Exercise Combats Frailty
By Karl Knopf, EdD
Exercise is key to maintaining muscle mass that enables performance of the activities of daily living.
US Census projections suggest that the majority of baby boomers will turn 65 between 2010 and 2030, reflecting the impending need for increasing medical care within this demographic.1-3
“Baby boomers are now senior boomers, and just as this group has influenced everything in the past, they will impact tomorrow’s health care services as well,” says Patrick Kearns, MD, a geriatrician at El Camino Hospital in Mountain View, California.
The health and function within this group will range from those who are extremely fit and healthy to those who are physically dependent. How an individual ages is, to some extent, determined by the cards (genes) they were dealt and, to a larger extent, how they’ve played those cards. Research confirms the relationship between living a healthful, active lifestyle and both quantity and quality of life. Proactive steps taken throughout a person’s lifetime may prevent or delay the advent of frailty.3-5
The medical profession continues to make significant strides in treating conditions that would have caused death years ago. And while the average life expectancy has increased dramatically since the 1900s, this increase in longevity comes with the possibility of living more years with physical limitations and reduced functional ability.3,5
Some studies have discovered that a sizable number of adults over the age of 65 cannot lift a 10-lb bag of groceries, walk a mile, or easily get up from a chair. One study suggests a significantly increased risk of falling for individuals who cannot lift themselves out of a chair at least eight times in 30 seconds.1 But how can frailty be prevented or even reversed?
Identifying the Problem
Many times a combination of these factors results in a person’s inability to function independently, leading to the classification of frailty. The term “frail elder” often refers to the role age plays in the above conditions. Most of us can visually identify a physically frail person, but currently no definitive criteria exist for defining frailty. However, some professionals are attempting to develop a universal objective definition of elder frailty traits.3,6
Often family members, in concert with health care professionals, are the first to recognize an elder’s decline in strength and level of independence. Assessment of diminished balance and muscle strength suggest the need to initiate a comprehensive general conditioning program.1
Never Too Late
Sarcopenia plays a major role in what many believe advances functional loss and contributes to becoming frail. Studies have shown that without the intervention of progressive resistance training, lean muscle tissue loss can begin as early as the age of 30.1,3,5 These small changes go unnoticed or are even accepted as part of normal aging until a person finds difficulty in completing simple tasks. While the outward circumference of a limb may remain the same, the interior integrity of the muscle mass is decreasing. We can visualize the muscle loss as analogous to a lean steak’s transformation to one with marbled fat. So it is with humans: A muscle biopsy shows intermuscular fat within the muscle.
Why is less muscle detrimental? One reason is that muscle tissue is the furnace that revs the metabolism, thus assisting an individual to better control body weight, which in many cases decreases the risk of type 2 diabetes, hypertension, and other metabolic diseases. An increase of only 7.7% in resting metabolic rate derived from strength training would result in an increase of 50,000 extra calories expended in one year, which could result in a loss of 14 lbs of fat (in a 180-lb person).1,5,7
Strong leg muscles lead to improved balance.1 Strong functional muscles enable a more active and independent lifestyle. Being involved in a sensible strength conditioning program can foster improved bone density. Wolf’s Law says the strength of the bones is in direct proportion to the forces applied to them. If a person sits during most of the day, then he or she will have bones made for that kind of lifestyle. “Use it or lose it” applies to muscle strength as well as bone strength.
The hallmark study done by Maria Fiatarone, MD, a researcher at Harvard Medical School, placed 100 frail nursing home residents aged 72 to 98 into several experimental groups.1,3,5-7 Her research found that those participating in progressive resistance exercises improved their strength significantly vs. those who were given nutritional supplements. The strength-training group increased their overall strength by 113%; gait velocity improved significantly as well stair-climbing ability over the nonexercising groups.
The take-home message was that resistance training is superior to nutritional supplementation and is far more cost-effective.
We’re all familiar with normal aging, but healthful aging often is determined by the activity or lack of activity that precedes old age. An inexpensive strategy to improve the prospects of living long and well includes a regular dose of sensible physical activity. Some commonly acknowledged benefits of a well-rounded exercise program include improved self-efficacy, metabolism, sleep patterns, cardiovascular capacity, balance, muscular strength, endurance, and movement along with reduced fatigue, depression, anxiety, and arthritic and low back pain.1,8,9
Designing a Fitness Program
Providing motivation to embark on an exercise regimen and stick with it presents a challenge, though. Suggesting participation in activities patients don’t want to do requires patience and skill. Focus on ways to make the activities appealing while preventing injury. Matching the exercise routine to a person’s personality and physical abilities often is more of an art than a science. A good coach/teacher can motivate a patient to do something he or she doesn’t want to do—and thank the coach for it later.4,8,9
It’s wise for health care professionals to provide patients with guidelines of indications and contraindications related to exercise. If possible, try to match patients with suitable options within the community that match their physical abilities, personalities, and social and economic issues. Some long term care facilities offer in-house and/or programs available to local older adults.4,6,7
An exercise program for patients at risk of becoming frail should aim to improve functional activities of daily living. An assessment by an occupational therapist, physical therapist, or nurse should provide some direction on the major areas to be addressed. While the aim of the intervention is to improve function, make sure the person leading the session keeps some fun in functional. This may require some socializing and interacting with patients. If patients are unmotivated to perform activities or exercise, even the best program will have low compliance rates and not produce the desired outcomes. All programs should follow some type of evidence-based guidelines.8,9
Improving muscular strength and endurance helps enhance patients’ functional muscular endurance and strength to perform daily activities without becoming fatigued. The basic concept of progressive resistance training, commonly called strength training, weight training, or weight lifting, is to begin with a resistance that can be comfortably performed six to eight times and then continue increasing the number of times (reps) until he or she can perform the movement easily between 10 and 15 times.6
Once that level is attained, patients can add small amounts of resistance to again challenge the muscles. As an individual advances, another set (a grouping of reps) can be added. The number of reps and sets varies depending on the objective. Matching activities to the functional tasks a person needs to perform can involve lifting a milk jug, opening jars, getting up from the toilet, or walking outside to get the mail, for example. The goal should be to build up a reserve of strength so patients can engage in any necessary activities.4
Strength training can include the use of resistance bands that come in varying levels of resistance. Light water bottles, hand weights, or attachable wrist/ankle weights work well. For patients who are particularly weak, simply using the weight of their limbs is a fine starting point.4
Balance and posture exercises should aim to improve the muscles that influence posture, such as the core muscles and muscles that retract the scapula as well as muscles that promote proper neck alignment. There is evidence that improved posture translates into standing erect and improved balance.
Balance activities should include both static and dynamic movements. Physical therapists can offer recommendations on exercises to enhance balance. Experts suggest patients can begin balance work in a chair, similar to activities for spinal cord-injured and poststroke patients, as a safe exercise method.
Comprehensive Program Design
Ideally, providers can perform individual patient assessment. Utilizing a group assessment method such as the Senior Fitness Test also can provide information on fitness levels and achievable goals.
The bottom line is that exercises and activities should be adapted to a patient’s abilities and should never exacerbate an existing condition, as patient safety is more important than any exercise. If an instructor cannot appropriately adapt the movements, then he or she is not qualified to be teaching this segment of the population.
• Range of motion/flexibility: Motion is lotion to stiff joints. A warm-up that addresses the major joints and helps prepare the body for physical activity should last between five and 15 minutes. Include gentle range-of-motion/flexibility activities that foster functional movements, such as putting on socks and shoes or getting dressed. In the early stages, this may be the limit of a patient’s capability, so stopping here is fine.
• Muscular strength and endurance: The focus is to improve functional muscular endurance and strength to enable a patient to perform daily activities without becoming fatigued. The activities should be matched to the tasks an individual needs to perform, such as lifting, dressing, and walking.
Plan of Action
Ideally, this article will serve as a wake-up call, not only to the fitness industry but also to health care professionals to work toward establishing national standards for trainers who work with older adults. A great opportunity will be lost if there are not enough trained fitness professionals available to serve this burgeoning demographic.
The field of gerontology promotes aging in place as a viable option. If early and comprehensive frailty prevention programs can be conducted in senior centers, hospital settings, or assisted-living communities, it could possibly delay the onset of frailty along with the associated costs.
— Karl Knopf, EdD, a member of the adaptive learning department at Foothill College in Los Altos Hills, California, and a frequent wellness speaker, has taught corrective exercise to special populations for almost 40 years. He has authored several textbooks on fitness therapy and 15 fitness books for older adults as well as numerous articles. He has served as a consultant to the state of California, Stanford University, Time Life Medical, and the PBS series Sit & Be Fit and contributed a chapter to a book by Richard Simmons.
2. Durstine JL, Moore G, Painter P, Roberts S. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. 3rd ed. Champaign, IL: Human Kinetics; 2009.
3. National Institute on Aging. Exercise & Physical Activity. Bethesda, MD: National Institutes of Health; 2009. NIH Publication No. 09-4258.
4. Knopf K. Total Sports Conditioning for Athletes 50+: Workouts for Staying at the Top of Your Game. Berkeley, CA: Ulysses Press; 2008.
5. National Institute on Aging. In Search of the Secrets of Aging. 2nd ed. Bethesda, MD: National Institutes of Health; 1996. NIH Publication No. 93-2756.
6. Brody LT, Hall CM. Therapeutic Exercise: Moving Toward Function. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010:1-49.
7. Ehrman JK, Gordon PM, Visich PS, Keteyian SJ. Clinical Exercise Physiology. 2nd ed. Champaign, IL: Human Kinetics; 2009:135-146.
8. Knopf K. Creating wellness. Paper presented at: Wellness Conference at the Palo Alto Medical Foundation Annual Meeting; October 2012; Palo Alto, CA.
9. Knopf K. Grow well, not old. Paper presented at: El Camino Hospital Aging In-Service; May 2013; Mountain View, CA.