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

Disclosures

J Am Board Fam Med. 2002;15(3) 

In This Article

Exercise Participation Assessment

There are few absolute contraindications for exercise by frail elders. Chief among these contraindications is severe heart disease, such as unstable coronary artery disease or recent myocardial infarction, congestive heart failure that has progressed to dyspnea at rest, tachyarrhythmias induced by activity, and critical aortic stenosis.[55] Any condition that becomes symptomatic with minimal activity beyond the routine activities of daily living would preclude meaningful exercise. It is important, however, to recognize that with less advanced disease, exercise can provide dramatic benefits for most patients with heart disease. In fact, exercise can be beneficial both for increasing self-assurance and confidence and for improving cardiovascular parameters. Noncardiac limitations to starting physical exercise include the immediate hypoxic period after a pulmonary emboli, retinal detachment, and unstable cervical spinal conditions.[55]

The more common concerns for family physicians when recommending exercise arise from the need to assess cardiovascular risks induced by exertion. Graded exercise stress testing is the standard approach to younger patients who have cardiovascular risk factors, such as diabetes or hypertension.[56] Recent guidelines suggest that for patients planning low-intensity exercise -- heart rates remain below 60% of the predicted maximal rate (220 beats per minute minus the patient's age) -- the physician can use clinical judgment to recommend an exercise stress test.[4] When a patient starts exercising, which for most frail elders will focus on strengthening or range-of-motion stretching, monitoring for early adverse symptoms can serve as a stress test. The level of exertion observed by both patient and caregivers might be the best way to assess initial exercise intensity during this period. It is especially important to avoid exhaustion, which is a negative reinforcement to exercise.

After an exercise regimen has been incorporated into the patient's routine, heart rate monitoring can provide the patient and involved caregivers feedback about exercise intensity. In the absence of cardiac or respiratory symptoms, a maximum heart rate of 60% to 75% of the predicted maximum heart rate should be set as a ceiling. Any exercise intensity that increases the baseline resting heart rate is desirable. For older patients who want more sustained aerobic forms of exercise and who can monitor their pulse rate, formal stress testing might be appropriate after an exercise routine has been established and increased intensity has been proposed.[54]

Table 1 lists safety concerns associated with other diseases and conditions commonly encountered in the frail elderly population for whom exercise should be considered.

For many frail elders living in institutional settings, cognitive impairment, such as Alzheimer disease, is a major factor contributing to their frailty. Although the impaired memory, judgment, and insight associated with such dementias complicate patients' participation in exercise programs, these conditions should not be considered contraindications for participation in supportive and supervised exercise activities. Cognitively impaired persons have been incorporated successfully into facility-based supervised movement and exercise programs with positive outcomes.[4,57]

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