Writing an Exercise
Prescription
for Older Adults
Gail Sullivan, MD, MPH
UConn Center on Aging
What to Prescribe?
 75 y/o woman
 HTN, mild OA, hyperlipidemia
 “Active”
 “Doc, what can I do to stay healthy?”
 Prescribe exercise?
 Need prior evaluation (eg treadmill)?
Clinician
 Determine stage of change & patient’s
motivations
 Assess type of exercise to benefit patient
 Identify likely barriers to physical activity & potential
solutions
 Write exercise prescription
Some Patients Want to
 Improve or maintain current function
 Improve pain or other symptoms
 Avoid or reduce falls; get up from fall
 Stay in home; avoid hospitalization
 Reduce medications
 Lose weight
Physical Activity Prescription
 Warm up
 Exercise
 Cool down
 Precautions & modifications
 Patient education
 Understand risks
 Improve adherence to
prescription
Patient Education
 Worrisome signs & symptoms
 CP, severe SOB, dizziness, palpitations, fast HR
 Potential drug-exercise interactions
 Diuretics
 Vasodilators
 Beta-blockers
 Insulin
 Sympathomimetics
 Adjust for illness, season, weather
 Need a plan for ‘bad weather’ days!
Risks: Cardiac
 Healthy elders without known cardiac disease
 1 death per 82,000 or per 26 million work-outs, over 2 yrs*
 Patients w/ CAD, studies of cardiac rehab**
 Cardiac arrest:
1 per 117,000 patient-hrs participation
 Non-fatal MI:
1 per 220,000
 Death:
1 per 750,000
 MI risk during exercise
 ↑ those most sedentary
 ↑ those performing unaccustomed activity
 ↑ highest exertional levels (jogging, shoveling snow)
*Franklin BA et al. Circulation. 2000; 102 (suppl II): II–612
**Franklin BA et al. Chest. 1998; 114: 902–906
Cardiac Patients & Hi Intensity
 Norwegian study, 4,846 patients, 8 years
 All had cardiac disease, 3 cardiac rehab centers
 Hi intensity interval exercise & moderate intensity
 Very low rates cardiac events, for both
Rognmo et al. Circulation. 2012;126:1436-1440
AHA
 “Perform exercise testing before vigorous exercise in
selected patients with cardiovascular disease &
other patients with symptoms or those at high risk”
 “Sedentary adults should avoid isolated bouts of
unaccustomed vigorous physical activity & should
follow the standard recommendation to increase
physical activity levels gradually over time.”
Thompson, Circulation. 2003; 107: 3109-3116.
Fihn SD. Circulation. 2012;126:3097-3137
Sudden Death During Vigorous
Exercise
80
74
70
60
50
RR Sudden
40
Death
30
20
19
11
10
0
<1/week
1-4/week
>4/week
Frequency of Vigourous Exercise
Albert NEJM 2000
Risk of MI with Frequency Level
120
100
80
RR Onset of MI 60
40
20
0
0
1 to2
3 to4
5+
Frequency of heavy exertion per week
Mittleman NEJM 1993
Guidelines to Minimize Cardiac Risk
 Identify special circumstances
 MI within 6 months or active angina
 Signs & symptoms of CHF - need to treat 1st
 Resting sys BP >200 or dias BP > 110
 Test cardiac reserve
 Walk up flight of stairs or cycle for 1 minute
 If unable, consider evaluation or monitor during
start
JAMA July 19, 2000
Exercise Risks: Musculoskeletal
 Most frequent cause of morbidity, but occurs less
vs. younger exercisers
 Risk related to exercise type
 Jogging: 57% injury rate, age 70-79
 5-10% per year with low impact activities
 Usually self-limited
 Avoid exercise with acutely inflamed joints
 Assess & modify according to fall risk
 Chair-based or aquatic, or buddy for high fall risk
Preventing Deconditioning
 Takes 2x longer to regain strength than it does to lose
 Minimize bed rest for hospitalized patients
 Utilize chair
 Write order to ambulate 3x daily
 Walking clubs at all residential living sites
 Chair sit-to-stands before meals at SNF, ‘walking
buddies’
Identify Supports
 Family
 Friends
 Local programs – senior centers, YMCA, Curves for
Women
 Exercise as a time to reflect, plan your day, relieve
stress, meet people
Best Walking Partners: Man vs Dog
NY Times 12/14/2009
 Research Center for Human-Animal Interaction
(Missouri)
 12 wk study of walking programs (5d/wk)
 54 older adults from ALF
 2 groups
 Paired with a partner (spouse, close friend) - mostly m/f
 Dog from local shelter
Results
 Dog-walking group twice as
likely to complete the program
 Walking speed increased
among dog walkers by 28%
compared to 4%
Endurance Tips
Don’t ask patients to check their pulse
unless post MI or new dx CHF → cardiac rehab
 Are you exercising?
= yes, if breathing increases
 Can you talk & sing?
= moderate
 Can you talk?
= vigorous
Slow down if you cannot talk or feel out of breath
Max HR=220 – age
Cool Down Tips
 Goal: gradual ↓ in vasodilatation & heat to ↓ risk of
dizziness & syncope
 Especially important in patients with CAD, CHF
 5-10 minutes
 Examples: slow walking, stretching, walking slowly in
pool
78 yr. woman, ‘too busy’
 New patient, retired
 Hx: osteoporosis, mild OA (back), obesity,
HTN, on HCTZ
 Fn: drives, IADL indepen., cares for grandchildren
 No exercise since high school – “I’m active; too busy
to exercise”
Should exercise be recommended, & further evaluation?
What benefits might exercise offer her & what types of
activities might be best?
Write an exercise prescription
Should exercise be recommended; does she need
more evaluation?
 YES
 NO
definitely
no angina & HTN under control, no need for eval
What benefits might exercise offer her?
 Precontemplator stage
 Aerobic exercise for obesity & HTN control
 Aerobic exercise reduces likelihood of being admitted for
cardiac reasons
 Weight-bearing exercise, strengthening (resistance) to
improve osteoporosis
 Stretching to improve back pain & overall joint symptoms
 Wt loss & strengthening abd. muscles may help back pain
What types of exercises might be best?
 If joint symptom control: focus on stretching & strengthening
 If concern to reduce meds (HTN), lose wt, become fit: aerobic
 Differentiate ‘activity’ from exercise - being ‘active’ is good,
but exercise adds benefits
 Work exercise into her lifestyle
 Provide exercise options: dancing to music w/ grandchildren
 PT may help – teach back stretches/ abd. muscle
strengthening, & generally ease her into exercise
 She drives: getting away from home, making new friends, &
having time to reflect on her own may be attractive
EXERCISE PRESCRIPTION (FITTS)
NAME
Case I: “Too Busy”
DATE_________
FREQUENCY
5 times per week, ‘start low, go slow’
INTENSITY
Moderate
HR 50-75% Max = 70-105
TYPE
TIME
Warm up
Gentle back stretches and leg stretches, taught by PT
5 minutes
Exercise
Week 1: 5 minutes
Walking in nice weather
“
2: 10 “
Dancing inside in bad weather or when caring
“
3: 15 “
for grandchildren (twice per week)
“
4: 20 “
“
5: 25 “
Cool Down
Yoga easy stretches, end in completely relaxed position
5 -10 minutes
as taught by PT (reinforced by video or audio tape)
SPECIFIC Instructions, Precautions, Modifications
Back stretches to be done on floor mat or against a wall (no unsupported back
stretches)
Remind patient her breathing should increase but she should be able to talk/sing.
Monitor back and other joints
82 yr. man with OA
 HX: knee OA, HTN, COPD, osteoporosis
 Avoids stairs because of knees; no SOB
 Meds – HCTZ, ACEI; albuterol 2x per month
 Drives, IADL independent
 Feels he is “slowing down” & not ready to
 No exercise – some outside work in summer
Should exercise be recommended; does he need
any further evaluation?
 YES
exercise should definitely be recommended
 NO
no angina, joints not acutely inflamed, COPD
stable, BP ok
 Might check other tests (CBC, BMP, TSH) – ensure
‘slowing down’ due to deconditioning)
What benefits might exercise offer him?
 Contemplator stage
 Stop ‘slowing down,’ improve knee pain/function
 Education that exercise is safe for his knees

RCT of walking showed as much pain relief as with
ibuprofen, for knee OA.
What types of exercises might be best?
 For fatigue, aerobic exercise key
 Also aerobic for HTN & cardiovascular risk
 Strengthening for OA & osteoporosis
 Stretches for pain prevention/relief
 Non-weight-bearing exercise (e.g., pool or floor) best if
knee OA is moderate or worse, or if he has flares
 May benefit from knee steroid injections and/or
replacement in future
EXERCISE PRESCRIPTION (FITTS)
NAME Case II: “Knee OA”
DATE_________
FREQUENCY
Resistance alternating with aerobic exercise, total 4 times/wk, at local YMCA.
Powerful Aging class once/wk (aerobic, stretching)
Start at mod. pace – may increase to vigorous after 6 mon. if no side effects
INTENSITY
Moderate
HR 60-79% MPHR =70-105
Vigorous
HR 80-90% MPHR = 112-126
TYPE
TIME
Warm up
Leg and back stretches
5 min.
Exercise
Powerful Aging (stretching, balance, & aerobic) 1x/wk
1 hour
Pool swim 2x/week
5-10 min., incr. by 5 min/wk, stop ~ 30’
Resistance – machine circuit - 2x/wk
start at 1 machine, add 1 machine each
session - stop at 25 min/session
& < 8-10 reps/machine
Cool Down
Leg, upper body, and back stretches
5 minutes
SPECIFIC Instructions, Precautions, Modifications
No leg press machine – & other modifications per joint exam.
Acetaminophen 1 gm TID & avoid exercises that stress the joint, during joint flares
Remind patient: breathing should increase but able to sing & talk. Slow down if feels breathless
86 yr. woman w/ hip fx
 Fell → fx 3 mon. ago, 3 wks rehab
 HTN, diet-DM, osteoporosis, mild OA (back, hands),
hypothyroidism
 Lives alone, 1-floor apt., daughter drives her
 Walked w/ no gait aid before fx, now reluctantly uses
a walker, walking slowly, balance poor & legs weak
 Wants to do “everything I can” to stay in her home
Should exercise be recommended, and if so, does
she need any further evaluation?
 YES
exercise should be recommended
 NO
no angina, CHF, & BP ok
(She needs osteoporosis rx, if not already underway)
What benefits might exercise offer her?
 Action stage
 Aerobic: stay out of hospital, overall health
 Balance & LE strength to reduce fall risk
 Strengthening/resistance for osteoporosis
 Stretching for back
What types of exercises might be best?
Depends upon her balance
• If balance very poor, may need aquatic or
chair/table-based until she improves
• She’ll benefits from balance, leg strengthening, &
aerobic – so focus on her priorities – which is to get
rid of walker!
• May not be possible
• Stretching as warm up/cool down for her back/joints
• Most activities will have to be at home as she is
dependent on daughters to drive
• Notes from PT at SNF may be helpful
EXERCISE PRESCRIPTION (FITTS)
NAME Case III: “After Hip Fracture”
DATE_________
FREQUENCY
6 times/wk
Exercise video, seated, first without weights, later with ½ lb weights
Aerobic aquatic class, YMCA, 3 times/wk, daughter drives & assists
Walk around block with neighbor/daughter, 1-2/wk, weather permitting
Chair sit-to-stands 1 before each meal, increase to 4 before each meal
INTENSITY
Low to Moderate
Mod:
HR 60-79% MPHR =60-93
TYPE
TIME
Warm up
Stretches, slow moves included in video and aquatic class
Before walking, back and leg stretches with chair
5 min
Exercise
Start at 5 min/day, add 5 minutes/wk to reach 30 min/session
Cool Down
Included in video and class
After walking, leg and back stretches in chair
5 minutes
SPECIFIC Instructions, Precautions, Modifications
Remind patient she should be able to talk and sing
Fall risk reduction behaviors & environmental review
Treat osteoporosis
82 yr. woman post-MI
 6 mon. ago non-Q-wave MI – no RF
 Stent placed; rx’n to Plavix - stopped
 Developed Afib; cardiac echo normal
 No CP since
 Meds: warfarin, β-blocker, statin
 Before MI was vigorous tennis player, swam 3x/ wk
 Stopped exercise due to rocky post-MI course, now
anxious to resume tennis & swimming
Should exercise be recommended, and if so, does
she need any further evaluation?
 YES
 YES


exercise should be recommended
submax stress test if not done. Education
about β-blocker & monitoring for CHF
Cardiac U/S is normal
Did she do cardiac rehab program?
What benefits might exercise offer her?
 Action stage - patient anxious to resume tennis &
swimming, will start even if you do not give ‘ok’
 Aerobic offers cardiac benefits
 Fall risk & osteoporosis benefits as well
 Enhance mood, identity as ‘well’ person
What types of exercises might be best?
 Teach patient to check her pulse & ‘red’ flag
symptoms
 No skipping warm up & cool down
 Start with low aerobic activity
 Slow walking, walking in water, progress to
swimming slow breast stroke or
elementary backstroke, not free-style
EXERCISE PRESCRIPTION (FITTS)
NAME Case IV: “Post-MI”
DATE_________
FREQUENCY
Slow walking alt with swimming, 6x/wk
Monitor breathing & pulse at first (P may not increase due to β-blocker)
INTENSITY
Low at first, goal of Moderate
TYPE
Warm up
Arm, back, leg stretches in pool
Leg, back stretches (counter, wall) before walking
Exercise
Walking alt. with swimming:
Start at slow pace & monitor breathing
TIME
5 min.
Week 1: 5 minutes
“
2: 10 “
“
3: 15 “
“
4: 20 “
“
5: 25 “
“
6: 30 “
Cool Down
Walk in pool (swim day) or walk last 5 minutes slowly
5 min
Stretch, same as warm-up
5 min
SPECIFIC Instructions, Precautions, Modifications
Cardiac rehab program/reminders about cardiac stressors (e.g. hot weather) & ‘red flag’
symptoms: fatigue, SOB, CP, light-headedness
Case 5 – 88 yr man w/ depression
 New patient: “couch potato” self-described
 New diagnoses
 Major depression, starting treatment
 DM – oral agent started
 Height loss, several inches
 Old dx – early macular degeneration
 Caregiver for wife w/ Alzheimer’s dementia
 IADL independent, but sons drive him
Should exercise be recommended, and if so, does
he need any further evaluation?
 YES
 NO
exercise should definitely be recommended
no angina, CHF
What benefits might exercise offer him?
 Precontemplator stage
 Exercise beneficial in depression
 Exercise to get out of house – for caregiver burden
 Exercise beneficial for DM – & osteoporosis which he
may have
 Options may be limited if his mac. degen. worsens
What types of exercises might be best?
 Patient shocked at new diagnoses, especially DM,
& wants to minimize meds & sequelae
 He feels overwhelmed as caregiver, doubts he
can find time to exercise
 Match resources & patient preferences
Reduction of caregiver time needed
 Are sons willing & able to help out or pay for aide?
 Can sons or friends drive him to activities?
 Can he walk with his impaired wife?
 Aerobic perhaps most beneficial
 Group activities or with a buddy good for ↓ vision
EXERCISE PRESCRIPTION (FITTS)
NAME Case V: “Caregiver w/ Depression”
DATE_________
FREQUENCY
Senior Fitness class at YMCA - includes stretches, aerobic, & some balance 2x/wk
Walking at school near home with “Sunset Walkers” with buddy
2x/wk
Bad weather, no ride: home exercise audiotape, chair-based
2x/wk
Low vision rep or son does these with patient first few times
INTENSITY
Moderate
HR 60-79% MPHR =65 - 97
TYPE
TIME
Warm up
Leg and back stretches, before walking
5 min
Exercise
Walking program – maintain ability to talk easily
Week 1: 5 minutes
“
2: 10 “
“
3: 15 “
“
5: 20 “
“
6: 25 “ & f/u at MD appt
If all well, progress to full 45 minutes with group
Senior Fitness program is graded, so recent joiners do short parts of program with breaks
Audio tape has beginner, interm., & adv. levels for chair-based exercises – start at beginner
Cool Down
Stretches with walking group
5- 10 minutes
(Cool down included in Fitness class and tape)
SPECIFIC Instructions, Precautions, Modifications assess fall risk prior to starting program
Tai Chi
[email protected]