Exercise for the

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• Exercise for the
• Special Population

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We will consider

• Global Aging
• Physiological Changes associated with aging
• Benefits of exercises in older adults
• Contraindications to exercise training
• Principles of training
• Evaluation tools
• Osteoporosis

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Useful Resource Link

• World Health Organization
• http//www.who.int/hpr/ageing/index.htm
• ACSM Exercise and Physical Activity for Older
  Adults Position Stand
• http//www.msse.org/
• Elderly Health Service (Hong Kong)
• http//www.info.gov.hk/elderly/english/index.htm

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Life Expectancy at Birth (male female),
1978-1998 (HK)
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Population Ageing - facts
By 2020,

• the number of elderly people worldwide will reach
  more than 1000 million
• elderly people will represent around 25 of the
  total population (currently 20)

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Regional Ageing facts
By 2020,

• projected proportion of population aged 60 and
  over is 17 in East Asia and 10 in South Asia
• China is one of the largest elderly population in
  the world (230 million)

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Ageing, morbidity mortality
By 2020,

• 3/4 of all deaths ageing-related
• Most caused by non-communicable diseases, such as
  diseases of the circulatory system, cancers and
  diabetes

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What happens when one gets older
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Effect of Aging Physiological Considerations

• Cardiovascular system
• Pulmonary system
• Musculoskeletal system
• Nervous system
• Body composition
• Renal function, thermoregulation
• Immune function
• Psychological function

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Cardiovascular Function

• VO2 max ? by 5-15 per decade after age 25
• Resting stroke volume ?
• Maximal HR ? 6-10 beats/min/decade
• Resting cardiac output ? 1 per year
• Myofilament disorganization, changes in
  mitochondrial structure ? ? oxidative capacity ?
  ? a-vO2 difference
• Anaerobic capacity ?

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Pulmonary Function

• Lung compliance ?
• Residual volume ? 30-50
• Vital capacity ? 40-50 by age of 70

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Musculoskeletal Function

• Muscle
• Sarcopenia (loss of muscle mass) ? reduction in
  muscle strength ? functional capacity
• Gradual and selective loss of muscle fibers (more
  marked in Type II muscle fiber)
• Muscle strength and walking speed correlation
  strong

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Musculoskeletal Function

• Bone
• Slow but continuous loss of trabecular BMD
  beginning 3rd decade
• ? in cortical BMD menopausal years
• Note
• Peripheral or cortical skeleton constitutes 80
  of skeletal mass (shafts of long bone)
• Trabecular or cancellous bone constitutes 70 by
  volume of the central skeleton

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Osteoporosis

• Low bone mass and mircoarchitectural
  deterioration of bone tissue ? bone fragility ?
  ? bone fracture
• Expressed as BMC or BMD
• Common measurement techniques
• Dual energy x-ray absroptiometry (DEXA)
• Computed tomography
• Site measured Lx vertebrae, proximal femur,
  forearm

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Changes in bone mass

• Bone is gained during adolescence
• Peak bone density at late adolescence
• Reaches plateau sometime during 3rd decade
• Stable till age 50
• Then progressive, gradual loss

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Regulation of BMD

• Physical activity
• Reproductive endorcine status
• Calcium nutriture

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Musculoskeletal Function

• Soft tissue Joints
• Flexibility ? - changes in collagen, decrease in
  extensibility
• Range of motion at joints ?

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Nervous System

• Vestibular, visual and somatosensory changes,
  inappropriate feedback to postural control
  centers
• Nerve conduction velocities and reaction times ?
  15 by 70 years
• Muscle effectors lack the capacity to respond
• Postural stability affected

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Other functions

• ? basal metabolic rate ? relative ? body fat
• ? renal function 30-50 between 30-70 years
  (affect acid-base control, glucose tolerance,
  drug clearance)
• Reduced sweating capacity
• ? in immune system function ? ? resistance to
  pathogens
• Vision

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Psychological Function

• ? cognitive function (decline in CNS)
• ? perception of control or self-efficacy
• Depression

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Benefits of Physical Activity in Older
Adults
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Endurance training

• Can achieve same 10-30 ? VO2 max as young adults
  (result of improvement of CO and a-vO2
  difference)
• Lower BP
• ? body fat
• Improve glucose tolerance
• Improve submaximal performance
• Reduction in risk factors associated with diseases

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Strength training

• Offset loss of muscle mass and strength
• Positive effect on bone density
• Reduction in risk of osteoporosis
• Improve postural stability
• Decrease risk of falling
• Improve flexibility and ROM

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Relationship

• Muscle strength, muscle mass and BMD STRENGTH
  is the key factor
• Age, activity and BMD
• WEIGHT-BEARING is the key factor
• Positive association between BMD and MUSCLE
  STRENGTH

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Physical Activity Bone Mass

• Positive correlation between activity level BMD
• Loads other than generated by gravity (e.g.
  muscular pull) actively stimulate bone deposition
• ? activity associated with lower rate of
  age-related bone loss

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Muscle Mass, Strength BMD

• Positive correlation (e.g. BMD lumbar spine with
  back extensor strength)
• Site-specific

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Benefits

• Preserve cognitive function (e.g. memory,
  attention, reaction time)
• Alleviate depression symptoms and behaviour
• Improve concept of personal control and
  self-efficacy

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Think about

• Health vs. Illness
• Functional capacity
• Quality of life
• Social contacts
• Cerebral function

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Contraindications to exercise testing and
training

• Absolute contraindications myocardial
  infarction, unstable angina, uncontrolled
  arrhythmias, third degree heart block, acute
  congestive heart failure
• Relative contraindications - ? BP, valvular heart
  disease, ventricular ectopy, uncontrolled
  metabolic disease
• Precautions diabetes, hypertension, obesity,
  left ventricular dysfunction

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Principles of training

• Specificity response to loading but does not
  impose orthopedic stress
• Overload training stimulus exceed normal
  loading without overtaxing
• Reversibility positive effect lost if program
  discontinued
• Ceiling effect and diminishing returns

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Principles of training
Great variability depending on pathology.

• F Emphasize increase frequency (5-7
  days/week)
• I lt 75 years gt 7 METS
• gt 75 years lt 4 METS
• RPE useful indication
• T 20-40 min/session (up to 60 min, if
  possible)
• T whole body activities, multi-joint
  activities, (enjoyable, company)

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Aerobic Conditioning

• Light intensity 35-54 HRmax
• Moderate intensity 55-69 HRmax
• Hard intensity 70-89 HRmax
• Very hard intensity ? 90 HRmax
• Duration 30 min
• Activities walking, cycling, dancing,
  swimming

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Resistance training

• Directed at large muscle groups important for ADL
• About 8-10 exercises
• Each set 8-12 repetitions
• 8-12RM for strength training and 20RM for
  endurance
• RPE rating 12-13 (somewhat hard)
• Frequency at least 2x per week (48 hours rest in
  between sessions)
• Duration of 20-30 minutes
• Progress every 2-3 weeks

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Exercise to improve bone health

• Wolffs law - Bone will accommodate the habitual
  stress that are imposed on it
• WB exercise mechanical stimuli to maintain or
  improve bone health
• Progressive resistance training gtgt effective than
  aerobic training

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Flexibility

• Perform on major joints of the body
• Slow movement, followed by static stretch 10-30
  seconds
• 3-5 repetitions
• Frequency 3-5 times per week (preferably daily)
• As warm-up and cool-down before exercises
• Duration 15-30 minutes

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Progression

• Think about the following parameters
• Duration
• Frequency
• Resistance
• Number of repetitions, time
• Complexity
• Static/dynamic balance, base of support, line of
  support, centre of gravity

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Think about

• Physical
• Psychological / behavioral
• Environmental
• Social and cultural determinants
• Adherence to Exercise

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Other practical issues

• Pre-existing medical conditions
• Maintain normal breathing patterns
• No ballistic movements
• Equipment (hand-grip, well-cushioned mats etc.),
  base of support, lighting, ventilation
• Gradual progression, increase duration rather
  than intensity (older adults)
• Accessible, convenient, SAFE

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Evaluation Tools
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Simple Fitness Tests

• Lower body strength 30 second chair stand
• Endurance 2 minute step-in-place
• Flexibility sit and reach
• Norm Scores provided
• http//www.acsm.org/activeaging.htm

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Common functional tests

• Timed up and go test
• 6-minute walk
• Berg balance
• Handgrip strength