Most people age > 65 years do not exercise at recommended levels despite the known health benefits of exercise:
Improved quality of life (eg, endurance, strength, mood, sleep, flexibility, insulin sensitivity, possibly cognitive function, bone density [with weight-bearing exercise])
Furthermore, many older 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 and most effective ways to improve health. Because of the decline in physical capability due to aging and age-related disorders, older people may benefit from exercise more than younger people. Exercise has proven benefits even when begun in later years. Basic, modest strength training helps older patients carry out activities of daily living. Many older 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 the ability to carry out daily activities. The same degree of muscle work demands less cardiovascular exertion; increasing leg muscle strength improves walking speed and stair climbing. Also, institutionalized older people with more muscle mass have better nitrogen balance, less deconditioning, and a better prognosis during critical illness.
Absolute contraindications (1 References Most people age > 65 years do not exercise at recommended levels despite the known health benefits of exercise: Longer survival Improved quality of life (eg, endurance, strength, mood, sleep... read more ) include
Acute myocardial infarction (MI), within 2 days
Ongoing unstable angina
Uncontrolled cardiac arrhythmia with hemodynamic compromise
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 References Most people age > 65 years do not exercise at recommended levels despite the known health benefits of exercise: Longer survival Improved quality of life (eg, endurance, strength, mood, sleep... read more ) include
Known obstructive left main coronary artery stenosis
Hypertrophic obstructive cardiomyopathy with severe resting gradient
Recent stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more or transient ischemic attack Transient Ischemic Attack (TIA) A transient ischemic attack (TIA) is focal brain ischemia that causes sudden, transient neurologic deficits and is not accompanied by permanent brain infarction (eg, negative results on diffusion-weighted... read more
Mental impairment with limited ability to safely cooperate
Resting hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more with systolic or diastolic blood pressures > 200/110 mmHg
Uncorrected medical conditions, such as significant anemia Overview of Decreased Erythropoiesis Anemia, a decrease in the number of red blood cells (RBCs), hemoglobin (Hb) content, or hematocrit (Hct), can result from decreased RBC production (erythropoiesis), increased RBC destruction... read more , important electrolyte imbalance (eg, hypokalemia Hypokalemia Hypokalemia is serum potassium concentration < 3.5 mEq/L (< 3.5 mmol/L) caused by a deficit in total body potassium stores or abnormal movement of potassium into cells. The most common... read more ), and hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms include palpitations, fatigue, weight loss, heat intolerance, anxiety, and tremor... read more
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 Cardiovascular Rehabilitation Cardiovascular rehabilitation may benefit some patients who have coronary artery disease or heart failure or who have had a recent myocardial infarction or coronary artery bypass surgery, particularly... read more ). 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 References Most people age > 65 years do not exercise at recommended levels despite the known health benefits of exercise: Longer survival Improved quality of life (eg, endurance, strength, mood, sleep... read more ):
Symptoms of coronary artery disease
≥ 2 cardiac risk factors (eg, hypercholesterolemia Dyslipidemia Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein cholesterol (HDL-C) level that contributes to the development of atherosclerosis... read more , hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more , obesity Obesity Obesity is a chronic, multifactorial, relapsing disorder characterized by excess body weight and defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders... read more , sedentary lifestyle, smoking Smoking and Other Tobacco Use Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and... read more , family history of early coronary artery disease)
Lung disease, 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
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 References Most people age > 65 years do not exercise at recommended levels despite the known health benefits of exercise: Longer survival Improved quality of life (eg, endurance, strength, mood, sleep... read more ).
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 (HRmax) 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 Falls in Older Adults A fall is defined as an event that occurs when a person inadvertently drops down to the ground or another lower level; sometimes a body part strikes against an object that breaks the fall. Typically... read more . 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. 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. 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