Exercise in Older Adults

Absolute contraindications (1) include

• Acute myocardial infarction (MI), within 2 days

• Ongoing unstable angina

• Uncontrolled cardiac arrhythmia with hemodynamic compromise

• Active endocarditis

• Symptomatic severe aortic stenosis

• Decompensated heart failure

• Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis

• Acute myocarditis or pericarditis

• Acute aortic dissection

• Physical, mental, or emotional disability that precludes safe and adequate exercise

Relative contraindications (1) include

• Known obstructive left main coronary artery stenosis

• Moderate to severe aortic stenosis with uncertain relation to symptoms

• Tachyarrhythmias with uncontrolled ventricular rates

• Acquired advanced or complete heart block

• Hypertrophic obstructive cardiomyopathy with severe resting gradient

• Recent stroke or transient ischemic attack

• Mental impairment with limited ability to safely cooperate

• Resting hypertension with systolic or diastolic blood pressures > 200/110 mmHg

• Uncorrected medical conditions, such as significant anemia, important electrolyte imbalance (eg, hypokalemia), and hyperthyroidism

Most patients with relative contraindications can exercise in some form, although typically at lower levels of intensity and in more structured circumstances than other patients (see Cardiovascular Rehabilitation). At times, shorter bursts of higher intensity (and sometimes even low or moderate intensity) exercise with rests between attempts can be more accommodating than sustained moderate-intensity exercise. Intensity and duration can be modified over time as appropriate. 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 must be instructed to stop exercising and seek medical attention if they develop chest pain, light-headedness, or palpitations.

Before beginning an exercise program, older people should undergo clinical evaluation aimed at detecting cardiac disorders and physical limitations to exercise. Routine electrocardiography (ECG) is not required unless history and physical examination indicate otherwise. Exercise stress testing is usually unnecessary for older 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 (1):

• 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)

• Lung disease, known or suspected

• Diabetes, known or suspected

For people recovering from an injury, the clinical evaluation before the start of an exercise program should assess whether they are apprehensive about the exercise program. The evaluation should also measure the range of motion and strength of an injured area, particularly as compared to the other side (eg, an injured knee versus the opposite, uninjured knee). Other considerations include the ability to climb stairs, walk with a proper gait, and complete basic activities of daily living (BADLs), such as eating, dressing, bathing, grooming, toileting, and transferring (ie, moving between surfaces such as the bed, chair, and bathtub or shower). Athletes recovering from an injury should be able to do simple sporting movements before trying aggressive and more complex sporting movements.

A comprehensive exercise program should include

• Aerobic activity

• Strength training

• Flexibility and balance training

• Variation (regular change in exercise to avoid over-adaptation to the same stimulus, but also to avoid minor injuries due to repetitive actions)

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. Alternatively, with certain exercises, adequate rest between sets (eg, 2 to 5 minutes with large muscle groups) can allow recovery of ATP stores sufficient to maximize performance on the following set, possibly maximizing gains in strength (2).

Duration of aerobic activity for older 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. Older people who have no contraindications can gradually increase their target heart rate (HR_max) to the one calculated by use of age-based formulas.

Some deconditioned older 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 adolescents and young 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. More aggressive training (the use of higher resistance initially) should be under the supervision of a qualified fitness professional.

To help increase flexibility, major muscle groups can be stretched daily, although stretching ≥ 3 times/week yields some improvements. Ideally, major muscle groups should be stretched 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 older people. 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 older people, flexibility and strength training exercises prevent falls more effectively; they also mitigate the impact of falls. 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.

1. 1. Fletcher GF, Ades PA, Kligfield P, et al: Exercise standards for testing and training: A scientific statement from the American Heart Association. Circulation 128(8):873-934, 2013. doi: 10.1161/CIR.0b013e31829b5b44

2. 2. de Salles BF, Simão R, Miranda F, et al: Rest interval between sets in strength training. Sports Med 39(9):765-777, 2009. doi:10.2165/11315230-000000000-00000