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Exercise and the Elderly: Guidelines and Practical Prescription Applications for
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Article in Journal of clinical outcomes management: JCOM · February 2004

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 CASE-BASED REVIEW

Exercise and the Elderly: Guidelines and Practical

Prescription Applications for the Clinician
Case Studies and Commentary, Ann Yelmokas McDermott, PhD, LN, and Heather Mernitz, MS

Abstract
• Objective: To review the components of exercise INSTRUCTIONS
prescription and approaches to developing an exer­ The following article, “Exercise and the
cise prescription for older persons. Elderly: Guidelines and Practical Prescrip­
• Methods: Case studies and qualitative review of the tion Applications for the Clinician,” is a continuing
literature. medical education (CME) article. To earn credit,
• Results: Effective exercise programs specify the read the article and complete the CME evaluation
appropriate mode, intensity, duration, frequency, and form on page 128.
progression of training. According to the American
OBJECTIVES
College of Sports Medicine, patients should partici­
After participating in the continuing educa­
pate in aerobic exercise 3 to 5 days per week, main­
tion activity, primary care physicians should
taining target heart rate for 20 to 60 minutes. Resis­
be able to:
tance training should be performed at least twice
1. Know the components of an exercise prescrip­
per week and should target the 7 major muscle
tion
groups. Proper technique is necessary and speed
2. Understand the different types of exercise and
and breathing should be controlled. Incorporation of
their potential benefits and risks in older age-
warm-up and cool-down sessions is recommended
groups
for exercisers of all ages and physical conditions.
3. Understand how to develop an appropriate
Increased lifestyle activity also should be encour­
exercise prescription that considers the
aged. In prescribing exercise for older patients,
patient’s health status, nutritional intake, abili­
nutrition must be closely monitored. The prescrip­
ties, preferences, and resources
tion needs to be individualized, taking into consider­
4. Know strategies for improving exercise adherence
ation the patient’s health status, nutritional intake,
abilities, preferences, and resources.
• Conclusion: Physical activity should be encouraged
in healthy seniors and should be considered a pri­
risk for chronic disease [2]. The Centers for Disease Control
mary or adjunctive therapy in the treatment of
and Prevention (CDC) recommends supplementing car­
chronic diseases associated with aging. Physician
diorespiratory endurance training with strength-developing
support of behavior changes is a major predictor of
exercises to improve musculoskeletal fitness, maintain inde­
patient compliance.
pendence in performing activities of daily living (ADLs), and

P
hysical activity (PA) recommendations have evolved reduce the risk of falls [3]. Recent CDC guidelines call for
over the past few decades from emphasizing vigorous active participation on the part of the media, government,
activity for cardiovascular health to supporting multi­ medical, and public health communities to influence PA pat­
ple bouts of moderate-intensity PAfor overall health. The 1996 terns, make common knowledge the beneficial effects of exer­
Surgeon General’s Report on Physical Activity and Health cise, and overcome real and perceived barriers to initiating
recommends that people of all ages include a minimum of and maintaining a physically active life [4,5].
30 minutes of moderate-intensity PA (such as brisk walking) This article is a companion article to “Exercise and the
on most, if not all, days of the week [1]. Based on more recent
scientific literature, the 2002 recommendations go even fur­
ther, recommending a cumulative 60 minutes of moderate From the Jean Mayer USDA Human Nutrition Research Center on Aging at
exercise per day to maintain a healthy weight and decrease Tufts University, Boston, MA.

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 EXERCISE PRESCRIPTION: APPLICATIONS

Table. Exercise and Physical Activity Web Sites

American College of Sports Medicine (ACSM) (www.acsm.org)

Contains information on professional education, certification and credentialing, research programs, and links to fitness and health
information, publications, guidelines, and product recommendations. Numerous position statements are available for download at
the ACSM journal’s Web site (www.acsm-msse.org) including recommendations on exercise in healthy adults, older adults, and
patients with specific medical conditions (ie, coronary artery disease, type 2 diabetes, osteoporosis, and hypertension). Papers that
address intervention strategies for weight loss and prevention of weight regain, progression models in resistance training, and nutri­
tion and athletic performance directives also are available.
American Heart Association (AHA) (www.americanheart.org)
The Healthy Lifestyle section of this site contains useful information on diet, exercise, and healthy lifestyles, including a section on
calculating BMI, a physical activity calorie use chart, target heart rate tables, and exercise tips for older Americans.
Centers for Disease Control and Prevention (CDC) (www.cdc.gov/nccdphp/dnpa)
The Nutrition and Physical Activity section contains information and tools on getting started with exercise, measuring exercise intensity,
definitions of physical activity terms, and healthy eating tips.
The National Institute on Aging (NIA) (www.nia.nih.gov/health/agepages/exercise.htm)
Contains information and safety tips, links to other reliable resources.
The President’s Council on Physical Fitness and Sports (www.presidentschallenge.org)
New interactive Web site with a section devoted to seniors. Includes tips on how to get started and challenges for seasoned senior
athletes.
The National Heart, Lung, and Blood Institute (NHLBI) (www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/phy_act.htm)
Guide to Physical Activity includes recommendations and useful tools aimed at maintaining a healthy weight; BMI calculator; menu
planner; daily food and activity diaries, recipes, shopping tips, and more.
The Cooper Institute (www.cooperinst.org)
Nonprofit research and education center conducts research in epidemiology, exercise physiology, behavior change, hypertension,
children’s health issues, obesity, nutrition, aging, and other health issues. Web site contains fitness training tools; active living
resources.
The 50-Plus Fitness Association (www.50plus.org)
Nonprofit organization whose mission is to promote an active lifestyle in older adults. Web site contains information on fitness chal­
lenge camps; annual fitness weekends; monthly discussion groups; links to health articles, product sites, senior health, diet and
nutrition sites.
The International Council on Active Aging (www.icaa.cc)
Offers courses in exercise training for fitness professionals, specializing in courses aimed at instructing older adults with chronic
diseases. Web site contains a research page with diet and exercise effects in health and disease; resources for health care teams
with links to facility planning for older adults; preferred vendors of exercise and rehabilitation equipment; active aging conferences
and exhibitions.

elderly: a scientific rationale for exercise prescription” (pp. interchangeably, it is important to differentiate between
106–116), which reviews the literature pertaining to the role of them. Physical activity is any body movement produced by
exercise in cardiovascular health, strength, postural stability, the contraction of skeletal muscle during work, daily activi­
cognition and psychological health, immune function, and the ty, or play that results in increased energy expenditure. Exer­
prevention and treatment of chronic disease. In this article, we cise, a subcategory of PA, consists of structured, planned,
present 3 cases studies to illustrate practical application of repetitive body movement with the intent of improving
exercise prescription. Given the diversity of cases a clinician physical fitness. With a balanced activity program, the end
will encounter and the specificity of therapeutic exercise, it is product is physical fitness, the summation of 4 factors: car­
not possible for a short review to provide sufficient details for diorespiratory endurance, muscle power, flexibility, and
prescribing in every case. We do provide references to useful body composition. In combination, these factors further
resources and refer liberally to the American College of Sports increase the ability to perform physical work. In the elderly
Medicine’s (ACSM’s) guidelines for exercise testing and pre­ population, increases in both planned exercise and in overall
scription [6]. Readers are referred to the Table of resources for PA should be encouraged.
additional position papers published by ACSM.
Components of Exercise Prescription
Definitions The 5 essential components of any exercise prescription are
While the terms physical activity and exercise often are used (1) mode, (2) intensity, (3) duration, (4) frequency, and

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 CASE-BASED REVIEW

(5) progression. A comprehensive exercise prescription activity, such as walking stairs, manually opening doors, car­
should address endurance, strength, and flexibility. Adietary rying groceries, or gardening. Lifestyle modifications can
prescription goes hand in hand with exercise to provide ade­ increase stamina and improve cardiovascular fitness or im­
quate energy as well as the nutrients needed for optimizing prove muscle strength and balance, depending on the type
the beneficial effects of exercise. and duration of activity. At all ages, total fitness requires a
combination of activities, or a “cross-training” program.
Mode
There are 4 main modes to improve physical fitness: aerobic Dose: Intensity, Duration, Frequency
exercise, resistance training, flexibility, and lifestyle modifi­ Heart rate is commonly used as a guide to exercise intensity,
cation. Aerobic exercise is any repetitive activity that in­ with 55% to 90% of maximum heart rate being the recom­
creases the heart rate for an extended period of time. To mended range for aerobic exercise [6]. Maximum heart rate
improve aerobic fitness, exercise must utilize large muscle can be estimated by subtracting the patient’s age from 220.
groups over prolonged periods in activities that are rhythmic The American Heart Association lists the following target
and aerobic in nature. Some aerobic activities are walking, ranges for moderate-intensity exercise (50% to 75% of aver­
jogging, cycling, swimming, dancing, and hiking. age maximum heart rate [max HR]):
Resistance training or progressive resistance training
Age Target Zone Average Max HR
(PRT) uses body weight, machines, or free weights to apply
60 years 80–120 bpm 160 bpm
resistance against which a muscle or muscle group must
65 years 78–116 bpm 155 bpm
generate force to move or resist. PRT maintains or improves
70 years 75–113 bpm 150 bpm
muscle mass and neurologic integration, increasing protein
75 years 73–109 bpm 145 bpm
stores essential to survival in the face of sickness and disease
[7]. While PRT does little to improve aerobic capacity, im­ Heart rate can be monitored manually by taking frequent
proved muscle strength and endurance enhance the ability pulse rates or monitored mechanically with personal heart
to perform aerobic exercise and ADLs, such as rising from a rate monitors or the built-in monitors available on some
seated position, carrying bags of groceries, or handling exercise machines. Exercise sessions should aim to maintain
objects above shoulder level. Muscle power is a strong pre­ target heart rate for 20 to 60 minutes, continuous or inter­
dictor of functional status [8] and declines more rapidly than mittent, with a minimum of three 10-minute bouts accumu­
strength with advancing age. lated throughout the day. According to ACSM, to achieve
Tools utilized in PRT may include gym-based weight cardiorespiratory fitness patients should participate in aero­
machines, hand-held weights, ankle and wrist cuffs (which bic exercise 3 to 5 days per week [6]. An alternative measure
do not require hand-grasp function), and rubber bands/ of aerobic exertion is the “talk test:” the exerciser’s breathing
tubes. Continued improvement requires the weight load lift­ is increased, but he remains able to comfortably carry on a
ed to increase progressively over time as the exerciser grows conversation. Incorporating more rigorous PA lowers the
stronger. Controlled, high-velocity resistance training (tim­ duration and frequency of exercise necessary to elicit benefit.
ing: “quick to lift, stop at the top, slowly lower, stop near the In both aerobic and resistance training, sedentary individu­
bottom”) increases muscle strength and peak power more als should start at lower intensity levels and progress, while
than the slow-but-steady muscular contraction commonly moderately fit individuals can start at higher intensities.
promoted for lifting [9]. Circuit training (moving from exer­ Resistance training should be performed at least twice
cise to exercise without stopping to rest) can be designed to per week. Exercises should target the 7 “major muscle
combine both strength training and aerobic conditioning in groups” (gluteals, quadriceps, hamstrings, pectorals, latis­
one time-efficient session. simus dorsi, deltoids, and abdominals) [13]. Patients can
Flexibility is the range of motion (ROM) around a joint exercise all muscle groups at each session (2–3 training ses­
and is associated with injury prevention through all life sions/week) or split the series into shorter sessions of 3 to
stages. Of particular importance in aging is the maintenance 4 muscle groups that are worked on alternate sessions
of lower back, posterior thigh, and ankle flexibility [10]. (4–6 sessions/week). Each set should consist of 8 to 12 repe­
Adequate flexibility can ward off chronic lower back pain titions at a somewhat hard to hard intensity level using the
and maintain the ability to perform ADLs and prevent falls Borg Rating of Perceived Exertion (RPE) scale [14]. Exercise
[6,11,12]. Activities that improve flexibility include exercises adherence appears maximal when sessions are kept to no
that lengthen the muscles such as swimming, tai chi, yoga, longer than an hour [6], with 48 hours between sessions in
and stretching. which the same muscle group is exercised.
Lifestyle modification encourages individuals to find A static stretching program involving all major muscle
opportunities within their existing daily routine to increase groups performed a minimum of 2 to 3 times per week can

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 EXERCISE PRESCRIPTION: APPLICATIONS

improve balance and agility in all age-groups [6]. Yoga and 4-pronged quad cane. Mild dementia is evident, with difficul­
tai chi movements as well as regular stretching may be use­ ty remembering people and events in her recent history. Each
ful during the warm-up and cool-down phases of an aerobic day Mrs. Flower takes a liquid high-protein, high-caloric
or resistance training workout. canned supplement, a soluble fiber product for diverticulosis,
and an antiresorptive medication for her osteoporosis.
Individualizing the Prescription The physician meets Mrs. Flower in her room and finds
The exercise prescription should take into consideration the her in good spirits and happy to chat, yet frustrated at the
patient’s health status, chronic disease risk factors, behav­ recent decline in her physical abilities and in her memory.
ioral characteristics, personal goals, and exercise preferences When asked about social activities, Mrs. Flower mentions
[6]. Some people like solitude, are disciplined, and prefer to only a weekly card game in the nursing home common
start an exercise program on their own. A brisk walk in the room. She reports no PA and spends the majority of her time
morning and/or evening or an efficient circuit of weight watching television. When asked if she is open to becoming
training may best fit their schedule and temperament. more physically active, Mrs. Flower expresses doubts, given
Others may prefer the support and camaraderie of a partner, the fact that she feels very tired most of the time, especially
while others may prefer attending a fitness club with orga­ when trying to move about the nursing home. She also wor­
nized classes, personal trainers, and group energy. In re­ ries about injuring herself, and she mumbles a remark about
sponse to community and public health activists, many missing her favorite shows. Upon speaking with her son, it
shopping malls now open early to accommodate “mall is evident that both Mrs. Flower and her family believe that
walking groups” in a safe, well-lit, climate-controlled envi­ her recent decline is “just a normal part of aging,” with noth­
ronment. Home-based exercise offers an effective modality ing to be done except to sit back and accept it. The mention
in individuals with physical limitations or financial con­ of strength training elicits fears that she’ll “break her fragile
straints [15,16]. For seniors worried about balance and agili­ bones.”
ty, aerobic exercise may include stationary cycling or swim­
ming. Many frail elders find greater confidence when under
supervision. Specialized aqua aerobics classes geared • What approach should be taken with regard to exercise
toward the elderly offer aerobic and ROM components, with prescription in this patient?
reduced joint stress and balance assisted by water buoyancy.
Chair- and bed-based exercises should usually be reserved
for the very frail and considered a beginning point. When Begin Organized Exercise Program
the goal is to improve physical fitness and increase function­ A “total fitness program” that includes exercises to improve
al capacity in performing ADLs, exercises that require the flexibility, ROM, and strength, with an emphasis on balance
participation of core muscle groups in the back, thighs, and involving the lower body muscles would be a good choice for
abdomen and weight-bearing exercises are preferred. this patient. Such integrative programs have been demon­
strated to be beneficial in improving strength and balance in
CASE STUDY 1 the oldest and frailest patients [17,18]. Gardner et al [19]
Initial Presentation describe an exercise program used for fall prevention. The
Mrs. Delicata Flower, an 82-year-old woman living 60-minute session, conducted to music, generally begins with
in a 650-bed nursing home, was brought to the 15 minutes of seated stretching and ROM exercises for arms,
attention of the medical staff because of her increasing diffi­ shoulders, lower back, lower legs, hamstrings, and ankles,
culty in getting out of her chair unaided. At 5’3” and 108 lb, and chair-assisted standing balance moves [19]. A 30-minute
Mrs. Flower is thin and frail but has no other major com­ strength training component includes 1 set of 8 repetitions of
plaints. The nursing home set up an appointment with a each of the following exercises: chair stands, knee extension,
facility physician. side hip raises, overhead dumbbell press, bent-over row, calf
raises, lateral shoulder raises, and arm curls. The intensity
History goal is to bring the muscle to the point of fatigue by the 8th
The patient has been living in the nursing home for 8 years. At repetition, whether lifting the weight of the limb alone or lift­
entry, her recorded height was 5’5”, and her weight of 128 lb ing weights. If time permits, the series is repeated for a total
had been held throughout her adult life. Her weight has grad­ of 2 sets of 8 repetitions each. The final 15 minutes are devot­
ually declined, and after losing her last 5 teeth, she is now ed to stretching and balance movements integrating yoga
edentulous and fitted with full dentures. Nursing home staff and tai chi, with external support provided by bars, chairs,
report that she takes most of her meals on a tray at her chair, and walkers as needed [19]. Emphasis is placed on maintain­
has not attempted stairs in over a year, and walks with a ing proper technique, posture, and continuing to breathe

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 CASE-BASED REVIEW

while performing all lifts in a controlled manner. Frail seniors take 3 meals a week in the dining room, and eat snacks be­
are encouraged to start out with light weights or body tween meals.
weight, and everyone is encouraged to progress as they grow Four weeks later, Mrs. Flower has gained 4 lb but contin­
stronger. ues to feel tired after exercise. She reports attempting to take
An awareness of fluid consumption during exercise is a walk every day but often has to stop and sit down, and
important for seniors. Given the daily fluid intake recom­ there are some days she does not feel up to it. Mrs. Flower
mendations in the elderly (≥ 2 quarts per day in addition to has attended the exercise classes 3 times per week, and while
water from foods [20]), plus a less effective thirst mechanism she hasn’t always been able to participate, she reports she
for sensing mild dehydration [21], monitoring fluids before, enjoys going, is inspired by the other residents, and feels she
during (8 ounces every 15 minutes), and after workouts is may be getting stronger and more stable on her feet. She con­
crucial. Elderly exercisers should be encouraged to drink sistently attempts the stretching exercises and some strength
even when not thirsty. moves, but doesn’t feel strong enough to add any weights or
attempt the more complicated balance poses. She reports
Increase Lifestyle Activity taking an increasing number of meals in the community din­
Increased PA should be encouraged as a way to improve ing room. Despite growing social interactions, the majority
functional capacity and quality of life for Ms. Flower, with of Mrs. Flower’s time is still spent isolated in front of the tele­
the possible additional benefit of increased appetite. Her PA vision.
prescription could include a daily 10-minute walk, even if When the physician asks about symptoms of depression,
she reports fatigue, with the staff encouraged to support her Mrs. Flower says that she feels better than she has in a long
efforts. This may include an accompanied walk around the time, especially when at exercise class or dinner with com­
floor, a trip to the nursing home gift shop or beauty shop, or panions, and agrees to continue the effort to increase activi­
stroll in the garden. If she is feeling OK, encouragement will ty and social interactions. Given her struggle to meet the
be offered to increase the walk duration by as little as 2 min­ daily walking goal and continued lack of strength, Mrs.
utes or add additional sessions. A fall risk assessment will be Flower redefines her PA goals. She will walk 5 days per
done and identified factors addressed [22]. week, with additional walks only when she feels up to it.
Because of her deconditioned state and frailty, the PRT pro­
Improve Caloric Intake gram starts out with no added resistance and progresses
In prescribing PA and exercise for elderly patients, nutrition slowly. A new goal during her exercise class will be to per­
must be closely monitored. In the general population, low form the strength component with rubber tubing resistance,
energy intake intensifies the muscle and bone loss associat­ rather than adding weights. In addition to her current dining
ed with aging and hinders the muscle growth and develop­ room meals, she will take at least 3 lunches per week in the
ment that should accompany exercise. Insufficient calorie dining room and join her dining companions for Sunday
and protein intake can further stress a weakened immune brunches at a nearby restaurant.
system and hamper illness recovery [17]. Further, when
energy intake is low, micronutrient needs often go unmet. CASE STUDY 2
Because Mrs. Flower is prone to memory lapses and resides Initial Presentation
in a nursing home, dietary intake information may best be George I. Joe, a 70-year-old male retiree, visits his
obtained by having staff monitor food served and eaten. primary care physician complaining of knee pain.
Mrs. Flower’s visible thinness and body mass index He takes acetaminophen for his diagnosed knee osteoarthri­
(BMI) of 19 is indicative of insufficient energy intake. To pro­ tis (OA) and back stiffness. He has a BMI of 32 (5’9” and
mote socialization and dietary variety and to provide staff 218 lb), a 42” waist circumference, weak abdominal muscles,
supervision and encouragement, the physician will suggest and tight hip flexors. Recent laboratory findings included a
that Mrs. Flower eat at least 3 meals per week in the nursing fasting glucose level of 125 mg/dL and hemoglobin A1c of
home dining room and eat a small snack between meals. A 6.0%, indicating impaired glucose disposal and possible
micronutrient supplement formulated for older adults, in­ underlying diabetes.
cluding calcium, vitamin D, and vitamin B12, may be benefi­
cial, especially with documented inadequate intake [20]. History
Mr. Joe is a widower who lives alone and walks with a cane.
Initial Management and Follow-up He reports no PA for health or leisure, drives his car even for
Mrs. Flower agrees to participate in the group exer­ trips of very short distances, and has been increasingly
cise sessions 3 times per week, participating inter­ sedentary since diagnosed with knee OA 2 years ago. His
mittently when tired. In addition, she will try the daily walk, meals consist largely of prepackaged frozen entrees, fast

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 EXERCISE PRESCRIPTION: APPLICATIONS

food, and cold cuts on white bread. Alcohol intake has tion, static stretching is recommended to decrease stiffness and
increased over the last 6 months, “mostly hard liquor,” but increase joint mobility [24]. For additional information, see the
he won’t try to estimate the amount. A Korean War veteran, American Geriatrics Society report on exercise for older adults
his social life consists of Saturday nights at the local VFW with OA pain [24].
post, often missing dinner. When asked about his interest in
increasing his PA level, the idea of initiating a daily aerobic
exercise regimen is unappealing, but Mr. Joe is intrigued by • What dietary goals should be recommended?
the idea of strength training and increasing his social oppor­
tunities. Mr. Joe expresses concern about lifting heavy
weights given his knee OA. One of the goals for this patient is to increase the amount of
dietary fiber, fruits, and vegetables in his diet while decreas­
ing intake of processed meats, refined carbohydrates, and
• What approach should be taken with regard to exercise alcohol. When asked about his culinary skills, Mr. Joe re­
prescription in this patient? sponded that his wife had been “responsible for the
kitchen.” To improve dietary knowledge and kitchen skills,
patients can be advised that local community and senior cen­
Mr. Joe is at increased risk of developing diabetes and is at ters may offer meals and/or cooking courses at reduced
increased cardiovascular risk. His prescription will include costs. Cooking courses can teach kitchen skills such as read­
increased PA and exercise combined with a healthier diet to ing food labels; identifying foods to incorporate or minimize;
strengthen the supporting weight-bearing musculature and preparing meals; and identifying easy, tasty, healthy entrees
to aid in weight and abdominal fat loss. Mr. Joe’s local senior and snacks.
center offers an exercise class that focuses on upper and
lower body strength training. The class meets twice per Initial Management and Follow-up
week and consists of ROM and flexibility exercises (10 min) Mr. Joe agrees to start the strength training program
and strength training (40 min) using a combination of hand and to eat more fruits and vegetables and whole-
and ankle weights and body weight as resistance, followed grain bread. To increase lifestyle activity, Mr. Joe agrees to a
by a cool-down with stretching and yoga poses (10 min). daily walk to the corner store for his newspaper, regardless of
Each session is designed to incorporate all major muscle the weather. The storeowner is an old friend and the patient is
groups. Strength training exercises consist of 2 sets of 10 to looking forward to socializing. The clinician and patient agree
12 repetitions using proper form and timing, bringing the that this combination of walking and community-based
muscle to fatigue by the final repetition, and alternating strength training is a reasonable start to an exercise program.
between upper and lower body exercises to allow local mus­ Mr. Joe returns 6 weeks later for assessment of compli­
cle recovery. If fatigue is not reached by the 12th repetition, ance with exercise and diet goals. He has been taking his
the weight is increased at the next session. daily walk and attending strength training classes twice per
Excessive alcohol intake and social isolation exacerbate week. He has been staying for the senior center’s low-cost
Mr. Joe’s risk factors and reduce his likelihood of successful meal served after his late-morning strength class and is
exercise intervention [23]. Since Mr. Joe will not try to esti­ enrolled in a 12-week cooking course. This has provided an
mate the amount of liquor he has been consuming, his first opportunity for increased social interaction and is giving
task will be to record alcohol volume and activities associat­ him needed knowledge and meal preparation experience.
ed with alcohol consumption. Mr. Joe reports drinking less over the past 6 weeks, explain­
ing, “I’m too busy with all the stuff you’ve got me doing.”
Review of an alcohol log that the physician asked him to
• What limits does knee OA impose on exercise? keep reveals that he tends to drink in the evening, when
home alone. The physician encourages him to continue to
explore options in terms of social activities, including dinner
While it is true that lifting inappropriately heavy weights can with friends from class.
negatively affect arthritic joints (especially leg extension and While the strength training course at the senior center
leg press exercises), moderate-level exercise does not exacer­ offers the supervision and social aspects that Mr. Joe desires,
bate OA pain or accelerate disease progression [24]. Strength he feels he may soon outgrow this program and require a
training with proper weight selection, timing, and form can more rigorous regimen. He is interested in progressing to
improve muscle strength and relieve joint stress [25]. In addi­ free weights and weight machines at a local gym.

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 CASE-BASED REVIEW

changes. For example, in Mr. Joe’s case, strength training

• What advice should Mr. Joe be given regarding gym- promotes increased muscle mass (the major site of glucose
based weight training? disposal) and glucose uptake by muscle [29]; a developed
lower body musculature will support his arthritic knees and
reduce pain [25,30]; flexibility/ROM exercises will help
This interest in gym-based weight training is encouraged, lengthen his lower back and hip flexor muscles; abdominal
but additional advice is needed to ensure his safety. As he crunches will stabilize and support lower back muscles,
moves to this next phase, proper technique will be essential thereby reducing his risk of back injury [6]; and calf and foot
to prevent injury or aggravate his OA. Initial weight room flexibility will improve his gait, making walking easier [19].
sessions should be supervised by trained personnel who The combination of daily PA and dietary change can result
have experience working with the elderly and health- in weight reduction and reduced total and visceral fat mass.
compromised individuals. If maximal strength testing is In patients at high risk for diabetes, this can reduce risk of
available, the initial resistance can be set at 30% to 40% the diabetes onset at an effectiveness level twice that of standard
1-repetition maximum (1-RM) for upper body exercises and medication and care [31].
50% to 60% 1-RM for leg exercises [13]. Mr. Joe will start with
2 sets of 10 to 12 exercises, including leg extension, leg flex­ CASE STUDY 3
ion, leg press, calf raises, standing arm curls, tricep exten­ Initial Presentation
sion, seated row, lat pull-downs, overhead press, chest press, After 5 years away from the doctor’s office,
back extension, and abdominal crunches. When a set of 12 to Mr. Hugo Stressor, a 61-year-old male with a BMI of
15 repetitions is performed comfortably, a 5% increase in 23 (6′0′′ and 169 lb) and a waist circumference of 34” presents
resistance should be recorded for the next session. If unable to his primary care physician for a check-up. He believes he
to complete 8 repetitions as one set, the weight should be has been experiencing bouts of angina and is feeling anxious
reduced [13]. A Borg RPE of 12 to 18 should be maintained because his older brother recently died of a heart attack. His
[14]. If the intensity is less than 12 (fairly light), the resistance blood pressure is 140/95 mm Hg.
should be increased; if the intensity more than 18 (very
hard), it should be decreased. History
Speed and breathing should be controlled when perform­ Mr. Stressor is the busy owner of a large company and works
ing resistance exercises, and exercises should only be per­ long hours. He has smoked 1 pack of cigarettes per day for
formed within a pain-free ROM. Mr. Joe is reminded to always the past 40 years. He admits to a poor diet (he considers him­
exhale when lifting a weight and continue to breathe as the self a “meat and potatoes man”) and notes that he eats very
weight is slowly lowered. Controlled breathing prevents a little of the vegetables that his wife serves with dinner. He
Valsalva maneuver, where exhalation force against a closed has thought about starting an exercise program but has “no
glottis increases pressure in the thoracic cavity, causing an free time” and is worried that exercise might induce a heart
acute rise in blood pressure while inhibiting venous return [26]. attack. He is, however, very interested in trying to address
The result can be dizziness, seeing “spots,” and even fainting. his health issues with a minimum of additional medications.
Incorporation of warm-up and cool-down sessions is rec­ His wife, who has a similarly sedentary lifestyle and is over­
ommended for exercisers of any age and physical condition weight, is willing to exercise with her husband if he starts a
[6]. Mr. Joe will include a 5- to 10-minute low-intensity calis­ program.
thenics and stretching warm-up followed by 5 to 10 minutes of
progressive aerobic activity (slow walking or an easy version Laboratory Data
of the activity about to begin) to increase metabolic rate and A lipid panel reveals a total cholesterol level of 250 mg/dL,
blood flow to the muscles, and reduce injury susceptibility [6]. low-density lipoprotein (LDL) of 190 mg/dL, high-density lip­
The cool-down period includes exercises of diminishing inten­ oprotein (HDL) of 30 mg/dL, and triglycerides of 150 mg/dL.
sity, allowing the return of heart rate and blood pressure to
near resting values. Especially important for cardiac patients,
the cool-down period enhances venous return and slowly • What safety issues need to be addressed before prescrib­
decreases heart rate and myocardial oxygen demands [6]. ing exercise in patients at high risk for heart disease?
Physician support of behavior changes, including diet
and exercise, is a major predictor of patient compliance
[27,28]. Physicians should provide positive reinforcement to Because of the patient’s risk factors and familial heart dis­
patients who are progressing toward their goals and remind ease, the safety issues of an exercise program are addressed.
them of the health benefits of their activity and lifestyle ACSM has suggested that individuals aged 65 and older and

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 EXERCISE PRESCRIPTION: APPLICATIONS

those at high risk of heart disease or stroke undergo a maxi­ do together, the physician learns that before the Stressors
mal, symptom-limited physician-supervised exercise stress- had children they enjoyed dancing. They agree to start ball­
test performed in a fasting state taking their normal medica­ room dancing again on Saturday nights. In addition, to help
tions before beginning to exercise [6]. Abnormal exercise loosen tight back and neck muscles and improve flexibility
tests are referred to a cardiologist for further diagnosis and and balance, the physician recommends they rent some yoga
treatment prior to beginning the exercise program. Moderate videos to try together on Sunday mornings. Mr. Stressor is
exercise can be incorporated into the treatment plan after encouraged to use his personal digital assistant to log daily
cardiology approval [32]. activities and identify factors that promote or interfere with
achieving his PA goals and bring it to his next appointment.
Initial Management
A blood pressure medication and lipid-lowering Adopt a Heart-Healthy Diet
drug is added to Mr. Stressor’s daily regimen of The recently released national hypertension guidelines sup­
aspirin and a multivitamin/mineral supplement. He is port the adoption of lifestyle modifications for patients with
referred to a nutritionist for a 3-day food record to evaluate high blood pressure, noting the enhanced results in blood
dietary intake, quality, and eating patterns. He also is re­ pressure reduction achieved with combination programs,
ferred for exercise stress testing. The stress test reveals poor such as exercise and the Dietary Approaches to Stop Hyper­
aerobic fitness but no clinical contraindications to exercise. tension (DASH) diet [36]. Mr. Stressor agrees to increase his
consumption of fruits, vegetables, and high-fiber foods and
reduce saturated fat intake (ie, meats and full-fat dairy). This
• What is the approach to this patient’s exercise prescrip­ goal also is communicated with his wife, as she is primarily
tion? responsible for meal preparation. Mr. Stressor agrees to have
2 fruits or vegetables prepared in a “heart-healthy” manner
with every meal and will pack 1 piece of fresh fruit to snack
Make Time for Daily Physical Activity on at work each day. The recommended increase in fruit and
Once his angina is under control and the cardiologist vegetable consumption should help Mr. Stressor increase his
declares Mr. Stressor clinically stable, an exercise program plasma antioxidant levels and decrease his blood pressure
should be started. A long-term goal of 45 to 60 minutes of [37]. In addition, the exercise program should help him meet
moderate exercise on most days of the week is acceptable to his dietary goals, as adults with higher fitness levels also tend
the Stressors. It is hoped that the exercise program will to consume diets that more closely approach national recom­
decrease blood pressure and improve lipid values. In previ­ mendations for fat, saturated fat, cholesterol, and fiber [38].
ously unfit people, PA resulting in increased aerobic power
was associated with a reduction in cholesterol and systolic Reduce Smoking
blood pressure in as little as 9 weeks [33]. Mr. Stressor believes he lacks the will power necessary to
The couple agrees to support one another and take daily quit smoking at this time, especially with all the lifestyle
20-minute walks together around the neighborhood both changes to which he has agreed. Instead, he agrees to cut
before and after work [34]. Mr. Stressor will wear an inexpen­ back from 1 pack to 3/4 pack per day, not smoke for 30 min­
sive heart rate monitor during these walks and remain in his utes before or after his daily walks, and search the internet
target heart rate zone of 95 to 120 bpm (60% to 75% of his pre­ for information about smoking cessation programs.
dicted maximum heart rate). During morning walks, the cou­
ple will attempt to hold a constant pace for the 20 minutes, Follow-up
recording the distance covered. In the evening, they will alter­ Six months later, Mr. Stressor reports that his diet has
nate speed (2 minutes comfortable pace, 1 minute strong). improved, the morning walk has become a ritual,
This form of interval training works both the aerobic and the and interval walks are attempted at least 3 evenings a week.
anaerobic system, further promoting synthesis of new capil­ Occasionally, he wears a pedometer throughout an entire day
laries, enhancing oxygen delivery, strengthening the heart and to see if he comes close to the “10,000 step a day” goal set by
lower body muscle, reducing the risk of injury associated with the U.S. Surgeon General’s “Shape Up America!” program
repetitive endurance exercises, and resulting in more rapid (www.shapeup.org) [39]. His systolic blood pressure has
physical improvements than seen with constant speed train­ decreased 4 mm Hg and his lipid panel reveals a 6% LDL
ing [35]. As part of his PAprescription, Mr. Stressor also agrees decrease, 9% triglyceride decrease, and 7% HDL increase.
to take the stairs up to his second floor office every morning Exercise was found to be a more positive experience than
and whenever he has to travel one flight up or down. Mr. Stressor had anticipated, although they did not find a
Upon probing for additional activities the couple could yoga video that they liked. To encourage stretching and

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 CASE-BASED REVIEW

PHYSICAL ACTIVITY Rx

As your partner in health, I strongly recommend that you accumulate a total of 30 min­
utes of physical activity throughout your day on most, if not all, days of the week.
Start slow. Walking or spending more time doing activities you enjoy with others is a
great place to start.

YOUR PHYSICAL ACTIVITY PRESCRIPTION:

How Often How Much

❏ Walk or wheel ____________________________________________________
❏ Walk stairs ____________________________________________________
❏ Dance fast ____________________________________________________
❏ Bicycle ____________________________________________________
❏ Swim ____________________________________________________
❏ Work in the garden ____________________________________________________
❏ Walk the dog ____________________________________________________
❏ Other activity ____________________________________________________

Start date: ___________________________

X
Patient _____________________________ X
Health care provider ____________________

Figure. Exercise prescription note that clinicians can give their patients to underscore the importance of regular physical
activity (reprinted with permission from Massachusetts Department of Public Health, Nutrition and Physical Activity Unit).

balance exercises, the physician suggests structured classes Exercise prescription requires a collaborative effort on the
at a local gym or senior center. Mr. Stressor agrees to try an part of the health professional and patient. For long-term sus­
8-week Pilates class at the gym. The physician also suggests tainability, the prescription needs to be individualized, taking
substituting gym-based PRT for walks 3 days per week to into consideration the patient’s health status, activity history
further improve muscular endurance and attenuate heart and preferences, time availability, and resources (equipment
rate and blood pressure response to a given load [40]. How­ and facilities or financial resources available to purchase
ever, Mr. Stressor believes a home-based program with equipment). To increase likelihood of compliance, patients
instruction from a certified trainer once per week and other should (1) understand how exercise impacts health, (2) rec­
sessions on his own would offer the flexibility he needs ognize obstacles to exercise, (3) have an interest in beginning
given his hectic schedule. Mr. Stressor understands that if a program (readiness), (4) be able to identify activities they
business constraints limit time, PRT sessions twice per week are willing to try, and (5) have the knowledge required to
including upper and lower body can still yield significant safely perform the exercise prescription. As with smoking
strength and lean mass improvements. cessation [41], clinicians should periodically counsel patients
about PA, especially those who remain sedentary.
Once an exercise prescription has been generated, specif­
• What strategies are helpful for improving exercise adop­ ic recommendations and clear instructions for increasing PA
tion and adherence? are required. Given that only a small fraction of auditory
messages are retained, written exercise prescriptions using a

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 EXERCISE PRESCRIPTION: APPLICATIONS

prescription pad can help emphasize the vital nature of the on work supported by the U.S. Department of Agriculture, under
message. The Massachusetts Department of Public Health agreement No. 58-1950-4-401. Any opinions, findings, conclusions,
has generated its own version of an exercise prescription or recommendations expressed in this publication are those of the
authors and do not necessarily reflect the view of the U.S. Department
contract to be signed by both physician and patient (Figure).
of Agriculture.
Continued advice, educational materials, telephone calls,
and behavioral counseling provided by members of the Financial disclosures: None.
medical team foster sustained lifestyle behaviors, especially Author contributions: conception and design, AYM, HM; drafting of
in female patients [42]. the article, AYM, HM; critical revision of the article, AYM, HM.

CONCLUSION References
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 CASE-BASED REVIEW

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Copyright 2004 by Turner White Communications Inc., Wayne, PA. All rights reserved.

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 JCOM
CME
EVALUATION FORM: Exercise and the Elderly: Guidelines and Practical Prescription Applications for
the Clinician
To receive 1 hour of AMA PRA Category 1 CME credit, read the article named above and mark your responses on this form. You
must complete all parts to receive credit. Then return this form using the fax number or address appearing at the bottom of this
page. A certificate awarding 1 hour of category 1 CME credit will be sent to you by fax or mail. This CME Evaluation Form must
be fax marked or postmarked within 1 year of this JCOM issue date. Please allow up to 4 weeks for your certificate to arrive.

Part 1. Please respond to each statement. Strongly Agree Strongly Disagree

5 4 3 2 1
I was provided with new information pertinent to my practice. ❏ ❏ ❏ ❏ ❏
I reaffirmed a specific skill or knowledge. ❏ ❏ ❏ ❏ ❏
This article will help with clinical decision making. ❏ ❏ ❏ ❏ ❏
Relevant clinical outcomes are addressed. ❏ ❏ ❏ ❏ ❏
The case is communicated in a manner that kept my interest. ❏ ❏ ❏ ❏ ❏
The case presentation is realistic and effective. ❏ ❏ ❏ ❏ ❏
I could easily interpret the tables and figures. ❏ ❏ ❏ ❏ ❏
My attitude about this topic changed in some way. ❏ ❏ ❏ ❏ ❏
Additional comments: ______________________________________________________________________________________
__________________________________________________________________________________________________________

Part 2. Please complete the following sentence.

As a result of reading this case study, I . . .
❏ see no need to change my practice.
❏ will seek more information before modifying my practice.
❏ intend to change the following aspect(s) of my practice: (Briefly describe)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Part 3. Statement of completion: I attest to having completed the CME activity.

Signature: _________________________________________ Date: _________________________________________________

Part 4. Identifying information: Please PRINT legibly or type the following:

Name: ____________________________________________ Fax number ___________________________________________
Address: __________________________________________ Telephone number ______________________________________
__________________________________________________ Social Security number: __________________________________
__________________________________________________ (Required and confidential)
Medical specialty: __________________________________
Wayne State University School of Medicine is ac-
credited by the Accreditation Council for Continuing
SEND THE COMPLETED Medical Education to provide continuing medical edu-
CME EVALUATION FORM TO: cation for physicians.
Wayne State University School of Medicine desig-
BY FAX: 313-577-7554
nates this CME activity for a maximum of 1 hour of cat-
BY MAIL: Wayne State University egory 1 credit toward the Physician’s Recognition
Division of CME Award of the American Medical Association. Physicians
101 Alexandrine, Lower Level should claim only those hours of credit actually spent in
Detroit, MI 48201 the educational activity.

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