Exercise prescription for older populations
While there is no consensus on the definition of older individuals, most developed countries have accepted the age of 65 as an older person. It is well known that our population is getting older. Today most people can expect to live into their 60’s and beyond and are enjoying better health in their later years than previous generations.
Health care professionals should aim to encourage healthy aging, which the WHO defines as:
“The process of developing and maintaining the functional ability that enables well-being in older age. This functional ability is determined by the intrinsic capacity of the individual (ie the combination of all the individual’s physical and mental – including psychosocial – capacities), the environments he or she inhabits (understood in the broadest sense and including physical, social and policy environments), and the interaction between these.”
As functional ability is aided by being physically active, it is easy to see how important a role exercise prescription plays in healthy ageing. Remember that healthy ageing is more than the absence of disease.
The range of physical capacity is greater in the older individuals than any other age group. This is likely due to genetic and lifestyle factors and highlights the need to consider that people differ widely in how they age. This graph shows the variation or spread in physical capacity by age.
Although there is a marked decrease in physical capacity after 80 years of age, the most interesting thing that this graph displays is just how heterogeneous older individuals are. Physical capacity in older individuals has the greatest spread when compared to other age groups. Therefore we are incorrect to assume that all older patients have functional limitations or reduced capacity.
Some deterioration with age however is inevitable. Physiological changes occur with ageing which no amount of exercise can prevent.
- VO2 max will decrease and almost every system will experience functional deterioration. Exercise can help prevent some of the decline in function seen with ageing.
- Despite this, older individuals are known to decrease both the volume and intensity of physical activity they participate in with age.
- It is important to educate patients on the benefits of exercise for their health, but also to manage expectations as some deterioration in function is inevitable, especially for those with chronic disease and multi-morbidities.
Resistance exercise often brings to mind images of heavy gym machinery and young athletes. However due to changes in body composition that occur with age, resistance exercise is very important for older individuals to maintain function. After the age of 65, older individuals generally experience a steady loss of muscle mass and power.
- Skelton et al (1994) reported that, after age 65: the loss of muscle mass is at a rate of 1.5% per year and the loss of power is at a rate of 3.5% per year. Sarcopenia often results in a reduced ability to perform activities of daily living, however we know that functional benefits can be reaped from strength training in the elderly, including those with Sarcopenia.
With normal ageing also comes a reduction in flexibility. This is due to changes in connective tissue which leads to a decrease in elasticity. The result is an increase in the risk of falling and poor balance. This risk should be taken into account when prescribing exercise. Research has shown that flexibility, range of motion and balance can all be improved in older individuals with appropriate exercise prescription. This may be the focus of your treatment and may precede aerobic exercise training.
As with all populations it is advisable to recommend a range of activities for elderly people to engage with. Evidence suggests that elderly populations prefer low impact low intensity activities such as Yoga, tai chi, gardening, walking and golf.
Education forms a large part of any exercise prescription. It is important to let older people know that although ageing is inevitable, it is not too late to reap significant health benefits from an active lifestyle. Physical activity is known to positively affect several chronic disease risk factors. Older patients should be encouraged to take an active role in their exercise prescription and self-monitor their activity levels.
Tips for prescribing exercise to older populations
- For those who are unable to meet guidelines, emphasize the fact that any activity is better than none, even if that starts with change as simple as breaking up periods of sedentary behaviour.
- Begin with low intensity and duration, even below recommendations, for older adults who are frail, deconditioned, functionally limited or have chronic health conditions.
- Many older people suffer from arthritic conditions. If this is relevant to your patient consider exercise which avoids orthopaedic stress.
- It is worth noting that a warm up and cool down are especially important for older individuals since their cardiovascular response to exercise may be delayed or blunted.
- Exercise prescriptions need to be dynamic for this population who may suffer from lapses in ability. A flexible prescription should allow for periods of lower activity without the patient feeling like they have “failed” or “aren’t able to keep up”.
- Emphasizing the relevance of exercise to the person’s age or condition may help to motivate. Older people often consider exercise to be something which is no longer relevant or achievable for them. This is not the case.
- Give concrete age-relevant advice. To communicate health messages in an effective way relate the exercise prescription and supporting evidence to their age group, e.g. ‘This type of exercise is especially important/effective for people of your age and has been shown to help …’
- Emphasize the positive rather than the negative.
- Be aware that changes in medication and nutrition can also greatly affect a person’s ability to exercise.
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