Benefits of Exercise for Community-Dwelling Older AdultsJonathsn F, Bean, MD, MS, Arians Vora, MD, lAaher R Fronters, MD' PhD

ABSTRACT. Bean JF, Vora A, Frontera WR. Benefits ofexercise for community-dwelling older adults. Arch Phys MedRehabil 2004;85(Suppl 3):53 I -42.

This focused review highlights the benefits of exercise andphysical activiry for community-dwelling older adults. It is partof the study guide on geriatric rehabilitation in the Self-Di-rected Physiatric Education Program for practitioners and train-ees in physical medicine and rehabilitation. This article specif-ically focuses on the benefits of physical activity and exerciselbr older adults with regard to morbidity, mortality, and dis-ability. It discusses the appropriate preexercise screening andevaluation procedures for older adults contemplating exercise.Last, it reviews the current literature on the benefits of varyingmodes of exercise to modify the most prevalent chronic med-ical conditions of late life, including arthritis, heart disease,diabetes, stroke, pulmonary disease, and osteoporosts.

Overall Article Objective: To summarize the currentknowledge regarding the therapeutic benefits of exercise forcommunify-dwelling older adults.

Key Words: Aging; Chronic disease; Exercise therapy; Re-habil itation.

@ 2004 by the American Academy oJ'Physical Medicine andRehabilitation

ff ERHAPS THE MOST SIGNIFICANT change impacting-F hcalth care in the 2lst century is the growth of the medianage of the population. A decline in fertility and a 20-yearincrease in the average life span during the second half of the20th century have resulted in significant changes notjust in theAmerican population but also in the world population.t Im-provements in life expectancy have produced consequences.The growing number of adults age 65 years or older placeslarge demands on the public health system and on medical andsocial services.2 Chronic diseases that commonly affect olderadults contribute to disability, diminish quality of life (QOL)'and increase the costs of basic health care and long-term care'The US Center for Disease Control and Prevention has empha-sized the importance of addressing the growing burden ofdisability and chronic illness, especially as it pertains to thecost of health care.2

Although many of the recent advancements in medical carederive from merging advanced technology with scientific meth-ods, perhaps the most universal and effective treatment forchronic illness and disability in late life is physical exercise'Reductions in physical activiry are associated with significantimpairments and limitations in function, augmenting. disable-ment and chronic illness. Exercise can reduce morbidity, re-

s31

FOCUSED REVIEW

From Spaulding-Cambridge Rehabilitation Center, Cambridge, MA (Bean); and

Dcpanme;t ofPhtsical Medicine and Rehabiliiation, Haruard Medical School, Spaul-

ding Rehabilitation Hospital, Boston, MA (Bean, Vora, Frontera).

)io commercial party having a direct financial interest in the results of the reserch

supporting this anicle has or will confer a benefit upon the authots(s) or upon any

organization with which the author(s) is/are associated

i.cprint requests to Jonathil Bem, MD, MS, Spaulding-Cambridg€ Rehabilitation

Center, 1575 Cambridge St, Cambridge, MA 02138' e-mail'. jJbean@parlners'org'

0003-9993/04/8507-92 I 7S30.00/0doi: I 0. I 0 I 6/j.apmr.2004.03.0 l0

verse physiologic impairments, ameliorate functional loss, andare an important means of both preventing and treating chronicdisease. Exercise therapy is a fundamental aspect of rehabili-tation, providing rehabilitation professionals with the opportu-nify to play an important role in meeting these public healthchallenges. The purpose of this review is to aid rehabilitationcl inicians in this task.

OUTCOMES INFLUENCED BY EXERCISE

To discuss the benefits of exercise for older adults, it isimportant to understand the varied rehabilitation outcomes thatexercise can influence. These include medical outcomes, suchas morbidity and mortality, disablement outcomes, such asfunction and disability, and psychobehavioral outcomes, in-cluding self-efficacy and QOL. In this review, we focus pri-marily on medical and disablement outcomes but mentionpsychobehavioral outcomes when pertinent. Although medicaloutcomes are generally well understood as representing mor-bidity, the burden of disease, and mortality, disablement out-comcs are often confused. This confusion likely arises fromdifferences in terminology between the disablement conceptsof Nagi3 and the first and second versions of the World Health

Organization's Internationrtl Classi/ication of Impairments,Disabilities and Hcrndicaps.a's In the present review, we followthe terminology advocated by Jette,a who makes these defini-tions: (l) impairments, dysfunction or abnormalities in bodysystems; (2) functional limitations, restrictions in basic physi-

cal actions; and (3) disability, difficulties in doing activities ofdai ly l iv ing (ADLs).

CHANGES ASSOCIATED WITH AGING

Much of the original research on exercise interventions in

older adults was directed at reversing age-associated physio-logic impairments such as reduced aerobic capacity6'7 andmuscle weakness.s'e This approach was based on the recogni-

tion that physiologic changes associated with aging were very

similar to those seen with physical inactivify and that are, inmany cases, reversible with exercise. Most rehabilitation pro-

fessi,onals are familiar with the common physiologic changesassociated with bedrest and aging. Common changes include

worsening cardiovascular status including reductions in aerobicendurance, changes in body composition, bone loss and skel-

etal muscle atrophy, and weakness. In contrast, exerclse can

improve maximal and submaximal aerobic capacity' augmentmaximal cardiac output, reduce resting blood pressure, andproduce favorable changes in body, bone, and muscle compo-

sition. Beyond age-associated physiologic declines and inde-pendent oi diseaJe burden, changes in function and disability

have long been recognized for their association with aging.l0-r2

It is estimated that32o/o of community-dwelling adults 70 years

or older have difficulties in physical functioning and 20o/o have

difficully in performing at least 1 ADL.I3 Importantly, a more

recent ieviewra of US trends in functioning and disability

among older adults suggests that rates of functional limitations

and disability are declining. The causes ofthese changes over

the past decade have yet to be sufficiently identified. Never-

theless, this reportra is important for various reasons. First, it

shows that thi commonly held assumption that functional

limitation and disability are normal consequences of aging is

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

s32 EXERCISE FOR COMMUNITY-DWELIING OLDER ADULTS. Bean

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Fig 1. The curvilinear rela-tionship between impair-ments (ie, reduced strength!and function shows that. atlow levels, small increases instrength lead to large in-creases in function. In con-trast, for people at or abovethe functional threshold(Healthy Elderly), strength im-provements have diminishingeffects on function; neverthe-less; these improvements addto strength reserves. thusaugmenting one's resistanceto functional decline.

Strength. ------|

not true. Second, these findings impact greatly on projectionsof future health costs and public health initiatives. Interest-ingly, changes in overall physical activity during this time (thepast decade) do not appreciably account for the apparent post-ponement of functional loss and disability.rj

PHYSICAL ACTIVITY'S RELATION TOMORTALITY, MORBIDITY, AND DISABILITY

Physical activity and fitness are directly linked to improve-ments in mortality, morbidity, and disability. From an epide-miologic perspective, the benefits of exercise are often charac-terized by measuring physical activity or physical fitness.Physical activity represents an optional behavior, and physicalfitness represents an achieved condition resulting from in-creased physical activity. Both are well acknowledged forimpacting positively on mortality.t6'r7 A graded, inverse rcla-tionship between total physical activity and mortalily has beenidentified.'7 Physical activity initiated in late life conrlnues toimprove mortality, having a strong effect on longevity, evenwhen accounting for factors such as smoking, hypertension,family history, and weight gain.r8 Further, high levels of phys-ical activity and physical fitness lessen morbidity. Many stud-ies have shown benefits for patients with conditions as variedas cardiovascular disease (CVD), respiratory disease, demen-tia, and cancer.re-23 More recent work has shown that physicalactivity may also offset disability. Analysis of the more than10,000 older adults participating in the Established populationsfor Epidemiologic Studies of the Elderly showed an almost2-fold increased likelihood of dying without disability amongthose most physically active compared with those who weresedentary.2a Over the past decade, recognition of these variedbenefits has led to several national consensus statements em-phasizing the importance of physical activity in late life, in-cluding statements provided by the National Institutes ofHealth25 (NIH), the American College of Sports Medicine26(ACSM), and the US Surgeon General's office.27

IFFECTS OF VARIOUS EXERCISE MODESInitial exercise research was predicated on the assumption

that improvements in physiologic impairments would leid toenhanced functional performance and amelioration of disabil-ity. Therefore, early sfudies that used forms of endurancetraining or resistance training evaluated physiologic outcomes.

Arch Phys Med Rehabil Vot 85, Suppl 3, July 2004

They showed improvements with regard to endurance, aerobicpower, balance, strength, muscle cross-sectional area, and fi-ber-type distribution. As studies expanded to evaluate func-tional outcomes, inconsistencies arose, with improvements inphysiologic outcomes not always leading to functional en-hancements. These inconsistencies were associated with sev-eral factors. First, endurance exercise without anv componentof resistancc training has a weak inf lucnce on funit ion. bndur-ance exercise, most commonly evaluated in the form of walk-ing or bicycl ing, has strong effects on cardiovascular impair-ments, leading to improvements in morbidity and mortality.With regard to function, however, studies have shown, at best,l imited improvements.28 Second, the relat ion between impair-ments and function is nonl inear.2e'3rAs shown in f igure l , andoriginal ly described by Buchner and de Lateur,2e a thresholdexists after which enhancements in an impairment, such asstrcngth, will no longer add to continued improvements infunction. This helps explain why augmentation of strengthcould produce dramatic improvements in function among frailnursing home residents32 and, at the same time, produce min-imal effects on the function of healthy elders.2e Above thefunctional threshold, additional impairment reduction may addto reserves of strength, augmenting one's resistance to func-tional decline.

Based on these concepts, progressive resistance training(PRT) has generally been best accepted as the optimal means olcnhancing and maintaining function in older adults. Theserecommendations are supported not only by the many inter-vention studies performed in both community-dwelling andinstitutionalized elders3r-35 but also by reports that show thepositive association between impaired strength and functionalperformance.3r,36-38 More recently, impairments in musclepower have gained attention.se Muscle power, which is theproduct offorce and velocity, is a related but different attributefrom muscle strength, which is the ability to exert force.Muscle power declines more precipitously in late life thanmuscle.strength.ao Across a large variety of important mobilitytasks, the associations between muscle power and function arlconsistently larger than the associations between musclestrength and function.ar'42 Muscle power can be improved inolder adults. In contrast to PRT, exercise with a hish-velociwtraining component can enhance power.as,aa Resistarice trainingdesigned to enhance muscle power enhances function,as but. to

Mobr Inpairrnent, [nlect Function

Severe Funr:tional Lirnitation

EXERCISE FOR COMMUNITY-DWELLING OLDER ADULTS, Bean s33

date, direct comparisons between this approach and PRT haveonly been conducted within pilot studies.46

In contrast to many of the previously mentioned studiesfeaturing resistance training via exercise machines or freeweights, other recent investigations have examined use ofexercises that are very similar to the target functional tasks.These studies build on the well-established concept of speci-ficity of training. In sports, specificify refers to the concept thatoptimal training will occur when an athlete's training exerciseis very similar to the task for which he/she is training. If the"sDort" for which older adults are trainine is functional inde-p.nd.n.e, then it would make sense to design exercises that arerich in functional specificity. Reportsaz-st in both instifutional-ized and community-dwelling older adults have shown func-tional improvements after participants performed exercises thatwere similar to bed mobility, transfers, and general mobilitytasks. Direct comparisons between specificity-rich exercisesand more classical forms of resistance training still need to becompleted.

The possibility that exercise could be an effective means ofameliorating or improving disability (ie, ADL performance) isless clear. Among the most functionally compromised olderadults, such as those in nursing homes, exercise has an ame-liorative effect on disability. In contrast, in an important reviewaddressing community-dwelling older adults, Keysor andJette52 noted that, although many exercise studies have shownimprovemcnts in impairments and function, relatively few haveshown improvements in disability. This disparity is confusingpartly because measures of function directly predict disabilityamong healthy elders as well as disabled ones.53 This discrep-ancy likcly reflects several t'actors. First, many studies were notadequately designed for the purpose of evaluating disability:thcy had insensitive disabil ity measures and insufficient samplesizes. Second, some sfudies may have feafured exercise inter-vcntions that had insufficient intcnsity to produce the desiredchanges. Last, disability is influenced other factors, includingthose related to the adult's beliefs. behaviors, and environ-ment.a It may be that the optimal exercise intervention mustaddress all 3 issues.

SCREENING OLDER ADULTS FOR EXf,RCISEIt is well acceptcd that all older adults, regardless of their

underlying medical conditions, should receive a medicalscreening before they begin an exercise program.26'54-57 Screen-ing examinations should serve a number of purposes, including( I ) screening individuals for sal'efy in performing exercise, (2)identifoing medical problems that would require modificationof the exercise prescription, and (3) identifuing impairmentsand limitations that the exercise program will target.

In discussing the safefy concems in exercising, it is helpfulto consider the risks of cardiac events and sudden death'Surprisingly, insuficient data exist regarding the risk of ad-verse cardiac events in older adults initiating exercise. The riskfor sudden death during exercise decreases with increasedage.sa Estimates of cardiac events, such as myocardial infarc-tion, suggest that the small increases in risk associated witheven vigorous exercise (ie, >6 metabolic equivalents, eg,climbing hills or doubles tennis) would be attenuated by thebenefits of exercise training and that increases in physicalactivity and exercise would over time reduce that risk.ss Theadverse effects of a sedentary lifestyle are also well under-stood. A sedentary lifestyle adversely affects every major bodysystem,33 and it contributes to the functional decline associatedwith all of the most prevalent chronic conditions of older age.Therefore, as has been previously suggested, perhaps the ap-proach to the elderly patient contemplating exercise should not

Table 1: Gontraindications to Participation in an Exercise Program

Unstable angina or severe left main coronary diseaseEnd-stage congestive heart fai lureSevere valvular heart diseaseMalignant or unstable arrhythmiasElevated resting blood pressure (systol ic, >200mmHg;

d ias to l i c , >110mmHg)Large or expanding aort ic aneurysmKnown cerebral aneurysm or recent intracranial bleedUncontrol led or end-stage systemic diseaseAcute ret inal hemorrhage or recent ophthalmologic surgeryAcute or unstable musculoskeletal injurySevere dementia or behavioral disturbance

staft with the question "ls this patient safe to exercise?" but,rather, "ls this patient safe to be sedentary?"s8 Nevertheless,contraindications to exercise exist (table l). They include con-ditions that reflect unstable or severe heart disease, severevascular pathology (eg, aortic aneurysm), uncontrolled or end-stage systemic conditions, severe dementia or behavioral dis-turbance, and recent ophthalmologic concerns.55's7,5R

The medical history and physical examination should ad-dress pertinent body systems (table 2). The history shouldinclude screening questions addressing cognitive impairments,depression, stroke, cardiopulmonary function, hydration status,endocrine disease (eg, diabctes mellitus, hypothyroidism), ret-inal disease, peripheral vascular disease, hernias, hemorrhoids,stress incontinence, neurologic impairments, and musculoskel-etal symptoms, including assessment for arthritis and osteopo-rosis. The physical examination should also be comprehensive.It should assess cognitive status, including orientation, atten-tion, and short-term memory, and should also include carotidartcry auscultation, auscultation of heart and lungs, abdominalexamination including inspection for hernias, palpation of theaorta and auscultation for bruits, evaluation of peripheralpulses, screening neuromusculoskeletal examination, and as-sessment of balance and mobil i ty ski l ls.

The history and physical examination findings that wouldherald further evaluation and treattnent before the older adultbegins an exercise program include delirium, previously undi-agnosed heart murmur (especially if consistent with aorticstenosis), resting tachycardia, resting bradycardia (especially ifnot drug induced), orthostatic hypotension, undiagnosed vas-cular murmur, undiagnosed bruit (carotid or abdominal), peri-cardial rub, enlarged aorta, and symptomatic or undiagnosedhernia. Additional diagnostic tests should include a restingelectrocardiogram, to ensure that there are not new ischemicchanges. According to both the ACSM5e and the AmericanHeart Association,sT all older adults for whom moderate tovigorous exercise is considered require a screening exercisetolerance test. Controversy exists regarding these recommen-dations as they pertain to older adults, especially to persons 75years or older.55,6o This controversy is well articulated by Gillet al5s who have stated that the guidelines are not applicable toolder persons and, even if they were, could not be implementedreliably. It is beyond the scope ofthe present review to discusstheir concems in detail. However, based on the information to

date, it would be reasonable for older persons having no overtcardiac disease to be monitored for signs and symptoms of

cardiovascular abnormalities only during the initial stages of anexercise program; one would then consider further evaluation

only if the person was symptomatic (eg, angina, decrease in

systolic blood pressure [SBP] >2OmmHg, increase in SBP to

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S34 ExERcrsE FoR coMMUNlry-DwELuNG oLDER ADUrrs, Bean

Table 2: Components of the Screening History and Physical Examination of an Older Adult Wanting to lnitiate an Exercise program

His tory and Phys ica l Examinat ion Comments

Screen for cogni t ive def ic i ts (execut ive funct ion,memory, concentrat ion)

Screen for symptoms of depressionAssess hydrat ion status (or thostat ic hypotension)

Cardiac symptoms or f indings (valvular heart d isease,eg, aort ic stenosis, angina, or arrhythmias)

Pulmonary symptoms or f indings (CHF, asthma)

Vascular d iseasePVDAAA

History or symptoms of endocr ine disease (d iabetes,hypothyroid ism)

History of ret inal d isease

History of hemorrhoids, hernias, or st ress incont inence

Neurologic d isease (stroke or t ransient ischemic at tack)

Musculoskeleta l d isease ( ie, severe ar thr i t is ,osteoporosis, jo int deformity or instabi l i ty)

Mobi l i ty and balance ski l ls

Indicates abi l i ty to part ic ipate independent ly vs need forsupervis ion

May inf luence part ic ipat ion and can be benef i ted by exerc iseNew onset or poor ly managed symptoms should be

addressed pr ior to part ic ipat ionNew onset or poor ly managed symptoms should be

addressed pr ior to part ic ipat ionNew onset or poor ly managed symptoms should be

addressed pr ior to part ic ipat ion

PVD symptoms may be targeted for t reatmentAAA may b€ contra indicat ion to exerc ise, especia l ly

resistance t ra in ingNew onset or poor ly managed symptoms should be

addressed before participationPotent ia l r isk for hemorrhage i f acute or poor ly managed,

al though under appropr iate condi t ions exerc ise wi l lenhance ret inal perfusion

Al l can be worsened wi th the Valsalva maneuver i f exerc iseis conducted inappropr iate ly

New onset or poor ly managed symptoms should beaddressed before part ic ipat ion

Acute or poor ly managed symptoms should be addresseobefore participation

Wil l in f luence design and goals of exerc ise program

Abbreviat ions: AAA, abdominal aort ic aneurysm; CHF, congest ive heart fa i lure; PVD, per ipheral vascular d isease.

>250mmHg.or diastolic blood pressure [DBp] to > l20mmHg,or repeated increases in heart rate Io >90%o of age-predictedmaximum).

Supervision or modification of the exercise program may benecessary under a variety of circumstances. Patients with cog-nitive impairments, such as mild dementia, may benefit froirsupervision to optimize safety and compliance. patients withstable conditions that could be exacerbated by the Valsalvamaneuver, such as hemias, hemorrhoids, or stress incontinence,may benefit from initial supervision, to ensure that they areperforming resistance exercises correctly. patients with diabe-tes mellitus, postural hypotension, or stable cardiac or pulmo-nary disease may require supervision and clinical monitoring toensure they are appropriately managing their condition, giventhe changrcs in physical activity. Additionally, for older peisonswith cardiovascular concems, resistance training, as opposed toendurance training, may be the initially chosen mode of exer-cis€: consensus is growing that resistance training may actuallyreduce the risk for cardiovascular events in comparison toaerobic exercise.3s'58'6r Musculoskeletal impairments associ-ated with contracture, joint instability. or inflammation willIikely require directed treatment before initiation or modifica-tion during an ongoing exercise program. The exercise pro-gram itself should target the specific impairments and limita-tions identified, providing the underlying chronic diseases areappropriately medically managed.

PREVALENCE OF CHRONIC DISEASES

- Although the causes of functional loss and disability amongolder adults are commonly multifactorial, certain chronic dis--eases are the most prevalent contributors. The 5 most commonchronic illnesses among older adults are arthritis, CVD, diabe-tes, respiratory disease, and stroke.62,63 Specifically, arthritisaffects over 60% of women and 50yo ol men 70 vears orolder.62 CVD, including hypertension and heart diiease. is

Arch Phys Med Rehabil Vol 85, Suppt 3, July 2004

present in40% and3l% ofall women and men aeed at or overthe age of 65 years, respectively. Diabetes mellitu-s, respiratorydisease, and stroke are also very prevalent, more so among menthan women, affecting over l0oZ of people 75 years or oider.63All 5 of these il lnesses are recognized as leading causes fordisability, hospitalization, and death in older 66u11s.2,e: 4rradditional condition that is very prevalent among older adultsis osteoporosis. Both osteoporosis and osteopenia increase dra-matically after age 65, with osteoporosis being more than 3hmes more prevalent among persons at or over g5 years ascompared with those between 65 and74 years.2 Exercise canplay an important role in the primary and sicondary prevcnrlonand management of each of these conditions.s8 References foreach topic and our summarized recommendations are presentedin table 3.

OsteoarthritisOsteoarthritis (OA) is the most prevalent chronic condition

of older adults, affecting over half of all adults over ase 65.Traditionally, recommendations for older adults in the-man-agement of OA included refraining from many types of phys_ical exercise for various reasons. Concerns werc that exircisecould increase pain, advance joint destruction, and lead toinjuries.6a As evidenced in recent consensus statements by boththe NIH and the American Geriatrics Sociefy, exercise is aneffective treatment in the primary, second;ry, and tertiaryprevention ofOA and its consequences.64,6s Reports show thatreductions in aerobic capacity, because of inaitivity in thesepatients, have been corrected effectively through waiking pro-grams,66'67 use of a stationary bike,68 or aquatic exercises.66Improvements in strength can be achieved lhrough low- andhigh-intensity progressive resistance exercises, with ereater1mp1oy-ery9nt9 reported in srudies using higher intensititrain-ing.64'67'6e,To.Interestingly, reductions in disability have beenreported with group, individual, and home-based exercise pro_

EXERCISE FOR COMMUNITY-DWELLING OLDEB ADUITS, Bean

Table 3: Recommendations for Independent Exercise, by Medical Condition

s35

Condi t ions Recommendat ion

Osteoarthritis.56,6a ca rdiovasculardisease,8o,134 diabetess2f

PRT2-3 t imes weekly at 13-17 on the Borg Scale2-3 sets of 8-10 repetitionsGreater st rength gains wi l l be achieved at h igher Borg Scale rat ings

Aerobic t ra in ingExamples: walk ing, b ik ing, aquat ic exerc ise2-3 times weeklyProgress up to 30-40min11 -13 on t he Bo rg Sca le

Train both upper and lower extremit ies separately at 60% exercise-tested maximal work capaci ty,

which is roughly equivalent to 1 l -13 on the Borg ScaleUpper-body exercises include arm ergometry, canoeing, swimming, low-resistance high-

repet i t ion weight l i f t ingLower-body exercises include walk ing, stat ionary b icycl ing, sta i r c l imbing

Perform exercise 3-5 t imes weekly progressing to 30-60min/session

Sel f -moni tor dyspneaIncreass intensi ty every 5th session as to lerated

Theoret ical benef i ts of PRT at h igher intensi t ies are yet to be shownPRT

2-3 t imes wsekly at 13-17 on the Borg Scale2-3 sets of 8-10 repetitionsGreater st rength gains wi l l be achieved at h ighor Borg Scale rat ings

Aerobic t ra in ingTreadmi l l walk ing at normal gai t speed or s l ight ly faster

More impaired sublects may benef i t f rom supported t readmi l l walk ing

2-3 times weeklyProgress to 30-40min11 -13 on t he Bo rg Sca le

Task-speci f ic t ra in ingPerform funct ional tasks such as r is ing f rom chair , c l imbing sta i rs, squat t ing

Progress to 2-3 sets of 8-10 repet i t ions

PRT2-3 t imes weekly at 13-17 on the Borg Scale2-3 sets of 8-10 repetitionsNote greater st rength gains wi l l be achieved at h igher Borg Scale rat ings

Speci f ic at tent ion to spinal extensors is important

Aerobic exerc iseOnly strenuous aerobic exerc ise, inc luding combinat ions of fast walk ing, sta i r c l imbing,

iogging, or cal is thenics have been shown to be benef ic ia l

Respiratory diseases4

StrO ke 1 03.1 os

O S t e O O O r O S i 5 3 3 , l 1 3 , 1 3 5

Fal ls , poor balance, and mobi l i ty PRTproblems33,51,12e,133 2-3 t imes weekly at 13- '17 on the Borg Scale

2-3 sets of 8-10 repetitions

Note gr€ater st rength gains wi l l be achieved at h igher Borg Scale rat ings

Aerobic t ra in ing. Examples: walk ing, b ik ing, aquat ic exerc ise

2-3 t imes weeklyProgress to 30-40min1 1-13 on the Borg Scale

Dynamic exerc isesTai ChiHigh-veloci ty t ra in ing: exerc ises wi th concenlr ic component performed as quickly as possib le

to augment muscle power

Examples: repeated performance of leg exerc ises on exercise machines or common

funct ional tasks such as chair r ise or c l imbing a step.

NOTE. Al l recommendations assume that the patient has successful ly passed appropriate screening and monitoring procedures to assesssafety for independent exercise.*For diabetes,iol low strategies to avoid hyper- and hypoglycemia (see table 2).

grams, with no clear difference seen when modes of exerciseare directly compared.64'66'67'7r These results suggest that, inaddition to conecting underlying physical impairments, in-volvement in exercise programs may alter individuals' beliefs

regarding their own capabilities, therefore contributing to re-ductions in disability.T'? At present, the consensus is that exer-cise for patients with OA is safe; does not cause diseaseprogression; and, rather than increasing pain, contributes to the

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s36 EXERCISE FOR COMMUNTTY-DWELLING OLDER ADUTTS. Bean

reduction ofpain.64'6s A recent report has suggested, however,that knee alignment and laxity may be an important factor toconsider before initiating quadriceps strength training. Greaterstrength in this muscle group contributed to increased progres-sion of radiographic changes among subjects with knee jointmalalignment and laxity.z: Randomized controlled trials(RCTs) are necessary to better evaluate the long-term effects ofvarying intensities of resistance training on disability and dis-ease progression.

Cardiovascular DiseaseCVD, characterized by hypertension, coronary heart disease,

and/or congestive heart failure (CHF), represents the secondmost common chronic disease in older adults and the numberI cause ofdeath.13 Ofall the chronic diseases that affect olderadults, it is perhaps CVD for which the benefit of exercise ismost recognized. Nevertheless, there are still gaps in knowl-edge regarding how exercise therapy should be applied to olderadults with these conditions.

Although hypertension is a leading cause of death in theUnited States for older adults, the literature contains littleinformation specifically addressing the benefits of exercise forolder adults with hypertension. This may, in part, be associatedwith the fact that the benefits of exercise on hvpertension areag-e independent.Ta Reports generally address lhe physiologiceffects of exercise on hypertension. A comprehensive meia-analysis in women and 2 comprehensive reviews showed thatmoderate intensity aerobic exercise, regardless of the exercisemode, can produce a2o/o reduction in SBP (=l lmmHg), pro-duce a 10% reduction in DBP (:8mmHg), and reduce-leftventricular hypertrophy in patients with more advanced hyper_tension. There is disagreement regarding the role of resisiancetraining in the absence of aerobic training. However, a meta-analysis specifically addressing this topic suggested that im_provements of2%o and4Yo canbe achieved for restins SBp andDBP, respectivalyla'ts Therefore, as suggested by K6kkinos etal,1a we advocate for patients to undergo a combined exerciseprogram that includes aerobic and resistance training.

Among patients with coronary heart disease, those 65 yearsand older account for more than half of all acute myocirdialinfarctions and coronary bypass operations in the UnitedStates.76 As part of the Cochrane Database of SystematicReviews, Jolliffe et al77 conducted a systematic review of theeffectiveness (on mortality) ofexercise only and exercise in thecontext of a comprehensive cardiac rehabilitation program. Byusing- meta-analysis, they reported that the exercise-only ap_proach reduced total cardiac mortality by 3l% and exerciieplus cardiac rehabilitation reduced at 26yo. Cardiac rehabilita_tion reduced cholesterol and low-density lipoproteins. It wasnot clear which form of intervention was superior, but analyseswere limited, in part, because of an insufficient number ofstudies in women and older adults. In other recent reviews?6,78specifically addressing the benefits ofcardiac rehabilitation forthe elderly, authors also cite the lack of a solid base of well_designed clinical studies defining the role of cardiac rehabili_tation for elderly patients. Even so, studies show that bothaerobic and resistance training can be beneficial in reducingcardiac.risk factors, in correcting physiologic impairmenticaused by, coronary heart disease, and in enhincingeOL. Incoronary heart disease-although conclusions regirding theimpact of exercise and disability cannot be made atihis tiire_the. results ofa recently reported RCTTe suggest that resistancetraining in physically disabled older women with coronarvheart disease can enhance multiple domains of physical func'_tioning. Despite the current evidence, appropri;te referral ofolder adults with coronary heart disease to exercise programs

Arch Phys Med Rehabil Vol 85, Suppt 3, July 2004

and cardiac rehabilitation is lacking. Future challenges includereducing these baniers as well as modifring the design andconduct of these programs to optimize participation andldher_ence.76,78

Most people suffering from CHF are age 70 or older, with adoubling ofprevalence with each advancing decade, reaching alevel of 7% to l0% in persons 80 years or older.so Onlethought to be contraindicated, exercise studies conducted overthe last decade have led to a number of recent consensusstatements from national and intemational sources emphasizingthe need for exercise training in the treatmenl 61 611p.so-siWitham et al80 stated, in their comprehensive review address-ing the needs of older adults, that exercise improves CHFsymptoms, maximal and submaximal exercise capacity, andmany pathophysiologic mechanisms underlying CHF, includ-ing abnormalities of heart rate, skeletal muscle myopathy,cytokine expression, and ergoreceptor function. They ;dded,howeveq that most studies have been conducted in younger,well-selected populations with CHF.so Despite the need forwell-designed RCTs in older adults, it is universally recog-nized80-83 that both aerobic and resistance training cun 5.beneficial. Two studies of older CHF patients highlight thispoint. Pu et al8a had older adults (mean age, 77y) perform l0weeks of progressive resistance training at 80yo single repeti-tion maximal lift (l-RM). Pu showed improvements in musclestrength and endurance, increases in submaximal aerobic ca-pacity, and cellular changes in skeletal muscle consistent withimproved.oxidative capacity. Ilnprovements in peak oxygenconsumption (Vorpeak) were not seen with this fbrm of trtin-ing. Pu's study also showed that high-intensity resistance train-ing could be conducted safely within this population. In a muchlarger study incorporating both gym- and home-based exercise,McKelvie et al85 had subjects participate in 12 months ofcombined aerobic and resistance training. In these subjectswith an age of 65 years and older, improvements were seen lnVorpeak and muscle strength. Together these studies under-score that optimal aerobic and peripheral skeletal muscle ef-fects are seen with a combination of aerobic and resistancetraining. Long-term effects on mortality and morbidity are notknown at this time, but will, one hopes, be addressed throughIarge, prospective, randomized trials currently underway InNorth America and Eurooe.83

Diabetes Mellitusniabetes mellitus (DM) is a major cause of mortality and

morbidity among older adults. It is the sixth leading cause ofdeath among adults 65 years and older and accounls for ao_proximately 5.8 mill ion US hospital discharges annually.o.Exercise is now recognized as a critical component in iheprevention and treatment of DM.86 Although

-a number of

studies have evaluated the effects of various forms of exerciseon DM, interpretations of the data are challenging because ofsmall sample sizes and varying results. Similar io h-ypenensron.most studies have focused on physiologic outcomii. In_depthdiscussions of this topic can be review!6 .1r.*1ts1..ae,sz

Insulin sensitivity increases with aerobic exercise86,8? andhas.been reported to increase with resistance training as well.88lerhaps the best conclusions regarding the benefits;f exercisein older persons with diabetes can be derived from a meta_analysis by Boule et al.se They concluded that exercise traininereduces glycosylated hemoglobin by an amount that shoulireduce the risk for diabetic complications. No significantchanges in the body mass of subjects were seen whin com_pared with controls. It is possible that the lack of changes inbody mass may have been caused by a lack of sufficient studlesevaluating high-intensity PRT. Also, only 3 of the l4 studies

EXERCISE FOR COMMUNITY-DWEIIING OTDER ADULTS, Bean

Table 4: Strategies to Avoid Hypo- or Hyperglycemia During and After Exercise

s37

Strategy DM Type I DM Type ll

Adjustments to the insul inregimen

Meals and supplementalfeedings

Sel f -moni tor ing of b lood glucoseand ur ine ketones

Determination of uniquemetabolic responses

Take insul in at least th before exerc ise.

l f <1h before exerc isa, take insul in innonexercis ing part of body.

Decreass dose of both short- and intermediate-act ing insul in before exerc ise.

Al ter dai ly insul in schedule.Eat a meal 1-3h before exercise and check to

see i f insul in is in safe range before exorc ise.Take carbohydrate snacks or beverage-at least

every 30min i f exerc ise is v igorous or longdurat ion.

Moni tor b lood glucose before, dur ing, and af terexercise to determine the need for and effectof changes in insul in dosage or feedingschedule.

Delay exerc ise i f b lood glucose is <100m9/dL

or >250m9/dL and i f ketones are present

Learn indiv idual g lucose responses to d i f f€renttypes, intensi t ies, and condi t ions of exerc ise.

Determine ef fects of exerc ise at d i f feront t imesof the day on blood glucose response.

Hypoglycemia is rare, but i f taking insul inor sulfonylurea, i t is more l ikely. Mayneed to reduce dose.

l f taking insul in or sulfonylurea, mayneed supplemental feeding.

Not required.

Not required.

NOTE. From Horton ES. Diabetes mel l i tus. In: Frontera WR, edi tor . Exercise in rehabi l i tat ion medic ine. 3rd ed. Champaign: Human Kinet ics;1999 . p 221 . Rep r i n ted w i t h pe rm iss i on . s2

analyzed had subjects with a mean age over 60 years, againsuggesting the need 1br more RCTs evaluating older adults. Ofnote, diabetic patients may reap many of the other cardiovas-cular benefits from exercise, such as improved lipid profile,blood pressure, and energy expcnditure, that provide positivecontributions to their overall health status and reduce the riskfor CVD.eo-e2 Because exercise can have immediate effects oncirculating insulin and glucose, and because of the associatedrisks for hypo- or hyperglycemia, recommendations for type Iand type II diabetic patients are presented in table 4.

Respiratory Disease

Chronic obstructive pulmonary disease (COPD), that is,bronchitis, emphysema, and asthma, affect 1l% of older adultsover age 70. Specifically, COPD is I ofthe 4 leading causes ofdeath among older adults between the ages of65 and 84 years,accounting for 6Yo to 7% of deaths in this age group.rr As lateas the 1970s, physicians were advising COPD patients thatdyspnea was harmful and that patients needed rest, whichcontributed greatly to levels of deconditioning seen amongpatients suffering from COPD.er Despite the prevalence ofchronic respiratory disease in older adults, a review of theliterature reveals an absence of appropriate systematic reviewsor meta-analyses of exercise interventions in older adults withCOPD.e4 Most studies have focused on physiologic and func-tional outcomes, and it is only recently that disability has beenappropriately evaluated as an outcome.

Given the pathophysiologic changes associated with COPD,the physiologic outcomes most commonly evaluated are thoseassociated with aerobic capacity. Improvements in aerobiccapacity with exercise can be achieved with both low- andhigh-intensity exercise.e3'e4 In a direct comparison, however,Casaburi et ales showed that greater ventilatory benefits areseen with higher intensify training. Endurance can be enhancedin elders with COPD, with greater benefits seen with longerdurations of participation,e6 which produces mitochondrial ox-

idative changes in skeletal muscle consistent with aerobictraining in healthy elders.eT'e8

In addition to gaining these aerobic benefits, patients withCOPD can improve their functional capacity through exercise.Physical function has been most commonly measured by the6-minute walk test, with studiesee showing improvement fromlower-extremify training. Subjective dyspnea is another usefuloutcome measure because it is the primary symptomatic com-plaint of patients with COPD. Studiese3'e4 have shown im-provement in subjective dyspnea with both upper- and/orlower-extremity exercises. Interestingly, use of extemal sen-sory stimuli, such as music, in combination with exerciseappears to augment the beneficial effects of exercise on dys-pnea. The mechanism of these benefits is not known, but maysuggest that, as is the case with arthritis pain, behavioral factorsalong with exercise may mediate improvements in function-ing. too

In addition to the evidence above, a recent RCT by Berry etalror is notable for its finding of benefits to both functional anddisability outcomes. The authors compared 3-month and l8-month combined upper- and lower-extremity exercise pro-grams. Those subjects who exercised for the longer durationshowed 6% improvements in 6-minute walk distances, 1l%improvements in stair climb speed, and a l2Yo decline indisability. Beyond showing the superiority of long-term exer-cise in COPD, the Berry study is important in that it showsimprovements in disability with exercise participation.

Although it is apparent that exercise can benefit patients withCOPD, many unanswered questions still exist regarding thephysiologic effects of exercise and the optimal mode of train-ing for patients with COPD.

StrokeA major cause of morbidity and mortality in the United

States, strokes affect approximately 600,000 people annually,influencing 9oh of all adults 70 years and older.r3 Although the

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s38 EXERCISE FOR COMMUNITY-DWELIING OTDER ADULTS, Bean

primary injury in stroke involves the upper motoneuron path-ways of the brain, it is the impairments in musculoskeletalstrength, limb range of motion, cardiovascular endurance, andfunctional performance that become the primary foci of reha-bilitation treatment. A review of the literature reveals only Isystematic reviewro2 and no consensus statements addressingthe role of speciflc exercises in the rehabilitation of stroke. Ina review on stroke rehabilitation and the role of exercisetraining, Shepherdt03 underscored several important points re-garding exercise therapy in stroke care. First, many of thetraditional individualized therapies for stroke are based onuntested and unproven concepts. Second, evidence is growingthat altered motor patterns and changes in muscle and connec-tive tissue may be adaptive features because of weakness,spasticity, and disuse, as opposed to primarily resulting fromneurologic injury. Last, therapies that focus on use and theperformance of functional tasks may actually drive neurologicrecovery, Because ofthe present review focuses on older adultsliving in the community, we do not address studies evaluatingexercise therapies for acute stroke rehabilitation.

Recognizing the potential for functional decline after thecompletion of acute rehabilitation,t0a investigators have madepostacute stroke patients the focus of a number of both RCTsand non-RCTs featuring conventional exercise therapy. Be-cause hemiparesis and sedentary lifestyle after stroke contrib-ute to reductions in endurance, cardiovascular exercise hasbeen investigated. In an RCT of chronic stroke survivors par-ticipating in a l0-week exercise program, Potempa et alro5reported that 30 minutes of exercise, 3 times per week, by usinga modified cycle ergometer, produced improvements inVorpeak, workload, exercise time, and SBP at submaximalworkloads. ln a nonrandomized study of chronic stroke survi-vors, treadmill aerobic exercise training produced improve-ments in submaximal energy expenditure, directly reducing thecardiovascular demands of walking.106 This study also high-lighted the potential benefit of task-oriented training.

Studies using forms of strength and flexibility training havereported broader therapeutic benefits. In a study of African-American stroke survivors with a mean age of 53 years, butwith approximately one third of participants over age 60, al2-week exercise program produced improvements inVorpeak, strength, and flexibility.r0T Two other pilot stud-iesr08,roe that assessed training in chronic stroke survivors havereported not only enhancement of strength but also improve-ments in function and decreases in self-reported disabilitywhen PRT was a major component of the training program. Astudy by Weiss et alroe showed strength improvements in boththe affected and unaffected sides of the body. In contrast to theclinical folklore that strength training would harm hemipareticpatients, these robust findings from studies of small sample sizesuggest that PRT may be an important mode of therapy.ro3Larger RCTs of PRT in stroke suryivors are underway.

Other investigators have attempted to develop exercises thatincorporate resistance training and emphasize specificity oftraining. By using methods similar to that described earlier formobility-limited elders, Dean et alrro reported an RCT ofsubjects who were 3 months or more poststroke (mean age,62.3y). After participating in a 4-week circuit-training programof task-related exercises, participants showed improvements infunctional performance, endurance, and force production of theparetic leg. Interestingly, it is becoming more broadly recog-nized that such specificity-rich exercise ofthe affected extrem-ities may promote neurologic recovery; this phenomenon is thebasis for ongoing research in both acute and chronic strokesurvivors.l03,n l

Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

OSTEOPOROSIS, FALLS, AND BALANCE

Exercise is an important component of treatment in themaintenance of bone mass and prevention of fractures in latelife, Cross-sectional analyses have shown that adults who arephysically active throughout life have a higher bone densitythan their sedentary counterparts.rr2'r 13 In a sfudy of postmeno-pausal women, comparing sedentary older women with age-matched controls who had run an average of more than 20miles a week since menopause, Nelson et alr14 showed that,when normalized for body weight, the bone mineral density ofthe spine and radius were higher among the runners. Anotherstudy of older male athletes age 70 to 8l showed that weight-bearing exercise, regardless of type (endurance, resistance, orspeed training), led to greater bone mineral content than thatseen in age-matched sedentary controls. Even when the role ofweight bearing is minimized, exercise that produces dynamicmuscular forces of short duration and high frequency on bonewill lead to greater bone density.trs'rr6 This fact is shown inpart by a studyt tz in active tennis players age 70 to 84, in whombone mass was 4Vo to 33% greater within the dominant versusnondominant arms.

A wide variety of RCTs and non-RCTs have shown thatexercise can assist in the maintenance of bone mass in latelife.rts A common conclusion from comprehensive literaturereviews and from meta-analyses is that low impact, generalexercise programs, such as watking alone, offer little protectiveeffect, compared with strenuous aerobic exercise or resistancetraining.rrs'rr8 Notable studiesrre-r22 incorporating strenuousaerobic exercise over 9 to 24 months found combinations offast walking, stair climbing, jogging, and calisthenics aug-mented bone mass in study subjects as compared with controls.Generalized PRT conducted at high intensities (*60Yo*80o/o ofl-RM) increased bone mass in both menr23 and women.r2a

In a meta-analysis by Wolff et al I I s that reviewed both RCTsand non-RCTs in older adults, the overall treatment effect ofexercise training was a reversal or prevention of bone loss of0.9Y0 per year. Data are insufficient to determine differences inoverall treatment effects between resistance training and theother forms of exercise described above. The treatment effect iscomparable to benefits seen in women with appropriate pre-menopausal calcium intake, leading some to minimize thepotential benefits.r25 Because the absorption rate for bone peryear occurs at appfoximately lYo per year, appropriate exercisecould potentially negate the age-associated declines in bonedensity.

Maintaining or improving bone density is a focus in osteo-porosis management because of the high association betweenbone density and the potential for fracture and associatedmorbidity and mortality.r16 Exercise can help modify otherimportant factors such as muscle mass, strength, balance, andrisk for falls. Along with improvements in bone density, Nel-son et alr24 showed increases in muscle mass and strength withhigh-intensity PRT. Their research highlights the appropriate-ness of this form of exercise for older adults at risk forfracture.33'r24 Along with enhancements because of high-inten-sity PRT,33'34 people at risk for falls have shown improvementswith other forms of dynamic exercise, such as Tai Chi,rze,rztweighted vests,r28 and standing ankle exercises performed athigh velocity.'2e Based on the existing RCTs, the estimated riskreduction in falls associated with exercise is between 29o/o and490/0.126,130'133 Additionally, Campbell et alr3o,r3 I reported thatthe risk for injurious falls was reduced by 37% with an exerciseprogram that included strength, balance, and walking exercises.The superiority of any single mode of exercise in regard tobalance enhancement or fall prevention has yet to be deter-

EXERCISE FOR COMMUNITY-DWELLING OTDER ADULTS. Bean s39

mined. Exercises that enhance combinations of force produc-tion, speed of movement, and balance would be rational. Fi-nally, it should be emphasized that causes of falls are mostcommonly multifactorial and that the provision of an exerciseprogram may partially address the varied factors contributingto falls and fractures.l33 Table 3 presents exercise recommen-dations based on the literature to date and also includes rec-ommendations concerning the other common chronic illnessesconfronting older adults discussed within the previous sections.

CONCLUSIONS

Exercise has therapeutic benefits for almost all community-dwelling older adults, especially those suffering from the mostprevalent chronic illnesses. Its benefits include reductions inmorbidity and mortality, and enhanced physiologic capacity,leading to improvements in overall functioning. Many ques-tions have yet to be answered about the effects of exercise inameliorating disability and the best mode, intensity, and dura-tion of exercise for treatins the most common chronic condi-tions of older age.

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