Prescribing Exercise for Frail Elders

John M. Heath, MD, and Marian R. Stuart, PhD

J Am Board Fam Med. 2002;15(3)

Exercise Environments for Frail Elders

Limited equipment and exercise space are often-cited reasons for not exercising by some patients, both old and young. Other common barriers include competing time demands from other activities (which frequently can involve caring for another, frailer adult), lack of a safe place to exercise, self-consciousness about physical appearance, fear of injury, and the lack of a partner. Many issues cited by older adults were classified as external factors in a British study examining lifestyle changes.^[52] Participants at the start of the study were asked to list perceived barriers that prevented them from adopting an exercise routine. These barriers were then classified as either internal factors, issues relating to their own feelings or attitudes, or external barriers such as those cited above. In the follow-up survey, the older adults who made the greatest changes in incorporating routine exercise into their lives were those who had reported external factors as barriers. The implication from this and other studies is that it is easier for older adults to overcome environmental barriers than to overcome will power barriers to exercise.^[53]

When responding to environmental barriers raised by patients, it is important that physicians advocate adapting the exercise to the setting and the time of day the older adult wants to exercise. There will be frail elders who have the requisite mobility, financial resources, and motivation to go to an exercise facility, and gyms and athletic clubs are required by law to accommodate the physical limitations of their membership. For most frail elders, however, exercise needs to take place in the home, senior center, place of worship, or institutional living setting. The latter includes both traditional skilled nursing homes and assisted living or other congregate housing. Many assisted and communal living facilities have dedicated common spaces for exercise activities and have made great efforts to integrate exercise into their residents' daily routine. Physician advocacy can support these efforts and promote accommodation of a variety of exercises. A key element of organized exercise classes is the opportunity for socialization, which is considered to be important for older patients to sustain exercise participation.^[54]

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Abstract and Introduction
Methods
Benefits of Exercise for Frail Elders
Appropriateness of Exercise for Frail Elders
Exercise Environments for Frail Elders
Exercise Participation Assessment
Prescribing Exercise for Frail Elders
Specific Conditions Requiring Special Consideration
Physician's Role in Motivating Exercise
Conclusions
References

Table 1. Common Medical Limitations for Exercise by Frail Elders
Limitation	Recommended Management
Heart disease	Electronic heart rate monitoring (by self or supervisor)
	Clearly established initial goals (eg, mobility over fitness)
	Availability of nitrates
Chronic respiratory condition	Oximetry monitoring
Chronic respiratory condition	Adequate oxygen tubing length, comfortable mask or cannula
Cognitive impairment	Supervision of mobility
Cognitive impairment	Limited concurrent sensory input during exercise
Diabetes	Consistent use of insulin injection sites
	Pre- and post-exercise home glucose monitoring
	Availability of hypoglycemic corrective measures
Osteoarthritis	Strength training along functional planes of motion, (avoiding rotational stresses)
	Reduce weight-bearing loads
	Pre- and post-exercise hot or cold packs to affected joints
Sensory impairment	Consistent use of adaptive devices before start of exercise
	Center movement around a fixed reference or support point
	Low-frequency musical impulses for rhythmic exercise

Table 2. Linking Potential Exercise Modes with Relevant Functional Limitations for Frail Elders
Functional Limitation	Precautions and Exercise Modes
Basic activities of daily living
Mobility and transferring
Walker use	Chair arms available for seated resistance training
	Ensuring secure match between walker tips and floor surface for walking
Wheelchair use	Truncal and upper body motion and resistance training
Dressing and bathing
Shoulder range of motion restricted	Pre-exercise local heat and active stretching
Truncal motion limited	Seated, non-weight-bearing rotational motion
Continence and toileting	Prompted voiding before and after exercise
	Bladder-strengthening exercise (eg, Kegel exercises)
	Vaginal weights for enhanced pubococcygeal muscle tone
	Prompted fluids during and after exercise session
Instrumental activities of daily living
Communication	Proactive postexercise interview and assessment
Medication management	Time dosing of selected agents (eg, diuretic medications)
Transportation	In-home mobility and strengthening options
Shopping and housekeeping	Simple footwear and loose clothing requirements

Table 3. Components of an Exercise Prescription for Frail Elders
Exercise Component	Examples
Intent: this exercise program will help my...	Circulation problems, heart condition, breathing condition, diabetic glucose control, arthritis, etc
Exercise type (mode): I agree to start this type of exercise	Strengthening arm and leg muscles
	Walking
	Balance practices
	Stretching neck and back muscles, etc
Dose (endurance): I agree to try this amount of exercise	10 minutes each session, I breath comfortably from my mouth, my heart rate reaches about ___ beats per minute, my oxygen saturation level is at ___
Frequency: I agree to try to do this exercise this often	Every morning at breakfast, every time my aide comes, before my nightly dessert, before my bath, during my favorite radio or TV show, etc

Table 4. Ways to Encourage and Reinforce Exercise for Frail Elderly Patients
Recommendation	Example
Make it fun	Add music and movement to exercise environment
Make it fun	Link exercise to other pleasurable or positive events, eg, favorite radio or television show, pre-bath activity
Make it social	Promote exercise in groups whenever possible; if not possible, create virtual groups using videotapes
Make it social	Seek out an exercise partner for mutual support and encouragement
Make it sustainable	Advocate for affordable exercise modes
Make it sustainable	Advocate for brief, dedicated time period(s) for exercise daily
Make it a priority	Explicitly validate exercise as a prescribed health intervention
Make it a priority	Enlist reinforcement from other health care providers and from family or caregivers

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Prescribing Exercise for Frail Elders

Exercise Environments for Frail Elders

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