Resistance Exercise Prescription for Elderly:
Quality of Life
The propose of this article is to provide exercise professionals with an overview of recommended guidelines for resistance training prescription design, benefits, and risk assessment to improve quality of life of elderly adults patients.
Elderly Adults, Resistance Exercise, Sarcopenia, Atrophy, Hypertrophy, Strength, balance, Activities of Daily Living, ADLs, Quality of life
One out of every three elderly adult over sixty-five years old will fall down each year causing injury. It is the leading cause of injury death among elderly (CDC, 2010; Hornbrook, 1994). Older men are more prone to die from a fall (Stevens, 2005). Not only can injuries due to falls be prevented with resistance training, but also the quality of life in elderly can greatly improve. It is widely believed that walking is the best exercise for the older population; however, in several cases, the elderly have difficulty standing up out of the chair. How can one be expected to walk when they do not have the strength to stand up? One must first build lower body strength before walking. Resistance exercise has been shown to increase muscle size and strength, which is important for sarcopenia prevention. This is in contrast to aerobic exercise that does not preserve muscle mass (Evans, 2004). A resistance-training program can slow down or even reverse the muscle atrophy caused by aging (Evans, 1999). Therefore, this article will review both the current research in regards to the effects of resistance training on muscle sarcopenia caused by aging as well as the latest recommendations for evaluation and a resistance-training program for the elderly population.
Pathophysiology of Aging
One attribute of the pathophysiology of aging includes sarcopenia; a loss of mass, strength, contractile speed, power and maximal oxygen uptake. The loss of mass is at a rate of 1.2 kilograms per decade from the fifth to the ninth decade and is attributed to atrophy and hypoplasia that can be attributed to a decrease in physical activity and/or poor nutrition. It is not necessarily a natural occurrence due to aging. As adults get older, the cellular mitochondrion creates less ATP. It is not known if this is a cause or a result of the decline of physical activity. There is no concrete evidence to support the claim that aging itself causes a reduction in activity levels (Nair, 2005; Evans, 2004). In addition to decreases in muscle strength and mass, there is also a decrease in balance and coordination along with bone density and elasticity in connective tissues. This can account for decrease in mobility. Older adults who have a history of falling or are frail may have limited ability to perform ADLs. This does not necessarily preclude them from participating in an exercise program (Barry, 1994). Some of the most common chronic comorbidities associated with elderly include coronary artery disease, arthritis, hypertension, diabetes mellitus and obesity. These comorbidities can also see benefit from exercise programs (Desai, 1999). A decline in general health and the reduced mobility will negatively affect an older person’s ability to perform activities of daily living (ADLs) (Boult, 1994). The current popular treatment for aging is assisted living facilities with little or no structured exercise and way too many medications.
The Role of Resistance Training
The role of resistance training is to reverse or slow down the aging effects of skeletal muscle by increasing strength and muscle cross sectional area (CSA) hypertrophy. Increases in strength may also increase postural stability and improve mobility (Tinetti, 1994). Even the very old and very frail individuals have demonstrated physiological adaptations to resistance training (Binder, 1999; Fiatarone, 1994). One study has demonstrated that a six-month combined resistance training and endurance-training program had seen gains in maximum VO2 by 11% as well as upper and lower body strength with adults up to 90 years of age (Cress, 1999). Increases in strength are due to adaptations in muscle hypertrophy and neuromuscular activity (Binder, 1999). A year long resistance training study has shown muscular hypertrophies in both types I and type II muscle fibers in elderly men and women (Pyka, 1994). Research has shown that resistance training can also see gains in bone density and mineralization (Nelson, 1994). Exercise training is important because there is no drug therapy for increasing muscle hypertrophy or strength.
Program Attributes & Assessments
A full medical history questionnaire should be assessed to determine preexisting conditions before designing an exercise program in order to evaluate risk of injury (Evans, 1999). A physician should evaluate subjects that are deemed at higher risks. The American College of Sports Medicine recommend that men older then 45 years old and women older than 55 years old should have a full physical examination prior to an exercise program considered vigorous-intensity of physical activity. Low to moderate risk individuals can participate in moderate-intensity cardiovascular exercise activities (3-6 METs or 40-60% VO2Peak) without an exercise test (ACSM, 2006). A physician should evaluate those individuals with hypertension, arthritis or low bone density before initiating a resistance-training program. The evaluation of an elderly adult’s strength can be modified to reduce risk of injury. The one-repetition maximum (1RM) test may be used to evaluate strength but can be modified based on the exercise professional’s discretion. The focus of the strength evaluations and training should be on the muscles typically used for ADLs, such as the hip flexors, extensors, and abductors; knee extensors and flexors; ankle dorsiflexors and plantar flexors; shoulder extensors, flexors, and abductors (Evans, 1999; Koch, 1994). An exercise professional should assess agility, coordination, posture, gait, and balance to recognize those at risk of falling. Assessment can be done using functional tasks such as chair standing, slow walking, one-leg standing, functional reach, and step-ups. Using a push on the shoulder can predict falling risk (Hausdorff, 2001; Davis, 1999). It is important to be aware of the comorbidities the individual has and adjust the training program accordingly. As with any population, a good resistance program must include warm-up and cool-down sessions. This can be especially important for elderly populations due to inflexibility issues associated. Large muscle groups can be emphasized during beginning weeks of training. Exercise variety can help keep the program interesting to maintain long-term adherence to the program.
Program Design Recommendations
Cardiovascular exercise is great for overall health, but the following are the recommendations for a resistance training program design. Machine weights are recommended because they do not require as much balance and they can reduce the risk of injury. If machines are unavailable, the use of resistance bands and body weight resistance can be utilized (Koch, 1994). Free weight can be used if supervised by an exercise professional and can benefit in stability component (Evans, 1999). According to the recommendations by the ACSM and the American Heart Association, resistance training should include eight to ten different resistance exercises for ten to 15 repetitions on at least two non-consecutive days per week. Intensity should be determined by the use of a 10-point exertion scale and should range from 5-6 for moderate training and 7-8 for high intensity (Nelson, 2007). Up to 3 sets can be performed. The program should utilize a progressive overload principle to maximize hypertrophy (Evans, 1994). Research has shown that elderly can benefit from an increase in protein intake. The current RDA recommendation is .8 grams of protein for every kilogram of body weight per day. This may be inadequate for elderly. According to study by Evans, et al., older adults would benefit from 1 gram of protein per kilogram. This will allow a greater availability of free amino acids for muscle protein synthesis (Evans, 2004).
Age itself is not a limiting factor when it comes to performance of strength training exercises. It is usually a lack of physical activity as we age that slow us down. It is the conditions that are usually associated with aging that can slow down performance; however, even those conditions can be improved with exercise. When initiating a resistance training program for elderly, supervision is important and health assessments should precede exercise and continued throughout. Proper technique and breathing should be emphasized during supervision and training. Ideal training protocol should consist of moderate-load and progressive volume exercised performed at least two consecutive days per week with emphasis on lower body and muscles used for ADLs. With close attention to assessment, supervised resistance training can be effective therapy to reverse the effects of normal aging sarcopenia. The CDC also recommends Tai Chi as a great exercise for increasing stability (CDC 2010). If the cause of falls can be attributed to atrophy of stability muscles than it makes sense that resistance training can decrease the risk of falling. The fear of falling can restrict one’s quality of life. Once strength is built up in the elderly patient, then one can perform ADLs better, including walking.
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