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Just What the Doctor Ordered

A Guide to Robust Assessment and Exercise Prescription in Older Adults

Schlicht, Jeffrey A. Ph.D.; Inskip, Michael Ph.D.; Fiatarone Singh, Maria M.D.

Author Information
ACSM's Health & Fitness Journal: 11/12 2021 - Volume 25 - Issue 6 - p 18-27
doi: 10.1249/FIT.0000000000000718
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PART I: NEEDS ASSESSMENT

Training older adults requires unique skills not normally used with younger clients. Physicians who work with people 65 years and older, known as geriatricians, call their initial patient intake session a comprehensive geriatric assessment (CGA). This differs from a typical personal training or physical therapy intake in that a CGA is a multidimensional exploration of a person’s physical, cognitive, social, environmental, medical, and medication history. Although some aspects of a CGA are beyond the scope of practice of personal trainers, exercise physiologists, or physical therapists, there are ways you can structure your intake protocol that will give you a better understanding of the challenges and limitations your older clients face while trying to initiate and maintain physical activity. Many aspects of a CGA can be performed during your exercise intake session, as well as during training, allowing a skillful exercise professional to make important contributions to a client’s ongoing health care.

THE COMPREHENSIVE GERIATRIC ASSESSMENT

CGA combines a semistructured interview with physical examination, similar to a primary care physician intake, but broader in scope. During the interview, geriatricians review past and present illness, current medications and social supports, and reason for referral. They then ask clients about symptoms they may be having anywhere in the body. Questions might include, “How are you sleeping?” and “Are your feet okay?” The aim is to identify trouble spots that warrant follow-up during the physical exam. For example, if a client is feeling short of breath, the geriatrician would assess cardiopulmonary function.

At the conclusion of the assessment, the geriatrician provides recommendations for treatment. These often include changing medications (deprescribing excess or duplicate medications if polypharmacy [≥5 medications/day] is detected, substituting for potentially inappropriate or hazardous medications, or starting new medications), improving nutritional intake through changes in dietary intake or meal support, improving social support, investigating neuropsychological issues, and prescribing exercise/rehabilitation, all with the goal of optimizing functional independence and quality of life while enhancing the opportunity to age in place.

However, the number of tests geriatricians can complete during a consultation may be limited if they see the patient only once a year. Exercise professionals typically engage with clients over longer periods of time, which means they can provide valuable longitudinal insight into a client’s health history by adopting a holistic approach to assessment. Structuring your client intake session like a CGA allows you to provide data to your client’s physician, making you an important part of the health care team, while improving the safety and effectiveness of your exercise prescription.

Exercise professionals typically engage with clients over long periods of time, which means they can provide valuable longitudinal insight into a client’s health history by adopting a holistic approach to assessment. Structuring your client intake session like a CGA allows you to provide data to your client’s physician, making you an important part of the health care team, while improving the safety and effectiveness of your exercise prescription.

PUTTING IT INTO PRACTICE

A holistic older adult assessment appropriate for exercise professionals to conduct includes, but is not limited to, screening for stability of chronic conditions, evidence of undiagnosed diseases or geriatric syndromes, frailty, cognitive impairment, depression, nutritional abnormalities, polypharmacy, and falls risk. The ultimate aim is to collect sufficient data to clearly articulate where further testing and treatment are needed, as well as design an appropriate exercise prescription to address modifiable risk factors or improve disease management. A brief summary of important assessment domains and tools is given below.

Frailty and Sarcopenia Assessment

The prevalence of frailty and sarcopenia increases with age and chronic disease burden; however, they are not inevitable. Frailty is an umbrella term that describes a modifiable condition of increased vulnerability to life’s stressors that predisposes individuals to an elevated risk of adverse events, morbidity, and mortality. Sarcopenia is a muscle disease involving deficits in strength, lean muscle mass, and physical function that also increases the risk of adverse outcomes. They are separate from chronic disease, but both exacerbate, and in turn are exacerbated by, underlying disease.

The typical presentation of frailty consists of weight loss, slowness, weakness, sedentariness, and fatigue. Current guidelines for both frailty (1) and sarcopenia (2) recommend screening followed by more detailed assessment to identify and treat potentially modifiable causes. Robust progressive resistance training is the core exercise treatment recommended for both conditions (3–6) (Figure 1).

Figure 1
Figure 1:
Frailty and sarcopenia screening.

Cognition, Delirium, and Depression Screening

For older clients who report or present with memory concerns, it is important to identify baseline cognition and affect to help guide exercise prescription and treatment. There is a bidirectional relationship between cognitive impairment and frailty: Cognitive decline significantly increases the risk of becoming frail, and frailty increases the risk of dementia in older adults. Additionally, assessing cognition in your intake provides a baseline measure that may highlight subtle cognitive improvements resulting from exercise.

Depression also can affect cognition. Older adults with mild depression or mild dementia can have similar scores on cognitive screening measures (formerly known as the “pseudo dementia of depression”), and it is now recognized that hippocampal atrophy occurs in both conditions and is reversible with treatment of depression. Both conditions may result in reduced appetite, increased falls risk, and decreased engagement in physical activity and social interactions.

Knowledge of baseline cognition and depression can help identify reasons for poor exercise adherence or progression, worsening neuropsychological symptoms, and even the onset of delirium during or outside of training. Delirium is an acute state of confusion, inattention, and disorientation that has many possible causes (e.g., dehydration, constipation, polypharmacy, and acute illness), and it is a contraindication to exercise that, if left untreated, can lead to serious deterioration in health and cognition (Figure 2) (7–10).

Figure 2
Figure 2:
Cognition, depression, and delirium screening.

Nutritional Screening: Malnutrition

Older adults are at increased risk of inadequate macronutrient, micronutrient, and fluid intake because of reduced appetite (anorexia of aging), social isolation, and functional impairments that may affect shopping, meal preparation, and/or eating and swallowing. Reduced dietary intake also may be exacerbated by frailty, side effects from medications, cognitive or mobility impairments, sedentariness, depression, and disease (e.g., Parkinson’s disease and ulcerative colitis).

Box: Recommended Dietary Allowance for Protein

The recommended dietary allowance for protein in an adult is 0.8 g/kg/day, but it increases to at least 1.2 g/kg/day in older adults to mitigate onset of sarcopenia and optimize related health outcomes.

A dietitian is responsible for comprehensive dietary assessment, intervention, and identification of potential drug–nutrient or disease–nutrient interactions. However, screening for the risk of malnutrition is a responsibility shared by both allied health and medical professionals alike, to ensure other treatments such as exercise work as intended. Exercise prescription can be affected by malnutrition as the anabolic effects of strength exercise may be attenuated if the client is not getting enough energy or protein to fuel strength gains (Figure 3) (11).

Figure 3
Figure 3:
Malnutrition screening.

Overnutrition

With aging, body fat centralizes around the waist and internal organs. Although the risk of mortality related to obesity decreases with age and is not readily apparent until a body mass index (BMI) of >35 kg/m2, obesity is associated with significant morbidity in older adults, including:

  • coronary artery disease
  • depression
  • insulin resistance
  • hypertension
  • systemic inflammation
  • endocrine and other cancers
  • obstructive sleep apnea
  • lower extremity arthritis
  • gout

Because BMI does not examine body composition, and with aging fat accumulates around the waist and vital organs, waist circumference should be used as an index of excess central adiposity in older clients (Figure 4) (12).

Figure 4
Figure 4:
Waist circumference screening.

Medication Screening

Older clients are more susceptible to medication-related adverse events because of the higher prevalence of polypharmacy and hazardous or potentially inappropriate medications. Exercise improves many physiological functions, which may change the effect of prescribed medications. An astute exercise professional can provide valuable information to the physician by documenting adverse adaptations or events potentially attributable to recent changes in medications (Figure 5) (13,14).

Figure 5
Figure 5:
Polypharmacy and orthostatic blood pressure screening.

Falls Risk Screening

Approximately one-third of adults older than 65 years will fall annually, and of that proportion 20% will sustain a serious injury (15). The greatest predictor of a future fall is a history of falling within the last year, and while many risk factors for falls are physical (poor visual acuity, muscle weakness, and antalgic, or pain-avoiding, gait), it is important to screen for neurological (delirium and cognitive impairment) and physiological risk factors (orthostasis, sedation, drowsiness, and hyperglycemia). Many of these factors can change suddenly; thus, it is important to not only assess for falls risk but also communicate this risk effectively to the physician to aid timely treatment. There is no single physical assessment that best identifies falls risk; therefore, a holistic screening tool should be used to identify areas needing further assessment (Figure 6) (16).

Figure 6
Figure 6:
Falls risk screening.

Final Thoughts on Needs Assessment

It is probable you will be exposing your clients to physiological effort beyond their normal daily activity. To ensure optimal safety and client care during exercise, you should be knowledgeable of domains that are typically outside the standard operating model of exercise professionals. Adopting a geriatrician’s holistic approach to client assessment improves understanding of your clients’ health and makes you an important part of the medical and allied health treatment team.

PART II: EXERCISE PRESCRIPTION

Exercise progression for older adults at falls risk follows the Get Up, Stay Up, Move rubric. First, clients must have adequate strength to stand up. Next, they need balance that allows them to move without falling. When strength and balance are sufficient, movement and aerobic exercise can proceed safely (Figure 7).

Figure 7
Figure 7:
Exercise progression.

Exercise progression for older adults at falls risk follows the Get Up, Stay Up, Move rubric. First, clients must have adequate strength to stand up. Next, they need balance that allows them to move without falling. When strength and balance are sufficient, movement and aerobic exercise can proceed safely.

Get Up

In a frail person, the ability to stand from a chair begins with adequate triceps strength needed to shift center of gravity from the chair to the feet and to assist the legs with rising (Figure 8). Gluteus maximus and quadriceps muscles then do the bulk of the work to extend the hips and knees (Table).

Figure 8
Figure 8:
Triceps push down. Photo reprinted with permission from source trial “Maintain Your Brain,” which is funded by a National Health and Medical Research (NHMRC) Dementia Research Team Grant (APP1095097), as well as the participant.
TABLE - Important Training Muscles for Older Adults
Get Up
Triceps brachii
Gluteus maximus
Quadriceps
Stay Up
Rectus abdominus
Erector spinae
Hip abductors
Move
Tibialis anterior
Hip flexors

The ACSM strength training guidelines (17) for older adults are the same guidelines used with adults of any age (Figure 9). The FITT prescription includes 2 to 3 days/week, 2 to 3 sets, 8 to 12 reps, at a vigorous intensity of 8 out of 10 on a rating of perceived exertion (RPE) scale.

Figure 9
Figure 9:
ACSM resistance training guidelines.

Because Type II (fast twitch) muscle fibers are disproportionately lost during aging, power training that emphasizes a rapid (1 to 2 seconds) concentric phase and a slow (3 to 4 seconds) eccentric phase is recommended as long as it is not contraindicated by underlying joint pathology, as it preferentially recruits this fiber type (Figure 9) (18).

In addition to training the triceps, gluteus maximus, and quadriceps, muscle groups that assist with stability and gait should be targeted. Core stabilizers include the rectus abdominis and erector spinae. Balance recovery muscles include the hip abductor muscle group that allows for rapid lateral leg movement needed to recover from a potential fall. Important gait muscles include the tibialis anterior for adequate dorsiflexion that prevents toes from catching and the iliopsoas group for hip flexion to provide adequate leg lift during ambulation.

It is important to note that high-intensity progressive resistance training is safe and effective in older adults (note the 8/10 RPE target from ACSM). Rapid and important strength gains occur when high-intensity resistance is used and relative intensity is maintained over time by increasing resistance as clients gain strength.

Stay Up

Once a person is able to stand up, balance becomes important for preventing falls. A frail individual may have difficulty controlling body sway in a narrow stance. Figure 10 illustrates the progression from easiest to most challenging stance (19).

Figure 10
Figure 10:
Standing balance progression.

If your client is able to stand on each foot separately without losing balance, closing eyes, adding arm movements (placing a peg in a board, spelling words with magnetized letters), or challenging proprioception with an unstable surface can add additional levels of difficulty.

Balance training is a form of neuromotor training. The ACSM guidelines for neuromotor training include 2 to 3 days/week, 20 to 30 minutes/bout, 60 minutes/week (17). As with any mode of exercise, the overload principle applies: Improvement results when the body is challenged beyond its normal limits. For balance training, this means working at a level of difficulty that has not yet been mastered (i.e., almost losing one’s balance but not falling).

Move

Someone with stable gait should be encouraged to practice functional movements that challenge neuromotor skills, such as walking up and down stairs or maneuvering around objects. Clients who can handle these tasks easily can progress to standard cardiorespiratory training, such as walking/hiking/jogging. Weight-bearing modalities are preferable to cycling or swimming because they target balance, ambulation, and bone health more directly. The ACSM FITT prescription includes 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity cardio (17).

Someone with stable gait should be encouraged to practice functional movements that challenge neuromotor skills, such as walking up and down stairs or maneuvering around objects. Clients who can handle these tasks easily can progress to standard cardiorespiratory training, such as walking/hiking/jogging. Weight-bearing modalities are preferable to cycling or swimming because they target balance, ambulation, and bone health better than non–weight-bearing exercises.

Final Thoughts on Exercise Prescription

It is important to remember that prescribing cardio is the last stage in exercise progression for older adults who have mobility impairment or frailty. Telling your older clients to go for a walk before they have sufficient strength and balance to do so safely is a recipe for potential disaster, as walking in the natural environment provides multiple opportunities for falls.

Across the life span, as your focus on disease prevention shifts to include treatment of chronic disease, disability, and age-related changes in physiology, the rationale and the evidence base for strength and balance training relative to aerobic exercise grow stronger with each decade of life.

BRIDGING THE GAP

Older adults often have complicated medical histories. Enhanced prescreening that evaluates more than blood pressure, body fat, and exercise history provides important information for proper exercise prescription that should follow the Get Up, Stay Up, Move rubric. Adding tests to your usual battery of intake exams enhances your value to clients and their medical teams.

References

1. Dent E, Lien C, Lim WS, et al. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty [published correction appears in J Am Med Dir Assoc. 2018 Jan;19(1):94]. J Am Med Dir Assoc. 2017;18(7):564–75.
2. Chen LK, Woo J, Assantachai P, et al. Asian working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21(3):300–307.e2.
3. Malmstrom TK, Miller DK, Morley JE. A comparison of four frailty models. J Am Geriatr Soc. 2014;62(4):721–6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4519085/pdf/nihms-709068.pdf.
4. Comprehensive Geriatric Assessment Toolkit Plus Web site [Internet]. Westmeath (Ireland): Angelo Grazioli; [cited 2021 Jan 13]. Available from: https://www.cgakit.com/sarc-f-questionnaire.
5. Shirley Ryan AbilityLab® Web site [Internet]. Short physical performance battery. Chicago (IL): Rehabilitation Institute of Chicago; [cited 2021 Jan 13]. Available from: https://www.sralab.org/rehabilitation-measures/short-physical-perfromance-battery.
6. Shirley Ryan AbilityLab® Web site [Internet]. Hand held dynamometer grip strength. Chicago (IL): Rehabilitation Institute of Chicago; [cited 2021 Jan 13]. Available from: https://www.sralab.org/rehabilitation-measures/hand-held-dynamometergrip-strength.
7. Montreal Cognitive Assessment Test Web site [Internet]. Quebec (Canada): Ziad Nasreddine; [cited 2021 Jan 13]. Available from: https://www.mocatest.org/.
8. Comprehensive Geriatric Assessment Toolkit Plus Web site [Internet]. GDS-15. Westmeath (Ireland): Angelo Grazioli; [cited 2021 Jan 13]. Available from: https://www.cgakit.com/p-4-gds-15.
9. 4AT – Rapid Clinical Test for Delirium Web Site [Internet]. Edinburgh (Scotland): Alasdair MacLullich; [cited 2021 Jan 13]. Available from: https://www.the4at.com/.
10. Shirley Ryan AbilityLab® Web site [Internet]. Older adults and geriatric care. Chicago (IL): Rehabilitation Institute of Chicago; [cited 2021 Jan 13]. Available from: https://www.sralab.org/rehabilitation-measures/walking-while-talking-test#older-adults-and-geriatric-care.
11. Nestle Nutrition Institute Web site [Internet]. Bridgewater (NJ): Nestlé Health Science; [cited 2021 Jan 13]. Available from: https://www.mna-elderly.com/forms/mna_guide_english_sf.pdf.
12. International Diabetes Federation Consensus Worldwide Definition of the Metabolic Syndrome Web site [Internet]. Brussels (Belgium): International Diabetes Federation; [cited 2021 Jan 13]. Available from:. https://www.idf.org/e-library/consensus-statements/60-idfconsensus-worldwide-definitionof-the-metabolic-syndrome.html.
13. Patient Safety Network Web site [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; [cited 2021 Jan 13]. Available from: https://psnet.ahrq.gov/issue/stoppstart-criteria-potentially-inappropriate-medications- potential-prescribing-omissions.
14. Stop Elderly Accidents, Deaths, & Injuries Web site [Internet]. Atlanta (GA): Centers for Disease Control; [cited 2021 Jan 13]. Available from: https://www.cdc.gov/steadi/pdf/Measuring_Orthostatic_Blood_Pressure-print.pdf.
15. Home and Recreational Safety Web site [Internet]. Atlanta (GA): Centers for Disease Control; [cited 2021 Jan 13]. Available from: https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.
16. Department of Health & Human Services Web site [Internet]. Melbourne (Australia): State Government of Victoria; [cited 2021 Jan 13]. Available from: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/falls-risk-assessment-tool.
17. Garber CE, Blissmer B, Deschenes MR, et al; American College of Sports Medicine. American College of Sports Medicine Position Stand: quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–59.
18. American College of Sports Medicine Web site [Internet]. Indianapolis (IN); [cited 2021 Jan 13]. Available from: https://www.acsm.org/docs/default-source/files-for-resource-library/resistance-training-for-health.pdf?sfvrsn = d2441c0_2.
19. Centers for Disease Control Web site [Internet]. Four stage balance test. Atlanta (GA); [cited 2021 Jan 13]. Available from: https://www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf.

Recommended Readings

  • Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31.
  • DeLorme TL, Watkins AL. Progressive Resistance Exercise: Technic and Medical Application. New York (NY): Appleton-Century-Crofts, Inc.; 1951. 245 p.
  • Dent E, Lien C, Lim WS, et al. The Asia-Pacific Clinical Practice Guidelines for the Management of Frailty. J Am Med Dir Assoc. 2017;18(7):564–75.

Keywords:

Older Adult; Geriatric Assessment; Sarcopenia; Falls Risk; Exercise Prescription

Copyright © 2021 by American College of Sports Medicine.