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Background: Frail elders often have chronic illnesses, such as osteoarthritis, hypertension, diabetes,
and peripheral vascular disease, for which exercise is a proven means of achieving nonpharmacologic
benefits, even at advanced age. Exercise has been shown to enhance the quality of life for these elders.
Methods: A literature search of exercise literature applied to older adults and lifestyle modifications
was conducted, summarized, and then reviewed with practicing colleagues.
Results and Conclusions: Exercise continues to be an underused therapeutic intervention for frail
elders as a result of barriers created by patients themselves, their caregivers, and their health care pro-
viders. Family physicians can overcome these barriers by prescribing appropriate exercises and by tai-
loring the exercise to the functional needs and preferences of their patients. An exercise prescription
for frail elders is based on a pragmatic strategy that makes therapeutic exercise both sustainable and
safe. Such a strategy incorporates motivational elements and knowledge of achievable benefits. (J Am
Board Fam Pract 2002;15:218 –28.)
This article reviews why exercise should be consid- bility and safety, which are critical to functional
ered for frail elders both as a general lifestyle en- independence.4
hancement and as a targeted disease state interven- In addition to its potential for improving general
tion and suggests strategies for family physicians to measures of health, exercise can be a specific ther-
increase the exercise activities of their patients. apeutic intervention for the many accumulated
Inactivity increases with aging. Although about chronic illness of frail elders. These diseases in-
one half of the overall population reports doing clude osteoarthritis, diabetes, peripheral vascular
some routine exercise activities, only 30% of those diseases, coronary heart disease and congestive
aged 65 and older report any regular exercise.1 This heart failure, obesity, and depression.4 Targeted
inactivity is in stark contrast to current recommen- exercise interventions for such conditions are com-
dations of 30 minutes of activity on most days of monly recommended for the affected younger pa-
the week.2 Exercise encouragement was an impor- tient populations and should also be considered for
tant element of Healthy People 2000,3 which sought frail elderly patients.
to enhance public health awareness. A target goal of Although there has been a shift from viewing
the initiative was that 50% of primary care provid- exercise as the purview of fit athletes and those
ers counsel all their patients on exercise. This issue participating in organized sports toward its use in
is not only important for young elders, it also ap- achieving improved health and well-being for ev-
plies to frail elders for whom dramatic changes in eryone, family physicians will encounter several
outcome measures have resulted from exercise in- barriers to motivating frail elders to exercise. These
terventions even at advanced age. These benefits patients’ overall level of functioning has decreased
include the direct measures of enhanced muscle as the result of one or more chronic conditions, and
mass, cardiovascular endurance, and bone density exercise is seldom considered either by the older
changes, and such indirect measures as greater mo- adults themselves or by their health care providers.5
Barriers to exercise for this patient population in-
clude a lack of knowledge about the documented
benefits of exercise in older patient populations,
Submitted, revised 26 July 2001.
From the Department of Family Medicine (JMH, MRS), attitudes about the appropriateness of physical ex-
Robert Wood Johnson Medical School, University of Med- ercise for older adults, and environmental factors
icine and Dentistry of New Jersey, New Brunswick. Address
reprint requests to John M. Heath, MD, One RWJ Place,
that do not encourage exercise.6 Understanding
Box 19, New Brunswick, NJ 08903-0019. and responding to overcome those barriers are key
sight associated with such dementias complicate There are documented benefits from having the
patients’ participation in exercise programs, these mode of exercise incorporate movement for bal-
conditions should not be considered contraindica- ance and flexibility, both of which are major factors
tions for participation in supportive and supervised in fall prevention.23 Once aerobic movement is
exercise activities. Cognitively impaired persons established and becomes routine, increasing the
have been incorporated successfully into facility- intensity by adding various forms of resistance
based supervised movement and exercise programs training can increase the strength of the involved
with positive outcomes.4,57 muscle groups. Resistance training can include
elastic bands of various tensile strengths, as well as
Prescribing Exercise for Frail Elders the more typical metal dumbbells or plastic-formed
The traditional elements of an exercise prescription weights filled with sand or water. Using weights in
can be applied to frail elders: mode of exercise, the form of hand-held drinking bottles filled with
intensity of exercise, and frequency of exercise.15 A water can provide a motivation for continued hy-
fourth element—progression—is often included dration, which is important with outdoors exercise.
but is less important in those for whom the primary The initial frequency of an exercise routine for
goal is not aerobic fitness. Likewise, exercise inten- frail elders can be as short as 6 minutes, repeated
sity might focus on establishing an upper level of throughout day. Whereas younger and more mo-
endurance rather than a specific threshold. bile patients might consider exercise as a single
The variety of exercise modes appropriate for defined event, shorter and more frequent exercise
frail elders depends on preserved functional skills, periods might be more feasible for frail elders,
available resources, and perhaps most importantly, whose schedules often allow more flexibility. Daily,
those forms of exercise that offer the most enjoy- specific exercise periods promote optimum sustain-
ment and can be sustained. Pain-free range of mo- ability, although documented benefits in frail elders
tion is key to all three factors. If whole body move- have resulted from as little as 30 cumulative min-
ment is not possible initially, the patient should utes of exercise a week. Exercise as a group activity
start with isolated upper and lower extremity move- encourages both socialization and peer reinforce-
ments from a stationary position. There is no com- ment.58
pelling evidence that endurance exercises (eg, aer- When family physicians discuss the various
obic activities) are better than resistance training modes of exercise for their frail elderly patient, it is
(eg, weights) for elderly patients, so a combination important to address explicitly the pleasurable as-
of approaches can be appropriate. pects of an exercise to help make it sustainable.
Pleasure can be derived from the environment in caregivers and other health care providers. Table 4
which the exercise will be conducted (eg, access to provides some guidance to support prescribing ex-
music, companionship, etc). Exercise can be inte- ercise.
grated into a daily routine by proactively eliminat-
ing barriers to activities of daily living (eg, having a
toilet available, creating a safe walking environ- Specific Conditions Requiring Special
ment). Further examples of exercise modes appear Consideration
in Table 2 and in the discussion of specific disease Chronic obstructive pulmonary diseases, such as
states and functional limitations. chronic bronchitis and emphysema, are common
Table 3 provides an outline of suggested exercise conditions for which exercising specific breathing
prescriptions adapted for a frail elderly population. musculature and general skeletal muscles can result
Although a written prescription of physician rec- in major improvements in disease status. The lim-
ommendations might reinforce adherence, it alone iting factor of breathlessness might require that
is unlikely to effect change without the accompa- oxygen desaturation be monitored during activity.
nying personal involvement of the patient’s own Pulse oximeters attached to the finger tip can
Intent: this exercise program will help my . . . . Circulation problems, heart condition, breathing condition,
diabetic glucose control, arthritis, etc
Exercise type (mode): I agree to start this type of exercise Strengthening arm and leg muscles
Walking
Balance practices
Stretching neck and back muscles, etc
Dose (endurance): I agree to try this amount of exercise 10 minutes each session, I breath comfortably from my
mouth, my heart rate reaches about beats per minute,
my oxygen saturation level is at
Frequency: I agree to try to do this exercise this often Every morning at breakfast, every time my aide comes, before
my nightly dessert, before my bath, during my favorite
radio or TV show, etc
record heart rate as well as measure the level of weight-bearing load over the affected joint is re-
oxygen saturation. Having supplemental oxygen duced and when the range of motion is maintained
available where the patient will be exercising is also to avoid painful rotational joint stresses.60 Exercis-
recommended. ing in water provides the greatest reduction of
Patients who have ischemic heart disease also weight over the joint, although nonaquatic pro-
can benefit from breathlessness assessment by grams that support the joint against gravity also are
monitoring oxygen levels at the start of routine helpful. For example, knee resistance exercise
exercise activities. In addition, nitrates in either might be done while lying on one’s side on a pad-
spray form or sublingual tablets should be imme- ded surface, with the lower leg sliding along the
diately available. Finally, electronic pulse monitor- surface. For weight-bearing exercise, wedge insoles
ing, either by the patient or by a supervisor, can or other forms of unloading orthotic devices de-
ensure that the intensity of exercise does not result signed to alter the alignment of stresses on the joint
in excess tachycardia. might have a disease-modifying effect for those
Diabetic patients who require insulin need to be who have osteoarthritis of the knee.61 Splints that
aware of the potential for hypoglycemia during limit range of motion to specific planes and prevent
exercise training and during the hours after cessa- hyperflexion of an impaired joint can also be used
tion of exercise. Patients should not exercise if their with muscle-strengthening exercises.
blood glucose levels exceed 250 to 300 mg/dL, and
blood glucose levels should be monitored before
and after exercise. High-carbohydrate foods should Physician’s Role in Motivating Exercise
be available.59 These patients should wear an iden- Given that benefits are possible from exercise and
tification tag or other means to alert those around that barriers to exercise can be overcome, how can
them of their diabetic status should they become the family physician motivate their elderly patients
unresponsive after their exercise period. Diabetic to begin exercising? One commonly used technique
patients with peripheral neuropathy need to take is to assess their patient’s readiness to start exercis-
precautions with their footwear during weight- ing according to their stage of change. The trans-
bearing activities. Weight-bearing activities such as theoretical model of change postulates there are
treadmill or step exercise are relatively contraindi- five distinct cognitive stages that must be resolved
cated, whereas general aerobic activates without when contemplating a change in lifestyle or habit:
weight bearing (eg, rowing, chair-based strength- precontemplation, contemplation, preparation, ac-
ening) are recommended. Physicians should also tion, and maintenance. The first step is to deter-
consider the temperature of the environment in mine whether patients have thought about incor-
which diabetic frail elders (and other frail elderly porating some form of regular exercise into their
patients) will be exercising. Nursing homes in par- lives, ie, whether they have moved from the pre-
ticular might need to ensure that the room used for contemplative stage to the contemplative stage.62
exercise not be overly heated to the temperature Once the decision to exercise has been made, the
required for sedentary activities. preparation stage includes planning for the exercise
Osteoarthritis of knees or hips will benefit most routine, seeking companions, arranging the sched-
from both resistance and aerobic exercise when the ule, and setting a start date. The next stage is