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At least 75% of people age > 65 yr do not exercise at recommended levels, despite the known health benefits:

• Longer survival
• Improved quality of life (eg, endurance, strength, mood, flexibility, possibly cognitive function)

Exercise has proven benefits when begun as old as 75 yr. Because of the effects of aging and age-related disorders, the relative benefits of exercise may even be greater in the elderly. In addition, exercise is one of the safest ways to improve health.

The largest health benefits occur, particularly with aerobic exercise, when changing from being sedentary to exercising. Progressively less benefit occurs as the intensity of exercise increases.

Strength decreases with aging and can compromise function. For example, almost half of women > 65 and more than half of women > 75 cannot lift 4.5 kg. Strength training can increase muscle mass by 25 to 100% or more, meaningfully improving function. The same degree of muscle work demands less cardiovascular exertion; increasing leg muscle strength improves walking speed and stair climbing. Also, institutionalized elderly with more muscle mass have better nitrogen balance and a better prognosis and less deconditioning during critical illness.

Contraindications: Absolute contraindications to exercise include

• Suspected acute coronary syndrome
• 3rd-degree heart block
• Uncontrolled hypertension
• Acute heart failure
• Uncontrolled diabetes mellitus

Relative contraindications include

• Cardiomyopathy
• Valvular heart disease
• Complex ventricular ectopy

Most patients with relative contraindications can exercise, although at lower levels of intensity than other patients (see Rehabilitation: Cardiovascular Rehabilitation). Other factors mandate modification of the exercise program (eg, arthritic disorders, particularly those involving major weight-bearing joints, such as the knees, ankles, and hips).

Patients should be told to stop exercising and seek medical attention if they develop chest pain, light-headedness, or palpitations.

Screening: Before beginning an exercise program, elderly patients should undergo clinical evaluation aimed at detecting cardiac disorders and physical limitations to exercise. Routine ECG is unnecessary. Exercise stress testing is usually unnecessary for elderly patients who plan to begin exercising slowly and increase intensity only gradually. For sedentary patients who plan to begin intense exercise, stress testing is indicated if they have any of the following:

• Known coronary artery disease
• Symptoms of coronary artery disease
• ≥ 2 cardiac risk factors (hypercholesterolemia, hypertension, obesity, sedentary lifestyle, smoking, family history of early coronary artery disease)
• Suspected lung disease
• Suspected diabetes

Exercise program: Exercise should ideally include

• Aerobic activity
• Strength training
• Flexibility and balance

Time spent doing aerobic activity is similar to that for younger adults, but exercise should be less intense. Usually during exercise, the person should be able to comfortably converse, and intensity should be ≤ 6/10 on a perceived scale of exertion. Elderly people who have no contraindications can gradually increase their target heart rate to the one calculated by use of age-based formulas. Some deconditioned elderly people need to improve their functional abilities (eg, by strength training) before they are capable of aerobic exercise.

Strength training is done according to the same principles and techniques as in younger adults. When beginning, forces may need to be small (eg, using bands or weights as light as 1 kg or arising from a chair).

To help increase flexibility, major muscle groups should be stretched once daily, ideally after exercise when muscles are most compliant.

Balance training involves challenging the center of gravity by undertaking exercises in unstable environments, such as standing on one leg or using balance or wobble boards. Balance training can help some people with impaired proprioception and is often used in an attempt to prevent falls in the elderly. However, it is often ineffective because any balance activity is skill specific (eg, good balance while standing on a balance board does not improve balance in dissimilar activities). For most elderly people, flexibility and strengthening exercises prevent falls more effectively. Such a program develops strength around the joints and helps people hold body positions more effectively while standing and walking. In people who have difficulty standing and walking because of poor balance, more challenging balance tasks (eg, standing on a wobble board) are simply likely to facilitate injury and are contraindicated.

Last full review/revision April 2009 by Brian D. Johnston; Paul L. Liebert, MD

Content last modified April 2009