The Geriatric Athlete

The Geriatric Athlete

Brian K. Unwin


  • Although the challenges of age-related changes may require training modifications and a reassessment of goals, exercise rarely requires complete elimination secondary to a medical disorder.

  • This chapter will discuss the following:

    • The demographic shift in aging of the American population

    • Normal age-related physical and physiologic changes related to aging

    • Physiologic and functional benefits of exercise and activity

    • Preparticipation screening

    • General exercise prescription for the older athlete


  • For purposes of discussion, an older athlete will be defined as age 65 years or greater.

  • By 2030, about 20% of all Americans (70 million) will be age 65 or older and will outnumber the pediatric population (15).

  • The average 75-year-old has three chronic conditions and is on five prescription medications. Exercise has been demonstrated to have positive effects in preventing a number of chronic diseases and is also an important tool to treat the very same conditions (22).

  • Sedentary lifestyle is the most prevalent modifiable risk factor for heart disease, a condition present in approximately 50% of individuals age 55-64 and 65% of those age 65-74. One-third of all men age 75 or greater and half of all women of the same age report no or limited physical activity (22).

  • Runners age 65 or greater currently make up only 1%-2% of American marathon runners (9,18). Individuals age 50 and older make up 23% of health club members. Adults born from 1946-1964 (“Baby Boomers”) attending health clubs are more likely to cross-train and more likely to attend the club regularly—112 days per year (24).

  • Although less likely to suffer from acute traumatic injury related to exercise, Baby Boomers are more likely to experience overuse injuries (5).

  • The benefits of sports and athletics shift from recreation and cardiovascular fitness in the young to middle-aged individual to preserving physical, cognitive, social, and emotional functioning in the older adult.

  • Preserving function in late life helps mitigate the direct and indirect costs related to the chronic care of older adults. Numerous studies support the contention that exercise is the key factor to minimize late-life disability and premature mortality (6,11,13,19,25).


  • Normal physiologic changes related to aging are discussed elsewhere in detail (15). These changes intertwine with common comorbidities in older adults such as hypertension, diabetes, hyperlipidemia, and arthritis (Table 114.1). The key physiologic change for athletes is the decrease in [V with dot above]O2max and maximal heart rate.

  • The older adult additionally copes with aging-associated syndromes such as dementia, depression, disability, falls, incontinence, and frailty. See Table 114.1 for a synopsis of these conditions.

  • An appreciation of this intersection of normal aging changes, common medical comorbidities, and geriatric syndromes is crucial to assist the aging athlete. Examples of this include:

    • The older golfer with hypertension and aortic valvular sclerosis who develops syncope

    • The older postmenopausal female cyclist who develops incontinence

    • Delirium manifesting in an older athlete who has just completed a marathon

    • A runner with refractory gastroesophageal reflux that results in malnutrition


  • Some of the physiologic effects of exercise are listed in Table 114.1. In addition to the direct effects on the heart and

    muscular system, exercise improves an older adult’s likelihood of preserved long-term, independent functional status (11,19,25).

    Table 114.1 Common Conditions and Exercise Effect in Older Adults

    Aging-Related Physiologic Changes

    Common Comorbid Conditions

    Common Geriatric Syndromes

    Exercise Effects


      Decreased [V with dot above]O2max

      Decreased maximal heart rate

      Decreased maximal cardiac output

      Rise in systolic blood pressure

      Widening pulse pressure

      Increased large artery stiffness

      Increased fibrosis

      Decreased innervation

      Valve fibrosis

      Myocyte dropout

    Skeletal muscle:


      Loss of Type I and II muscle fibers

      Decreased basal metabolic rate

      Decreased fiber volume

      Muscle denervation

      Decreased mitochondrial volume; increased collagen

      Decreased flexibility


      Lower maximal expiratory flows

      Stable total lung capacity

      Lower diffusing capacity

      Increased ventilation/perfusion mismatch

      Lower respiratory muscle strength

      Loss of lung elastic recoil

      Stiffer chest wall

      Increased airway reactivity

      Lower respiratory drive

      Declining partial pressure of arterial oxygen to age 65

    Bone, ligament, cartilage, meniscus, and tendon

      Bone: loss of mineral density; “tubularization” of diaphyseal bone

      Cartilage: chondromalacia; disuse activity with inactivity

      Ligaments and tendons: stiffness; increased risk for complete

       failure; decreased vascularity

      Meniscus: degeneration; subject to tears; less stress dissipation


      Decreased renal blood flow and glomerular filtration rate

      Age-related glomerulosclerosis

      Impaired concentrating capacity

      Impaired sodium preservation

      Impaired response to vasopressin

      Decreased thirst perception

      Decreased total-body water

      Decreased plasma renin and aldosterone production


      Drug interaction


      Decreased anal sphincter pressure

      Delayed transit

      Decreased lower esophageal pressure



      Decreased hematopoietic response to stress







    Atrial fibrillation


    Chronic kidney disease

    Chronic obstructive pulmonary disease



    Heart disease




    Thyroid disorders

    Vascular disease







    Health illiteracy

    Iatrogenic injury

    Immune deficiency

    Impairments of instrumental activities of daily living (IADLs) and activities of daily living (ADLs)




    Instability (falls)

    Irritable bowels


    Pressure ulcers

    Social isolation


    Temperature dysregulation


      Increased [V with dot above]O2max

      No change in maximal heart rate

      Increased stroke volume

      Increase in arterial-venous oxygen difference

      Reduced mortality from cardiovascular disease and stroke

      Decreased risk of type 2 diabetes, high blood pressure, dyslipidemia, metabolic syndrome, colon and breast cancers

      Moderate evidence for decreased risk of lung and endometrial cancers


      Prevention of weight gain

      Weight loss

      Weight maintenance after weight loss

      Reduced abdominal obesity


      Increased strength

      Increased Type I and II fibers

      No change in number of fibers

      Increased muscle fiber size and area

      Increased muscle oxidative capacity

      Increased motor unit function

      Fewer falls

    Bone and connective tissue:

      Increased bone mass

      Increased bone strength

      Decreased bone reabsorption

      Decreased risk of hip fracture


      Effective in treatment of depression

      Enhanced self-efficacy


      Suggestion of preserved cognition


      Reduced falls

      Improvements in ADL/IADLs

      Improved quality of life

      Improved sleep quality

  • Exercise increases high-density lipoprotein cholesterol levels, lowers low-density lipoprotein cholesterol levels, lowers blood pressure, improves insulin sensitivity, and decreases blood coagulability (3).

  • Direct effects on the heart muscle include increased myocardial oxygen supply, increased myocardial contraction, and electrical stability (3).


  • Masters athletes are older adults (generally defined as age 35 or greater) who have strived to preserve or exceed their prior athletic performance and serve as a model to understand the limits to endurance performance with regard to aging.

  • Peak athletic performance is maintained to approximately age 35, followed by gradual decline to age 60, and accelerated decline thereafter. Examples here are marathon running times and swimming performance (21). See Tables 114.2 and 114.3 for examples of performance levels of older athletes.

  • The primary physiologic determinants to endurance exercise performance are exercise economy, lactate threshold, and maximal aerobic capacity.

    • Exercise economy is the steady-state oxygen consumption that occurs during submaximal exercise below the lactate threshold. Multiple cross-sectional and longitudinal studies demonstrate that running economy does not change in masters athletes trained for endurance activities (20).

    • Lactate threshold does not appear to change with advancing age in masters athletes (20).

    • Maximal aerobic capacity is the primary determinant of decreased endurance exercise performance (10).


  • Responsibility for the preparticipation screening first begins with the athlete contacting a health care provider for assessment. Screening recommendations vary based on the individual’s:

    • General health

    • Medical comorbidities

    • Desired level of activity

  • The clinician should have a clear understanding of the patient’s exercise plan for development of endurance, strength, speed, flexibility, and balance.

    Table 114.2 Examples of Performance Records by Older Athletes (26)

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    May 22, 2016 | Posted by in SPORT MEDICINE | Comments Off on The Geriatric Athlete
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    Outdoor 100 m

    Outdoor 100 m

    Age 35:10.74

    Age 35: 9.97

    (Merlene Ottney)

    (Linford Chritie)

    Age 50:11.67

    Age 50: 10.88

    (Merlene Ottney)

    (Willie Gault)

    Age 65:14.10

    Age 65:12.37

    (Nadine O’Connor)

    (Stephen Robbins)

    Age 80: 18.42

    Age 80: 14.35

    (Hanna Gilbrich)

    (Payton Jordan)

    Outdoor 1 Mile

    Outdoor 1 Mile

    Age 35: 4:17.33

    Age 35:3:51.38

    (Maricica Puica)

    (Bernand Lagat)

    Age 50:5:00.59

    Age 50: 4:27.90

    (Gitte Karlshoj)

    (Nolan Shaheed)

    Age 65: 6:16.28

    Age 65:4:56.40

    (Marie-Louise Michelson)

    (Derek Turnbull)

    Age 80: 7.09.60 (Joseph King)

    Outdoor Marathon

    Outdoor Marathon

    Age 35: 2:21.29

    Age 35:2:03.59

    (Lyudmila Petrova)

    (Haile Gebrselassie)

    Age 50: 2:48.47

    Age 50:2:19.29

    (Edeltraud Pohl)

    (Titus Mamabolo)

    Age 65: 3:28.10

    Age 65:2:41.57

    (Lieselotte Schultz)