Physical activity and exercise for health promotion, disease prevention and treatment in older adults
Distinctive phenotypes of Ageing
Physical activity and exercise: Global recommendations for health
Preserving exercise capacity with age via habitual engagement in physical activity/exercise
Evidence for specific modalities of exercise in older adults
Resistance Training | Aerobic Exercise Training | Balance Training | |
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Frequency (days per week) | 2 – 3 | 3 – 7 | 1 – 7 |
Volume | 1–3 sets of 8–12 repetitions, 8–10 major muscle groups | 20 – 60 minutes / session | 1 – 2 sets of 4 – 10 different exercises emphasizing static and dynamic postures |
Intensity | Start at 30–40% of 1RM and progress to heavier loads of 70–80% 1 RM (15–18 on Borg Scalea) 1–3 min rest between sets Power training at 40 – 60% of 1RM | 12–14 on Borg Scalea (55–70% heart rate reserve or maximum exercise capacity) | Progressive difficulty as toleratedb Narrowing the base of support Perturbation of ground support Decrease in proprioceptive sensation Diminished or misleading visual inputs Movement of the centre of mass of the body away from the vertical or stationary position Dual tasking: adding a cognitive distractor or secondary physical task while practising a balance task |
Specific Physiological adaptations | • Strength • Power • Hypertrophy • Endurance • Maximal aerobic capacity | • Maximal aerobic capacity • Sub-maximal endurance • Cardiac contractility/stroke volume • Peripheral oxygen extraction • Arterial stiffness • Heart rate variability | • Dynamic stability |
Exercise examples | • Multiple and single joint exercises (free weights and machine) with slow to moderate lifting velocity • Bench press and squat • Knee extensions and knee curls • Exercise selection can be varied through alterations in body posture, grip, hand and foot stance, unilateral vs bilateral exercises • Once body weight no longer serves as a sufficient source of overload, additional resistance can be provided by machines or free weights as needed to ensure progression. | • Dancing • Cycling • Hiking • Jogging / long distance running • Swimming • Walking with change in pace and direction • Treadmill walking • Stair climbing • Step-ups • Seated stepping • Recumbant cycling May start with 5–10 mins and progress to 15–30 mins. The intensity is proportional to heart rate and/or perceived exertional scales if on B blockers or has pacemaker and can be increased from moderate to vigorous depending on fitness. | • Tai Chi • Standing yoga or ballet movements • Tandem walking • Standing on one leg, stepping over objects, climbing slowly up and down steps • Turning • Standing on heels and toes, walking on a compliant surface such as foam mattresses • Maintaining balance on a moving vehicle, such as a bus or train • Dual-tasking: adding cognitive distractor while maintaining balance Many conditions in older adults require balance training before aerobic exercise/ gait retraining |
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Sequencing: Sequence exercise in people living with severe frailty the same way as the physical requirements underpinning mobility: standing up requires strength and power, staying upright involves balance, and walking any distance requires endurance. This sequence then follows a logic progression. Attempting to ambulate those who cannot lift their body weight out of a chair or maintain standing balance is likely to fail and increase risk of falls (51).
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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. For example, triceps /elbow extensor strength is critical to transfer ability, and improving it has been linked to reduced nursing home admission after hip fracture (68).
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In some cases, a chronic health condition may benefit equally from resistance or aerobic training (e.g., as in the treatment of depression). Still, the decision made is based on the ability to tolerate one form of exercise over another, or the presence of a second disease which requires a specific prescription. Severe osteoarthritis of the knee, recurrent falls, and a low threshold for ischaemia may make resistance training safer and more tolerable than aerobic training as an antidepressant treatment, for example.
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Prioritisation requires careful consideration of the risks and benefits of each mode of activity, as well as the current health status and physical fitness level. If one modality of exercise addresses multiple conditions, it is preferable to one that is more limited. For example, in patients with osteoporosis and depression, resistance training is a more logical choice than aerobic exercise, which evidence suggests can only address depression (51).
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Patient preference for group versus individualized exercise, structured versus lifestyle PA, level of supervision desired, and attraction or aversion to specific exercise modalities must be considered to optimise behavioural change and long-term adherence.
Gait training recommendations
Resistance training recommendations
Power training recommendations
Aerobic training recommendations
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Walking—add small weights around wrists, swing arms; use race walking style, add inclines, hills, or stairs; carry weighted backpack or waist belt; push a wheelchair or stroller (with someone in it).
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Cycling—increase pedalling speed, increase resistance to pedals, add hills.
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Water activities—use arms and legs in strokes, add resistive equipment for water; increase pace.
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Tennis—convert from doubles to singles game.
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Golf—carry clubs, eliminate golf cart.
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Dance—increase pace of movements, add more arm and leg movements.
Balance training recommendations
Multicomponent training
Multicomponent Training in Dementia
Safety of long-term physical activity and exercise interventions in Older Adults
Role of physical activity and exercise on bone health, adipose tissue, muscle mass, and maximal strength and power
Exercise recommendations | Decreased adipose tissue mass and visceral/central deposition | Increased muscle mass and function | Increased bone mass and density and reduced fracture risk |
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Modality | • Aerobic or resistance training | • Resistance training | • Resistance training • High-impact activities (e.g. jumping using weighted vest during exercise) if tolerated by joints. Not recommended for people with vertebral osteoporosis • Balance training |
Frequency | • Aerobic: 3–7 days/week • Resistance: 3 days/week | • 3 days/week | • Resistance training: 3 days/week • Balance training: up to 7 days/week |
Volume | • Aerobic: 30–60 min/session • Resistance: 2–3 sets of 8–10 repetitions of 6–8 muscle groups | • 2–3 sets of 8–10 repetitions of 6–8 muscle groups | • 2–3 sets of 8–10 repetitions of 6–8 muscle groups • 50 jumps per session for high impacta • 2–3 repetitions of 5–10 different static and dynamic balance postures |
Intensity | • Aerobic: 60–75% of maximum exercise capacity (VO2 max or maximum heart rate) or 13–14 on the Borg Scale of perceived exertion • HIIT training: 85–95% peak heart rate; 1 to 4 intervals of 4 min, 3 days/week • Resistance: 70–80% of maximum strength (one repetition maximum) exertion | • 70–80% of maximum capacity (one repetition maximum) | • 70–80% of maximum capacity (one repetition maximum) as load • 5–10% of body weight in vest during jumps; jumps or steps of progressive height • Practice the most difficult balance posture not yet mastered |
Bone health, physical activity, exercise, and fracture risk
Optimal exercise modality and intensity for bone health
Adipose tissue, physical activity and exercise
Experimental studies of the influence of physical activity on abdominal fat
Relationship between exercise intensity and changes in body fat
Relationship between exercise modality and changes in body fat
Role of physical activity and exercise in preserving muscle mass with age
Exercise to maintain or increase muscle mass and strength
Predictors of muscle hypertrophy after exercise
Role of physical activity and exercise in primary, secondary and tertiary Disease Prevention
Disease | Postulated mechanisms of exercise effect on disease prevention | Considerations for the prescription for secondary and tertiary prevention (disease expression and progression) | Recommended exercise modality |
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Arthritis | • Decreased body weight • Maintenance of cartilage integrity • Maintenance of muscle and tendon strength | • Low impact • Sufficient volume to achieve a healthy weight if obese | • Aerobic exercise • Resistance exercisea |
Cancer (breast, colon, prostate) | • Decreased body fat • Decreased oestrogen levels • Altered dietary intake • Decrease in gastrointestinal transit time • Increased prostaglandin F2 | • Resistance training with dietary intervention may offset myopathy and reduce prevalence of cancer cachexia | • Aerobic exercise • Resistance exercisea |
Chronic obstructive pulmonary disease | • Increased adherence to smoking cessation, dietary behaviours • Increased muscle mass • Improved lung function | • Resistance training may be more tolerable in severe disease, combined effects complementary if feasible • Time exercise sessions to coincide with bronchodilator medication peak. • Use oxygen during exercise as needed | • Aerobic exercisea • Resistance exercisea |
Chronic renal failure | • Reduced risk of hypertension • Reduced risk of type 2 diabetes mellitus | • Exercise reduces cardiovascular and metabolic risk factors, improves depression • Resistance training offsets myopathy of chronic renal failure | • Aerobic exercise • Resistance exercisea |
Congestive heart failure | • Decreased risk of ischaemic heart disease • Decreased risk of hypertension • Decreased risk of type 2 diabetes mellitus | • Improves cardiovascular function and contractility • Improves hypertension and lipid profile | • Aerobic exercise • Resistance exercisea |
Coronary artery disease | • Decreased blood pressure • Decreased LDL cholesterol • Increased HDL cholesterol • Decreased fibrinogen • Decreased total body fat, visceral fat • Decreased insulin resistance, hyperinsulinaemia • Decreased cortisol levels, inflammatory cytokines • Increased adherence to smoking cessation, dietary behaviours • Decreased depression, anxiety • Improved endothelial cell function | • Complementary effects on exercise capacity and metabolic profile from combined exercise modalities • Resistance training may be more tolerable if the ischaemic threshold is very low due to lower heart rate response to training | • Aerobic exercise • Resistance exercise |
Dementia | • Improved cerebral blood flow • Increased neurotrophic factors in CNS • Hippocampal neurogenesis • Anabolic hormones • Prevention of diabetes/insulin resistance • Prevention of stroke • Prevention of hypertension • Prevention and treatment of depression | • Exercise under supervision if cognition is moderately to severely impaired • Avoidance of head trauma during exercise is critical | • Aerobic exercise • Resistance exercisea |
Depression | • Increased self-efficacy, mastery • Internalised locus of control • Decreased anxiety • Improved sleep • Increased self-esteem • Increased social engagement, decreased isolation • Decreased need for drugs associated with depression (beta blockers, alpha blockers, sedative hypnotics) • Decreased body fat, improved body image | • High-intensity resistance training and adequate volumes of aerobic exercise are more efficacious than low-intensity/low-volume exercise in major depression | • Aerobic exercise • Resistance exercisea • Yoga/other mind-body exercisea |
Osteoporosis / Osteoporotic fracture | • Increased bone density • Increased tensile strength • Increased muscle mass • Improved gait stability and balance • Improved nutritional intake (energy, protein, calcium, vitamin D) • Reduced fear of falling, improved self-efficacy • Increased overall activity levels, mobility • Decreased need for drugs associated with postural hypotension, falls, hip fractures (antidepressants, antihypertensives, sedative-hypnotics) | • High-impact, high-velocity activity (e.g., jumping) is potent if tolerable; avoid if osteoarthritis is present. • Resistance training effects are local to muscles contracted. • Balance training should be added to prevent falls and must be challenging | • High-impact exercisea • Resistance exercisea |
Peripheral vascular disease | • Prevention of hypertension • Prevention of diabetes • Improved lipid profile • Assistance in smoking cessation • Reduction in adiposity/visceral adiposity | • Vascular effect is systemic; upper limb ergometry may be substituted for leg exercise if necessary • Resistance training has a similar effect on claudication as aerobic exercise • Low-intensity resistance training is ineffective. • Exercise only to the onset /early phase of claudication; rest and repeat • Avoid trauma to skin or feet; high impact training | • Aerobic exercise • Resistance exercisea |
Stroke | • Decreased obesity • Decreased cholesterol • Prevention of diabetes • Prevention of hypertension | • Start with resistance and balance training until ambulation is safe • Cognitive impairment may require close supervision • Avoid Valsalva and breath holding to minimise hemodynamic excursions | • Aerobic exercise • Resistance exercisea • Gait and balance exercise; mobility traininga |
Type 2 Diabetes Mellitus | • Improved insulin sensitivity • Increased GLUT-4 protein and translocation to membrane sites • Reduced visceral fat mass • Decreased cortisol response to stress • Improved lipid profile • Decreased blood pressure • Increased muscle mass | • Exercise at least every 48 hours to optimise glucose regulation • May need to avoid impact exercises if peripheral neuropathy present • Monitor blood glucose before and after exercise if not well-controlled | • Aerobic exercise • Resistance exercise (combined with diet and aerobic exercise) |
Venous stasis disease | • Increased muscle mass • Decreased adiposity | • Local muscle contractions stimulate the return of fluid via the lymphatic system • Utilise lower body training; elevate legs when possible • Avoid trauma to skin | • Aerobic exercisea • Resistance exercisea |
Role of physical activity and exercise in the secondary and tertiary Prevention
Exercise in type 2 diabetes
Role of physical activity and exercise in mental health
Effects of physical activity and exercise interventions on geriatric syndromes
Frailty and Sarcopenia
Falls
Cognitive Impairment
Considerations regarding physical activity and exercise for frail individuals with cognitive impairment
Role of physical activity and exercise in the prevention and treatment of disability
Exercise to counteract iatrogenic disease
Geriatric syndromes | Considerations for the prescription | Recommended exercise modality |
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Frailty and Sarcopenia | • Resistance and power training: 2 to 3 sessions per week, combining slower and faster (power training) muscle actions at intensities of 40 – 80% of 1RM. • Functional exercises e.g., standing from a chair with progressive increases in loading/speed • Balance and gait exercises progressing in complexity: line walking, tandem foot standing, standing on one leg, heel-toe walking. | • Resistance training • Power training • Balance exercises • Gait retraining • Multicomponent exercise |
Falls/Mobility impairments | • Resistance training aimed to improve muscle strength and power. • Balance and gait exercises progressing in complexity: line walking, tandem foot standing, standing on one leg, heel-toe walking. • Dual task exercises including dual task gait and resistance exercises (serial numbers, naming animals, etc). • Adapted Tai Chi exercises progressing in complexity. • Dance interventions may improve adherence. | • Resistance training • Balance exercises • Gait retraining/dual task training • Multicomponent exercise • Dance interventions • Tai Chi exercises |
Cognitive impairment | • High-intensity resistance training combined with power training aimed to improve cognitive and functional abilities. • Walking may reduce the risk of dementia. • Dual task exercises may be beneficial to cognitive function. • Use of mirror techniques rather than complex oral instructions. Use of haptic support. • Considerations of emotional aspects such as reassurance, respect, and empathy. | • Walking • Aerobic training • Resistance training • Dual-task training |