March 2018 Issue

Focus on Fitness: Exercise for the Very Elderly
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 3, P. 54

Tao Porchon-Lynch, a 98-year-old yoga instructor. Robert Marchand, a 105-year-old cyclist. Ida Keeling, a 102-year-old world record-setting runner. Lew Hollander, an 85-year-old Ironman triathlete. All of these elder athletes made the news in 2016 and 2017 for their fitness and athletic ability during what's generally considered extreme old age. Unfortunately, these elders are the rare exception in their age group. Most adults older than age 75 aren't physically active on a regular basis. Many have chronic medical conditions, such as arthritis and osteoporosis, that affect musculoskeletal functioning, and/or cardiovascular and respiratory conditions, such as heart failure and COPD, that limit activity. Depression and isolation also may contribute to inactivity. Regular exercise is essential for healthful aging and maintaining daily functioning, but the very old may view it as dangerous for their heart or bones and joints. However, appropriate exercise has many benefits for those who have become frail and deconditioned in old age.

Increasing daily physical activity can improve cardiovascular and respiratory capacity, physical functioning, and sleep quality, as well as reduce susceptibility to diabetes, cognitive impairment, constipation, and depression.1 The threshold for benefit is quite low for the very old—a recent study found that as little as 48 minutes weekly of moderate activity (walking combined with strength, flexibility, and balance exercises) improved overall physical functioning and decreased risk of immobility and disability in adults aged 70 to 89.2 By helping maintain and improve physical functioning, exercise helps older adults remain active socially and even can provide additional opportunities for socialization if they participate in group exercise.1 Regular exercise also helps the elderly remain independent and capable of living on their own. A 2016 study found that adults aged 75 to 85 who exercised for about three hours per week and could walk more than 350 m at a time were able to avoid institutionalization.3

Cardiovascular conditioning is often emphasized over all other components of fitness in discussions about aging because of its link to heart disease prevention. While aerobic exercise for the heart is important, maintaining muscle mass may be even more critical for the very old. The normal aging process causes a loss of muscle mass of about 1% per year, beginning at approximately age 30. After age 50, annual muscle loss escalates, and without regular strength training will begin to affect physical functioning. This age-related muscle mass loss was initially referred to as sarcopenia; however, the definition of sarcopenia has been refined as medical knowledge of aging has increased. Now, sarcopenia is considered a complex medical condition characterized by progressive and generalized loss of skeletal muscle mass and strength associated with aging.4

While certain diseases can cause sarcopenia, its primary cause is inactivity. Some researchers have proposed that a sedentary lifestyle—not aging—is the actual underlying cause of sarcopenia. Sarcopenia may affect up to 30% of adults over age 65 and more than 50% of those over age 80. Elders affected by sarcopenia have limited mobility and greater disability, and, as a result, are less independent, are at higher risk of falls, and have reduced quality of life. Although there are pharmacologic and nutritional treatments to address sarcopenia, the most important therapeutic intervention is exercise, especially progressive resistance training—exercises that require moving or resisting weight, with intensity increasing as strength increases. Progressive resistance training increases muscle size, improves muscular function, and improves balance and range of motion, thereby decreasing the risk of developing sarcopenia.4

Starting an exercise program may be daunting for an elder who has never exercised, has multiple medical conditions, and/or is very frail. Even a small increase in daily physical activity is better than no exercise at all and can improve function.

Exercise Guidance
Very old and frail elders will require medical evaluation before beginning exercise, and many will require physical therapy and exercise under medical supervision. An exercise program for this population should include aerobic exercise ("cardio"), progressive resistance exercise ("strength"), flexibility, and balance training. For the very old who can attend a senior fitness class specifically designed for older deconditioned adults, all of these components generally are included. Most senior living communities, long term care facilities, and senior community centers offer fitness classes that are appropriate and accessible for the very old. While some gyms also provide such classes, older adults who have never formally exercised—that is, performed some physical activity specifically for exercise—may be intimidated by gyms and fitness classes or may not be able to drive themselves. Or, classes may be dominated by more fit older adults, and deconditioned elders may feel self-conscious in this setting. Consider the following when working with very old and frail elders1,4:

• Conduct a preexercise assessment of their preferences, sociocultural beliefs, physical activity history, motivation, goals, and capabilities. A woman aged 85 who was raised to believe sweating isn't feminine likely won't view gym exercise as appealing; dancing may be a good option. A male veteran aged 90, on the other hand, may be motivated by a gym class with an instructor giving commands. An elder who has difficulty getting up out of a chair and walking across the room will have a very different exercise plan than one who can play a round of golf.

• Start with strength, flexibility, and balance training first to improve stability and control before adding cardio activities. Focus on functional exercises intended to improve ability to perform daily activities (eg, squats to assist in getting up from chairs/toilets). Many elders will need to start with seated chair exercises before being able to exercise while standing.

• Be aware of impaired senses, such as vision and hearing, which can affect ability to follow exercise instructions, and make appropriate accommodations to facilitate exercise.

• Group together elders with similar levels of physical functioning in class settings to encourage and motivate. For example, those who need to sit for support during exercise or who are in wheelchairs should be grouped together and separated from those capable of doing standing exercises to avoid intimidation and pushing themselves to perform beyond physical capabilities.

• Encourage more daily activity in the form of dancing, walking, gardening, and/or social games (eg, Wii bowling) for very old adults who never have exercised before and who may be resistant to "formal" exercise activities.

Safety is an important consideration for very old exercisers, who are more susceptible to physical injury and cardiovascular events. In general, exercising elders and those supervising them should adhere to the following guidelines1,4:

• Avoid extreme conditions in temperature or weather, such as high heat and humidity, cold temperatures, snow and ice, and cold pool water, all of which increase risk of injuries, blood pressure fluctuations, and cardiovascular events.

• Avoid poor air quality, which could aggravate respiratory conditions or stress respiratory function.

• Ensure that trainers or class instructors have specialized training in safe exercise for seniors and knowledge of health issues in older adults.

• Understand the side effects of medications and possible complications associated with certain exercises.

• Ensure availability of exercise equipment appropriate for the very old and facility safety features for those with movement limitations or balance issues (eg, safety rails, lifts for accessibility in pools).

• Ensure that activities chosen are appropriate for the individual elder's medical conditions and functional level.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. Shephard RJ. The scientific basis of exercise prescribing for the very old. J Am Geriatr Soc. 1990;38(1):62-70.

2. Fielding RA, Guralnik JM, King AC, et al. Dose of physical activity, physical functioning and disability risk in mobility-limited older adults: results from the LIFE study randomized trial. PLoS One. 2017;12(8):e0182155.

3. Pereira C, Fernandes J, Raimundo A, Biehl-Printes C, Marmeleira J, Tomas-Carus P. Increased physical activity and fitness above the 50(th) percentile avoid the threat of older adults becoming institutionalized: a cross-sectional pilot study. Rejuvenation Res. 2016;19(1):13-20.

4. Montero-Fernández N, Serra-Rexach JA. Role of exercise on sarcopenia in the elderly. Eur J Phys Rehabil Med. 2013;49(1):131-143.