Theme Issue: Exercise and Sports
Exercise in the Older Adult: From the Sedentary
Elderly to the Masters Athlete
Leah G. Concannon, MD, Matthew J. Grierson, MD, Mark A. Harrast, MD
Abstract: The diverse exercise goals of the aging population present several challenges to
physicians. Whereas some Masters athletes aim to set personal time records, sedentary elderly
persons may look to exercise to help maintain independence and combat functional decline.
This review article examines the common cardiovascular and neuromuscular physiological
changes associated with aging and how regular exercise is used to improve physiological
parameters and functional abilities. Exercise precautions specific to the elderly population
are discussed. Exercise recommendations for persons with osteoarthritis and after joint
arthroplasty also are presented.
PM R 2012;4:833-839
INTRODUCTION
The definition of the term “elderly” varies depending on the physical requirements placed
on an individual. Among sedentary persons, individuals ages 65-75 years are considered the
young old, whereas persons ages 75-85 years are considered the middle old and those older
than 85 years are considered the very old [1]. Adults aged 50-64 years with functionally
limiting chronic medical conditions likely will benefit from the same recommendations as
those appropriate for older individuals [2].
Even greater diversity exists among Masters athletes, where age-based stratification
begins at age 18 years for swimmers, age 35 years for track and field competitors, and age 50
years for golfers. World Masters Athletics has international events and standards for age
grading that take into account the natural physiologic changes that occur with aging and
allow masters runners to compare their performance with younger competitors. Masters
athletes may be newcomers to sport and exercise or may have had prominent, competitive
careers since adolescence. The Masters athlete, therefore, is competing not only against
others but often also against the prior performance capabilities of his or her younger self. In
endurance sports, older athletes compete against the clock, and expectations about time
performance often must be restructured. In team sports, these athletes are faced with
younger and younger opponents and may need to employ different strategies to remain
competitive. The Masters athlete continues a regular and structured training regimen, often
with the goal of improving performance and exercise capacity. Part of the exercise prescription and routine evaluation of these individuals should include not only education regarding the natural physiology of aging and the benefits of continued activity, but also how best
to refine their competition goals without diminishing their competitive spirit.
Compared with Masters athletes, even basic activities of daily living can exceed the
functional capacity of a sedentary elderly individual. The spectrum of function with normal
aging challenges the patient and physician alike, requiring the clinician to periodically
re-evaluate goals and expectations and assist the patient in maximizing both functional
independence and quality of life. With close attention to the functional losses and physiologic changes of aging, it may be possible to address these changes through individually
tailored exercise programs to specifically target areas of need.
PHYSIOLOGICAL CHANGES OF AGING
Physical endurance directly correlates with the ability to transport and metabolize oxygen
during exertional activity. A peak aerobic power (VO2max) of 15-20 mL/kg per min is
PM&R
1934-1482/12/$36.00
Printed in U.S.A.
L.G.C. Department of Rehabilitation Medicine,
University of Washington, Box 359721, 325
Ninth Ave, Seattle, WA 98104. Address correspondence to: L.G.C.; e-mail: lgconcan@
uw.edu
Disclosures related to this publication: none.
Disclosures outside this publication: payment
for manuscript preparation, Medscape Pediatrics (article on concussion management in
adolescents) and Current Sports Medicine Report (article on radiating upper limb pain in the
contact sport athlete)
M.J.G. Department of Rehabilitation Medicine, University of Washington, Seattle, WA
Disclosure: nothing to disclose
M.A.H. Department of Rehabilitation Medicine, Orthopedics and Sports Medicine, University of Washington, Seattle, WA
Disclosures related to this publication: none.
Disclosures outside this publication: royalties,
Demos Medical Publishing (editor, Sports
Medicine Study Guide and Review for Boards)
© 2012 by the American Academy of Physical Medicine and Rehabilitation
Vol. 4, 833-839, November 2012
http://dx.doi.org/10.1016/j.pmrj.2012.08.007
833
834
Concannon et al
necessary to support independent community living; sedentary individuals often reach this milestone by age 80-85 years
[1,3,4]. A natural decline in peak oxygen transport occurs
that accelerates after age 50 years, when losses can average
0.4-0.5 mL/kg per minute per year, equivalent to 5%-10%
per decade [5,6]. Much of this decline has been attributed to
progressive inactivity, changes in body fat composition, and
peripheral and cardiac muscle deconditioning [7]. A metaanalysis concluded that a healthy but sedentary 67-year-old
person could expect to improve his or her VO2max by approximately 3.8 mL/kg per minute after 4-5 months of moderate
intensity exercises performed 3 times per week [4]. Given
that VO2max fluctuations of 5 mL/kg per minute roughly
correlate with a 10-year change in biologic age [1], attention
to potentially modifiable risk factors through such an intervention may sustain a person’s ability to live independently in
the community.
Even for healthy persons, progressive impairments in
cardiovascular function affect activity tolerance [1]. Aging
individuals experience a steady decline in maximal heart rate,
impaired compliance with diastolic filling, incomplete emptying in systole, and reduced inotropic response to sympathetic input, all of which negatively affect stroke volume,
ejection fraction, and cardiac output [5]. Although these
changes are unlikely to affect an elderly person at rest, activity
or exercise-induced tachycardia can exacerbate any mechanical disadvantages of the heart. Impaired diastolic function
can predispose an individual to the development of further
cardiac comorbidities, such as atrial fibrillation, ischemia,
and heart failure [8], with additional implications for physical activity.
Sarcopenia, which is characterized by losses in muscle
mass, strength, and endurance, also contributes to the functional consequences of aging because of changes in muscle
fibers, protein synthesis, and mitochondrial function. Even
in healthy persons, muscle strength and power begins to
decline around age 25 years, particularly in the lower extremities [9]. The process accelerates after age 65 years, when a
typical person already has lost 25% of his or her peak youth
strength [1,10]. By age 80 years, up to 50% of peak skeletal
muscle mass can be lost, likely related more to loss of actual
muscle fibers rather than fiber atrophy [10].
These changes disproportionally contribute to deficits
in total strength, strength per unit of cross-sectional muscle area, power, and fatigue [11], and can lead to functional decline. Age-related decreases in androgens and
other growth factors may contribute to this process with
selective loss of type II (fast twitch) muscle fibers, less synchronization of motor units, and deteriorating muscle quality
and myosin function [12,13]. The functional consequences
of age-related muscle fiber loss can be tempered through
regular physical activity, because active individuals exhibit
more favorable trajectories of muscle atrophy and potentially
EXERCISE IN THE OLDER ADULT
can recover losses accumulated during periods of relative
inactivity [11,14,15].
EXERCISE PRESCRIPTION
The exercise prescription for elderly patients does not differ
significantly from the prescription for younger adults. It is
recommended that adults participate in a minimum of 150
minutes of moderate intensity or 60 minutes of vigorous
physical activity per week. Older adults with functionally
limiting chronic diseases should be as active as their medical
condition allows in order to reduce sedentary behavior [2].
Intensity is measured by perceived exertion rather than metabolic equivalents of the task to take into account varying
levels of fitness in elderly persons [2]. Elderly patients have
longer recovery periods and require longer warm-up and
cool-down periods. The mantra of no more than a 10%
increase in volume or intensity is vital for older athletes,
because fatigue plays a larger role as we age [16].
Traditional resistance training recommendations for older
adults consists of 10-15 repetitions of 8-10 exercises that
train major muscle groups at moderate to high intensity at
least twice per week [2]. Older adults should also participate
in flexibility exercises for at least 10 minutes twice a week
with 10-30 seconds per static stretch and 3-4 repetitions for
each exercise [2]. Balance activities should be performed at
least twice per week for older persons at risk of falls. Balance
training should be progressed by gradually reducing the base
of support, adding dynamic movements to perturb the center
of gravity, stressing postural muscle groups, and reducing
sensory input [6].
When choosing the type of exercise program to prescribe,
it may be that a staged prescriptive approach is better, first
targeting the urgent needs of the patient, and then including
other modalities. This approach is particularly evident in
sedentary elderly persons who may benefit from balance
training acutely after a series of falls before the addition of
resistance or aerobic training [17].
BENEFITS OF EXERCISE
A significant decrease in cardiovascular and all-cause mortality occurs with increased activity. Regular physical activity
not only helps reduce the risk of many conditions associated
with aging, including cardiovascular disease, diabetes, and
stroke, but it also is recommended as treatment for many of
these same conditions [5,18,19]. The greatest benefit is seen
between sedentary adults and normally active adults, indicating that even a small increase in physical activity can produce
large gains. A combination of resistance and aerobic training
seems to be more effective than either alone [5].
Weakness and functional deficits that accumulate with
aging are predictors of age-related morbidity and loss of
autonomy [20]. Improvements in strength can lead to de-
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creased physical disability with a delay in onset of functional
decline [21], helping the elderly to remain independent.
Regular physical activity also can improve mood and psychological health and has been shown to be effective for treatment of depression [5,22].
Resistance training increases muscle mass, helping to
combat age-related sarcopenia [20,23]. In fact, disuse may be
the underlying reason for muscle atrophy and weakness,
rather than simply aging [24,25]. High velocity training
improves power (the ability to generate force rapidly), which
is disproportionally decreased in the elderly, and may be
more associated with functional abilities and fall risk than
muscle strength alone [5,26].
Aerobic exercise training can increase maximal aerobic
capacity to help reduce age-related decline. It also leads to
decreased stiffness of large elastic arteries, an independent
risk factor for cardiovascular disease in older adults [5,27].
Endurance athletes have lower levels of large elastic artery
stiffness, enhanced vascular endothelial function, less arterial
wall hypertrophy, and lower blood pressure than do sedentary adults. Even 3 months of regular brisk walking has been
shown to improve carotid artery compliance [28,29].
Balance
Balance is affected by accumulating factors that occur with
age, including postural hypotension, as well as impaired
proprioception, vision, and other sensory losses. Older
adults also demonstrate larger postural sway, slower gait
velocity, and decreased ability to recover from perturbation
with slower correcting reflexes. Slow walking speeds have
been associated with an increased risk of fractures, hospital
admissions, institutionalization, and death. Up to 30%-60%
of community dwelling older adults fall each year, and 5%10% of these falls result in serious injury [30]. An increased
number of medications also is associated with an increased
risk of falls [31,32].
Even simple walking is an effective intervention to improve locomotor function, as measured by such tests as the
6-minute walk and timed get up and go. The addition of low
intensity/high velocity strength training is helpful in frail
older adults, but healthy adults may require a more varied
program, with the addition of aerobic exercise, flexibility
exercise, and balance training to improve functional outcomes [33]. Frail or institutionalized persons may have an
increased risk of falls when initiating a physical activity
regime and require proper supervision [31].
Traditional balance programs include only voluntarily
controlled exercises, whereas newer balance training methods increase training specificity by adding more perturbation
or multitask activities, such as cognitive and motor tasks.
Perturbation training improves compensatory strategies for
recovery of balance and equilibrium [34]. Although this
training improves balance, it is not yet proven that it can
reduce fall risk when performed alone.
Vol. 4, Iss. 11, 2012
835
The addition of power strength training to balance training also can be useful. Elderly persons often lose not only
strength but also the ability to generate force rapidly, making
it more difficult to regain balance after a stumble or trip.
Multimodal exercise programs that include balance training
have been shown to reduce falls and injuries from falls [5].
Some evidence also exists that practicing tai chi can reduce
the risk of falls and fear of falling, although gains may not be
seen in the frail elderly population [21,35].
Bone Density
A history of weight-bearing activity as an adolescent or
young adult is not sufficient to prevent against osteopenia/
osteoporosis, and continued weight-bearing or resistive
exercise is needed to counteract age-related decreases in
bone mineral density (BMD) [36]. BMD is an important
risk factor for fractures in elderly patients, and it begins to
decline after peaking in the third decade [37,38]. The
typical loss of 0.5% per year seen after age 40 years is even
more exaggerated in postmenopausal women, who accumulate deficits of 2%-3% per year [5,39].
Bone loss is most rapid during the early postmenopausal
years [40], which likely explains why exercise implemented
within the first 10 years of menopause has a larger effect size
on BMD than if it is started later [36]. A simple walking
program may not be enough to increase BMD in previously
sedentary adults [41], but it may prevent age-related decline
in BMD and may lower fracture risk [5]. The addition of
resistance exercises or higher impact training may be more
beneficial [41,42]. It may be that the improvement in BMD is
not as important as the decrease in fall risk seen with exercise
that ultimately leads to a decreased risk of fracture [43],
although this theory remains to be proven.
Cognition
Regular physical activity is linked to a decreased risk of
dementia and cognitive decline [44] and leads to improved
cognitive performance in older adults, especially for executive functioning [5]. Regular exercise has been shown to
improve cognitive function [45] and is associated with a
decreased risk of mortality [46] in patients with dementia.
Walking and light exercise also can decrease wandering,
aggression, and agitation in patients with dementia [47].
Combined physical activity with caregiver training may
improve physical functioning, decrease depression scores,
and delay institutionalization in patients with Alzheimer
disease [48].
PREPARTICIPATION EVALUATION
Elderly patients are at an increased risk of injury compared
with their younger counterparts. From the Masters athlete to
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Concannon et al
EXERCISE IN THE OLDER ADULT
Table 1. Recommendations for cardiovascular screening prior
to initiating an exercise program
Age (y)
Cardiovascular
Risk
Recommended
Test
⬎40
⬎40 M, ⬎50 F
⬎65
Any
Any
Any
Low
Moderate to high*
Low
Symptoms of CAD
Documented CAD
Inducible ischemia
ECG
Stress test
Stress test
Stress test
Echocardiography
Echocardiography
ECG ⫽ electrocardiogram; M ⫽ male; F ⫽ female; CAD ⫽ coronary artery
disease.
*Moderate to high risk ⫽ age plus one or more of the following:
dyslipidemia, hypertension, current or recent smoker, diabetes, or a history of
myocardial infarction or sudden cardiac death in a first-degree relative ⬍60
years old.
the sedentary elderly person about to begin a walking program, all can benefit from a dedicated preparticipation evaluation.
Older athletes may be at higher risk of chronic overuse
injuries. Collagen fibers begin forming cross bridges in early
adulthood, affecting elasticity of connective tissues and joint
flexibility [5]. This decreased elasticity of tendons, combined
with decreased tensile strength, can lead to increased risk of
tendinopathy. An increased risk of degenerative meniscal
tears, rotator cuff injuries, tendon rupture (particularly of the
Achilles and quadriceps), and rotator cuff injuries also exists
[49]. A complete musculoskeletal examination before beginning an exercise program may help to identify areas that are at
increased risk, whether from decreased available range of
motion, muscle imbalances, altered muscle firing patters, or
other biomechanical deficits that could benefit from a targeted rehabilitation approach.
Coronary artery disease is the most common cause of
sudden cardiac death in athletes older than 40 years [50,51].
Unaccustomed vigorous activity is more likely to result in
acute myocardial infarction or sudden cardiac death than is
less-intense activity [52]. A thorough history and physical
examination is the first step in preparticipation screening.
Specifics for cardiovascular screening in Masters athletes
before they initiate or resume an exercise program are outlined in Table 1 [50,51].
Masters athletes should not participate in high-intensity
sports if their left ventricular ejection fraction is less than
50% or if evidence is found of exercise-induced myocardial
ischemia, ventricular arrhythmia, or systolic hypotension
because of the increased risk of an acute cardiac event [51].
Athletes still may participate in low-intensity sports for recreation or exercise. Patients with moderate to severe hypertension should not participate in static sports such as weightlifting until blood pressure is controlled [51]. Patients should
not exercise if their resting systolic blood pressure is greater
than 200 mm Hg or their diastolic blood pressure is greater
than 115 mm Hg [5].
EXERCISE PRECAUTIONS
Certain medical conditions are more prevalent in the elderly,
which, when combined with the physiological changes that
accompany aging, can lead to increased risks associated with
exercising in this population. Physicians should educate their
patients about these risks appropriately so that exercise may
be undertaken safely.
Persons with diabetes should monitor blood sugars more
closely both during and after physical activity and should
recognize that insulin requirements may decrease. Medical
alert identification is helpful in times of emergency. Persons
with peripheral neuropathy should wear proper footwear
and perhaps should avoid heavy weight-bearing activity.
Patients with nephropathy should maintain blood pressure at
a rate lower than 200 mm Hg, and persons with retinopathy
should avoid rapid increases in blood pressure, such as with
weight lifting or sprinting, that may precipitate retinal hemorrhage or detachment [5].
Many common medications that are more commonly used
in the elderly population can have negative effects on performance in active persons. Elderly persons also are more likely
to be taking multiple medications, which can lead to increasing adverse effects. Statin-induced myalgias may be more
apparent in athletes than in sedentary individuals [50].
␤-Blockers can impair performance in persons engaging in
high-intensity competitive sports [51]. Vasodilators, such as
calcium channel blockers, nitrates, and ␣-blockers, can decrease cardiac output and may cause hypotension if exercise
is stopped abruptly [53]. Longer cool-down periods are
recommended for athletes taking these medications [5].
Elderly athletes also must pay special attention to fluid
intake to prevent dehydration and overheating [18]. In elderly persons, the thirst mechanism is less sensitive and
increased excretion of water from the kidneys occurs, which
places elderly athletes at increased risk of dehydration. Hydration status can affect the toxicity of medications, including nonsteroidal anti-inflammatory drugs, and recovery from
dehydration also takes longer [16,54]. Diuretics and drugs
that lower peripheral vascular resistance may cause increased
susceptibility to the effects of dehydration and lead to dizziness and hypotension [53].
Exercising in extremes of temperature also requires special consideration. The elderly are less able to maintain body
temperature when exposed to cold. They also display impaired cutaneous vasodilation and decreased sweating abilities in heat, although the latter may be more related to aerobic
capacity than to chronological age [55].
Certain nutritional requirements also change with age.
Elderly persons experience a decline in the resting metabolic
rate, accompanied by a decline in energy expenditure and
lean body mass, that results in a lower amount of calories
necessary to maintain body weight [18]. Exercise can help to
combat these changes and allow the active older person to
consume more calories without associated weight gain.
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Elderly persons may need increased amounts of protein
compared with younger counterparts, but in general, carbohydrate and fat requirements are unchanged [16]. A decreased ability to synthesize vitamin D and to absorb calcium
and food-bound vitamin B12 leads to increased daily intake
requirements of these micronutrients [16]. In addition, low
vitamin D levels may be independently correlated with increased fall risk [56]. Supplementation is recommended for
all older adults at risk of falls, and when combined with
calcium, may reduce the risk of fractures [31].
EXERCISE IN PERSONS WITH
OSTEOARTHRITIS
Aging-related changes to joints include cellular changes
within the extracellular matrix that lead to loss of cartilage
thickness, proteolysis, glycation, and abnormal calcium deposition [57], which may predispose a joint to developing
osteoarthritis (OA). Both animal studies and retrospective
human studies offer conflicting evidence about the risk of
developing OA with high-impact physical activity. A recent
review [58] concluded that not enough evidence exists to
draw an unequivocal conclusion but that moderate running
does not seem to increase the risk of knee OA and may even
have a protective effect. A history of joint trauma is a greater
risk factor for development of OA than sports participation.
Higher intensity and duration of sport or underlying joint
instability may increase the risk of developing OA [58,59].
Patients with OA of weight-bearing joints tend to self-limit
activities in an effort to decrease pain. A great deal of individual variation exists over time, with some patients experiencing improvement and some experiencing deterioration. The
presence of a higher morbidity count, increased pain, avoidance of activity, and decreased range of motion all have been
associated with limitations of activities and functional decline
[60,61]. A lack of regular self-reported physical activity almost doubles the odds of functional decline and limitations
in daily tasks in persons with OA [61].
Both global and segmental strengthening have a favorable
effect on pain and function in sedentary patients with OA
[59]. Even simple education and performance of a walking
protocol [62] or aquatic therapy [63] can help improve
function and decrease symptom severity.
Vol. 4, Iss. 11, 2012
837
Table 2. Recommendations for selected sports following total
joint arthroplasty
Allowed
Golf
Bowling
Cycling
Hiking
Dancing
Allowed with
Experience
Doubles tennis
Alpine Skiing
Nordic Skiing
Weightlifting
Not Allowed
Football
Basketball
Soccer
Running
Snowboarding
No
Consensus
Singles Tennis
Martial Arts
Before any return to activity after an arthroplasty, the
patient first must have adequate strength, balance, and coordination [49]. In general, activities performed for regular
exercise should be low impact, but higher impacts may be
acceptable for occasional recreational activities performed
less frequently [64,65]. Risks of higher activity levels include
instability, fracture, early loosening, and premature revision,
but these risks must be balanced with the multiple health
benefits of exercise [66]. Some evidence exists that patients
are more likely to return to high levels of activity after hip as
opposed to knee replacements, which may be the result of
higher levels of residual pain after knee arthroplasty [67].
Studies that compare the survival rates of joint replacements between active and nonactive patients generally are
retrospective with limited length of follow-up. It follows,
then, that recommendations of allowed sports are generally
expert opinion. Updated surveys of the Hip Society, the Knee
Society, and the American Association of Hip and Knee
Surgeons reveal an increasing number of allowable activities
for patients after total joint arthroplasty [66,68]. Recommendations for selected sports are presented in Table 2 [66,68].
Certain sports such as hiking and running, which place
high loads on the knee in flexion, may be better tolerated after
total hip arthroplasty rather than total knee arthroplasty [64].
A right-handed golfer will place more torque on the left knee,
which may increase pain and lead to decreased performance
and length of drives [66]. To decrease pain and wear on the
knee, hikers should use poles and find routes that are less
steep when descending hills. Skiers should avoid moguls,
steep slopes, and hard snow if possible. Cyclists should
increase their saddle height and use a lower gear with higher
cadence to decrease loads across the knee [64].
SUMMARY
Exercise After Total Joint Replacement/
Total Joint Arthroplasty
Patients increasingly are choosing joint replacements not just
for pain relief but also to allow them to resume activity and
sports participation. Unfortunately, athletic activities lead to
increased forces across the prosthetic joint, with increased
surface wear, stress at the bone-implant surface, and a higher
risk of traumatic injury to the joint [64].
Understanding the biologic changes that occur with age and
their social implications is essential for a practitioner working
to maximize an aging patient’s quality of life and functional
independence. With appropriate guidance and a personally
tailored exercise program based on a patient’s fitness goals
and functional abilities, as well as medical and orthopedic
comorbidities, persons of all levels can achieve improvements in performance and general well being.
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Concannon et al
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