Physicians rarely receive instruction in designing exercise programs for older patients, although the evidence about the benefits of exercise is clear. Christmas and Andersen review the benefits of exercise and discuss how the physician can best tailor an exercise program to an individual patient.
Exercise has been shown to improve body composition, reduce falls, depression and arthritis pain, and increase strength. In addition, with exercise, diabetes and coronary artery disease risks are reduced and lifespan is increased. Even in patients who exercised but did not lose weight, there were mortality benefits from the exercise.
A number of questions need to be addressed when designing exercise plans for the older patient, as shown in the accompanying figure
. The patient's history of interest in physical activity and activity level in the previous few months will provide some clues as to whether this patient will be able to maintain an intense activity program, or whether very slow changes will need to be made. Knowledge of the patient's attitudes toward exercise and perceived barriers to exercise will also be important. For example, if a patient believes that his or her neighborhood is unsafe, he or she will be less likely to continue an exercise program that relies on activity in the neighborhood. For these patients, “referral” to a shopping mall or school where they can exercise in a safer environment may help ensure success.
Patients may be worried about the cardiovascular risks of exercise; these patients should be told that the American College of Sports Medicine currently recommends stress testing before beginning an exercise program if the program is likely to be vigorous. Patients with a contraindication to stress testing and exercise would include patients who have recently had a myocardial infarction, and patients with severe aortic stenosis, decompensated congestive heart failure and serious dysrhythmias. Relative contraindications include moderate aortic stenosis, uncontrolled supraventricular tachycardia and moderate uncontrolled hypertension (systemic or pulmonary).
The patient's social preferences must also be considered. Older persons often find it easier to follow through with an exercise program if a friend or family member also participates in the program, to give support. For patients who prefer less social interaction or have difficulties with transportation, a home-based program would be more appropriate.
Patients with diabetic retinopathy should avoid activities where they may have to strain (e.g., weight lifting), and patients with intermittent claudication should not try to exercise beyond what is tolerable. Patients taking diuretics should be reminded to maintain adequate hydration when embarking on an exercise regimen.
The authors recommend actually writing the exercise plan on a prescription pad, as a means of reinforcing the importance of exercise. Such a prescription should reflect the patient's interest (e.g., what activity would the patient like to do) as well as the necessary equipment and time that is recommended for exercise. In addition to increasing physical activity, decreasing sedentary activity is also important. Physicians can encourage patients to watch less television, to climb stairs (instead of using the elevator) and to park farther away from the door when shopping. The goal is to exercise for 30 minutes with moderate intensity more days than not. Stretching and warmups are particularly important in the older age group. When performing strengthening exercises (e.g., weight lifting), patients should be instructed not to perform the Valsalva maneuver during the activity, as this can cause hypotension. Finally, inquiring about activity and progress at each office visit will underscore the importance of exercise, no matter what the age of the patient.