functioning, is best known for its predictive capabilities for disability, institutionalization, and death, but it also has known ceiling effects that limit its use as an outcome for exercise interventions in generally healthy older adults. A change of 0.5 point in the SPPB is considered a small meaningful change, whereas a change of 1.0 point is considered a substantial change (54), Usual gait speed, widely considered the simplest test of walking ability, has comparable predictive validity to the SPPB (90), but its sensitivity to change with exercise interventions has not been consistent, A change in usual gait speed of 0.05 ms = 1 is considered a small meaningful change, and a change of 0.10 m « s™ is considered a substantial change (54). Exercise Prescription The general principles of Ex R, apply to adults of all ages (see Chapter 6). The relative adaptations to exercise and the percentage of improvement in the components of physical fitness among older adults are comparable with those reported in younger adults and are important for maintaining health and functional ability and attenuating many of the physiologic changes that are associated with aging (see Table 7.2). Low aerobic capacity, muscle weakness, and deconditioning are more common in older adults than in any other age group and contribute to loss of independence (9), and therefore, an appropriate Ex Ry should include aerobic, muscle strengthening/endurance, and flexibility exercises. Individuals who are frequent fallers or have mobility limitations may also benefit from specific neuromotor exercises to improve balance, agility, and proprioceptive training (e.g., tai chi), in addition to the other components of health-related physical fitness. However, age should not be a barrier to PA because positive improvements are attainable at any age. For Ex R,, an important distinction between older adults and their younger counterparts should be made relative to intensity. For apparently healthy adults, moderate and vigorous intensity PAs are defined relative to METs, with moderate intensity activities defined as 3-5.9 METs and vigorous intensity activities as >6 METs. In contrast for older adults, activities should be defined relative to an individual’s physical fitness within the context of a perceived 10- point physical exertion scale which ranges from 0 (an effort equivalent to sitting) to 10 (an all-out effort), with moderate intensity defined as 5 or 6 and vigorousintensity as >7. A moderate intensity PA should produce a noticeable increase in HR and breathing, whereas a vigorous intensity PA should produce a large increase in HR or breathing (85). Neuromotor (Balance) Exercises for Frequent Fallers or Individuals with Mobility Limitations There are no specific recommendations regarding specific frequency, intensity, or type of exercises that incorporate neuromotor training into an Ex R,. However, neuromotor exercise training, which combines balance, agility, and proprioceptive training, is effective in reducing and preventing falls if performed 2-3 d- wk! (9,46). General recommendations include using the following: (a) progressively difficult postures that gradually reduce the base of support (e.g., two-legged stand, semitandem stand, tandem stand, one-legged stand); (b) dynamic movements that perturb the center of gravity (e.g., tandem walk, circle turns); (c) stressing postural muscle groups (e.g., heel, toe stands); (d) reducing sensory input (e,g., standing with eyes closed); and (e) tai chi. Multimodal exercise programs that include two or more components of strength, balance, endurance, or flexibility exercises have been shown to reduce fall rates and the number of people falling (124). Exercise done in supervised groups, such as tai chi, or individually prescribed home programs have all been shown to be effective at reducing fall risk. (51); however, there may be times when supervision of these activities is warranted (9). FITT RECOMMENDATIONS FOR OLDER ADULTS (9,46,85)Aerobic Resistance Flexibility Frequency =5d-we-!formod- =2d- wk? 22d-wk? ‘erate intensity; 23 d + wk for vigorous intensity; 3-5 d- wk? fora combina tion of moderate and vigorous inlensiy Intensity On a scale of 0-10 for Light intensity (ie, Stretch to the level of ohvsicalexer- 40%-50% 1-RM) for_ point of feeling tion, 5-6 for moderate beginners, progress fo tightness or slight intensity and 7-8 for moderaleto-vigorous discomfort. Nigorous intensity Intensity (60% 80% 1-RM} alternately, moderate (5-6) to vig- eee ee Time 30-60 min- of Hold stretch for moderaie intensity involving the major 30-60 s. exercise; 20-30 min muscle groups; 1-3 =d‘ ofvigorousin- seis of 0-12 repeti- ‘tensty exercise: oran_ tions each ‘equivalent combination of rroderate and vigor- us intensity exercse: may be accumulated in bouts of at least 10, -mineach_ Type ——Arlymodalty that Progressive Ary physical acti does not impose ‘weight-treining ities that maintain excessive orthopedic programs or or increase | stress such aswak- weight-bearing feb using ing. Aquatic exercise calisthenics, slar slow movements andsiationary cycle climbing, and other thet terminete in exercise may be ad- strengthening Static stretches ‘anlageous for those activities thal vse for each muscle with limited tolerance the major muscle group rather than for weighi-bearing groups ‘rapid balistic activity. {RIM one repetition maxinurn Special Considerations for Exercise Programming There are numerous considerations that should be taken into account to maximize the effective development of an exercise program, including the following:Intensity and duration of PA should be light at the beginning, in particular for older adults who are highly deconditioned, functionally limited, or have chronic conditions that affect their ability to perform physical tasks. Progression of PA should be individualized and tailored to tolerance and preference; a conservative approach may be necessary for the older adults who are highly deconditioned or physically limited. Muscular strength decreases rapidly with age, especially for those aged >50 yr. Although resistance training is important across the lifespan, it becomes more important with increasing age (9,46,85). For strength training involving use of selectorized machines or free weights, initial training sessions should be supervised and monitored by personnel who are sensitive to the special needs of older adults. Older adults may particularly benefit from power training because this element of muscle fitness declines most rapidly with aging, and insufficient power has been associated with a greater risk of accidental falls (20,24). Increasing muscle power in healthy older adults should include both single- and multiple-joint exercises (one to three sets) using light-to-moderate loading (30%-60% of 1-RM) for 6-10 repetitions with high velocity. Individuals with sarcopenia, a marker of frailty, need to increase muscular strength before they are physiologically capable of engaging in aerobic training. If chronic conditions preclude activity at the recommended minimum amount, older adults should perform PA as tolerated to avoid being sedentary. Older adults should gradually exceed the recommended minimum amounts of PA and attempt continued progression if they desire to improve and/or maintain their physical fitness. Older adults should consider exceeding the recommended minimum amounts of PA to improve management of chronic diseases and health conditions for which a higher level of PA is known to confer a therapeutic benefit. Moderate intensity PA should be encouraged for individuals with cognitive decline given the known benefits of PA on cognition. Individuals with significant cognitive impairment can engage in PA but may require individualized assistance Structured PA sessions should end with an appropriate cool-down, particularlyamong individuals with CVD. The cool-down should include a gradual reduction of effort and intensity and, optimally, flexibility exercises. 1 Incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance participation in a regular exercise program (see Chapter 12). mt The exercise professional should also provide regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence. ONLINE RESOURCES Continuous Scale Physical Functional Performance Battery (28): hitp://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx? ID=1125 Short Physical Performance Battery (12): hitp://www.gre.nia.nih.gov/branches/ledb/sppb/index.htm PREGNANCY Healthy pregnant women without exercise contraindications (Box 7.2) are encouraged to exercise throughout pregnancy (7,33,93). Not only are the health benefits of exercise during pregnancy well recognized (Box 7.3), but also the short- and long-term risks associated with sedentary behavior are of increasing concern (33). In their respective guidelines, the American College of Obstetricians and Gynecologists (7,11) and the US Department of Health and Human Services (119) outline the importance of exercise during pregnancy and provide evidence-based guidance on Ex R, for the minimization of risk and promotion of health benefits. With appropriate modifications and progression, pregnancy is an opportunity for sedentary women to adopt PA behavior (93). Relative m Severe anemia m Unevaluated maternal cardiac dysthythmia & Chronic bronchitis