Identify the correct recommendation for how often you should engage in functional fitness training:

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A combination of aerobic activity, strength training, and flexibility exercises, plus increased general daily activity can reduce medication dependence and health care costs while maintaining functional independence and improving quality of life in older adults. However, patients often do not benefit fully from exercise prescriptions because they receive vague or inappropriate instructions. Effective exercise prescriptions include recommendations on frequency, intensity, type, time, and progression of exercise that follow disease-specific guidelines. Changes in physical activity require multiple motivational strategies including exercise instruction as well as goal-setting, self-monitoring, and problem-solving education. Helping patients identify emotionally rewarding and physically appropriate activities, contingencies, and social support will increase exercise continuation rates and facilitate desirable health outcomes. Through patient contact and community advocacy, physicians can promote lifestyle patterns that are essential for healthy aging.

Evidence suggests that regular physical activity provides substantial health benefits, reducing the risk of many chronic diseases.1 Physical activity is associated with reduced medical costs, especially for women, and these cost reductions become more significant with increasing age.2 Current recommendations encourage activity on most or all days of the week, but only 31 percent of persons 65 to 74 years of age report regularly engaging in moderate physical activity for 20 minutes or more three days a week; this rate drops to 20 percent by 75 years of age.1 Women are more likely than men to report engaging in no physical activity. These trends have not improved over the past decade.1 In addition, less than 50 percent of older adults report that their physicians have recommended exercise.3

Research has consistently shown that older adults who remain or become active have a significantly decreased risk of all-cause and cardiovascular mortality compared with their sedentary counterparts.4–6 Starting an exercise program later in life can significantly reduce risk factors even if a person was sedentary when he or she was younger. By understanding the specifics of disease prevention and treatment through exercise, physicians can play a significant role in offering patients effective and inexpensive primary or adjunct therapies, encouraging appropriate physical activity, and eliminating barriers that prevent older adults from exercising regularly.7 Table 1 defines common exercise terminology.

STRUCTURED PHYSICAL ACTIVITY AND LIFESTYLE MODIFICATION

There are four ways for patients to improve physical fitness: aerobics, resistance training, flexibility training, and lifestyle modification. Repetitive aerobic exercise that uses large muscle groups (e.g., walking, dancing, cycling, swimming) increases the heart rate (Table 28) for an extended period.

Progressive resistance training requires muscles to generate the force to move or resist a given weight. Weight resistance can be created using elastic bands, weight cuffs, free weights, weight machines, or the patient's body weight. Progressive resistance training maintains or improves muscle mass, strength, and endurance. It improves balance, allowing the patient to exercise and perform daily activities (e.g., rising from a seated position, carrying groceries, preparing meals) more safely. Although data9 on tai chi are emerging, the strongest data10 on effective balance training methods support combination programs that include progressive resistance training. Emphasis on muscle power (how fast the muscle contracts) rather than strength alone may help patients retain the greatest amount of functional capacity as they age.11,12 Regardless of age or health status, continual improvement requires a progressively increasing resistance as the patient becomes stronger.13,14

Flexibility is the ability to move a joint through a complete range of motion.15 Flexibility facilitates movement and can help prevent injury throughout life. Poor lower back and hip flexibility may contribute to pain in the lower back muscles.15 Limited range of motion in the hip, knee, and ankle joints may increase the risk of falls and contribute to age-related gait changes.16,17 Lifestyle modifications include finding opportunities within patients' existing daily routines to increase activity (e.g., manually opening doors, taking stairs rather than elevators, parking further from entrances).

COMPONENTS OF AN EXERCISE PRESCRIPTION

A successful exercise prescription is succinct, measurable, patient-appropriate, and in a form that allows the physician to address compliance expectations and barriers. Exercise prescriptions will vary depending on the desired outcomes; however, they should include cross-training (combinations of activities) to optimize health outcomes, reduce injury risk, and encourage program continuance. Cross-training programs emphasizing core muscle groups (i.e., back, thighs, abdomen, and other weight-bearing muscles) are preferred. An exercise prescription should include the following components: Frequency, Intensity, Type, Time, and Progression (FITT-PRO) of exercise. Table 313–15,18,19 provides recommendations for prescribing aerobic, resistance, and flexibility training for older adults. The activities and intensity levels should depend on the patient's daily health and energy needs, and the training routine should vary to maintain interest and promote optimal gains. Chair- and bed-based exercise should be considered as a starting point and used by frail patients.

Effective exercise prescriptions should consider comorbidities and be reevaluated and adjusted periodically to maintain the desired therapeutic effect. Physicians can evaluate patients' physical activity levels during health maintenance examinations and chronic disease visits. Prescriptions should encourage patients to limit sedentary activities such as television watching and computer use. Table 4 is a sample patient-based exercise prescription that addresses lifestyle modification and aerobic, strength, and flexibility training. Many activity selections (e.g., circuit training, yoga) can fulfill multiple requirements.

COMMUNICATION BARRIERS

Quality physician-patient communication, including shared decision making, improves patient satisfaction and clinical outcomes associated with exercise prescriptions. More than 33 percent of patients 65 years or older and up to 80 percent of patients in public hospitals have poor health literacy.20 Written, disease-specific handouts containing simple language and diagrams can reduce misinterpretation. Physicians should keep directions explicit and measurable and clearly define activity intensity and variety. For example, a physician can tell the patient, “Take a 10-minute walk, three times a day, every day of the week. Choose a speed that allows you to talk but that is moderately hard work. The distance is not important, but make sure to walk for the entire 10 minutes.”

EXERCISE AND COMORBIDITIES

In older adults, medical clearance and appropriate follow-up are important parts of exercise programs.15 By following the American College of Sports Medicine's assessment guideline, medical and trained exercise professionals can determine the appropriate components for the patient's individual exercise program. Exercise testing protocols specific to the patient's age, health status, current activity level, and desired exercise intensity are available.15 Maximal exercise testing (a stress test) is recommended for older adults (men 45 years or older, women 55 years or older) who are starting vigorous training programs.15

Risk factors also should be identified using a screening tool; however, some patients require a more thorough examination.15 Screening tools from the American College of Cardiology and the American Heart Association are available athttp://www.acc.org/clinical/guidelines/exercise/exercise_clean.pdf.15,21 Table 515 lists disease-specific exercise considerations.

THE FIVE A's

To support behavior change, physicians should use the five A's model (i.e., Assess, Advise, Agree, Assist, and Arrange) when helping a patient with an exercise regimen. Physicians should begin by assessing the patient's current fitness level and willingness to begin an exercise program. Activity readiness questionnaires from the Canadian Society for Exercise Physiology are available athttp://www.csep.ca/forms.asp.15 These questionnaires can be given to patients in the waiting room before their appointments.

During the office visit, the physician should stress the importance of physical activity and introduce exercise options and guidelines. Support networks within the family and community are key to long-term exercise compliance and should be discussed. Physicians can improve compliance by making exercise programs social activities. Physicians may provide a take-home information packet including handouts on exercise-associated health benefits; resistance, aerobic, and flexibility training; and lifestyle modification, plus illustrations and guidelines for balance balls or other specialized exercise equipment.22,23

The patient and physician should collaboratively select long- and short-term fitness goals, including how the patient will meet the goals (e.g., social support, time management, behavior changes).24 Physicians should counsel patients on performing some form of activity every day, problem solving, and gradual incorporation of additional exercise to meet patient-specific goals. The patient can keep a log, including questions and barriers to exercise, that can be discussed at follow-up visits. For example, if the patient does not exercise because of inclement weather, the physician can discuss appropriate clothing, moving exercise indoors, or changing activities. Short-term support can include a brief phone call one week after the program begins. Finally, the physician should provide referrals for physical therapy or special assistance, if needed.

Age should not limit exercise training25,26; however, experts recommend a more gradual approach in older patients.18 Before arranging for an exercise program, physicians should consider social preferences (e.g., solitude or socialization), cultural norms, exercise history, instructional needs, readiness, motivation, self-discipline, short- and long-term goals, and logistics. For example, home-based exercise can be effective for physically or financially limited patients,27,28 whereas patients who are frail or who have balance and agility problems may benefit more from supervised activities. Patients who usually do not exercise may enjoy moderately vigorous activities such as dancing or walking.

PRACTICAL TIPS

A Scandinavian study29 suggests that older patients whose physicians had advised them to exercise were five to six times more likely to participate in supervised exercise classes, and men were more than 12 times more likely to perform calisthenics at home.29 Incorporating activity counseling into routine patient care involves the following:

• Confirm that the patient understands the exercise prescription and its expected health benefits (e.g., ask what activity the patient is doing, how often and how intensely he or she is active, and what health benefits are expected).

• Translate new exercise-related information that is presented in the media.

• Recommend credible resources from which patients can get information about exercise.

• Encourage affordable community-based exercise and support programs.

• Foster a continued exercise and health message.

• Serve as a resource for the nonmedical personnel who implement community and home-based exercise programs (e.g., offer annual question-and-answer or medical update sessions).

Successful exercise prescriptions require collaboration between the physician and the patient.30,31 Physicians should consider offering group visits and workshops to address the whys and hows of exercise. Collaboration with hospital-sponsored or hospital-approved exercise programs and physical therapy and community-based programs increases exercise accessibility and provides patient support while cutting costs. Physicians also should support personal, local, and federal initiatives that encourage increased physical activity. Table 6 includes resources for more information on creating exercise programs; many of these Web sites offer downloadable handouts.

How often you should engage in functional fitness training?

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Which principle of training States in order to improve fitness a person should engage in activities that target a specific component of fitness?