Pedometers (number of steps) and accelerometers have gained
considerable popularity as reliable methods of objectively
measuring physical activity

Pedometers and accelerometers
1. As a useful guide, an older adult achieving 10
000 or more daily steps is categorised as
highly active, over 5000 but less than 10 000
as moderately active, and 5000 steps or
below as inactive

Questions
1. What are the most effective methods to increase
and then maintain physical activity and exercise
participation in older adults?
2. What is the most effective approach to improving
the health of older adults with mobility limitations?
3. How can societies prevent the decline in physical
activity that occurs through middle and into older
age and thus reduce the future health burden?

• WM CHAN is 68-year-old man, who used to
enjoy a sedentary lifestyle. His past medical
history is unremarkable and he has got no
other significant risk factors for cardiovascular
disease and is in the moderate risk category
for exercise participation.
• Design a comprehensive exercise prescription
for Mr. CHAN.

Exercise in elderly

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