Materi Kuliah Ilmu Kedokteran Olahraga Pendidikan Profesi Dokter Umum, modul Praktek Klinik Ilmu Geriatri

Dr. R. Wishnu Hidayat, SpKO, Staf Akademik Program Studi Ilmu Kedokteran Olahraga FKUI

Principle of Exercise for the Elderly

Elderly is community that need special attention. This is because every year the amount of
elderly is always increase and begin to suffer from many health problems. Elderly commonly in
situation in which they are frail and dependent to younger person and their family. Physical
problem commonly affect elderly are decrease or low cardiorespiratory function, decrease in
muscle strength and endurance, also flexibility and balance function, disease of
musculoskeletal, metabolic and other degenerative diseases, like cardiovascular disease.

Being health and active elderly is everybodys dream. This condition will reduce health
problems in elderly significantly. Being Health and active elderly can not be happened instantly,
but has a long process in which ideally begin at young age. For the elderly who is sedentary,
there is never too late for becoming health. They also can get the beneficial effect of exercise
but surely not as high as if they begin at younger age. The beneficial effect of health by
engaging regular exercise are increase in cardiovascular and respiratory function and efficiency,
lower resting blood pressure and heart rate, controlled metabolic status, increase in muscle
strength and endurance and flexibility, et cetera, including improvement in mental and cognitive
function. Improvement in those weakend physical condition towards better will make better
quality of life of the elderly.

Physical activity and exercise has to conduct in correct/good ways, regularly and
measurable, so the elderly will get high benefit and lower risk of injury. To know that, we need
knowledge and skill that we learn from active learning process. In the context of geriatric
medicine module, primary physician candidate is expect to understand and knowing the
exercise principle for elderly and so they can give advice to them in the context of health
promotion and prevention.

Aging and Exercise Performance

Aging process is the process of decreasing the function of tissue/organ slowly to repair
itself, maintain its structure and function normally, so the cell can not struggle from injury or
infection. In Indonesia, the definition of elderly based on Elderly Health Act number 13/1998 is a
person who is aged 60 years old and above.

Every person will come to aging process. Even though, the process in every person is
different in the speed of aging. The factors that influence the aging process in general is genetic
and environment. The genetic factor can not be change, while the environtment can. The
environment factors include nutrition, pattern of physical activity, emotional/mental stress,
smoking/pollutant, etc.

In general, elderly will has change in their body structure (anatomical, histological) and
functional (sensory, motor function and cognitive).

Table. Effect of Aging Process on Physiology and Health Variables

Variable Changes

Resting heart rate unchanged

Maximal heart rate lower

Maximal cardiac output lower

Resting and exercise blood pressure higher

Maximal VO2 lower

Residual volume higher

Vital capacity lower

Reaction time slower

Muscle strength lower

Flexibility lower

Bone mass lower

Fat free body mass lower

Percent body fat higher

Glucose tolerance lower

Recovery time longer

The ability of the body to take the oxygen, distribute and using it to produce the energy become
basis of functional changes in aging process. Maximal oxygen consumption is decrease 8-10 %
every decade since the age 25 in men and women. Decrease in daily physical activity is part of
the cause. Also persons who regularly engage in regular exercise the VO2max will decrease 5-
10 % per decade. With regularly engage in exercise, the loss of VO2max in elderly will low or
protected. Person 60-70 years old can tolerate exercise to increase cardiorespiratory fitness,
and the results can over the younger inactive adults. Healthy person 50 years old with high
intensity cardio training can increase their VO2max 20-30% higher than younger inactive

In musculoskeletal system there is decrease in muscle mass (sarcopenia) and bone mass
(porotic) due to aging process, which caused decrease in muscle and bone strength and
physical disability. Muscle strength will peak at third decade and maintain until 50s then
decrease. Muscle fiber will decrease 10% every decade after 50s. By the age 65, muscle
strength will decrease 20%. Cortical and Trabecular bone mass decrease so the risk of fracture
especially in vertebral and long bone increase. Women at higher risk than men with this fracture
and the incidence increase after 50s. In a joint, there is degenerative process caused by
decrease in condrocit function and cause osteoarthritis. Tendon, ligament and joint capsule
become fibrotic so the stretch capability decrease and easier to torn or injured. Tendon and
ligament that easily rupture are rotator cuff and long head biceps, patellar tendon, and Achilles
tendon. The decrease in muscle mass and strength in aging can prevent by engaging proper
muscle strength program.

Physical Activity and Exercise in Elderly

The benefit of physical activity or exercise in elderly are:

- Elderly who engage regular physical activity able to do daily activity task better
than no regular physical activity.

- Aerobic exercise program increase cardiorespiratory fitness and, longer life and
decrease risk of cardiometabolic disease such as hypertension, low HDL-C level,
high glucose level.

- Strengthening exercise program will decrease the muscle mass loss and
increase muscle strength, increase bone health and decrease risk of
osteoporosis

- Exercise training lower the risk of falling and improve flexibility and range of
motion.

- Exercise routinely can improve mental health, maintain or improve cognition or

memory function , reduce or prevent from depression and anciety, and increase
self esteem.

Screening Participants of Exercise Program / Pre Exercise Assessment

Screening participants or pre exercise assessment is aim to gain information about health status
or cardiovascular risk. It is very important to do to the elderly before they begin to exercise
regularly. The assessment also important to find any contraindication to exercise, because
exercise also has some negative impact or risk if done incorrect. One tools that we can use to
do screening in fast way is PAR-Q assessment (Physical Activity Readiness Questionnaire), for
the person 17-69 years old. The questionnaire is consist of 7 question as follow:

1. Has your doctor ever said that you have a heart condition and that you should only do physical
activity recommended by a doctor?

2. Do you feel pain in your chest when you do physical activity?

3. In the past month, have you had chest pain when you were not doing physical activity?

4. Do you lose your balance because of dizziness or do you ever lose consciousness?

5. Do you have a bone or joint problem (for example back, knee or hip) that could be made worse
by a change in your physical activity?

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or
heart condition?

7. Do you know of any other reason why you should not do physical activity?

This questionnaire is useful for individual who want to begin mild or moderate intensity
exercise/physical activity. If the answer to each question is yes to more than 1 question then
the person is recommend to meet the health professionals first. Basically, it is much better to do
complete medical examination for the elderly before they begin to exercise.

American College of Sports Medicine (ACSM) recommend to stratified the participants prior to
exercise program based on two things, the first is the risk factors for coronary artery disease
(CAD) and second is major signs or symptoms suggestive of cardiovascular, pulmonary, or
metabolic disease.

The CAD risk factors are (positive risk factors):

- Family history: myocardium infarction, coronary revascularization, or sudden death

before 55 years of age in father or other male first degree relative, or before 65 years of
age in mother or other female first-degree relative.

- Cigarette smoking: current cigarette smoker or those who quit within the previous 6
months.

- Hypertension: Systolic blood pressure > 140 mmHg or diastolic > 90 mmHg, confirmed
by measurements on at least two separate occasions, or on antihypertensive medication.
 - Dyslipidemia: LDL cholesterol > 130 mg/dl (3.4 mmol/L) or HDL cholesterol < 40 mg/dl
(1.03 mmol/L), or on lipid lowering medication. If total cholesterol is all that is available
use > 200 mg/dl (5.2 mmol/L) rather than LDL cholesterol

- Impaired fasting glucose: fasting blood glucose > 100 mg/dl (5.6 mmol/L) confirmed by
measurements on at least two separate occasion.

- Obesity: body mass index > 30 Kg/m2 or waist girth 102 cm for men and > 88 cm for
women or waist/hip ratio > 0.95 for men and > 0.86 for women.

- Sedentary lifestyle: persons not participating in a regular exercise program or not meeting
the minimal physical activity recommendations from U.S. Surgeon Generals report
(accumulating 30 minutes or more of moderate physical activity on most days of the
week).

Negative risk factors: high serum HDL cholesterol (> 60 mg/dl (1.6 mmol/L))

If HDL is high, substract one risk factor from the sum of positive risk factors, because high HDL
decreases CAD risk.

Major signs or symptoms suggestive of cardiovascular, pulmonary, or metabolic disease are:

- Pain, discomfort (or other angina equivalent) in the chest, neck, jaw, arms, or other areas
that may result from ischemia

- Shortness of breath at rest or with mild exertion

- Dizziness or syncope

- Orthopnea or paroxysmal nocturnal dyspnea

- Ankle edema

- Palpitations or tachycardia

- Intermittent claudication

- Known heart murmur

- Unusual fatigue or shortness of breath with usual activities

The data of CAD risk factors and major sign or symptoms suggestive of cardiovascular,
pulmonal or metabolic disease are gained from medical examination. After the data collected,
the doctor should cathegorized the patient according to ACSM risk stratification which explained
below.
ACSM Risk Stratification Categories

- Low risk: men < 45 years of age and women < years of age who are
asymptomatic and meet no more than one risk factor threshold (CAD risk factors)

- Moderate risk: men > 45 years and women > 55 years or those who meet the
threshold for two or more risk factors (CAD risk factors)

- High risk: individuals with one or more sign and symptoms suggestive of or
known cardiovascular, pulmonary, or metabolic disease.

The stratification above is then used to decide the next step before a person engage in exercise
program. The person with categorize as low risk if (s)he will be given moderate nor vigorous
exercise then the exercise testing is not necessary and if the exercise test is done the
supervision of physician during the test is not necessary too. The moderate risk person if (s)he
will be given moderate exercise the exercise test and physician supervision if submaximal test is
conduct is not necessary but if vigorous exercise is planned the exercise test and the physician
supervision during maximal test is recommended. Finally for the high risk person if (s)he will be
given moderate nor vigorous exercise the exercise test and physician supervision during
submaximal nor maximal test is recommended.

Recommendation of Physical Activity/Exercise for Elderly

1. Moderate intensity aerobic exercise (cardiorespiratory endurance training), minimum 30

minutes 5x/wk or high/vigorous intensity minimum 20 minutes 3x/wk. The exercise
intensity is measured subjectively with 0-10 scale (quiet sitting is 0, maximal effort
activity/all out is 10). The moderate intensity activity then is 5 or 6 scale, which mean
that the activity is cause raising the heart rate and respiratory rate above the resting
level. Walking exercise, swimming, low impact aerobic dancing, static ergocycle are the
examples of safe exercise modality for the elderly.

2. Resistance training at least 2x/wk, which train large muscle groups all over body. It is
recommended to do 8-10 muscles exercise in 2 nonconsecutive days in a week. To gain
maximal benefit for muscle strength, it is recommended to use additional/external weight
(e.g dumbbell) which lead to 10-15 repetition each movement. The intensity of exercise
is set to moderate to vigorous subjectively.

3. Flexibility exercise is recommended minimum 2x/wk and duration per session is

minimum 10 minutes. The recommended type of flexibility exercise is with static
stretching. The stretching movement is done until maximum range of motion without
pain, and hold to that position about 15-30 second. Each stretching movement can be
repeat until 5 times.
 4. Balance exercise is done to reduce the risk of falling caused by balance disturbance in
elderly. The session of exercise can use equipment such as chair, medicine ball, in the
pool or as part of aerobic dancing (e.g. standing with one leg, standing with the eye
closed)

5. The exercise programming or physical activity is planned in gradually until the

recommendation is met, although it will spend in long periods (in months).

The Risk of Exercise in Elderly

The risk of exercise for the elderly are musculoskeletal injury or health problem. The
musculoskeletal injury is common in frail elderly because they easy to fall. Most musculoskeletal
injury happen because of to fast in doing the movement. Kannus et al, Menard and Stanish,
Kallinen and Markku and Kallinen and Alen report that the incidence of musculoskeletal injury
happens 8-21% in elder women and 9-35% in elder men. The injury more to happen if the
movement need high level of coordination, balance and speed (e.g. racket and ball sports,
aerobic dancing with fast beat music). Until this time there is still no evidence that high intensity
exercise can lead to degenerative arthritis. Previous joint injury, abnormal musculoskeletal
anatomy, low muscle strength, and obesity are few factors which increase the risk of
osteoarthritis.

The health problem can be happen to elderly who exercise is cardiovascular problem such as
myocardium infarction or sudden death. To reduce this risk, the elderly who want to begin
exercise program should undergo health screening and recommend to have fitness test.

References
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