are two training methods: the "turnabout", where the walker or jogger is timed out and back from a given point. If he takes longer to return than he did to go out, ...
A Conditioning Program For The Elderly T. KAVANAGH, MD
SUMMARY Elderly people often need a fitness program, both to improve their physical condition and mental outlook. Provided their medical examination shows them to be reasonably healthy, they may participate in regular exercise sessions which are "low-tempo" in type and free from a competitive atmosphere. Interval or continuous walking/jogging is recommended, or circuit training. Various indoor activities are described. Regular testing of progress is advocated.
STUDIES SHOW that the aging process is not so much a matter of passing years as it is the presence of arteriosclerosis, and that the healthy 70 year old can demonstrate a fitness level equal to that of a 21 year old.", 2 Further, there is evidence to suggest that those individuals whose daily activities include regular physical activity tend to live longer than those who lead sedentary lives.2 Certainly we are all familiar with the rapid physical and mental deterioration which takes place when the retiree suddenly finds he has time on his hands, and dutifully tries to take his "well-earned rest" by sitting about watching television. If he has previously been an active man the decline is even more dramatic. To visit some of our older citizens in nursing homes or similar institutions is to see far too often a sad state of affairs, with inactivity going hand in hand with apathy and boredom. CANADIAN FAMILY PHYSICIAN
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JULY, 1971
Today, we recognize the need for physical fitness in our school children and young adults. I believe that activation, or fitness, programs can greatly benefit the elderly, both in terms of renewed physical wellbeing and improved morale. Such programs are relatively easy to organize, and with the physician's guidance they can be competently supervised by many of the various workers who come in contact with the aged. Basic Principles in Conditioning the Aged 1. Avoid unduly competitive physical activity. The onetime track star or football hero may become overenthusiastic at the beginning of the program and forget the intervening years. 2. Spasmodic bouts of exercise probably do more harm than good; the participants must exercise regularly at least three to five times weekly. 3. Concentrate on "low-tempo" activities, e.g. walking, jogging. Short, intensive workouts do little to develop the sort of fitness the older person needs. Remember also that with increasing age, there is a drop in maximum heart rate, maximum oxygen consumption, and pulmonary ventilation.3' 4 This means that the elderly exerciser is limited physiologically to a lower intensity of effort than is his younger counterpart. 4. Don't prescribe too much calisthenics, at least to start with. Old ligaments and tendons do not take kindly to unaccustomed stretching.
Selecting Individuals for the Program A preliminary medical examination is mandatory. Obviously there will be some who cannot participate Dr. Kavanagh is medical director of the Toronto Rehabilitation Centre. 31
because of an incapacitating disease, but a surprising number, while not admitting to positive health, will nevertheless be quite sound. The presence of mild to moderate arteriosclerosis is not necessarily a deterrent to exercise. However, it may slow progress towards fitness, and so lead to discouragement and a tendency to drop out. The presence of musculo-skeletal problems will require caution against certain types of calisthenics. There is a slight drop in hemoglobin with increasing age, and this may need to be corrected. An exercise test should always be carried out, the Harvard Two-Step Test or any of its various modifications being quite satisfactory. An ECG during the exercise provides more information than a pulse count, but the latter is still a valuable guide to suitability for a program. With the very unfit, or those over 65, one should use a mild test such as 12 step-ups on a 12-inch high bench in 30 seconds. If the pulse has returned to 100 or less one minute after exercise, the subject is fit for a program. Fitter individuals can use the Sloan Test, which utilizes an 18-inch (two x nine inch) bench, a rate of 30 steps per minute, and a duration of five minutes. The pulse rate is counted three times following exercise, in 30-second periods; from one to one-and-a-half minutes, two to two-and-a-half minutes, and three to three-and-a-half minutes. The Fitness Index is calculated from the formula (Duration of exercise in seconds) x 100 (Sum of Pulse Counts) x 2 Fitness Index standards are as follows: Below 55 = Poor 56 to 79 = Average 80 to 89 =Good Above 90 = Excellent This test can be applied from time to time during the program to check progress.
Types of Program Before starting the exercise course, teach the patient to take his carotid pulse. For convenience, he should learn to count for 10 seconds and multiply by six. By checking this during and after a workout, he can insure a level of activity vigorous enough to obtain a training effect, and yet not too strenuous to be dangerous. Karvonen finds the ideal increment to be 70 percent of the difference between the resting heart rate and the maximum heart rate.5 Assuming an individual aged over 65 has a maximum heart rate of 160 and a resting rate of 72, then his working heart rate would be 134. However, this might be expecting a little too much of an elderly untrained subject, and so it would be wiser to use lower percentages. Thus for the first three months of the course you might wish to limit the pulse rate to 30 beats above the resting level, and then, with increasing fitness, permit a progression to higher levels. Forms of exercise to choose from are: Continuous Walking, Walking/Jogging, Jogging. The activity is continuous, with more emphasis on walking for the 60 year olds and over. As one becomes fitter, the relative time spent in jogging increases until eventually the 32
whole workout consists of a slow, comfortable trot. There are two training methods: the "turnabout", where the walker or jogger is timed out and back from a given point. If he takes longer to return than he did to go out, then the distance was too ambitious. Starting with six minutes, the total time can be increased one minute a week until eventually the overall session takes 20 to 30 minutes. In the "time and distance" method, the subject starts with a distance of a half mile at a comfortable speed and works towards a goal of running two-and-a-half miles in 35 minutes, or walking four miles in one hour. This may take a year of practice to achieve. Progress is always guided by the pulse rate which should not exceed the agreed level, and should return to 100 beats per minute or less, 10 minutes after exercise. As with all types of exercise program, five minute warm-up and warm-down periods are essential. Interval Walking or Jogging. I have found this to be most effective in achieving cardio-respiratory fitness. Muscle soreness and stiffness are less than with the continuous method; the beginner can complete more work with less fatigue. The method utilizes the principle of intermittent periods of activity followed by intervals of rest. In practice, the subject walks or runs for three minutes at an intensity sufficient to raise his pulse to the requisite speed, and then rests for a similar period. He continues to do this for 30 to 45 minutes, or until his pulse rate has failed to return to 1 10 beats per minute or less at the end of any given interval (assuming the target pulse to be 140 to 150). It may take some time to reach the 45-minute workout, but progress is likely to be quicker than with continuous running. Circuit Training. Introduced by Morgan and Adamson of Leeds University, England, this system has much to commend it.6 It can be adapted to any level of proficiency or any age group, and may be carried out in limited space. Since it is an indoor activity, it may provide the answer to exercising during the Canadian winter. Basically it consists of a series of ten exercises or activities laid out in the form of a circuit. Each exercise has a prescribed number of repetitions, and the circuit is so arranged that it can be accomplished three times in about 12 minutes. Obviously, there is great scope here for varying activities, and as the individual becomes fitter, it is a simple matter to adjust the exercises and their timing in order to achieve the prescribed pulse rate in the 12-minute period. Recreational type procedures can be introduced for variety, e.g., driving 20 golf balls into a tarpaulin backdrop. Indoor Exercise. Generally speaking, outdoor exercise is the most satisfying and, weather permitting, should be the method of choice. However, there are times when it would be decidedly foolhardy for the older person to go outdoors. Running on the spot does not require any equipment, but it is very hard on the legs and should be approached cautiously. Stepping on and off a 12 inch stool (to the count of four) is less severe, and, using the interval method with pulse count monitoring, can be an excellent substitute. A less boring alternative and one readily available to apartment dwellers is repetitive stair climbing. Of the various mechanical exercisers on the market, probably the most familiar is the exercycle. This can be CANADIAN FAMILY PHYSICIAN * JULY, 1971
very useful and is often equipped with a resistance screw which increases the work load, and a speedometer- which can be used to measure improvement. Again, the optimum load is derived by reference to the pulse rate, and the interval system is the one of choice. If possible, avoid those models which have a small flywheel and thus too rapid a pedal excursion. This can play havoc with elderly knee joints. Other Activities. Bowling, curling, tennis, badminton, downhill skiing, skating, etc., are activities which give full pleasure only to the fit participant. They are not, in themselves, effective pursuits for the attainment or maintenance of fitness. There are two exceptions: cross country skiing (if you can call that recreational!), and swimming. The former is not likely to attract the elderly, and the latter requires skill and technique. For the lifelong swimmer, there is no better exercise, but its special requirements make it less suitable for our purpose. In all these programs, the training session can be split into two or even three periods .a day, provided that each period lasts for at least 10 minutes, and the pulse rate reaches the required level in this time.
cardiovascular fitness. The checking of body weight together with the average of five skinfold thicknesses (using skin calipers and taking folds over the iliac crest, suprapubic, submental, triceps, and subscapular areas) will show if excess fat is being lost, and a simple grip strength test will indicate the increase or otherwise in muscle power. More elaborate testing becomes too time consuming and defeats the purpose of a practical, easily executed program. The participants should be kept informed of the results. Regular "feedback" is a great incentive to continued attendance. The benefit of regular exercise is readily apparent to all who do it. It is a pity that the older person has been excluded from the current propaganda to involve more of the population in active pursuits. It is, of course, precisely in this age group that the myth about exercise being "bad for the heart" holds greatest sway. Small wonder that our senior citizen clubs are geared to the more gentle hobbies, with crib, bridge, and checkers usually the most strenuous. I hope that this attitude can be changed, and we can look forward to the elderly being encouraged and aided to remain active for their full span. 4
Warning Signs Class instructors should be alert during the exercise sessions for the following signs of circulatory trouble: 1. Facial pallor. 2. Vertigo, headache. 3. Excessive fatigue. 4. Irregular pulse. 5. Various manifestations of angina, including numbness in the hands or arms, constriction in the throat, and "heartburn". If any of these warning signs occurs, the subject should be stopped immediately and observed for five minutes. It is important to remember that coronary insufficiency may persist and even increase during the recovery period.
References 1. Birren, J. E., Butler, R. N., Greenhouse, S. W., Sokoloff, L. and Garrow, M. R.: Human Aging, U.S. Dept. ofHealth, Education & Welfare. Public Health Services. Publication No. 986, 1963. 2 Chebotaryov, D. F. and Sachuk, N. N.: Sociomedical Examination of Longevous People in the US.S.R. Amer. J. Gerant 19. 435, 1963. 3. Astrand, L: Aerobic Work Capacity in Men and Women with Special Reference to Age, Acta. Physiol. Scand., 49 (169 Suppl.) 1960. 4. Astrand, I., P. 0. Astrand, and Rodahl, K.: Maximal Heart rate during Work in Older Men, J. Appl. Physiol. 14: 562, 1959. 5. Karvonen, M J.: Effects of Vigorous Exercise on the Heart. Work and the Heart ed. by Rosenbaum, F. F. and Conclusions An essential feature of any fitness program is the regular Belknapp, E. L. Paul Hoeber, N. Y. 1959. measurement of progress. The Sloan Test can be carried out 6. Morgan, R. E. and Adamson, G. T., Circuit Training, G. every three months to measure the progress being made in Bell and Sons, London, 1962.
QUOTE When the physician said to him, "You have lived to be an old man," he (Pausanias) said, "that is because I never employed you as my physician ". - Quoted by Plutarch in Moralia, "Sayings of Spartans," 231 A. 6 (tr. by F. C. Babbitt)
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