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Over sixty years ago, a Dr. White said this about exercise for elderly patients: "exercise of almost any kind, suitable in degree and duration. . . can and does play a useful role in the maintenance of both physical and mental health of the aging individual" (White, 1957). A large body of scientific evidence now supports this observation.
In this Report, I will concentrate on the benefits of exercise to the elderly population. It is well known that regular exercise is beneficial to both body and mind. It reduces the chances of suffering from coronary heart diseases, osteoporosis, stress-related disorders and even neurological diseases. I will return to these issues later.
Becoming fitter is beneficial for young or old men and women. Generally, though, an older person will start from a lower level of fitness and achieve a lower level than younger people achieve. Surprisingly, older people show greater gains in muscle oxidative enzymes than younger people, but this may be because they have lower activities to begin with. Apart from reducing the risk of diseases such as those listed above, exercise in the elderly can also improve physiological and psychological attitudes. Such people can be happier (due to a sense of physical well-being), more mobile (less arthritic and stiff) and even more sociable (due to meeting others through clubs and gyms).
Ageing is irreversible, but lack of exercise is not. Even those taking up exercise later in life can show substantial benefits, including a marked increase in life expectancy compared to a sedentary individual. Increases in bone mass and muscle strength will reduce not only the risk of falling, but the consequences of doing so. Together with the reduction of disease incidence, such as those listed above, this results in fewer burdens being placed on the NHS and less long-term 'bed blocking' by elderly patients.
The forms of exercise recommended for those who take up sport later in life will differ to those indicated for younger people. Naturally, exercises such as swimming spring to mind as suitable. Surprisingly, however, the more adventurous elderly can also engage in activities such as weight lifting and tennis, albeit with some restrictions. Here, I will discuss the likely audience who will benefit, the physiological improvements than can be observed, the diseases that can be reduced in incidence, the appropriate forms of exercise and the overall benefits to both the individual and society in general.
Physiology of the Elderly Relevant to Exercise
It is well known that ageing is accompanied by changes in many body systems, and one of the major of these is the cardiovascular system. These do not include pathological changes, such as coronary artery disease. The changes associated with ageing will occur in everyone, but not at the same rate, with the result that chronological age does not always correlate with physiological age. The main cardiovascular changes associated with ageing are a decrease in elasticity of the walls of the blood vessels (particularly arteries) which leads to 'hardening of the arteries'. This produces an increased workload on the left ventricle of the heart, leading to an increase in systolic blood pressure. This can result in left ventricular hypertrophy and a progressive pathological chain of events that can result in, amongst other things: systolic hypertension, aortic valve calcification and heart failure; all diseases which are seen in the elderly.
Ageing affects us all. It is genetically programmed but altered by environmental influences. The rate of ageing can vary greatly between individuals (Cheitlin, 2009). Some individuals can be considered 'old' at a young age, and vice versa. The pathological condition of progeria shows how even children can age to old persons within a short time span. Studies of these diseases will give us a greater understanding of the ageing process. In the meantime we have little understanding of how exercise affects the ageing process.
Gradual loss of function in many organ systems is characteristic of physiological ageing. Some elderly people may have 'latent' coronary arterial disease (CAD) and it is therefore important that such individuals be excluded from comparative studies.
Exercise involves extreme stresses on the body. It has been estimated that in people with a potentially lethal fever (such as that caused by cerebral malaria) the body metabolism increases to about 100% above normal. However, the metabolism of a runner in a marathon may increase to 2000% above normal (Suleman, 2008). Another problem with many of the physiological studies of the benefits, or otherwise, of exercise in the elderly is that a sizable proportion of the studies have not been undertaken in otherwise healthy individuals. Many of the studies, perhaps for convenience, have been undertaken on elderly patients who have suffered coronary heart disease or heart failure. Perhaps such individuals, already hospitalized, are too greatly compromised by their disease to show any beneficial effects of exercise.
Studies of Exercise in the Elderly
In this section, I will look at some of the results of studies of the effects of exercise on the healthy elderly. I will compare and contrast this with studies which have shown no beneficial effect of exercise and studies undertaken on patients who have an underlying pathology.
Healthy elderly people can engage in moderate to even high levels of physical exercise. Favourable outcomes, such as the following, have been recorded (Wenger, 2001):
Lowered blood pressure
Reduced rates of diabetes, insulin resistance and falls
Improvements in depressive symptoms, general health and happiness
Reduced cardiovascular morbidity and mortality
Relative risk (RR) is a useful criterion to gauge the effect a certain lifestyle may have on health (Nied and Franklin, 2002). These authors showed that the RR for cardiovascular disease caused by sedentary living, i.e. no exercise, is 1.9, compared to 2.1 for hypertension and 2.5 for cigarette smoking. They also reviewed studies which showed that up to one-third of the age-associated decline in aerobic capacity (VoO2 max) can be reversed by a minimum of six months of aerobic training. Paffenbarger et al. (1986) showed, rather surprisingly, that mortality rates were lower in individuals who exercised late in life compared to those who exercised at a younger age but then gave up. The obvious conclusion is that it is never too late to start physical exercise.
Benefits of Exercise in Older Adults (Adapted from Nied and Franklin, 2002)
Physiological parameters improved (VoO2 max, cardiac output, decreased submaximal rate pressure product)
Decreased blood pressure
Decreased risk of CAD
Improves lipid profile and reduces incidence of congestive heart failure
Diabetes mellitus (type 2)
Reduces incidence and increases glycaemic control
Decreases haemoglobin A1C levels and improves insulin sensitivity
Decreases bone density loss in postmenopausal women
Decreases risk of falling and hip and vertebral fractures
Decreases pain and improves function
Improves sleep and cognitive function
Improves Beck depression scores and short-term memory function
Decreases morbidity, mortality and obesity
Improves peripheral vascular occlusive disease symptoms
Improves quality of life
Conflicting reports have appeared about the benefits of exercise in the elderly. For example, although physical activity can increase brain volume and cognitive function in elderly people and reduce beta-amyloid accumulation in a mouse model of Alzheimer's disease, Eggermont (2009) could find no benefits in a group of 97 elderly men and women. The author put this down to the high age (mean 85.4 years) which may mean a high frequency of co-morbid cardiovascular disease i.e. disease that was likely but not obvious in this sample.
Thus, these occasional reports, which do not appear to support the benefits of exercise in the elderly, are often explained away by the authors on the basis of some underlying pathology or pathophysiology that is already present, but not necessarily clinical manifest, in their patients.
Assessment and Training
Although aerobic training is important in the elderly, the importance of resistance training has become increasingly recognised. After the age of 50, muscle strength declines by 15% per decade, and after the age of 70 this has increased to 30% (American College, 1998). This is principally as a result of loss of muscle mass (sarcopenia) and occurs to a greater degree in women than in men. Even minimal lifting can be beneficial in counteracting this loss of muscle mass.
Everyone who undertakes a physical exercise programme should undergo some form of assessment. This is arguably more important in the elderly where there may be an underlying pathology which could be exacerbated by exercise. Resnick et al. (2008) have developed a specific tool for this purpose, based on a questionnaire called the EASY tool. (Naturally, a physical examination should also be undertaken by a qualified nurse or doctor.) The questions can be summarised as follows:
Do you get any pains or tightness in your chest?
Do you experience dizziness or lightheadedness?
Have you ever been told you have high blood pressure?
Do you have pain or stiffness that prevents you doing something?
Have you fallen or felt unsteady?
I have merely indicated the points raised. The paper by Resnick should be consulted as in includes a very useful table which explains the rationale for asking these questions. It also gives interpretations of yes and no responses.
In this report I have summarised some of the evidence which supports the beneficial effects of exercise in the elderly population. I have highlighted some of the disease processes (morbidity) which are more prevalent in this population, and the physiological effects of exercise. I see several main conclusions. The first, and very important observation, is that it appears that is never too late to start an exercise programme. This is the case not only for the healthy elderly, but also those recovering from coronary disease or heart failure. It is somewhat surprising that diseases such as type 2 diabetes may also improve as a result of exercise. I think this may be due to a general improvement not only in the vascular infrastructure, but also as a consequence of improvements in blood lipid and sugar profiles. Exercise not only helps the body, it also helps the mind. Again, improved blood circulation with lowered blood pressure and perhaps even opening up of collateral circulation (such as occurs in muscle with exercise and increase in muscle mass) may all play a role, as it is undoubtedly beneficial to improve the supply of oxygen to the brain. This has been shown by improved cognitive function and better short-term memory recall. And not only will the individual elderly person benefit from exercise, society too benefits because there is less demand on the NHS and other services.