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* This is the Professional Version. *

Exercise in the Elderly

By Brian D. Johnston

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Patient Education

At least 75% of people age > 65 yr do not exercise at recommended levels despite the known health benefits of exercise

  • Longer survival

  • Improved quality of life (eg, endurance, strength, mood, flexibility, insulin sensitivity, possibly cognitive function, bone density [with weight-bearing exercise])

Furthermore, many elderly people are not aware of how hard to exercise and also do not appreciate how much exercise they are capable of.

Exercise is one of the safest ways to improve health. Because of the decline in physical capability due to aging and age-related disorders, the elderly may benefit from exercise more than younger people. Exercise has proven benefits even when begun in later years. Basic, modest strength training helps elderly patients carry out activities of daily living. Many elderly patients need guidance regarding a safe and appropriate regular exercise regimen.

The largest health benefits occur, particularly with aerobic exercise, when sedentary patients begin exercising.

Strength decreases with age, and decreased strength can compromise function. For example, almost half of women > 65 and more than half of women > 75 cannot lift 4.5 kg. Strength training can increase muscle mass by 25 to 100% or more, meaningfully improving function. The same degree of muscle work demands less cardiovascular exertion; increasing leg muscle strength improves walking speed and stair climbing. Also, institutionalized elderly with more muscle mass have better nitrogen balance, less deconditioning, and a better prognosis during critical illness.


Absolute contraindications to exercise include

  • Suspected acute coronary syndrome

  • Untreated 3rd-degree heart block

  • Uncontrolled hypertension

  • Acute heart failure

  • Uncontrolled diabetes mellitus

Relative contraindications include

  • Cardiomyopathy

  • Valvular heart disease

  • Complex ventricular ectopy or other unstable rhythm disorders

Most patients with relative contraindications can exercise, although typically at lower levels of intensity than other patients (see Cardiovascular Rehabilitation). At times, shorter bursts of higher intensity exercise with rests between attempts can be more accommodating than sustained moderate-intensity exercise. The exercise program may be modified for patients with other disorders (eg, arthritic disorders, particularly those involving major weight-bearing joints, such as the knees, ankles, and hips).

Patients should be clearly told to stop exercising and seek medical attention if they develop chest pain, light-headedness, or palpitations.


Before beginning an exercise program, elderly people should undergo clinical evaluation aimed at detecting cardiac disorders and physical limitations to exercise. Routine ECG is not required unless history and physical examination indicate otherwise. Exercise stress testing is usually unnecessary for elderly people who plan to begin exercising slowly and increase intensity only gradually. For sedentary people who plan to begin intense exercise, stress testing should be considered if they have any of the following:

  • Known coronary artery disease

  • Symptoms of coronary artery disease

  • 2 cardiac risk factors (eg, hypercholesterolemia, hypertension, obesity, sedentary lifestyle, smoking, family history of early coronary artery disease)

  • Suspected lung disease

  • Suspected diabetes

Exercise program

A comprehensive exercise program should include

  • Aerobic activity

  • Strength training

  • Flexibility and balance training

Often a single program can be designed to achieve all exercise goals. Strength training improves muscular mass, muscular endurance, and strength. If strength training is done through a full range of motion, many exercises improve flexibility, and the enhanced muscle strength improves joint stability and, consequently, balance. Moreover, if rests between sets are minimal, cardiovascular function also improves.

Duration of aerobic activity for elderly people is similar to that for younger adults, but exercise should be less intense. Usually during exercise, the person should be able to comfortably converse, and intensity should be 6/10 on a perceived scale of exertion. Elderly people who have no contraindications can gradually increase their target heart rate (HRmax) to the one calculated by use of age-based formulas.


Some deconditioned elderly people need to improve their functional abilities (eg, by strength training) before they will be capable of aerobic exercise.

Strength training is done according to the same principles and techniques as in younger adults. Lighter forces (loads/resistance) should be used initially (eg, using bands or weights as light as 1 kg or arising from a chair) and increased as tolerated.

To help increase flexibility, major muscle groups should be stretched once daily, ideally after exercise when muscles are most compliant.

Balance training traditionally involves challenging the center of gravity by undertaking exercises in unstable environments, such as standing on one leg or using balance or wobble boards. Balance training can help some people with impaired proprioception and is often used in an attempt to prevent falls in the elderly. However, it is often ineffective because any balance activity is skill specific (eg, good balance while standing on a balance board does not improve balance in dissimilar activities). For most elderly people, flexibility and strength training exercises prevent falls more effectively. Such a program develops strength around the joints and helps people hold body positions more effectively while standing and walking. In people who have difficulty standing and walking because of poor balance, more challenging balance tasks (eg, standing on a wobble board) are simply likely to facilitate injury and are contraindicated.

* This is the Professional Version. *