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.
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
Cardiovascular:
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:
Sarcopenia
Loss of Type I and II muscle fibers
Decreased basal metabolic rate
Decreased fiber volume
Muscle denervation
Decreased mitochondrial volume; increased collagen
Decreased flexibility
Pulmonary:
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
Renal:
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
Gastrointestinal:
Drug interaction
Cholelithiasis
Decreased anal sphincter pressure
Delayed transit
Decreased lower esophageal pressure
Dysphagia
Hematologic:
Decreased hematopoietic response to stress
Sensory:
Presbyopia
Presbycusis
Cataracts
Anemia
Arthritis
Atrial fibrillation
Cancer
Chronic kidney disease
Chronic obstructive pulmonary disease
Constipation
Diabetes
Heart disease
Hyperlipidemia
Hypertension
Osteoporosis
Thyroid disorders
Vascular disease
Delirium
Dementia
Depression
Dizziness
Falls
Frailty
Health illiteracy
Iatrogenic injury
Immune deficiency
Impairments of instrumental activities of daily living (IADLs) and activities of daily living (ADLs)
Incontinence
Infection
Insomnia
Instability (falls)
Irritable bowels
Polypharmacy
Pressure ulcers
Social isolation
Syncope
Temperature dysregulation
Cardiovascular:
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
Metabolic:
Prevention of weight gain
Weight loss
Weight maintenance after weight loss
Reduced abdominal obesity
Neuromuscular:
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
Mood:
Effective in treatment of depression
Enhanced self-efficacy
Cognition:
Suggestion of preserved cognition
Function:
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)
Women:
Men:
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)
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