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Exercise Recommendations for Older Adults

Aging results in a slow decline in maximal heart rate, aerobic capacity, lung function, and nerve function (unrelated to diabetes), regardless of physical activity levels, and some of these processes can be accelerated by the presence of diabetes1,2.

The usual declines in insulin action with aging, however, actually may be more associated with obesity and physical activity than with aging itself3. Elderly individuals face unique challenges related to continued physical activity participation, including joint injuries, arthritis, osteoporosis and fracture risk, falls, and frailty4,5. Regular physical activity is critical to managing many of these conditions, however, and in many cases may actually prevent or possibly reverse them.

Recommended intensity of aerobic activity should take into account the older adult’s aerobic fitness. In addition, physical activities that maintain or increase flexibility are recommended, along with balance exercises, particularly for older adults at risk of falls. In short, activity should be both preventive and therapeutic and emphasize moderate-intensity aerobic activity, muscle-strengthening activity, reducing sedentary behavior, and risk management6.

Exercise Prescription for Older Adults

Elderly adults who have been primarily sedentary may have physical limitations6. Getting an elderly person to do any kind of physical activity can benefit not only blood glucose control but also muscle tone, flexibility, and mental outlook. Physical activity during weight loss also prevents weight regain in this population7. Yard work and housework are activities many people feel comfortable doing and can be beneficial for maintaining ability to engage in activities of daily living, but inclusion of resistance work to gain strength and retain muscle mass is recommended6,8.

Although the exercise guidelines for adults also apply to older adults, some additional guidelines apply only to older adults6,8:

  • When older adults cannot do 150 min/week of moderate-intensity aerobic activity because of chronic conditions, they should be as physically active as their abilities and conditions allow.
  • Older adults should do exercises that maintain or improve balance, particularly if they are at risk of falling.
  • Older adults should determine their level of effort for physical activity relative to their level of fitness.
  • Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely.

Frequency and intensity. Generally, elderly individuals should engage in some physical activity each day6. Setting goals that this population can reach is the most important strategy. For example, a very sedentary elderly person may only be able to walk for 5 min for 3 days/week and increase that by 1–2 min/week.

Safety considerations. Safety is an issue as well. Safety concerns may preclude someone from walking who has a high risk for falls and subsequent fracture. Options may include using a stationary bicycle, lifting light weights, or exercising while seated. Exercise videos, classes, and routines that can be done from a chair, rather than standing, may be helpful in this population.

 

Table 23.3 Recommended Exercise Rx for Elderly Adults

 
Mode

Aerobic: Walking, cycling, swimming, rowing, aquatic activities, seated exercises, dancing, conditioning machines, and more

Resistance: All major muscle groups, using resistance bands, free weights, resistance training machines, isometric exercises, and/or calisthenics (using body weight); include four or five upper body and four or five lower body/core exercises

Flexibility: Include exercises that stretch the major muscle groups in both the upper and the lower body.

Balance: Simple balance training exercises, such as practice standing on one leg, are important in preventing falls.

Intensity

Aerobic: 40–89% heart rate reserve, or HRR (initial intensity may need to be on the lower end for sedentary, deconditioned, and overweight individuals)

Resistance: 50/60–80% 1 RM (starting on the low end)

Both: Perceived exertion of “somewhat hard” to start; 5–7 (on 10 point scale)

Frequency

Aerobic: At least 3 nonconsecutive days/week, but ideally 5–7 days/week, depending on orthopedic or other limitations

Resistance: A minimum of 2 days per week (preferably 3), with at least 48 h of rest between sessions

Duration

Aerobic: 30 min daily, for a total of at least 150 min/week of moderate-intensity (or possibly higher) activity; start with a minimum of 5–10 min/exercise session; intersperse brief rest periods until a continuous activity for at least 10 min at a time can be achieved, and add 2–5 min/week until desired goal is met

Resistance: 8–12 repetitions per exercise as a goal, but 10–15 repetitions initially; one to three sets per exercise

Progression

Aerobic: Start out on the “low” side and progress slowly over weeks to months; increase duration and frequency first, intensity last (if at all)

Resistance: Start with one or two sets of 8–15 repetitions: one set of 10–15 repetitions to fatigue initially, progressing to 8–10 harder repetitions, and finally to two or three sets of 8–10 repetitions), although the presence of orthopedic or other limitations may require staying with higher repetitions and less resistance

Note: 1 RM, one-repetition maximum.

Physical activity modifications for older adults

When working with older adults, give special consideration to changes in body composition that may have occurred over the years (e.g., declines in muscle mass and muscle strength, with resultant decreases in basal metabolic rate, activity level, and energy expenditure). Guidelines for adults with and without diabetes also apply to older adults (ages ≥65 years)6,8,9,10. Brisk walking, gardening, yard work, and housework are good examples of recommended moderate-intensity activities that help retain physical function, build strength, and expend calories.

For older individuals, it is never too late to begin an exercise program and benefit from it. For example, in the Diabetes Prevention Program, the older adults who met the activity goal of 150 min/week were found to derive the greatest benefit from exercise in preventing T2D compared with their younger counterparts11. Guidelines for adults ages 18–64 years for aerobic exercise, resistance training, and flexibility exercise also apply to older individuals; however, special considerations may be needed for an older population or one that is symptom or condition limited.

Daily Movement

Exercising most days for just a short time, albeit important, is in many ways less critical than what individuals do during the rest of the day. For elderly adults, simply increasing their spontaneous physical activity will bestow innumerable health benefits, including preventing the loss of muscle mass, reductions in mobility, and the onset of frailty12,13. To be most effective, a formal exercise program lasting 30 min/day needs to be combined with more frequent unplanned activities of daily living.

In conclusion, aging reduces physical function on its own, but the presence of diabetes can be an exacerbation to many of these declines over time. The best defense is prevention or reversal of some of these with regular physical activity participation. Older individuals can exercise safely and effectively when certain modifications are made to accommodate normal changes associated with aging and abnormal ones caused by diabetes and other health comorbidities.

References:

  1. Anton, M. M., W. W. Spirduso, and H. Tanaka: Age-related declines in anaerobic muscular performance: weightlifting and powerlifting. Med Sci Sports Exerc 36 (1):143–147, 2004
  2. Abate, M., C. Schiavone, P. Pelotti, and V. Salini: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 23 (4):997–1003, 2011
  3. Amati, F., J. J. Dube, P. M. Coen, et al.: Physical inactivity and obesity underlie the insulin resistance of aging. Diabetes Care 32 (8):1547–1549, 2009
  4. McCabe, L., J. Zhang, and S. Raehtz: Understanding the skeletal pathology of type 1 and 2 diabetes mellitus. Crit Rev Eukaryot Gene Expr 21 (2):187–206, 2011
  5. Morrison, S., S. R. Colberg, M. Mariano, et al.: Balance training reduces falls risk in older individuals with type 2 diabetes. Diabetes Care 33 (4):748–750, 2010
  6. Nelson, M. E., W. J. Rejeski, S. N. Blair, et al.: Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 39 (8):1435–1445, 2007
  7. Wang, X., M. F. Lyles, T. You, et al.: Weight regain is related to decreases in physical activity during weight loss. Med Sci Sports Exerc 40 (10):1781–1788, 2008
  8. Physical Activity Guidelines Advisory Committee: Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC, U.S.Department of Health and Human Services, 2008
  9. Garber, C. E., B. Blissmer, M. R. Deschenes, et al.: 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 43 (7):1334–1359, 2011
  10. Colberg, S. R., R. J. Sigal, B. Fernhall, et al.: Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 33 (12):e147–167, 2010
  11. Knowler, W. C., E. Barrett-Connor, S. E. Fowler, et al.: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346 (6):393–403, 2002
  12. Manini, T. M., J. E. Everhart, S. D. Anton, et al.: Activity energy expenditure and change in body composition in late life. Am J Clin Nutr 90 (5):1336–1342, 2009
  13. Manini, T. M., J. E. Everhart, K. V. Patel, et al., and Aging Health and Body Composition Study: Activity energy expenditure and mobility limitation in older adults: differential associations by sex. Am J Epidemiol 169 (12):1507–1516, 2009

This article is excerpted from Chapter 23 of Exercise and Diabetes: A Clinician’s Guide to Prescribing Physical Activity, a case-study based book available through the American Diabetes Association in June 2013 and written by Dr. Sheri Colberg (find more information about the book online at www.shericolberg.com/exercise-diabetes.asp).

In addition, anyone wishing to earn free CME credits through the ADA for completing a new self-assessment program on exercise and diabetes may do so now through the ADA’s web site at http://professional.diabetes.org/ce