In Focus: Exercise for Older Adults
Fighting Cardiovascular Disease
Buckle Up – We are getting older
Perhaps due to geographic and socio-economic factors such as where my clinics and gym spaces are situated, and the tendency for certain populations to find themselves moving there after a hard life working in the city - I find that a high proportion of the individuals I see are older adults, aged 65 or over. These folks range in age, fitness, and exercise history, but one thing is certain: They are not in the minority. A quick look at population projections will tell you that we are an ageing population, and that by the year 2050, we can expect over 2 billion over-60s, and 434 million over-80s. These are huge numbers. For context, just ten years ago, best estimations showed there to be just under 1 billion over 60s.
Now, getting older is not a problem by itself. Certain biological processes do occur, such as sarcopenia and the menopause, and these will be covered in other articles. However, getting older does unearth a debate: Which is preferable – a good lifespan, or a quality ‘health’ span? In other words, would we rather live for longer, with a lower quality of life and lack of independence, as is commonly seen in elderly populations now, or would we rather improve and extend the number of years spent living freely and independently? Surely, if we are getting older as a population, then we would like to ensure that our quality of life doesn’t spiral as the years tick by. What use is living to 100 years old, if we can’t live unassisted after the age of 75? This is the realisation that many individuals are coming to now, and, as seen by the population projections, more and more of us will join them on this journey.
The Cardiovascular System: The Old Ticker
Perhaps the most common ailment seen in older adults is high blood pressure (hypertension). This diagnosed in 70% of this population. Considering it has a reputation as a ‘silent killer’ due to the lack of symptoms, we can make an educated assumption that this figure is realistically north of 70%. This is a problem for many reasons – hypertension is a leading risk factor to the development of cardiovascular disease (CVD), including coronary heart disease, stroke, peripheral artery disease, heart failure, and atrial fibrillation (AF). This is a big issue - CVD is the leading cause of death in older adults. Furthermore, co-morbidities such as obesity, diabetes, and high cholesterol put increased pressure on the cardiovascular system, which then limits the individual’s capacity to perform physical activity, and forcing them into a more sedentary lifestyle, which exacerbates the ongoing symptoms. This vicious cycle is incredibly common in many of those that I see in person. As a slight aside - and perhaps this is a generational viewpoint, but I see many 65 year olds who are afraid of getting ‘out of breath’ as this is associated, in their mind, with a heart attack, or cardiac event. This adds to the cycle of declining fitness, worsening cardiovascular health, and increased sedentary time
So, what actually happens to us? Why does our cardiovascular system start to suffer?
Well, in short, things stiffen up. Our blood vessels will naturally stiffen as we age. We lose some of the nice elastic fibres and deposit some other nasties, including calcium, into the artery walls. This is the lead driver behind higher blood pressure, particularly systolic (the bigger number) blood pressure. Sadly, the heart itself also starts to struggle. The wall of our left ventricle, which is the main heart chamber, becomes a bit thicker, increasing the risk of heart failure and other unwanted symptoms and outcomes.
These processes ultimately increase the effort required to get blood, and subsequently oxygen, around the body to where it is needed. One standard measure of the ability to take in and use oxygen is known as VO2max (as a purist, there should be a dot above the V to indicate that this is a measure of rate, but my laptop is under repair and I cannot for the life of me work out how to insert this on my iPad – any help appreciated!). Naturally, VO2max decreases with age, predominantly due to the decreased ability of the heart to beat as quickly when we are older. Hence the reason that maximum heart rate equations require age to be a known factor. The decrease in oxygen consumption as we age is pretty significant – at 80 years old, the average person’s oxygen consumption will be half that of a 20 year old. This all adds up the one major outcome: Activities of daily living become more strenuous, and independence is decreased.
So, what can be done?
Evaluating current function
Evaluation of aerobic capacity, or VO2max, can be a very technical and tedious process. Luckily, reliable estimations of aerobic fitness can be made without the need to step foot in the lab and be hooked up to masks and wires whilst performing incremental exercise. For elderly adults, the next best measure is the six-minute walk test. The only requirements for this test are access to a 30m flat stretch of space, and if necessary, a heart rate monitor or pulse oximeter device (the test should be terminated if blood saturation drops below 88%). The primary outcome measure is total distance covered during six minutes of walking as quickly as possible. Normative data is difficult to obtain, but a general reference can be found below. Of course, some individuals may struggle to even complete 6 minutes of uninterrupted fast walking. In this case, rests are permitted, but the clock continues to run. A post-intervention improvement of these scores would suggest an improvement in aerobic capacity.
Age (Yrs) Lower limit (metres) Upper limit (metres)
60 - 69 525 550
70 - 79 450 525
80 - 89 375 425
Training Interventions – Considerations
With age comes a host of complications and variation in ability. Osteoporosis, osteoarthritis and other musculoskeletal conditions are common in this age group, and as such, there is no ‘one size fits all’ approach to improving aerobic function in this group. The key, as with any exercise intervention, is selecting exercise modes, frequencies and intensities, which are sensible, achievable, and that the individual can remain consistent with. Generally, an exercise mode which involves multiple muscle groups, such as walking, cycling, or rowing is preferred if possible. Low level cardiorespiratory exercise on three or four days a week is recommended, as it allows for ample rest between training days. Intensity, measured on a 10-point RPE scale, should ideally peak at 8 out 10 on any given training session. Gentle progression of these variables under the eye of experienced practitioners is the best way to ensure safe and successful improvement of fitness.
‘Success’ may take many forms. For some, increasing the ease at which they complete activities of daily living, such as climbing the stairs, will be a key measure. Others will want to exercise to improve or retain independence. Increased aerobic capacity is linked with improved heart and vascular health,  better metabolic health, and reduced inflammation – so the benefits span across the bio-psycho-social model of health.
One key takeaway….
This brief piece has focussed on the drawbacks of poor cardiac health and cardiorespiratory fitness. However, there is one factor that affects older individuals more than any other age group, and that is a lack of social interaction. As a clinical practitioner, you may be one of the few individuals to regularly see your elderly client. Make no mistake about it: Loneliness is a killer, and unfortunately, elderly people are often isolated from friends and family. They may have lost their partners or spouses, or live alone and away from sons, daughters and grandchildren. Seeing you once a week could be their only regular social appointment, so make it worth it. You are making a big difference to their lives, and it probably means more to them than you will understand, so keep it going!