Aging and Exercise

Jeralyn Allen, MD*, Vincent Morelli, MD

KEYWORDS
Elderly Exercise Benefits Barriers

Aging is a complex process that involves the interaction of both physiologic and
behavioral factors. Generally, as people grow older, the basal metabolic rate slows;
blood pressure increases; and there is a decrease in maximum heart rate, cardiac
output, maximal oxygen consumption, and overall muscle mass. Other changes that
can occur include a decline in cognitive function, reduced lung compliance, and
decreased bone mass.
Not only does exercise ameliorate these changes of aging, but it also helps ward
off modern-day sedentary diseases such as coronary artery disease (CAD), diabetes, hypertension, and osteoporosis13 that contribute to premature aging and death.
Approximately 60% of adults do not exercise regularly and approximately 31% are
completely sedentary. Activity levels tend to decrease with age, especially in adults 65
years of age and older, and 50% of this population have no plan to initiate an exercise
program.4,5 The groups who have an increased likelihood of exhibiting sedentary
behavior include those of advanced age, female gender, nonwhite ethnicity, lower
educational levels, and lower income.6
This article discusses the benefits of exercise in the elderly and how physicians can
help such patients overcome barriers to exercise (eg, lack of education, coexisting
morbidities), and also offers some practical exercise prescriptions for both healthy
and compromised elderly patients.
BENEFITS

Numerous benefits to exercising have long been proven. Cardiovascular improvements are seen in the form of physiologic parameters (eg, VO2max, cardiac output),
improvement in blood pressure, decreased risk of CAD, improvements in congestive
heart failure (CHF), and improvement in lipid profiles.710
The incidence of type 2 diabetes mellitus is decreased among patients who exercise.11
For those who already have the diagnosis, exercise improves glycemic control, decreases hemoglobin A1C levels, and improves insulin sensitivity.12 Benefits also include
improvements in bone health. Exercise lessens bone loss in postmenopausal women,

Department of Family and Community Medicine, Meharry Medical College, 1005 Dr D. B. Todd,
Jr, Boulevard, Nashville, TN 37208, USA
* Corresponding author.
E-mail address: jeralyn_allen@yahoo.com
Clin Geriatr Med 27 (2011) 661 671
doi:10.1016/j.cger.2011.07.010
geriatric.theclinics.com
0749-0690/11/$ see front matter 2011 Elsevier Inc. All rights reserved.

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decreases hip and vertebral fractures, decreases risk of falls, and improves joint
function by decreasing pain in arthritic patients.13
Exercise also provides neuropsychological health benefits. It improves sleep
quality and cognitive function and decreases rates of depression.14,15 In addition,
exercise decreases the incidence of colon and breast cancer16 18 and decreases
all-cause morbidity and mortality.19
There is increasing interest in the area of exercise and its effect on longevity. In
rodents, exercise has been found to improve health but not longevity. In humans,
there is some evidence that exercise increases longevity,20,21 but this is based on
retrospective data, not on high-quality prospective trials.
BARRIERS TO EXERCISE

Lack of physical activity is an increasing public health concern22 that is not excluded
in the elderly population. Pain and concerns about poor health are the two most
common barriers to exercise in the elderly.23 Other barriers include inadequate
physician education, patient myths concerning exercise, as well as social and
environmental factors. Many elderly patients view exercise as too time consuming,
noting that transit time to exercise facilities as well as time spent exercising are
non-motivators.24 The physical environment in which one lives can be a factor. The
availability of exercise facilities or convenience of resources for exercise, as well as
crime level in the environment, may influence level of activity.25 Primary care
physicians should help patients overcome these barriers and move toward a healthier
lifestyle through focused patient education and the design of an achievable exercise
program.
EDUCATING SENIORS ABOUT BENEFITS AND BARRIERS

Clinicians play a significant role in the promotion of exercise. As people age, the
frequency of physician visits increases,26 and these visits provide opportunities to
educate and motivate. Studies have shown that direct physician counseling is the
most effective means of influencing patient behavior in terms of exercise promotion.27
Safety

For an older person, safety is a major concern when starting an exercise program.
Approximately one out of three adults older than 65 years reports falls each year,28 so
fall prevention is an important issue to address in the initiation and maintenance of an
exercise regimen. People who previously experienced falls, whether or not injury was
involved, may develop a fear or falling and, as a result, limit their activities, which may
lead to a reduction in physical activity.29
Once a patient has fallen, it is important to evaluate the cause of the fall. In the
outpatient setting, this includes careful history-taking, scrutiny of medications,
evaluation of the many risk factors for falling, and a physical examination to include
evaluation of postural control and physical ability.30 The one-leg balance test is one
such fall prevention screening exam. In this test, the patient stands on one leg
without assistance, while flexing the opposite knee. The goal is for the patient to stand
for 5 seconds in this position.31 Inability to complete this test calls for strengthening
programs to be included in the exercise regimen (as discussed later). Another
important test is the get up and go test. A patient is asked to rise from a standard
armchair, walk a distance of 10 feet, then turn, walk back to the chair, and return to
a seated position. Patients may use walking aids, but otherwise are unassisted. A test
time of 30 seconds or greater is indicative of impaired mobility.32 In older adults with

Aging and Exercise

balance issues, Tai chi and physical therapy also have been shown to be beneficial in
preventing falls.33 In addition, it is important to determine if medications and the home
environment are safe. Drug side effects or polypharmacy may contribute to fall risk;
thus, medication review is an important part of a pre-exercise evaluation.
Treat Comorbidities

Comorbid medical or psychiatric conditions should not be thought of as contraindications to exercise. In fact, physical activity has been shown to be associated with
improvements in many of these conditions.14,34 However, it is important to optimize
treatment of comorbid medical conditions before beginning exercise programs. In
addition, primary care physicians should periodically monitor patients in hopes of
increasing exercise compliance and, perhaps, decreasing medication dosages as
these chronic conditions improve. It is also important to screen regularly for
deterioration in vision to optimize vision for physical activities.
Tools to Motivate

An exercise program should include gradual activity progression with achievable

short-term goals. An individuals belief in his or her ability to exercise can be a
determinant of how active or inactive he or she will be. The stronger peoples
expectations and perceived successes, the more likely they will initiate and continue
with exercise.24 Discussions with patients are opportunities to set short- and
long-term goals. Counseling patients on the expected functional gains from increased
strength and aerobic capacity can increase compliance.35,36 Feelings of pleasure and
satisfaction and a regular monitoring of patient progress are some of the most
important factors in exercise prescription adherence.24
In the green prescription study,37 sedentary patients given written exercise
instructions were more compliant that those given only verbal instructions. Thus, the
prescription pad can serve as a motivational tool when combined with active
physician counseling.38
Several studies have examined how best to motivate seniors to continue compliance with exercise regimens.27,39 43 Several of these studies have found motivational
office visits, in which the importance of exercise was stressed by health care
providers, useful in maintaining increased physical activity in elderly participants in
the short but not long term.42 45
However, the most recent data have demonstrated some continued long-term
adherence (up to 1 year) to exercise prescriptions with follow-up health provider
contact or computer-generated telephone reminders.46 In addition, when counseling
patients, it is beneficial for physicians to be familiar with the accessibility of
community facilities and organized health programs within the patients community.
The elderly are more likely to change their level of activity if time is spent counseling
and providing information on specific companies or agencies that offer exercise
programs.47 Together with offering knowledge of where to go for exercise, providing
a level of socialization begets success.48 Organized physical activity can motivate
elders to continue an exercise regimen. Especially in elderly women, a higher level of
exercise compliance is associated with social support.49
EXERCISE SCREENING

Pre-participation screening is important in maintaining patient safety and determining

the level at which intensity physical activity can begin. A thorough history and physical
examination should be performed to stratify patients and identify physical limitations
and concerning symptoms.

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Absolute contraindications for exercise in the elderly are generally related to

cardiac conditions and include acute coronary syndrome, third-degree AV block,
uncontrolled hypertension, and acute heart failure. In addition, uncontrolled diabetes
is an absolute contraindication due to lack of normal glucoregulation.
Relative contraindications include cardiomyopathy, valvular heart disease, and
complex ventricular ectopy. Those with relative contraindications should still participate in exercise, but at a lower level of intensity and after careful medical evaluation.
Patients with known CAD, symptoms of CAD, multiple cardiac risk factors, suspected
diabetes, or known or suspected lung disease should undergo stress testing before
starting an exercise program.50
Cardiac stress testing is also recommended for those with known CAD, two or
more cardiac risk factors, diabetes, or major signs/symptoms of pulmonary or
significant metabolic disease. In addition, men older than 45 and women older than
55 years of age who want to begin a vigorous exercise regimen (60% VO2max)
should undergo stress testing before initiation.
EXERCISE PRESCRIPTION

The recommended levels of activity for elderly patients should include a combination
of aerobic exercise, strength training, flexibility, and balance exercises. According to
the American College of Sports Medicine, in an update developed by a panel of
experts, it is recommended that patients adhere to the following regimen:
1. Frequency: Exercise most days of the week.
2. Duration: 20 to 60 minutes of continuous or intermittent aerobic exercise. Activities
of lower intensity should be performed for a longer duration (at least 30 minutes)
whereas those of higher intensity can be done in shorter bouts.
3. Intensity: Physically fit patients should exercise at approximately 60% to 90% of
maximal heart rate (206.9 [0.67 age]), or 50% to 85% of oxygen uptake reserve
(the difference between maximal and resting VO2). Patients who are not physically
fit should begin at an intensity of 55% to 64% of maximal heart rate and 40% to
49% of VO2max.
4. Mode: Use of large muscle groups in a continuous aerobic fashion is the goal of
exercise, for example, walking, hiking, jogging, and swimming.
5. Resistance training: This is important in enhancing strength and preventing falls. It
is recommended that patients participate in two to three sessions per week. One
to three sets of eight to ten exercises targeted at major muscle groups should be
done.51
Patients should be counseled on the level of intensity they should use during
exercise. A low intensity level allows for talking or singing, muscles feel normal, and
there is no perspiration. Moderate intensity allows for talking but not singing,
perspiration but normal muscle feeling. High intensity does not allow for easy talking
and muscles feel some fatigue. It is important that most patients begin at a moderate
level of exercise if no other risk factors exist. In those who need a graduated exercise
program, beginning at a low intensity and working up to moderate is best.
Aerobic Programs

Aerobic programs for the elderly should correspond to the patients needs and
abilities. Excellent examples include walking briskly, jogging, running, swimming,
cycling, tennis, and golfing without a golf cart. If the patient is new to exercise, it is
best to start with 5 to 10 minutes of cardiovascular exercises three times a week,

Aging and Exercise

allowing the patient to become acclimated. Patients may be graduated up to

continuous aerobic activity for 30 or more minutes most days of the week. Always
stress the importance of a warm-up with 5 or more minutes of light activity and
stretching after the workout.
Resistance Programs

Major muscle groups should be included in resistance programs, to include chest,

back, shoulders, arms, abdomen, and legs. Resistance bands are an excellent tool for
seniors because they offer a safe alternative to the use of heavier free weights.
Choose a band that offers a medium resistance. Specific exercises include the
following:
Knee extensions

Have the patient sit in a chair and tie a loose loop around one ankle with a resistance
band. The other end of the band should be secured around a leg of the chair. Have
the patient slowly raise and straighten the leg in question. He or she will then lower the
leg and repeat the motion for 10 to 15 repetitions on each side. As the exercise gets
easier, have the patient progress to two sets of 10 to 15 repetitions.
Ankle flexion

Have the patient sit on the ground with both legs straight out in front. Tie one end of
the resistance band around the toe and the other end to a sturdy object positioned
level with the ankle in front. Using the hands for support, slowly flex and extend the
ankle. Repeat 10 to 15 times on each side and increase repetitions as strength is built.
Bicep curl

Have the patient sit on a chair with the back straight and shoulders relaxed. Take one
end of the band in each hand and place the feet on the band to keep it on the ground.
Bend the elbows up so the hands approach the shoulders, then lower them to the
starting position. Repeat this exercise 10 to 15 times and increase sets as strength
increases.
Seated row

Have the patient sit in a chair and hold the ends of a resistance band in each hand.
Place the feet on the middle of the band, holding the band to the floor. Have the
patient start with hands and arms beside the legs. Then, slowly pull both elbows up
and back, then return them to the starting position, as if to pull the bands backward.
Repeat this exercise 10 to 15 times and progress as tolerated.
Balance Program

Balance exercises can be incorporated by adding an exercise ball. As an aid to

balance, the ball can be used in place of a chair. Another balance exercise is the
single-leg stand. The patient begins by standing on one foot while stabilizing him- or
herself lightly, resting a hand on a chair or wall for 10 seconds and then alternating
feet. Another exercise is the staggered stance. Here, the patient steps forward with
one foot, maintains this position for 10 seconds, then repeats with the opposite foot.
It is important that the patient lift his or her chest and keep his or her gaze locked on
the wall at eye level.
Flexibility Program

Flexibility is important for exercise safety. Stretching may produce a mild pulling
sensation, but should not cause pain. Patients should be instructed not to bounce into

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stretches, but instead gradually stretch into each movement. Several stretching
programs are easily available on the Internet and, generally, 10 to 30 seconds of
stretching is maintained before returning to neutral position. Stretches are repeated
three to five times.52
SPECIAL CONSIDERATIONS
Dementia

There is evidence that exercise delays the onset of Alzheimers dementia (AD),5356
reduces the incidence of the disease,57 and reduces age-related brain function loss.
In one study,53 it was shown that those who exercised three or more times per week
were more likely to be dementia free than those who exercised less frequently.
Patients who already have a diagnosis of AD have also been shown to benefit from
exercise. A recent meta-analysis of more than 2000 patients with AD demonstrated
that exercise resulted in significant increases in strength and flexibility and
decreased behavioral, functional, and cognitive deficits.57,58 Patients with AD can
adhere to the same exercise guidelines as their nondemented counterparts, but
with closer monitoring.
Osteoarthritis

Both aerobic exercise and resistance training have been shown to decrease disability
and improve painful symptoms in patients with osteoarthritis (OA).13 However,
because an increased risk of knee pain and further joint damage exists in patients with
quadriceps weakness, primary care physicians should include quadriceps strengthening exercises (to reduce the load on the knees) in their exercise prescriptions for
patients with OA.59,60
Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) also benefit from
exercise. Endurance exercise is extremely important in these patients. According to
The American Thoracic Society, a patient with a forced expiratory volume in 1 second
(FEV1) less than 50% to 60% should be considered for pulmonary rehabilitation.61
Pulmonary rehabilitation programs should aim for patients to exercise 3 to 5 days
per week for at least 20 to 40 minutes. For resistance training, one to three sets of
eight to twelve exercises, two to three times per week is recommended.62 Pulmonary
rehabilitation benefits patients with known COPD by increasing patients walking
endurance, reducing mortality and morbidity (thereby reducing hospital admissions),
and improving health-related quality of life.63 The goals of pulmonary rehabilitation are
to reduce COPD symptoms and disability, improve quality of life in terms of
independence, and increase social and physical participation. Outpatient rehabilitation programs are normally attended two to three times per week for 6 to 8 weeks and
need to be continued indefinitely. Techniques learned involve strengthening respiratory muscles (to decrease fatigue when being active), pursed lip breathing, and
pulmonary hygiene.
Congestive Heart Failure

There is no consensus on an exact regimen that patients with congestive heart failure
(CHF) should follow. These patients should receive individualized prescriptions. In
Class II to III CHF patients with less than 40% ejection fraction (EF), aerobic exercise
has been shown to increase exercise tolerance and VO2max by 12% to 33%.64 In
addition, there is evidence that, along with adherence to a medication regimen,

Aging and Exercise

aerobic exercise can decrease mortality and the number of repeat hospitalizations.
Strength training in this group produced up to a 43% increase in strength and a 13%
increase in 6-minute walk distance.64 Gradual and graded exercise programs are best
for these patients, beginning with simple strength and resistance training and
gradually increasing intensity to include more aerobic exercises as the patient
improves and can tolerate it.
Hypertension

According to the Framingham Heart Study, 90% of people who are normotensive at
age 55 years will eventually develop hypertension. Hypertension increases the risk for
end-organ damage, coronary events, stroke, heart failure, and peripheral vascular
disease.65,66
With normal aging, there is decreased arterial compliance and an increase in
sympathetic tone. Exercise is beneficial because it improves these parameters; it
increases arterial elasticity and decreases sympathetic tone, resulting in decreased
blood pressure. Exercise can improve blood pressure by roughly 10/7 mm Hg.
Hypertensive patients should participate in approximately 30 minutes of moderate
intensity at least three times per week.67 69
SUMMARY

In older adults, regular exercise provides numerous health benefits that include
improvements in blood pressure, diabetes, lipid profile, OA, osteoporosis, mood,
neurocognitive function, and overall morbidity and mortality. Most elderly Americans
do not gain this benefit because they adopt a sedentary lifestyle, often as a result of
preexisting health conditions, inadequate physician education and motivation, and
actual and perceived barriers to exercise.
An exercise prescription consists of aerobic exercise, strength training, balance,
and flexibility training. Because the number of physician visits increases with age, it
is the task of primary care providers to motivate older patients during each visit and
advise them regarding regular exercise and dietary modifications. The prescription
pad is a powerful tool to motivate patients on the exact frequency, duration, mode,
and intensity with which to exercise. A prescription is modified depending on a
patients comorbid conditions. Motivating patients to begin exercise is best achieved
by focusing on individual patient goals, concerns, and barriers to exercise. To
increase compliance, discussions at each doctors visit should ensue, and an
individualized prescription outlining the patients short- and long-term goals should
be discussed.
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