INTRODUCTION — Exercise is beneficial for older adults. Older individuals who are physically active report better overall health, lower health care expenditures, and fewer mobility limitations than their sedentary counterparts [1-3]. However, the prevalence of older adults performing activities for aerobic conditioning, muscle strengthening, flexibility, and balance is low, and many older adults are not aware of the recommended components of a physical activity plan.
This topic will review the benefits of physical activity in older adults and make recommendations for how to engage older adults in appropriate exercise. Several other topics in UpToDate discuss the role of exercise in the general population:
●(See "Exercise physiology".)
BENEFITS OF PHYSICAL ACTIVITY IN OLDER ADULTS — Physical activity has multiple health benefits for people of all ages (table 1) . Among older adults in particular, physical activity is associated with decreased mortality and a greater likelihood of healthy aging (survival with intact physical and cognitive functioning) [5-10]. All older adults can benefit from physical activity, and participation in any amount of physical activity, even unstructured “leisure-time” activity, will result in some health benefit .
In older adults, the key benefits of increasing physical activity include improved strength, flexibility, mobility, and fitness, all of which can improve daily function, help to maintain independence, and reduce the risk of falls and fall-related injuries [12-15]. In a single-group intervention study of 206 healthy older adults, six months of aerobic exercise improved several elements of cognition, including executive function and verbal memory . In addition, exercise can reduce depressive symptoms, and group exercise programs can provide social engagement.
Exercise can lessen the normal age-related declines in aerobic capacity, muscle mass, and strength and mitigate the detrimental effects these changes have on function. For example, although aerobic capacity declines at about 1 percent per year from mid-life forward, it declines at only half that rate among habitually active persons . Similarly, while muscle loss occurs with normal aging, muscle strengthening activities can slow this loss. (See "Normal aging", section on 'Muscle'.)
It is never too late to become physically active. Even individuals who have been sedentary but initiate exercise in their 80s demonstrate a survival benefit compared with individuals who remain sedentary . Improved fitness and strength with exercise has been noted among very frail older adults and those in nursing homes [19,20].
Although epidemiologic evidence suggests that physical activity may confer a cognitive benefit, systematic reviews have found no evidence that aerobic activities provide cognitive benefit for healthy older adults  or improved cognition or neuropsychiatric symptoms in patients with dementia . (See "Risk factors for cognitive decline and dementia", section on 'Lifestyle and activity' and "Prevention of dementia", section on 'Lifestyle and activity'.)
RISKS OF EXERCISE — There is no evidence that the risks of physical activity outweigh the benefits for healthy older adults. However, there may be risks associated with medical conditions which are more prevalent in older adults, such as cardiovascular, renal, or metabolic disease. The risk of falls and fall-related injuries are also greater in older adults. (See "The benefits and risks of aerobic exercise", section on 'Risks of exercise'.)
The Exercise Assessment and Screening for You (EASY) Tool is a six-item patient questionnaire for older adults that can be used to screen for health issues and concerns and develop a tailored physical activity program appropriate for different health circumstances and situations [23,24]. The EASY tool offers recommended guidance and resources for individuals with joint pain or swelling, with chest pressure with activity, or at high risk for falls. The questions are:
●Do you have pains, tightness, or pressure in your chest during physical activity (walking, climbing stairs, household chores, similar activities)?
●Do you currently experience dizziness or lightheadedness?
●Have you ever been told that you have high blood pressure?
●Do you have pain, stiffness, or swelling that limits or prevents you from doing what you want or need to do?
●Do you fall, feel unsteady, or use an assistive device while standing or walking?
●Is there a reason not mentioned why you would be concerned about starting an exercise program?
THE ROLE OF THE PROVIDER — Useful provider actions include motivating patients to exercise, providing pre-exercise evaluation if needed, facilitating referral to physical therapists or other health professionals, and directing patients to online or community resources. Many patients will benefit from a combination of such provider interventions.
Motivating patients — Health care providers are perceived as respected sources of health information and should take an active role in promoting physical activity. Primary care clinicians should emphasize the importance of physical activity for health maintenance, ask patients if they are physically active, and advise patients to become physically active.
Initial motivational strategies should focus on personally meaningful and immediate benefits such as improved mood, better sleep, maintaining weight, and increased energy to do desired activities with family and friends. Identifying patient-specific goals for continued physical function (eg, being able to play with a grandchild, maintaining independence to walk to the grocery store, being able to continue to climb stairs in the home) can be helpful motivators for ongoing participation. Clinicians should discuss that interruptions in physical activity due to illness, caregiving, or other obligations are normal, and that patients should return to physical activity as soon as possible.
The US Preventive Services Task Force (USPSTF) has no specific recommendation for behavioral counseling for physical activity for older adults and recommends that clinicians selectively counsel patients based on risk factors, readiness for change, social support, and other health care priorities . The evidence of the effectiveness of physical activity counseling among older adults is sparse .
Specific strategies for assessing patient willingness to engage in exercise are discussed in detail elsewhere. (See "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Assessment of patient willingness to begin exercising'.)
Patient evaluation prior to initiating exercise — We agree with recommendations from the American College of Cardiology (ACC) and American College of Sports Medicine (ACSM) regarding patient evaluations prior to initiating physical activity . These recommendations are based on the individual’s current level of activity, the presence of signs and symptoms of known cardiovascular, metabolic, or renal disease, and the desired exercise intensity. There are no special considerations based on age. The approach described in the ACSM’s guidelines is summarized in the following algorithm (algorithm 1). The recommendations and are also discussed in detail elsewhere. (See "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Medical assessment and clearance for exercise'.)
Routine testing by either electrocardiogram (ECG) or cardiac exercise testing is not indicated for asymptomatic adults who are preparing to undertake a physical activity program [28,29]. Evaluation of symptomatic adults is always indicated, whether or not they are planning to initiate an exercise program, and is discussed separately. (See "Chronic coronary syndrome: Overview of care".)
Resources for patients and providers — Providers may suggest that patients explore specific websites designed to encourage activity for older adults. Many patients may have access to local resources at senior or community centers.
Some resources in the United States include the following:
●Many health plans affiliated with Medicare provide access to a Silver Sneakers fitness program .
●The US National Institute on Aging at the National Institutes of Health (NIH) provides exercise and physical activity guidance on their website. Links to sample exercise videos appropriate for older adults are available on the site.
●The Exercise is Medicine website has information directly aimed at providers seeking physical activity resources. The RX for Health Series includes guidelines on exercise for individuals with various chronic diseases and medical conditions. Handouts for individuals with osteoporosis, arthritis, and frailty might be of particular use to providers with older adults with these conditions.
●Public Broadcasting Service (PBS) has an exercise program for older adults, Sit and Be Fit, which is available on air and as a series of videos.
OVERVIEW OF PHYSICAL ACTIVITY COMPONENTS — We suggest that providers make specific recommendations for exercises that fall into four categories, in agreement with guidelines from the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) :
These recommendations are similar to those of the World Health Organization (WHO)’s 2020 guidelines on physical activity and sedentary behavior, which encourage older adults to engage in physical activity at moderate or greater intensity on three or more days a week, emphasizing functional balance and strength training, in order to enhance functional capacity and to prevent falls .
Aerobic exercise — Aerobic exercise involves the sustained use of large muscle groups that stimulate and strengthen the heart and lungs, thereby improving the body’s ability to utilize oxygen. Examples of aerobic activities include brisk walking, jogging, swimming, water aerobics, tennis, golf without use of a cart, aerobic exercise classes, dancing, bicycle riding, and use of "cardio" equipment (eg, elliptical machines, stair climbing machines, stationary bicycles, and treadmills).
Some guidance for implementing aerobic activity for older adults is as follows:
●Activities do not have to be done at one time but can be accumulated throughout the day .
●Individuals with chronic disabling conditions may not be able to achieve the minimal recommended amount of physical activity (described below) but should be as physically active as can be achieved without harm. An emphasis on reducing sedentary behavior (to sit less, move more) and adding light activity, such as short walks, may be more reasonable goals for some older adults who are unable to adopt more intensive exercise prescriptions .
Guidelines from the AHA and ACSM for older adults suggest a minimum of 150 minutes per week of moderate-intensity aerobic activity (30 minutes on five days each week), or a minimum of 60 minutes per week of vigorous activity (20 minutes on three days each week), or some combination of the two .
Physical activity guidelines from the United States Department of Health and Human Services suggest 150 to 300 minutes of moderate-intensity aerobic activity per week for all adults, including older adults . Recommendations specific to older adults include incorporation of multicomponent activities that include balance training and muscle strengthening. In addition, clinician should help older adults with chronic conditions to understand whether and how their conditions affect their ability to do regular physical activity safely. Patients whose chronic conditions limit the intensity of aerobic activity should be as physically active as their abilities allow. If sedentary, these patients should begin activities that are easy to do and then gradually build up to more moderate intensity over time. The emphasis should be on reducing the amount of sedentary time and encouraging activities that are feasible and where small successes can be achieved with gradual progression.
Definitions for moderate and vigorous aerobic activity depend on the person's baseline conditioning and are based on a perceived relative exertion of effort. In older adults, intensity of effort is best measured on a relative scale of required effort. Using a scale of 0 to 10, with 0 considered the amount of effort used while sitting and 10 considered the greatest effort possible, moderate-intensity activity would be defined as between 5 and 6 and should produce a noticeable increase in breathing and heart rate, while 7 and 8 would indicate vigorous intensity and should produce a large increase in breathing and heart rate . A good rule of thumb for moderate to vigorous aerobic activity is that the individual should be able to carry on a conversation during activity; if the person cannot sustain a conversation, the effort is too high.
Muscle strengthening — Activities to maintain and increase muscle strength include weight training, weightbearing calisthenics, or resistance training. Development of muscle strength and muscle endurance is progressive and requires gradual increases in resistance over time. Muscle-strengthening activities, including guidance for training in older adults, are described in detail elsewhere. (See "Practical guidelines for implementing a strength training program for adults", section on 'Important considerations for strength training in older adult patients'.)
Muscle strengthening for frail older adults is described below. (See 'Functionally limited or frail' below.)
Flexibility — Flexibility is considered paramount to overall good physical health and is necessary to perform daily life activities such as putting on shoes, reaching for objects overhead, or turning around to back a car out of a driveway.
Some guidance for older adults implementing a flexibility program is as follows:
●Flexibility exercises should be performed twice a week for at least 10 minutes.
●Stretching is best performed after aerobic or strengthening activities when the body is warmed up.
●Patients should breathe normally while stretching and avoid bouncing into a stretch.
●It is best to slowly stretch into the desired position and hold each stretch for 10 to 30 seconds.
●Patients should feel a slight pull but should not stretch to the point of pain.
Balance training — Balance problems are common in older adults. In a data analysis from a US National Health Interview Survey, nearly 20 percent of 37 million older adults (mean age 74 years) reported dizziness or balance problems in the preceding 12 months .
Balance exercise improves stability and may prevent falls and reduce injuries related to falls. Balance exercises are especially important for individuals who have a history of falling or who have mobility problems. A list of evidence-based fall prevention programs can be found on the National Council on Aging website. This website also provides guidance on how patients can find falls prevention programs near their home.
In addition to tai chi, balance training may involve activities that challenge gait patterns, such as heel-to-toe walking; increase awareness of use of the center of gravity for basic movements; and augment different sensorial systems involved in balance maintenance. Examples of balance exercises are shown (picture 4A-C and movie 3 and movie 4 and movie 5).
Many patients at risk for falls will likely benefit from a physical therapy referral to enhance strength and balance. Further information on preventing falls is available elsewhere. (See "Falls: Prevention in community-dwelling older persons".)
DEVELOPING AN ACTIVITY PLAN
General principles — An activity plan is recommended for all older adults. Older adults are a heterogeneous population, and many persons over 65 can participate in physical activity at the same levels as younger persons. It is therefore important for any activity plan to have individualized recommendations based on the particular abilities of the patient. Patients who are in the oldest segment of the population (over 75 years), who are frail, or who have been previously sedentary should likely initiate exercise of lighter intensity and duration than younger or more robust older adults. “Start low and go slow” is a good rule of thumb with the recognition that patients can start well below recommended guidelines and gradually build up. As little as 5 to 10 minutes a day of aerobic exercise with one or two simple functional strength-based exercises may be a good starting point for some patients.
The plan should have patient-specific recommended levels of physical activity and specific instructions for how the individual will meet each recommended type of activity. It should specify what, how, when, where, and how often each activity will be done and include a progressive and stepwise approach to increase physical activity to meet recommended goals. An example of an activity plan is shown in the table (table 2). However, it should be noted that even exercise that does not meet recommended goals still has a mortality benefit in older adults .
For patients of all ages, maintaining motivation to continue an exercise routine can be challenging. A successful exercise program will likely incorporate activities that the patient enjoys and finds interesting, which can be incorporated easily into the patient’s daily routine, and which offer social engagement. Older adults in particular may find that having a companion or “exercise buddy” can help to maintain motivation and make activities more enjoyable. Many adult day health programs, community senior centers, and assisted living accommodations have supervised group exercise programs.
For patients with certain chronic conditions, the development of an activity plan may need input from physical therapists/exercise physiologists or referral to specialty programs (eg, cardiac or pulmonary rehabilitation). Individuals who have difficulty performing basic self-care tasks or who are at high risk of falls would likely benefit from a physical and/or occupational therapy intervention prior to transitioning to a physical activity program. (See 'Special populations' below.)
Greater detail about prescribing an exercise program can be found elsewhere. (See "Exercise prescription and guidance for adults".)
In addition to an exercise plan, patients should be encouraged to limit sedentary behavior, which is an independent risk factor for adverse health outcomes, above and beyond low physical activity . Providers can help patients strategize ways to incorporate more movement into their day, as breaking up periods of sedentary time is associated with better physical function .
Special populations — Patients with specific health conditions may require special instruction or consideration. The American College of Sports Medicine (ACSM)'s initiative, Exercise is Medicine, has prepared an online library of patient handouts with specific exercise prescriptions for a wide variety of specific health problems (eg, Alzheimer disease, atrial fibrillation, anxiety, peripheral arterial disease). Some specific populations are discussed below.
Functionally limited or frail — Although functionally limited or frail individuals may not be able to meet minimum recommended activity levels, even modest activity and muscle strengthening can impact the progression of functional limitations [12,20]. While all elements of the physical activity recommendations should be incorporated into an activity plan, the adage "start low and go slow" should be kept in mind. It is acceptable to begin a baseline physical activity recommendation of walking for five minutes twice a day as a starting point. The key is to identify a set of activities the patient feels capable of doing, thus incorporating the concept of self-efficacy into the physical activity recommendation . Functional exercises that focus on particular skills or daily tasks (eg, getting up from a chair, climbing stairs) are likely to be particularly useful. Physical and occupational therapy consults may be needed.
Some guidance for muscle strengthening, including frail adults, is as follows:
●The initial weight should be one that an individual can lift about eight times before experiencing muscle fatigue. This weight should be maintained until the person can easily lift the weight 10 to 15 times, then increased to a weight that again they can only lift eight times, continuing with this gradual approach to progression. If a weight cannot be lifted eight times, it is too heavy and should be decreased. Resistance bands, color coded for degree of difficulty, can be used instead of weights following similar guidance.
●Breathing should be normal while lifting weights, exhaling as the weight is lifted or as the elastic band is pulled.
●Movements should be slow through a repetition: two to three seconds to lift, hold for one second, and three to four seconds to return to the starting position.
●Joints should not be locked in a tightened position.
●Patients should be advised that muscle soreness is normal at first and should subside in a few weeks. For individuals with painful chronic conditions, muscle-strengthening activities should not exacerbate pain. More gradual incremental strengthening is advised for patients with chronic pain to maximize tolerance and their long-term commitment to a strengthening program.
●Muscle strengthening can be performed at home, using standard exercise equipment, or if needed, homemade weights such as soup cans, water bottles, or empty milk jugs filled with water or sand.
Arthritis — For patients with osteoarthritis, aerobic activities should be selected, if possible, that minimize joint stress (eg, swimming, water aerobics, stationary cycling). Some local fitness or city recreation facilities have access to warm water aquatic programs or pool-based arthritis classes that are non-weightbearing. Any water-based, low weightbearing activities, eg, lap swimming, water walking, or water aerobics, are beneficial.
If non-joint-bearing options are not available, the focus should be on gradual initiation and progression of aerobic activities that can be tolerated. Strengthening activities should start at a relatively low intensity and gradually progress as pain tolerates. Maintaining/developing flexibility and full range of motion in affected joints is a major goal. Patients should be advised that although they may experience discomfort during or following physical activity, activity is viewed as beneficial for joint health. Icing the affected area for 10 minutes following physical activity will provide symptom relief and can prevent inflammation. Activity should be moderated if pain persists. Consideration should be given to timing physical activities to the optimal timing of prescribed pain medications . Detailed information on exercise in patients with knee osteoarthritis is provided elsewhere. (See "Management of knee osteoarthritis", section on 'Exercise'.)
Rheumatoid arthritis differs from osteoarthritis in that it is an autoimmune disease with chronic inflammation of the synovial fluids surrounding the joints. There is insufficient research to determine whether exercise activity should be avoided during acute flares. However, exercise remains important in maintain function . A more detailed discussion of exercise in patients with rheumatoid arthritis is presented elsewhere. (See "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Physical activity'.)
Cognitive impairment — The standard recommendations for physical activity apply to individuals with cognitive impairment. In many instances, it may be useful to have a partner or caregiver monitor and provide ongoing support for activities performed. This may be necessary for teaching the physical activity and for safety reasons or to help patients keep track of their exercise efforts. For example, activity logs to track physical activities may present difficulties for individuals with cognitive impairment and may become a barrier to exercise compliance, rather than a facilitating tool as intended. In addition, patients with cognitive impairment may require assistance with equipment that uses electronic display boards.
Although there is no evidence that aerobic activities provide improve cognition or neuropsychiatric symptoms in patients with dementia, exercise may improve the ability of patients with dementia to perform activities of daily living . (See "Management of the patient with dementia", section on 'Exercise programs'.)
Osteoporosis — The standard activity recommendations apply for individuals with osteoporosis, but greater emphasis should be placed on weightbearing and strengthening activities. Strengthening programs should be gradual, because excessive weightbearing with the initiation of exercise may increase the risk of fractures. (See "Overview of the management of low bone mass and osteoporosis in postmenopausal women", section on 'Exercise'.)
Fall avoidance is important, so individuals with osteoporosis are encouraged to participate in fall prevention activities or balance training, such as tai chi. (See "Falls: Prevention in community-dwelling older persons", section on 'Exercise' and "Falls: Prevention in nursing care facilities and the hospital setting", section on 'Exercise'.)
Individuals who have had osteoporotic fractures of the hip or vertebrae should avoid sudden, jarring, or twisting movements; abdominal crunches or curls; and heavy lifting. There is evidence that exercise may increase the risk of fractures under certain conditions. These include performing quick twisting movements during transitions between exercise positions, such as flexion and extension of the spine or internal and external rotation of the hips [45,46]. It is best to consult a professional therapist for activity after a fracture to relieve pain and regain mobility. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment", section on 'Exercise'.)
Diabetes — Exercise considerations in patients with diabetes mellitus are discussed elsewhere. (See "Exercise guidance in adults with diabetes mellitus", section on 'Exercise guidance'.)
Chronic low back pain — Exercise considerations for patients with chronic low back pain are discussed elsewhere. (See "Exercise-based therapy for low back pain".)
Patients with multi-morbidity — Physical activity should be considered part of medical management of most chronic conditions, and in general activity recommendations are similar across conditions. Implementing a global physical activity prescription that minimizes sedentary time will likely address all chronic conditions .
Other — A discussion of exercise in patients with pulmonary disease or peripheral vascular disease, or for cardiac rehabilitation, is beyond the scope of this topic and is presented elsewhere. (See "Pulmonary rehabilitation", section on 'Exercise training' and "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Exercise in adults".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (See "Patient education: Exercise (Beyond the Basics)" and "Patient education: Arthritis and exercise (Beyond the Basics)".)
SUMMARY AND RECOMMENDATIONS
●Physical activity benefits people of all ages and may decrease all-cause morbidity and increase lifespan. Some physical activity is better than none, and participation in any amount of physical activity will result in some health benefit. It is never too late to become physically active. (See 'Benefits of physical activity in older adults' above.)
●Key benefits of exercise in older adults include improved strength, flexibility, mobility, and fitness, which can improve daily function, help to maintain independence, and reduce the risk of falls and fall-related injuries. Group exercise programs have an added benefit of providing social engagement. (See 'Benefits of physical activity in older adults' above.)
●Guidelines from the American Heart Association (AHA) and the American College of Sports Medicine (ACSM) identify four categories for specific recommendations for exercises in all adults: aerobic exercise, muscle strengthening, flexibility, and balance. (See 'Overview of physical activity components' above.)
●We agree with recommendations from the American College of Cardiology (ACC) and ACSM regarding patient evaluations prior to initiating physical activity which are based on the individual’s current level of activity; the presence of signs and symptoms of known cardiovascular, metabolic, or renal disease; and the desired exercise intensity. There are no special considerations based on age. The approach is summarized in the algorithm (algorithm 1). (See 'Patient evaluation prior to initiating exercise' above.)
●Routine testing by either electrocardiogram (ECG) or cardiac exercise testing is not indicated for asymptomatic adults who are preparing to undertake a physical activity program. Evaluation of symptomatic adults is always indicated, whether or not they are planning to initiate an exercise program, and is discussed separately. (See 'Patient evaluation prior to initiating exercise' above.)
●An individualized activity plan is recommended. For older adults, it should include specific physical activity instructions and advice for progression of activity. (See 'Developing an activity plan' above.)
●Aerobic exercise involves the sustained use of large muscle groups. Minimal recommendations advise moderate-intensity aerobic activity for 30 minutes (in several smaller time increments if needed) on five days each week or vigorous activity on three days each week for all adults, including older adults. Moderate or vigorous intensity is based upon a person's baseline conditioning and is determined by an individual's perceived relative exertion of effort. (See 'Aerobic exercise' above.)
●Flexibility is necessary to perform daily life activities, and exercises to increase or maintain flexibility should be performed twice a week. Stretching is best performed after aerobic or strengthening activities when the body is warmed up. (See 'Flexibility' above.)
●Balance exercise, such as tai chi, improves stability and may prevent falls and reduce injuries related to falls. (See 'Balance training' above.)
●Initial motivational strategies should focus on personally meaningful benefits, and immediate goals should be incorporated into the physical activity plan. (See 'The role of the provider' above.)
●There are a variety of online and community based resources for older adults who wish to exercise. (See 'Resources for patients and providers' above.)
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