(Reprinted with permission)

Safety

      There is considerable debate about just how many tests the frail elderly should undergo before they begin an exercise program. Two national organizations have established criteria for screening prior to beginning an exercise program, American College of Sports Medicine (ACSM, 2000) and the American Heart Association (AHA; Fletcher et al., 2001). These guidelines are similar in that each organization recommends that exercise stress testing should be done before sedentary older adults start a vig-orous exercise program, even in the absence of known cardio-vascular disease (Gill et al., 2000). However, Gill and c o l l e a g u e s (2000) argue that these guidelines are not applicable for older adults because the conditions for recommending exercise stress t e s t i n g are too vague. Also, the distinction between moderate and vigorous exercise is open to interpretation. Although these organizations may specify intensity as being a proportion of oxygen consumption (VO 2 max), it is extremely uncommon for frail older adults to be able to reach their VO 2 Max with the usual exercise stress t e s t i n g . Considering that most frail older adults have at least one c h r o n i c m e d i c a l condition, few are capable of starting a vigorous exercise program. The most practical method to monitor intensity for the frail population is by using the ratings of perceived exertion (RPE) (See Table 1 on page 18). RPE uses a scale from 6 to 20 to allow exercisers to subjectively rate their exertion level during exercise (ACSM, 2000). RPE is especially useful for the frail elderly because many take medications that alter the physiologic re-sponse to exercise. Gill and colleagues further argue that given the large number of older adults with asymptomatic cardiovascular disease, routine exercise stress testing would likely lead to "a cascade of increasingly invasive cardiac procedures" which places these individuals at unnecessary risk of iatrogenic complications. After reviewing the findings of previous studies with older adults, they concluded that moderate exercise three days a week throughout the year only negligibly increased older adults’ risk of myocardial infarction and that regular exercise may actually reduce their risk of myocardial infarction and death by improving their cardiovascular risk factors and physical fitness.

Contraindications to Exercise

      In spite of this negligible risk in older adults, ACSM (Mazzeo et al., 1998) and Shephard (2000) outline several contraindications to exercise. Absolute contraindications to exercise testing and training include (Mazzeo et al., 1998):

1. recent ECG changes or myo-cardial infarction

2. unstable angina

3. uncontrolled arrhythmias

4. third degree heart block

5. acute congestive heart failure

      Shephard (2000) recommends that older adults permanently avoid vigorous exercise if they have:

1. an inoperable and enlarging aortic aneurysm

2. a malignant arrhythmia induced by exercise

3. severe aortic stenosis

4. end-stage congestive heart failure

5. severe behavioral agitation induced by exercise

      Relative contraindications include elevated blood pressure, cardiomyopathies, valvular heart disease, complex ventricular ectopy, and uncontrolled metabolic diseases (Mazzeo et al., 1998). Shephard (2000) recommends care-ful evaluation before such contraindications as:

1. acute febrile illness

2. unstable chest pain or congestive heart failure

3. poorly controlled diabetes

4. severe hypertension

5. severe asthma

6. acute musculoskeletal pain

7. repeated falling episodes

       Finally, temporary contraindications include hernias, cataracts, retinal bleeding, and joint injuries (Mazzeo et al., 1998; Shephard, 2000). B e c a u s e sedentariness generally appears to be a far more dangerous condition than physical activity in the very old (Mazzeo et al., 1998), elderly people who wish to begin a light-to-moderate exercise program should be encouraged to do so without preliminary triage or special medical clearance. These are not only unnecessary but are also negative motivators. Thus, older adults should progress slowly by engaging in a little more exercise than during the previous week (Shephard, 2000).

Exercise Prescription

        Exercise goals for the frail elderly are different from those for younger adults for whom exercise helps prevent disease and increase life expectancy. In the frail elderly, exercise has three different goals: to minimize the effects of aging and chronic diseases; to reverse the effects of disuse; and to maximize psychological health (Mazzeo et al., 1998). Health care professionals working with the frail elderly need to clearly understand these differences and focus on the unique needs and concerns of these older individuals. To effectively tailor an exercise program to the frail elderly, health care professionals should be aware of the exerciser’s:

1. medical history

2. lifestyle

3. current activity level

4. interests

5. equipment and facility availability

6. modes of transportation

7. health and orthopedic limitations

8. financial status

 

      The most effective exercise programs are those that are realistic, start with short-term goals, and progress slowly. Several modalities are involved for a well rounded exercise program for the frail elderly.

These include:

1. stretching

2. resistance or strength training

3. aerobic or endurance training

4. balance exercises

     Frequency, intensity and duration also should be considered when introducing each of these modalities. Stretching improves tendon flexibility, joint range of motion, and function and muscular performance (Pollock et al., 2000). Health care professionals should teach the frail elderly to isolate and stretch specific muscles. Older adults should use slow movement such as static stretches to a point of mild discomfort but not pain. Stretches should be sustained for 10 to 30 seconds and repeated 3 to 4 times for a total of up to one minute for each muscle group. Stretching exercises should be performed a minimum of 2 to 3 days per week and can be included in the warm up and cool down phases of resistance or endurance exercises (ACSM, 2000; NIA, 1999).

     Resistance (or strength) training helps maintain and improve muscular strength and endurance, which helps to prevent falls, improve mobility, and reverse frailty. Improvements in strength will help the frail elderly with routine functional activities such as gait and balance, rising from a chair, climbing stairs, and performing aerobic activities, as well as improving psychological aspects such as morale and depression. Increased strength also improves energy intake. Resistance training should expose the muscle tissue to a load greater than what is usual (the overload principle), thus increasing its overall strength and function(ACSM, 2000). Studies indicate that strength gains are more influenced by intensity of resistance training than by age and health status (Mazzeo et al., 1998). Large massive groups and opposing muscle groups should be targeted to avoid imbalances leading to poor posture and musculoskeletal injuries. Once achieving 10 to 15 repetitions per set for 2 to 3 sets, older adults should increase their intensity by adding more resistance or weight. Resistance training workouts should be limited to 30 minutes. This is more conducive to promoting maintanence (ACSM, 2000). To do this exercisers can work upper body muscles on one day and lower body muscles the next day. Resistance training should be done a minimum of 2, preferably 3 days per week. In either case, 48 hours of rest should be given to each muscle group before additional resistance training (ACSM, 2000).

     When working with frail elderly, choose activities that do not impose excessive orthopedic stress and are well tolerated with their orthopedic limitations. During both stretching and resistance training, discourage exercisers from holding their breath, as this will increase intrathoracic pressures. Finally, stress the importance of strength training as the means of increasing muscle strength and mass, an important step in maintaining function and independence.

     Aerobic training increases heart rate for an extended period of time and improves the cardiovascular system. For moderate intensity, exercisers should work somewhat hard (RPE of 13; NIA, 1999). A daily accumulation of 30 minutes or more of moderate intensity most days of the week will provide health benefits. To progress, duration should be increased before intensity is increased in order to reduce the risk of injury (ACSM, 2000). Engaging in aerobic exercise for a minimum of 3 days of the week is recommended. Extremely frail individuals may not be able to engage in aerobic activities. For these people, exercise training should begin with strength and balance training to assure safety before engaging in as little as 5 minutes of aerobic training. Initially, health care providers should train the frail elderly in proper technique, performance, and monitoring. Exercisers should begin slowly and gradually progress to allow proper adaptation to muscles and surrounding joints and connective tissue. Proper instruction in technique and performance will help the elderly avoid injury. Stress the importance of warming up and cooling down by explaining that the body needs a chance to shift from a resting state to a working state and back. An extended cool down should be encouraged to diminish the risk of postexercise hypotension, syncopal episodes, or arrhythmias during recovery.

     Balance exercises can help prevent falls, a major concern in the frail elderly. Most lower body exercises for strength that require standing are also balance exercises. Something as simple as raising one foot off the floor while balancing on the other foot can be done anytime and anywhere there is some type of support to grasp if needed.

     Exercise prescriptions for the frail elderly should accommodate their personal orthopedic or cardiovascular limitations. For example, during periods of severe arthritic pain and inflammations, exercise training may be reduced or eliminated until symptoms have subsided. For individuals with severe arthritic limitations, recom-mend beginning with lowlevel activities during the first few weeks with mild increases as activity becomes tolerated. Proper footwear is also essential because of potential circulatory limitations, muscle sarcopenia, or degenerative changes in bones or joints. Because physical frailty results from a combination of aging, chronic disease, sedentariness, and malnutrition (Mazzeo et al., 1998), health care providers should discuss other health issues such as diet, fluid intake, and appropriate attire for the environment. Stress the importance of being alert to and acting upon new or changing symptoms. Specifically outline which symptoms should alert them to contact their health care provider. Maintenance of an exercise program depends upon removing obstacles that prevent or hinder regular exercise. Encouraging activities that are accessible, enjoyable, convenient, and affordable may remove barriers that prevent incorporation of exercise into the lifestyle. Practical tips such as exercising with others or planning specific days and times to exercise may also increase adherence to an exercise program.

References:

     American College of Sports Medicine. (2000). ACSM’s guidelines for exercise testing and prescrip-tion (6 th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

     Christmas, C. & Andersen, R.A. (2000). Exercise and older patients: Guidelines for the clinician; Journal of the American Geriatrics Society, 48, 318-324.

     Fletcher, G.F., Balady, G.J., Amsterdam, E.A., Chaitman, B. Eckel, R., Fleg, J., Froelicher, V.F., Leon, A.S., Pina, I.L., Rodney, R., Simons-Morton, D.G., Williams, M.A., & Bazzarre, T. (2001). Exercise standards for testing and training: A statement for healthcare professionals from the American Heart Association, Circulation, 104, 1694-1740.

     Gill, T. M., DiPietro, L., Krumholz, H. M. (2000). Role of exercise stress testing and safety monitoring for older persons starting an exercise progra m. Journal of the American Medical Association, 284(3), 342- 349.

     Mazzeo, R.S., Cavanagh, P., Evans, W.J., Fiararone, M., Hagberg, J., McAuley, E., & Startzell, J. (1998). ACSM position stand on exercise and physical ac-tivity for older adults. Medicine & Science in Sports & Exercise, 30(6), 992-1008.

     National Institute on Aging. (1999). Exercise: A guide from the National Institute on Aging. Bethesda, MD: NIA.

     Pollock, M.L., Franklin, B.A., Balady, G.J., Chaitman, B.L., Fleg, J.L., Fletcher, B., Limacher, M., Pina, I.L., Stein, R.A., Williams, M., & Bazzarre, T. (2000). AHA Science Advisory. Resistance exercise in indi-viduals with and without cardiovascular disease: An advisory from the Committee on Exercise, Rehabili-tation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation, 101(7), 828-833.

     Shephard, R. J. (2000). Does insistence on medical clearance inhibit adoption of physical activity in the elderly? Journal of Aging and Physical Activity, 8, 301-311. n