"Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it." - Plato
According to the U.S. Census Bureau, in 2000, individuals aged 80 to 84 years comprised 4.9 million or 14% of the older population (older than 65 years). Those older than 85 years numbered 4.2 million or 12%; moreover, persons aged 85 to 94 years represented a 37.9% increase from the 1990 census for the age group "65 years and over." During this period, each state reported an increase in the population of older adults, with only the District of Columbia reporting a decrease (31).
With the escalating number of older adults, the importance of maintaining good health and functional independence is critical, considering the prevalence of premature disability and the escalating cost of assisted living and nursing home facilities. Indeed, the 2008 national monthly rate for an assisted living facility private room was $3,008.00. The national daily rate of a private room in a nursing home averaged $209, which approximates $6,270 per month (13).
Often, the elderly are stereotyped in the media as frail, inactive, and "senile." As such, they may be overlooked as potential patrons of health-fitness facilities, especially individuals 80 years and older. Clearly, potential clients lie within this escalating population, whether your target customer is a cardiac rehabilitation patient or fitness center participant. For seniors seeking supervised physical activity in a dynamic noncompetitive environment, an instructor-led group is increasingly viewed as an attractive option.
This article reviews the benefits of physical activity in older individuals, with specific reference to contemporary issues, including fitness and mortality, cognitive and sexual function, and preventing premature disability. A review of motivating factors and goal setting, updated physical activity recommendations for older adults from the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), and exercise-programming ideas for seniors is provided.
BENEFITS OF PHYSICAL ACTIVITY
Research has documented the benefits of maintaining an exercise program into the later years, using resistance and aerobic training, ideally in combination. In fact, a moderate-intensity aerobic training program has been shown to increase the exercise capacity of community-based subjects 80 years and older (32). In addition, nursing home residents aged 70 to 92 years demonstrated an increase in quadriceps strength after 12 months of low-intensity training (17). The associated improvements in cardiorespiratory endurance and muscular strength can mean the difference between institutionalization and independent living for the senior population.
Falls have the potential to lead to the deterioration and debilitation of health status in the elderly. According to the National Safety Council, the leading cause of disability and injury deaths for individuals 65 years and older is falls. The cost of medical treatment related to falls for persons older than 65 years in 2020 is projected to be $43.8 billion (21). Exercise professionals can proactively focus on balance training and fall precautions to help attenuate this sobering estimate. Programs aimed at fall prevention and improving balance, including the use of Tai Chi training, have been shown to be beneficial in community-dwelling older adults (30) and residential care facility residents (10).
Regular exercise also seems to have antiaging effects. A recent provocative study compared the cellular morphology of twins (aged 18-81 years) who demonstrated varying levels of physical activity (inactive, light, moderate, and heavy). Participants who were less physically active, had a higher body mass index, and were smokers had cellular characteristics that were 10 years older than their more active, normal weight, nonsmoking twin counterparts (9). Collectively, these data suggest that lifestyle habits and regular exercise may have major ramifications for attenuating the consequences of aging in our society.
FITNESS AND MORTALITY
The United States spends more on health care than any other nation in the world, yet it ranks poorly on many measures of health status. The estimated 2009 life expectancy at birth of a person living in the United States is 78.1 years. Accordingly, longevity in the United States ranked 50th of 225 countries, using statistical data from the Central Intelligence Agency (8). Clearly, deleterious behavior patterns, including physical inactivity, represent the major contributor to premature death.
The difference between regular participation in moderate-to-high levels of physical activity and a sedentary lifestyle can mean adding additional years of cardiovascular disease-free life, according to a recent study (12). Using the Framingham database, researchers reported that men older than 50 years added 3.7 years in total life expectancy while living 3.2 more years without cardiovascular disease if they engaged in high levels of physical activity. In contrast, moderately active individuals gained only 1.3 years in total life expectancy and 1.1 years of cardiovascular disease-free lives. Women demonstrated similar results to that of men for both total life expectancy and years lived free of cardiovascular disease.
Additional studies also emphasize that fitness reduces mortality in older adults. In particular, the amount of daily exercise seems to play a role. According to one study (14), the mortality rate in men aged 61 to 81 years was significantly lower if they walked more than 2 miles daily compared with men who walked 1 mile or shorter during a 12-year follow-up period. A more recent study examined the relationship between fitness, adiposity, and mortality in older adults (mean age, 64 years) (28). Results indicated that fitness was a significant mortality predictor, independent of overall or abdominal adiposity. It seems then that older adults who engage in routine physical activity live longer.
COGNITIVE AND SEXUAL FUNCTION
In addition to the functional and social benefits that result from regular exercise, improvements in memory and cognitive function have also been reported among older adults. Recent observational studies support the effectiveness of a regular exercise program on reducing the risk for or delaying the onset of dementia in elderly men and women (1,18). Moreover, improvements in cognitive function have been noted after participation in a regular endurance program (36).
According to the 2009 Alzheimer's Disease Facts and Figures report, Alzheimer's disease is the sixth leading cause of death in the United States, with 5.3 million people living with the condition. A new case is diagnosed every 70 seconds. Essentially, the disease triples health care costs for Americans 65 years and older (2). Although definitive data are lacking regarding the effect of regular exercise on cognitive function, dementia, and Alzheimer's disease, several observational studies support the potential benefits of a physically active lifestyle (19,26).
Underlying chronic health conditions can adversely influence sexual function in middle-aged and older men. Erectile dysfunction may occur in up to 80% of men 75 years and older (20). One widely cited study of male subjects aged 53 to 90 years investigated the association of age, lifestyle habits, and sexual function. Physical inactivity and overweight/obesity were the two lifestyle factors most strongly associated with erectile dysfunction. Participants with the lowest risk of developing erectile dysfunction generally practiced healthy lifestyle habits and had no evidence of chronic disease (3).
As of March 2009, according to the Bureau of Labor Statistics, nearly 12 million adults 65 years and older have a disability; of these, 11 million are not currently in the labor force (7). Several years ago, a classic study addressed cumulative disability and its relationship to aging and health risks (e.g., overweight/obesity, cigarette smoking, physical inactivity). The authors reported that being an active, lean, nonsmoker in midlife and late adulthood could delay disability by approximately 5 years compared with sedentary overweight smokers. In addition, the findings indicated that initial and lifetime disability could be markedly postponed if these health risks were favorably modified (35).
More recently, researchers studied the impact of a 12-week lifestyle intervention program on frail obese older adults (≥65 years), specifically examining the effects of weight loss and regular exercise on physical function. The treatment group demonstrated increased peak oxygen consumption and functional status, improved strength and walking speed, and a reduction in body weight and fat stores. In contrast, the control group remained largely unchanged. These results suggest that frailty could be improved with weight loss and exercise in this escalating patient population (34).
The potential for exercise professionals to minimize disability because of lifestyle choices in the growing elderly population is a lofty goal; however, it has major socioeconomic ramifications. Because regular physical activity has been shown to promote independent living and delay the disability threshold, organizations that assist seniors are increasingly including fitness and exercise information on their Web sites. Several are listed below.
* American Association of Retired Persons www.aarp.org
* American Council on Exercise www.acefitness.org
* Centers for Disease Control www.cdc.gov/physicalactivity
* International Council on Active Aging www.icaa.cc
* National Institute on Aging www.nihseniorhealth.gov
* National Senior Games Association (associated with the Senior Olympics) www.nsga.com
In summary, health and fitness experts can help middle-aged and older adults live a longer and more productive life by emphasizing the improved quality and quantity of life that results from regular participation in a structured exercise program, increased lifestyle activity, or both.
MOTIVATION AND SOCIALIZATION
For the exercise professional, parts of the benefits of training clients 80 years and older are the challenge and fulfillment of working with individuals with varied comorbid conditions and physical frailty and witnessing firsthand the improvements in functional capacity and psychosocial well-being. For the elderly exerciser, moreover, the ability to discuss relevant topics and ask questions related to personal health issues and concerns can be highly therapeutic. In addition, an exercise class composed of senior attendees can be a forum for discussion among those with similar interests and life experiences, such as playing golf or tennis. New friendships among classmates can be fostered in and extended out of class, opening additional avenues for social support. In turn, these may assist with exercise compliance issues not related to physical ailments that often affect the elderly, including psychosocial barriers to participation such as sadness, loneliness, or depression. Regular exercise may reduce depression, particularly in older individuals (4); thus, the value of structured physical activity in reducing depressive symptoms in both healthy and clinical populations should not be ignored (6). Moreover, the formation of a social support group through exercise not only provides motivation for the elderly client, but can also cultivate a network of friends with whom they can regularly confide in and interact with. For the older participant, the benefits of exercise go beyond the physical improvements and include socialization with others, especially important for the client who has lost his/her spouse or the participant with a limited network of family/friends (29).
Two methods of motivation (25) that exercise professionals can use with clients include goal-oriented gradual activity progression (setting goals) and adaptation of activities and equipment (exercise programming).
Initial communication with elderly clients should include questions regarding their short- and long-term goals. These may involve improving balance and muscle strength related to activities of daily living or, from a practical perspective, more easily carrying a basket of laundry or bag of groceries up a flight of stairs. Although improving body composition may be regarded as desirable for improving health, reducing body weight and fat stores may be of lesser importance to the participant.
Goal setting can be accomplished using the following suggestions (5,29):
* set long-term goals for exercise (e.g., improving overall health, reducing borderline hypertension, increasing cardiorespiratory fitness)
* choose one or two short-term goals first, focusing on behavior change (e.g., attending class three times a week vs. weight loss)
* set the client up to succeed with specific trackable goals (e.g., avoid vague goals and use a log or diary to track progress over time)
UPDATED PHYSICAL ACTIVITY RECOMMENDATIONS
In 1995, recommendations for physical activity for adults were published by the U.S. Centers for Disease Control and Prevention and ACSM (23). An updated version was published by the ACSM and the AHA in 2007 (15), which focused primarily on physical activity guidelines to promote public health in young and middle-aged adults. Moreover, ACSM, in collaboration with the AHA, simultaneously published a companion statement for older adults (summarized in the Table) (22). These recommendations included:
* aerobic intensity for the older adult
* balance exercises for those with fall risk
* activity plan incorporating preventive and therapeutic approaches
Exercise programming for the elderly follows similar principles designated for younger exercisers (11). Before initiating an exercise program, it is recommended that the functional ability level of your client, such as "physically dependent, frail, independent, fit, or elite," be identified (33). Such evaluations may include walking tests for time and/or distance (27); completion of the Duke Activity Status Index (16) to estimate aerobic capacity, expressed as metabolic equivalents; and peak or symptom-limited treadmill or cycle ergometer stress testing. The physical capability of the elderly can vary significantly across sexes, age ranges, and comorbid conditions. Activities for older adults, which can accommodate varied fitness levels, include chair, low-impact and water aerobics, walking, resistance training, and Tai Chi (11,33). In addition, designing physical conditioning programs to enhance the ability to perform recreational activities (e.g., playing golf) may be especially important for some participants. Lastly, it is highly recommended that "senior-appropriate" strength training machines, that is, those that are user-friendly and easily adjusted, be used (24,33).
A few "Dos and Don'ts" for leading aerobic exercise and strength training include (5,11,24,29,33)
Recommendations and alternatives to traditional exercise programming ideas include (5,11,24,33)
* tossing balls of various sizes, shapes, and surfaces (e.g., rubber, soft, spongy) can challenge and improve reaction time, agility, and kinesthetic awareness
* squeezing sponges or balling newspaper with the hands and feet to increase strength
* using machines versus free weights for better stabilization and control during range of motion
* using elastic tubing or bands as viable strength training options that appeal to elderly and novice exercisers
* using light ankle or wrist weights
* practicing balance exercises such as standing on one leg while waiting in line or sitting on a large ball
* performing crossover, sideways, or heel walking to improve balance
CONDENSED VERSION AND BOTTOM LINE
Potential exercise clients can be identified within the escalating elderly population in the United States. Safe and effective exercise practices require appropriate activity modifications in the elderly. Socialization within participant groups is a highly beneficial aspect of the exercise program and can enhance attendance at classes and reduce symptoms of depression and loneliness. Risks for disability and dementia may be decreased and cognitive function improved with regular exercise in older adults.
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