Exercise is a subset of physical activity. Multiple types of exercise exist, including, but not limited to, aerobic, strength, flexibility, and balance. The recommendations for aerobic exercise are typically considered to be the physical activity recommendations (ie, 30–60 minutes 5 or more days a week). Strength training to all major muscle groups is recommended 2 or more days per week, but not on consecutive days to allow for muscle recovery. Flexibility exercises should also be performed at least 2 days per week, and can be incorporated into an aerobic or strength program. For those older adults at risk for falls, balance exercises should be performed 3 times per week. Examples of the different types of activities or exercises for each of the categories are provided later in this chapter.
Older adults benefit from a prescription that includes all types of exercise, as all types are important for mobility and function. Major constraints on combined programs are time and fatigue; it is unrealistic for most older adults to undertake a program that demands hours of exercise each day. Some programs combine a mix of aerobic, strength, and balance activities into an hour-long session 3 days a week. The individual’s preferences and current level of health should dictate the details of the prescription (Table 67–4).
Table 67–4.Physical activity prescription by patient type.a ||Download (.pdf) Table 67–4. Physical activity prescription by patient type.a
|Patient Type ||Duration (minutes) ||Frequency ||Examples of Exercise |
|Overt Disability |
|Recently bed bound ||5–10 ||Several times per day ||Sitting ADL, passive and active range of motion, progress to standing and walking |
|Nonambulatory ||5–10 ||Several times per day ||Self-propel wheelchair, seated self-care, upper-extremity games and activities individually and in groups |
|Subclinical Disability |
|Very sedentary ||5–10 ||Several times per day ||Slow walking program, group recreation |
|Inactive ||20 or more ||Most days of the week ||Walking, gardening, housework, bicycling |
|Usual aging ||30 ||Most days of the week ||Brisk walking, stair climbing, moderate endurance recreation |
|Fit ||30 or more ||Most days ||Moderate-to-high intensity: very brisk walks on uneven surfaces and hills, brisk stair climbing, moderate-to-vigorous sports |
Aging limits peak performance of aerobic exercise, but not the ability to benefit from training. Unsupervised aerobic exercise is appropriate for healthy older adults who are able to walk steadily at a brisk pace. Supervised aerobic exercise is appropriate for persons who have clinical or subclinical disability and cannot exercise continuously at moderate intensity.
Some examples of aerobic activity include walking, jogging/running, biking, and swimming. Other activities can be considered aerobic exercise if done at a high enough intensity; activities such as dancing, golfing, gardening, vacuuming, cleaning windows, and mowing the lawn are just a few examples.
The major risk associated with aerobic exercise is a cardiac event, such as myocardial infarction or death; however, this risk has been described after participation in vigorous exercise. Participating in regular aerobic exercise improves many cardiac risk factors and subsequently reduces the risk of cardiac events during activity.
Aging is associated with loss of muscle mass and power but both are responsive to strength training in older adults. Strength training can be performed with weight machines, free weights, or using body weight for resistance. Weight machines offer safe ways to lift heavier weights and provide complex systems to control the rate of muscle contraction. Using free weights such as wrist or ankle weights, low-tech items such as elastic bands, or household items like milk jugs or tin cans will work for strength training. Bearing the weight of the whole body in standing, transfers, and walking or performing active range of motion exercises can be a strength training activity for many frail older adults. Examples of body weight exercises include repeated chair stands, wall squats, and step ups.
Strength training should be performed for all major muscle groups, including, but not limited to, the shoulders, arms, hips, legs, ankles, back, and trunk. The lower-extremity muscle groups are larger and more important for functional mobility and independence; however, upper-extremity exercises will induce a higher heart rate response. Initial durations may be much briefer than with lower extremity exercise, as many people tend to have more deconditioned arms than legs.
The major risks with strength training include muscle soreness and musculoskeletal injury. Completing the exercise in good form by moving in a smooth, controlled manner rather than shaking or jerking through the movement will reduce the risk of injury. Starting with a low number of repetitions and a low amount of resistance will also reduce the risk of injury. It is also very important to avoid holding one’s breath during strength training as it induces increased blood pressure. Key breathing guidelines are to start by taking a breath before lifting, exhale during lifting, and inhale during controlled release.
Flexibility decreases with age and can become significantly restricted with disease or disuse. Loss of range of motion affects mobility and function, and, in the worst case, can result in contractures that limit standing, walking, and reaching. Stretches should last 30–60 seconds and involve all major joints of the upper and lower extremity and trunk. The stretch should cause a sensation of pulling but not acute pain. To prevent injury, light to moderate activity to warm up the muscle before stretching for flexibility is advised. Contraindications to flexibility exercises include acutely inflamed joints, fused joints, and recent fracture.
Balance training is recommended for those older adults at risk for falls. The types of exercises and activities included in “balance training” are rarely defined in the literature, and there is little to no consensus on the frequency, intensity, and duration needed to induce benefits. Healthy older adults can improve balance through recreational activities that require displacement and recovery, such as dancing or tennis. Balance training for the very frail person involves movement practice in a seated position that requires displacement of the trunk and arms. Balance training in water allows patients to explore the margins of their ability to displace and recover without fear of injury, as falls are cushioned by the water.
Balance training requires progression of difficulty, making it inherently more dangerous than other types of exercise due of the increased risk of falling. Therefore, to reduce this risk, an older adult should only begin a balance training program after proper instruction by a health professional.