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Clinicians in the ambulatory or hospital setting traditionally focus on diagnosis and treatment of specific diseases. However, it is clear that effective exercise and nutrition prescriptions, adequate counseling, and support of healthy lifestyle choices are at least as important if older adults are to achieve healthy aging.
Exercise
Aging and physical activity goals
Currently, disparities exist among population groups in habitual physical activity patterns that exaggerate the negative health consequences of a sedentary lifestyle. Unchanged from the 1996 Surgeon General’s Report on Physical Activity and Health,[1] demographic groups still at highest risk for suboptimal activity levels are older adults, women, minorities, those with low income or educational background, and those with disabilities or chronic health conditions.[2] As might be expected, these are the same demographic groups that both bear a large burden of the diseases amenable to prevention and treatment with exercise, and yet often have the least access and opportunity for health promotion efforts related to physical activity. Therefore, health-care providers should identify and understand barriers to physical activity and incorporate theoretically grounded behavioral programs and strategies that address these barriers into their practice, particularly for such vulnerable individuals. If exercise is truly to be viewed as medicine, then it requires the same attention to specific indications, evidence-based application, prescriptive elements, assessment of risks and benefits, and monitoring and promotion of adherence and outcomes, such as applied to other medical treatments.
Objectives for middle-aged and older adults have traditionally focused on physical activities designed to improve cardiorespiratory fitness and thus potentially prolong life, as well as prevent and treat cardiovascular and other chronic disease.[3] However, it is increasingly recognized that older adults can benefit substantially from physical activities designed to maintain or improve functional independence, by addressing age-related changes in physiology and geriatric syndromes, and thus enhancing quality of life.[4] The specific physical fitness components that optimize physical function as individuals age include muscle strength and power, cardiovascular and muscular endurance, balance, and flexibility.[5, 6] The prevalent problems of mobility impairment, falls, arthritis, osteoporotic fractures, and functional status are clearly related in part to sarcopenia (loss of muscle mass and function),[7] a feature of aging that is amenable to intervention even in frail elders.[8] Additionally, the metabolic benefits of retention and activation of muscle mass are now increasingly recognized as an important facet of the epidemic of age and obesity-related insulin resistance and type 2 diabetes.[9, 10] The Physical Activity Guidelines Advisory Committee Report, 2008 suggests the following minimum goals for older adults:[2]
(1) 150 minutes of moderate or 75 minutes of vigorous aerobic leisure time physical activity per week or an equivalent combination
(2) muscle-strengthening activities at moderate or higher intensity for all major muscle groups two times per week
These guidelines recognize that modification may be needed for those with chronic conditions and low fitness, and such individuals should be as physically active as their abilities and conditions allow. Additionally, the guidelines state that higher levels of activity (e.g., 300 minutes per week of moderate intensity aerobic activity or more) will provide additional health and functional benefits. These guidelines have recently been examined for their relationship to mortality in the National Health Interview Survey cohort of 242,397 adults, demonstrating that adherence to the aerobic or combined aerobic and strength training guidelines significantly reduced mortality, with the greatest benefits in older adults with at least one chronic condition, where adherence reduced adjusted mortality risk by 48%.[11]
Unfortunately, US survey and other data indicate that women in general (who are at higher risk of sarcopenia-related morbidity) report lower than average adult participation levels, particularly for strength training (11% vs. 16%).[12] Additionally, despite the evidence on safety and efficacy in even frail elders, the prevalence rate for resistive exercise is even lower among the old (6% at ages 65–74) and the very old (4% above age 75).[13, 14] Individuals in this latter age group, particularly over the age of 85, are primarily women, making an understanding of the risks and benefits of exercise in this population a priority.[15]
Rationale for the integration of exercise prescription into geriatric care
The rationale for the integration of a physical activity prescription into geriatric health care is based on four essential concepts.[16] First, there is a great similarity between the physiologic changes that are attributable to disuse (sarcopenia, osteopenia, central and generalized adiposity, low fitness, insulin resistance, etc.) and those that have been typically observed in aging populations, leading to the speculation that the way in which we age may in fact be greatly modulated with attention to activity levels.[17] Second, chronic diseases increase with age, and exercise has now been shown to be an independent risk factor and/or potential treatment for most of the major causes of morbidity and mortality in industrialized societies (see Table 6.1), a potential which is currently vastly underutilized. Third, traditional medical interventions don’t typically address disuse syndromes accompanying chronic disease, which may be responsible for much of their associated disability. Exercise is particularly good at targeting these syndromes of disuse. Finally, many pathophysiologic aberrations that are central to a disease or its treatment may be equally or better addressed by exercise than by pharmacologic therapy (e.g., the visceral adiposity and insulin resistance of metabolic syndrome), which therefore deserves a place in the mainstream of medical care, not as an optional adjunct.
It is clear that the optimum approach to “successful aging” or to health care in the older population cannot ignore the overlap of these areas. In some cases, exercise can be used to avert “age-related” decrements in physiologic function and thereby maximize function and quality of life in the elderly. On the other hand, the combination of exercise and sound nutrition, particularly in relation to favorable alterations in body composition, will have numerous important effects on risk factors for chronic disease as well as the disability that accompanies such conditions. Therefore, understanding the effects of aging on exercise capacity and how habitual physical activity can modify this relationship in the older adult, including its specific utility in treating medical diseases, is critical for health-care practitioners of all disciplines.
Monitoring the benefits of exercise
Many health outcomes appear to be related to the accumulated volume and/or intensity of exercise, and so simply monitoring adherence to the physical activity recommendations will theoretically provide evidence that the targeted benefits are occurring, in addition to the role exercise plays in promoting adherence to the prescription.[18] However, there may be benefits also in monitoring the actual physiological improvements from training. For example, aerobic capacity itself has an even stronger relationship to mortality than level of physical activity,[19] and increase in muscle mass after resistance training is directly linked to improved metabolic and inflammatory profile in older adults with type 2 diabetes.[10, 20] Documenting improvements in fitness, function, or body composition may have a reinforcing effect on long-term behavioral adaptations as well. Improved fitness/function across the multiple domains of exercise capacity may be shown, for example, by:
improved measurements of peak aerobic capacity
decreased heart rate and blood pressure response to a fixed submaximal workload
decreased rating of perceived exertion for a fixed submaximal workload
improved muscle strength, endurance, or power
ability to lift a submaximal load more times
ability to withstand postural stress or negotiate obstacles without losing balance
improved joint range of motion
improved functional performance (e.g., gait speed, chair stand time, stair climbing, six-minute walk distance, etc.).
Exercise testing for older adults
Cardiovascular endurance
Since treadmill testing and indirect calorimetry are not always available or feasible, particularly in frail older adults over 75, field estimates of aerobic capacity and cardiovascular responses are often substituted. A simple way to do this in clinical practice that requires minimal equipment is the six-minute walk test.[21] This test has been used as an index of rehabilitation in cardiac, pulmonary, and other patients, and it is known to predict outcomes and improve with effective interventions. With training, pulse and blood pressure at six minutes should decrease, and distance covered should increase by at least 25 m–50 m. Alternatives to the six-minute walk are walking a fixed distance (e.g., 400 m), climbing multiple flights of stairs as rapidly as possible, or stepping up and down a single step for several minutes, followed by the preceding measurements. However, availability of stairs and the potential for musculoskeletal injury due to balance, hip and knee arthritis, or vision problems make rapid stepping tests less desirable in the older adult. The six-minute walk test reflects not only aerobic capacity, but also contributions from gait stability, muscle strength, pain, body composition, and neuropsychological function, and thus is a good overall index of exercise capacity (not simply aerobic capacity), and has direct clinical relevance to ambulatory function in daily life.[22]
Strength testing
If maximal strength itself cannot be measured, or is not considered safe or feasible in an elderly individual, there is an option that is commonly used to rate effort during a lift, using a scale of perceived exertion, such as Borg’s Rating of Perceived Exertion (RPE) scale.[23] On this scale from 6 to 20, a rating of 15 to 18 (hard to very hard) is equivalent to 70%–80% of maximum lifting capacity in studies conducted in young and older adults, and is therefore an appropriate training goal for a robust and safe resistance training prescription.[9, 15] In addition, functional tests that may be used as an index of muscle strength and power include multiple chair stand time and stair climb time, although lower extremity arthritis or poor balance may distort the relationship between muscle capacity and performance on these tests. Although in epidemiological studies, grip strength is often used as a general index of muscle function or nutritional status in older adults and does predict mortality, morbidity, and disability,[24, 25] measures of lower extremity muscle strength and power, if obtainable, are more directly applicable to mobility impairment, fall risk, and specific exercise recommendations for relevant muscle groups of the hip, knee, and ankle.[4, 26]
Pre-exercise assessment in older adults
Most older adults, despite the presence of chronic diseases and disabilities, are able to undertake and benefit from an exercise prescription that is tailored to their physiological capacities, comorbidities, and neuropsychological and behavioral needs.[2, 16] The relatively few permanent exclusions to any structured exercise are generally for severe, irreversible conditions that are obvious exclusions because of the nature of the specific exercise prescription under consideration or the risk the exercise would impose upon the health status of the individual. There may be some forms of exercise that even permanently bed-bound patients, or those with severe behavioral problems, may engage in, even if such individuals are not able to participate in the usual aerobic, resistive, or balance exercises that will be described shortly. For some older adults, such as those with critical aortic stenosis, cardiac or peripheral vascular ischemia at rest, or an enlarging aortic aneurysm or known cerebral aneurysm (when surgery is not an option due to other medical considerations or very advanced age), any exercise that significantly elevates cardiac workload or blood pressure is considered high risk, and therefore not recommended.[9, 15] It is anticipated that relatively few older adults (even those in long-term care) would be excluded from all exercise programs based on items in this category (see Table 6.2) other than those with severe forms of dementia or terminal illness.
The majority of questions about exercise prescription eligibility will be because of items in the “temporary exclusion” or WAIT category (see Table 6.2), so judgments must be made based on the severity of the diagnosis, timing of the event in question, and re-evaluation after a diagnostic workup or an adjustment of medications is made. Most older adults in this category will be able to be reclassified as appropriate for exercise once their condition has been treated or stabilized. Notably, these are all conditions that require stabilization or medical attention regardless of the intent to begin exercise, so a review of exercise eligibility also serves as a check for optimal control of most acute and chronic health conditions.
Notably, the vast majority of chronic illnesses (GO category, Table 6.2) are indications for, rather than contraindications to, regular exercise. For example, if a patient with osteoporosis, chronic renal failure, osteoarthritis, and depression is not exercising, his or her medical management can be seen as suboptimal, as regular exercise is in fact additive to the benefits of usual medical care in these and all of the other chronic conditions listed. Therefore, screening a patient for exercise should be seen as an opportunity to “screen in” those sedentary adults who have exercise-responsive diseases, rather than primarily as a task of “screening out” those few adults with conditions which absolutely preclude exercise of any sort.
Exercise prescription in older adults
It is quite likely that after initial screening, many barriers and difficulties with adherence will be identified in the typically sedentary older individual. Therefore, it becomes important to know how to deliver the prescription in logical stages that are palatable and feasible, and have some likelihood of successful implementation. Current position stands and consensus guidelines for physical activity in older adults generally recommend a multi-modal exercise prescription including aerobic, strengthening, balance, and flexibility training, via a combination of structured and incidental (lifestyle–integrated) activities.[5, 6] However, it is usually best to start with only one mode of exercise and let the older adult get used to the new routine of exercise before adding other components, or optimal adherence and adaptation may be compromised.[27] This approach obviously requires attention to risk factors, medical history, physical exam findings, and personal preferences in order to prioritize prescriptive elements, and will be different for each individual. However, there are a few generalizations that can be made.
If significant deficits in muscle strength or balance are identified, then these should be addressed prior to the initiation of aerobic training. Prescribing progressive aerobic training in the absence of sufficient balance or strength is likely to result in knee pain, fear of falling, falls, and limited ability to progress aerobically, and is not recommended. Attempting to ambulate those who cannot lift their body weight out of a chair or maintain standing balance is likely to fail.
Paying attention to the physiological determinants of transfer ability and ambulation, and targeting these specifically with the appropriate exercise prescription when reversible deficits are uncovered is most likely to succeed.
In some cases, a chronic health condition may benefit equally from resistance or aerobic training (as in the treatment of depression, for example [28]), but the decision is made based on ability to tolerate one form of exercise over another. Severe osteoarthritis of the knee, recurrent falls, and a low threshold for ischemia may make resistance training safer than aerobic training as an antidepressant treatment in this case.
Prioritization requires careful consideration of the risks and benefits of each mode of activity, as well as the current health status and physical fitness level.
Patient preference for group vs. individual exercise, structured vs. lifestyle physical activity, level of supervision desired, and attraction or aversion to specific modalities of exercise must be considered to optimize behavioral change and long-term adherence.
Aerobic activity
Aerobic or cardiovascular endurance training refers to exercise in which large muscle groups contract many times (thousands of times at a single session) against little or no resistance other than that imposed by gravity.[9] The purpose of this type of training is to increase the maximal amount of aerobic work that can be carried out, as well as to decrease the physiologic response and perceived difficulty of submaximal aerobic workloads. Extensive adaptations in the cardiopulmonary system, peripheral skeletal muscle, circulation, and metabolism are responsible for these changes in exercise capacity and tolerance. Many different kinds of exercise fall into this category, including walking and its derivatives (hiking, running, dancing, stair climbing, biking, swimming, ball sports, etc.). The key distinguishing feature between activities that are primarily aerobic vs. resistive in nature is the much lesser degree of overload to the muscle in aerobic training as well as the higher number of contractions compared to resistance training. Obviously, there may be some overlap if aerobic activities are altered to increase the loading to muscle, as in resisted stationary cycling or stair climbing machines. However, such activities are still primarily aerobic in nature, as they do not cause fatigue within a very few contractions the way resistance training does, and they therefore do not cause the kinds of adaptations in the nervous system and muscle which lead to marked strength gain and hypertrophy.
Modes of aerobic exercise
There are many more kinds of cardiovascular exercise available than is the case for strengthening exercise. The decision about how to train aerobically depends on factors such as preference, access, likelihood of injury, and health-related restrictions or desired benefits. In general, although there are differences in oxygen consumption among various kinds of aerobic exercise, unless one is training for a particular sport, personal preference can provide much of the direction in this regard, as long-term compliance will require that an enjoyable pursuit has been selected. Given attention to the following intensity and volume requirements, most activities can contribute to improvements in cardiovascular efficiency, a reduction of metabolic risk factors, and reduced risk of many chronic diseases.
Two other factors assume importance in older adults, and older women in particular. The first is the beneficial effect of weight-bearing aerobic activities on bone density.[29] The loading of bone is critical to this outcome; thus, non-weight-bearing aerobic activities (such as swimming and biking) have not been shown to maintain or increase bone density, but aerobics, jogging, and stepping have positive effects in cross-sectional and longitudinal studies. Secondly, isolated high-impact activities such as skipping rope, hopping, and plyometrics (jumping), although exceptionally beneficial for bone formation in animal models, children, and premenopausal women,[30, 31] particularly at the hip, have been associated with significant rates of knee and ankle injuries, even in healthy older adults, and have generally not been shown to increase bone density by themselves in postmenopausal women.[32] In older adults with preexisting arthritis or fall risk, such high-impact activities are neither feasible nor recommended, as they are even more likely to result in injuries and exacerbations of arthritis in this cohort. Balancing the skeletal need for weight-bearing or mixed loading and the safety requirements of the joints and connective tissues for low-impact loading, one would favor exercises such as walking, dancing, hiking, and stair climbing over running, step aerobics, and jumping rope in most very old or frail adults. By contrast, men and women without underlying arthritis or balance disorders may generally perform higher impact activities safely as long as muscle and ligament strength and joint structure is normal, and such exercise should improve muscle power and associated functional outcomes as well as bone strength.[26, 33]
Overall, walking and its derivations surface as the most widely studied, feasible, safe, accessible, and economical mode of aerobic training for men and women of most ages and states of health. This does not require special equipment or locations, and it does not need to be taught or supervised (except in the cognitively impaired, very frail, or medically unstable individual). Walking bears a natural relationship to ordinary activities of daily living, making it easier to integrate into lifestyle and functional tasks than any other mode of exercise. Therefore, it is theoretically more likely to translate into improved functional independence and mobility than other types of aerobic exercise.
Intensity
The intensity of aerobic exercise refers to the amount of oxygen consumed (VO2), or energy expended, per minute while performing the activity, which will vary from about 5 kcal/min for light activities; 7.5 kcal/minute for moderate activities, and 10–12 kcal/min for very heavy activities.[9] Energy expenditure increases with increasing body weight for weight-bearing aerobic activities, as well as with inclusion of larger muscle mass, and increased work (force × distance) and power output (work/time) demands of the activity. Therefore, the most intensive activities are those that involve the muscles of the arms, legs, and trunk simultaneously, necessitate moving the full body weight through space, and are done at a rapid pace (e.g., cross-country skiing). Adding extra loading to the body weight (backpack, weight belt, wrist weights) increases the force needed to move the body part through space, and therefore increases the aerobic intensity of the work performed. Biomechanical inefficiency (e.g., gait disorder, arthritis pain, use of an assistive device) increases the oxygen demands of a given task, which must be considered when prescribing aerobic exercise to adults with such impairments.
The rise in heart rate is directly proportional in normal individuals in sinus rhythm to the increasing oxygen consumption or aerobic workload. Thus, monitoring heart rate has traditionally been a primary means of both prescribing appropriate intensity levels as well as following training adaptations when direct measurements of oxygen consumption are not available. The heart rate reserve (HRR) method is the most useful estimate of intensity based on heart rate5, calculated as:
Maximal HR can be taken from a maximal treadmill test or very roughly estimated as [220 – age]. Training intensity is normally recommended at a moderate (40%–59% HRR) level,[5, 34] although vigorous (60%–84% HRR) training levels may be used in selected individuals, and may provide increased adaptation or health benefits for some disease outcomes. High-intensity interval training (HIIT), using short bouts (most commonly 4 minutes) of near-maximal (approximately 90% peak HR) effort interspersed with rest periods of several minutes, has been demonsrated to be a more time-efficient and effective way to increase aerobic capacity and some health outcomes in recent years,[35, 36] although the long-term safety and benefits of HIIT, particularly outside of supervised clinical trials, requires more study in older and clinical cohorts before it can be generally recommended.
Difficulties with an intensity prescription based on heart rate in the older adult include inaccurate pulse recording during exercise and the presence of arrhythmias, pacemakers, or beta-blockers (systemic or ophthalmologic) that will alter the heart rate response to exercise. Therefore, a more easily obtainable and reliable estimate of aerobic intensity is to prescribe a moderate level as 12–14, or a vigorous level as 15–17 on the rating of perceived exertion (RPE) scale, which runs from 6 to 20.[34] At a moderate level, the exerciser should note increased pulse and respiratory rate, but still be able to talk. This scale has been validated for use in men and women, young and old, those with coronary disease as well as healthy adults, and is therefore of widespread applicability. It is easy to teach and is a way to “supervise” training intensity from afar, by means of written or electronic diaries or telephone calls, making it cost-effective in community programs and health-care or e-health settings. Usually a visual representation of the RPE scale is used to increase accuracy, but assessment can even be done without this prop in patients who are blind or cannot read.
As is the case with all other forms of exercise, in order to maintain the same relative training intensity over time, the absolute training load must be increased as fitness improves. In younger individuals, typically walking may be changed to jogging and then running to increase intensity as needed. More appropriate in older or frail adults are progressive alterations in workload that increase energy expenditure without converting to a high-impact form of activity. Examples of how to prescribe such progression for various modes of aerobic exercise are given in Table 6.3. The workloads should be progressed based on ratings of effort at each training session. Once the perceived exertion slips below 12 on the RPE scale, the workload should be increased to maintain the physiologic stimulus for continued cardiovascular adaptation. As with resistance training, the most common error in aerobic training is failure to progress, which results in an early suboptimal plateau in cardiovascular and metabolic improvement. In very frail adults, the workloads that elicit a moderate rating of based on perceived exertion, rated subjectively or objectively.
| Mode of exercise | Ways to increase intensity |
|---|---|
| Walking | Add small weights around wrists |
| Swing arms | |
| Use “race walking” style | |
| Add inclines, hills, stairs | |
| Carry weighted backpack or waist belt* | |
| Push a wheelchair or stroller (with someone in it) | |
| Cycling | Increase pedaling speed |
| Increase resistance to pedals | |
| Add hills | |
| Add backpack* | |
| Add child carrier to back of bike | |
| Water activities | Use arms and legs in strokes |
| Add resistive equipment for water | |
| Increase pace | |
| Tennis | Convert from doubles to singles game |
| Golf | Carry clubs* |
| Eliminate golf cart | |
| Dance | Increase pace of movements |
| Add more arm and leg movements |
* Avoid flexing the spine when doing this to prevent excessive compressive forces on the thoracic spine
Volume
In most older adults, 150 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic exercise each week will be sufficient to provide benefits in the domains of improved maximal and submaximal cardiovascular efficiency, psychological well-being, and control of chronic diseases such as arthritis, diabetes, peripheral vascular disease, chronic lung disease, coronary artery disease, and congestive heart failure, for example, and even lower amounts of exercise (60 minutes moderate intensity) will provide benefit in the initially sedentary. Higher volumes of exercise generally result in greater fitness adaptations[37] and health and mortality benefits,[11, 38] and up to 420 minutes per week are recommended for the treatment of obesity.[39] It should be noted, however, that very little research on aerobic training in very old or frail adults has actually been conducted, and most recommendations are simply extrapolated from studies in younger individuals.
It has been shown that aerobic exercise does not need to be carried out at a single session to provide training effects, and may be broken up into bouts of 10 minutes at a time to reach the desired volume of training.[9] Shorter duration sessions of moderate intensity have not been evaluated for efficacy, although public health recommendations for integrating short bouts of even five minutes into the daily routine have been made recently. As mentioned, high-intensity interval training bouts may be even shorter (ranging from one to four minutes in most studies),[36] although the feasibility of such prescriptions requires further study. Very frail adults may only tolerate two to five minutes of walking or other aerobic activities initially, and a reasonable goal is to increase tolerance for longer workloads until 10 to 20 minutes of exercise can be sustained without resting. This would provide substantial functional benefit in the nursing home, as walking for 20 minutes would likely enable the older adults to get to almost any location in the home without having to stop and rest.
Overall, a session or sessions of aerobic exercise carried out at least once every three days adding up to at least 60 minutes a week appears to be the minimal prescription for health and longevity and justifiable based on the currently available literature. Higher volumes of exercise than this (e.g., 30–60 minutes per day, 5 days per week, or 150–300 minutes per week), or short bouts of higher-intensity activity are generally associated with greater health-related outcomes and improvements in fitness.[9, 36] It is not recommended to exercise in very long bouts once or twice a week as an alternative to several shorter sessions, as this is likely to result in overuse muscle soreness and injuries. The risk of sudden death during physical activity appears to be concentrated in those who do not exercise on a regular basis (at least one hour per week), which is another reason for advocating regular, moderate doses of exercise rather than periodic high volume training.
Benefits
The benefits of aerobic exercise have been extensively studied over the past 50 years, and the most important benefits for older adults are listed in Table 6.1. They include a broad range of physiological adaptations that are in general opposite to the effects of aging on most body systems, as well as major health-related clinical outcomes.[40] The health conditions that are responsive to aerobic exercise include most of those of concern to older adults: osteoporosis, heart disease, stroke, breast cancer, diabetes, obesity, hypertension, arthritis, depression, memory loss, and insomnia.[38] These physiological and clinical benefits form the basis for the inclusion of aerobic exercise as an essential component of the overall physical activity prescription for healthy aging.[41]
Risks
The major potential risks of exercise are listed in Table 6.4. Most of these adverse events are preventable by paying attention to the underlying medical conditions present, making appropriate choices regarding the modality of exercise used, avoiding exercise during extreme environmental conditions, wearing proper footwear and clothing, and minimizing or avoiding exercise during acute illness or in the presence of new, undefined symptoms. Most fluid balance problems can be handled by exercising in reasonable temperature and humidity only and drinking extra fluid on exercise days.
| Musculoskeletal | Cardiovascular | Metabolic |
|---|---|---|
| Falls | Arrhythmia | Dehydration |
| Foot ulceration or laceration | Cardiac failure | Electrolyte imbalance |
| Fracture, osteoporotic or traumatic | Hypertension | Energy imbalance |
| Hemorrhoids* | Hypotension | Heat stroke |
| Hernia* | Ischemia | Hyperglycemia |
| Joint or bursa inflammation, exacerbation of arthritis | Pulmonary embolism | Hypoglycemia |
| Ligament or tendon strain or rupture | Retinal hemorrhage or detachment, lens detachment | Hypothermia |
| Muscle soreness or tear | Ruptured cerebral or other aneurysm | Seizures |
| Stress incontinence | Syncope or postural symptoms |
* Primarily associated with increased intra-abdominal pressure during resistive exercise, but may occur if Valsalva maneuver occurs during aerobic activities
All older adults should have yearly ophthalmologic exams for glaucoma and retinal changes, and the initiation of an exercise regimen is a good time to reinforce this preventive health measure, particularly in those with hypertension or diabetes. Retinopathy is not a contraindication to exercise, except in the case of proliferative retinopathy or an acute bleed or retinal tear/detachment until stabilized. If someone has had recent ophthalmologic surgery, exercise is contraindicated for several weeks to avoid raising intraocular pressure, and the exact recommendations should be obtained from the ophthalmologist in these cases.
Metabolic complications are rare unless diabetes is out of control at the time exercise is initiated, or dehydration, fever, or acute illnesses are present. The improvement in insulin sensitivity at the initiation of regular exercise may require modification of insulin and oral hypoglycemic medications to prevent hypoglycemia. Exercising in the one to two hours after meals should both prevent hypoglycemia as well as minimize the post-prandial rise in serum glucose, which is an independent risk factor for cardiovascular events, even in those who are not diabetic.[42] This cardiovascular toxicity is mediated by oxidant stress, which triggers inflammation, endothelial dysfunction, hypercoagulability, sympathetic hyperactivity, and other atherogenic changes. Exercise has been shown to attenuate this post-prandial dysmetabolism, which may mediate some of the cardio protective effects of exercise.[42, 43]
Cardiovascular complications are most likely if ischemic heart disease is not well controlled medically or surgically prior to exercise initiation, if warning signs are ignored, or if sudden, vigorous exercise is tried in a previously completely sedentary individual. When properly prescribed and monitored, both aerobic and resistance training have been shown to reduce the incidence of angina and medication use in cardiac rehabilitation settings, and are indicated as part of standard medical management of coronary artery disease.[15] Although claudication is mentioned as a possible adverse side effect of exercise in those with peripheral vascular disease, there is an important treatment caveat here. It has been shown that aerobic exercise (even arm ergometry) significantly increases exercise tolerance in patients with peripheral vascular disease (i.e., time to claudication), and resistance training has some benefit as well.[44] However, exercise has been intentionally continued for about 30–90 seconds if possible after the onset of claudication in some trials (“exercise to maximal pain”). This remains the recommendation of the TASC-II consensus group,[45] although the most recent meta-analysis suggests that inducing moderate to severe claudication may attenuate fitness benefits in this cohort.[46] Recommendations to continue exercise in the face of peripheral ischemic pain stands in contrast to angina or any of the other symptoms listed in Table 6.4, for which exercise should be stopped immediately if they occur.
Musculoskeletal problems are more common than any other risk of aerobic or resistive exercise, particularly in the novice exerciser or very frail adult, and those with underlying joint disease. Often if significant weakness or balance impairment is present, it is best to avoid aerobic exercise altogether until strength and balance have been improved sufficiently with specific training, so as to allow safe weight-bearing exercise such as walking. If this is not done, falls, arthritis pain, fear of falling, and muscle fatigue will be so limiting that effective aerobic training is precluded. Warming up muscles gently with slow movements prior to aerobic routines is important to avoid soft tissue injury. The most important point is to avoid high-impact activities (such as jumping, step aerobics, jogging) in those with pre-existing arthritis or weak muscles and ligaments, as this is a principal cause of sports-related injury.
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