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Senior Fitness Research Roundup
Len Kravitz, Ph.D.

According to the Centers for Disease Control (CDC 2009), by 2030 the proportion of the U.S. population aged 65 and older will double to about 71 million senior adults. The ramifications of the growing number of older Americans will impart unique demands on public health, aging services, and the nation's health care system. The CDC suggests that chronic diseases (e.g., cardiovascular disease, stroke, cancer, and diabetes) place a profound health and economic burden on older adults due to associated long-term illness, diminished quality of life, and increased health care costs. Although the risk of disease and disability does increase with advancing age, the CDC proposes that poor health is not an inevitable result of aging. Health promotion initiatives of the CDC include practicing a healthy lifestyle (e.g., avoiding tobacco use, regular physical activity, and healthy eating) and the use of early detection practices (e.g., screening for breast, cervical and colorectal cancers, diabetes, and depression). In this research round-up some principal age-related topics are reviewed, which are then accompanied by some practical applications for exercise professionals on how to utilize these findings with their older adult clientele.

Is Dancing a Good Activity for Promoting Health in Older Adults?
Article Reviewed: Keogh, J.W.L, Kilding, A., Pidgeon, P., Ashley, L., and Gillis, D. (2009). Physical benefits of dancing for healthy older adults: A Review: Journal of Aging and Physical Activity, 17, 479-500.
Some of the proposed benefits of resistance training, balance drills, and aerobic exercise include improvements in muscular strength, muscular endurance, body composition, cardiovascular fitness, functional independence in activities of daily living and a reduction in the occurrence of falling (Keogh, 2009). However, much less is known about the health benefits of dancing in a senior population. There are many different forms of dancing that may be quite appealing to a variety of older individuals of varying ages. As well, Keogh and colleagues note that some of the unique aspects of dancing for older adults are that it may also promote social interaction, a sense of belonging to a community, and long-term dancing compliance.

This comprehensive study reviewed 15 training studies and 3 cross-sectional investigations (i.e., an observation of the senior population at a specific point in time) of apparently healthy adults (>60 years of age). The forms of dancing included ballroom, line dancing, folk dancing, as well as some traditional dance forms from certain cultures including Korean, Argentine tango, Turkish folkloristic, Greek and Caribbean. The results of this original investigation show that dancing can improve aerobic power, lower body muscular endurance, strength, flexibility, balance, agility, and gait speed for older males and females. It will also reduce cardiovascular health risk and can be central in the prevention of falls.
Practical Application: As exercise professionals widen their 'net' of ways to involve special populations in more health promoting activities, the idea of adding dance classes/sessions to an exercise program may be quite alluring for some older clients.

What are The Deleterious Effects of Diabetes Mellitus with Aging?
Article Reviewed: Araki, A. and Ito, H. (2009). Diabetes mellitus and geriatric syndromes. Geriatrics Gerontology International, 9, 105-114.
Many older adults have what is referred to as 'geriatric syndrome', which describes when a multifactor health condition, such as diabetes, affects several of the body's regulating systems (e.g., musculoskeletal, cardiovascular, respiratory, nervous, endocrine, immune and digestive) (Araki and Ito, 2009). Diabetes has been shown to increase the prevalence (total widespread numbers) and incidence (rate of occurrence) of geriatric syndrome. In the Araki and Ito study, the association of diabetes to functional ability, depression, falls, malnutrition, and cognitive function is reviewed.

One of the more serious problems of diabetes is its impairment of functional ability. Investigations show that some diabetic older adults (>60 years of age) are not able to walk _ quarter mile, do housework or climb stairs. Others are more severely affected, with limitations in bathing, dressing and eating. Araki and Ito (2009) state that the diabetes-related diseases contributing to functional disability include coronary heart diseases, obesity, stroke, peripheral artery disease, neuropathy (disease that impairs sensation and movement in arms and legs), arthritis and depression.

It is attention-grabbing to note that depressive symptoms are higher in elder diabetic populations as compared to their non-diabetic counterparts (Araki and Ito, 2009). In fact, 30% of people with diabetes have depressive symptoms. Araki and Ito continue that the impact of depression on the older diabetic person is quite extensive, reducing the quality of life, happiness, life satisfaction, morale and overall well-being of the person.
Falls can lead to fractures and significant reduction in the quality of life in older adults. Araki and Ito (2009) highlight, in their recent research review, that a considerable amount of evidence suggests that diabetes mellitus is one of the foremost predictors of risk of falling. It is suggested that diabetes negatively affects walking gait and balance. Other contributing factors to falls, which are very related to diabetes, include coronary heart disease, arthritis, lower extremity function, overweight, poor vision, musculoskeletal pain and insulin resistance.

Older adults with diabetes may also be at greater risk to malnutrition deficiencies. More specifically, Araki and Ito (2009) clarify that older adults with diabetes tend to have what is referred to as 'sarcopenic obesity'. Sarcopenic obesity describes a physiological syndrome where a person is gaining excess body fat while concurrently losing muscle mass. Insufficiencies in diet (particularly in Vitamin B: B1, B2, B6, B12, and folate) may exaggerate this declining condition in elderly diabetic individuals.

Diabetes has also been shown to impair memory, learning, information processing, psychomotor skills and overall cognitive function in older diabetic individuals. It is proposed that a decrease in cerebral blood flow and high blood glucose negatively affect the central nervous system function and health (Araki and Ito, 2009)

Araki and Ito (2009) emphasize that exercise therapy is paramount for the treatment of diabetic patients with geriatric syndrome. Cardiovascular exercise and resistance training are highly recommended to maintain blood glucose and prevent further disability. They also recommend a fall prevention program as well as specific home environment modifications (e.g., replacing rectangular tables that have sharp edges, taking away carpet pads, removing extension cords off the floor, adding brighter lights in low-lighting areas, and lubricating door hinges for ease in opening and closing). The authors note that psychological counseling may also be needed for elder clients with depressive symptoms and a low sense of well-being.
Practical Application. There is a commanding need for trained exercise professionals to intervene in perhaps one of the fastest growing health problems of this century, diabetes and geriatric syndrome. A strategic design with supervised and well-designed exercise therapy (e.g. cardiovascular exercise, resistance training, fall prevention, healthy nutrition education, non-exercise activity {i.e., spontaneous physical activity} guidance, metabolic profiling {see IDEA Fitness Journal, Vol. 6, No. 9, pp 14-17}) is a major professional area of opportunity personal trainers can skill themselves with hopes of helping older clients enjoy a more satisfying life.

What's New with Osteoporosis Interventions and Seniors?
Vondracek, S.F. and Linnebur, S.A. (2009). Diagnosis and management of osteoporosis in the older senior. Clinical Interventions in Aging, 4, 121-136.
With advancing age the risk for the development of osteoporosis and fractures increases. Case in point, the prevalence of osteoporosis, based on hip bone density, has been estimated at 4% in women 50-59 years of age compared to 44% in women &Mac179;80 years of age (Vondracek and Linnebur, 2009). Vondracek and Linnebur state that hip fractures and their associated costs could double or triple throughout the world by 2040. The authors add that hip fracture risk rises dramatically with age, with only 50% of people able to return to their 'pre-fracture' movement ability level. Sadly, 20% to 40% of patients die within the first year of a hip fracture.
The risk of falling noticeably increases with age. Vondracek and Linnebur (2009) highlight that 50% of seniors 85 years of age and older will fall at least once per year. The causes of falling include impaired balance, limited gait and mobility, poor vision, reduced muscle strength, declining cognition and the use of multiple medications. Vondracek and Linnebur note that older seniors tend to fall backwards or sidewards and are thus unable to catch themselves or break the fall.

Vitamin D deficiency is highly associated to bone strength and falls. Data suggest that most older men and women in the U.S are low in Vitamin D (Vondracek and Linnebur, 2009). As well, Vitamin D is important to maintain muscle function and strength, particularly in the weight-bearing muscles of the lower body. Muscle weakness in older adults is characterized by a person exhibiting difficulty in climbing steps, rising from a chair, walking distances and participating in outdoor activities. Older adults with Vitamin D deficiency may tire easily with weight bearing physical movement and feel heaviness in the legs.

Exercise, fall prevention, smoking cessation and adequate intake of calcium and vitamin D are recommended for the older adult to preserve bone mineral density and reduce the risk of falling. See Side Bar 2 for the ACSM/AHA physical activity guidelines for seniors. Bone-loading exercises for the spine and hip (e.g., squats and lunges with resistance) are encouraged to be included in a well-developed exercise plan for seniors. A fall prevention program and home environment modification plan (as discussed above in the 'What are The Deleterious Effects of Diabetes Mellitus with Aging' section) are advocated for older men and woman.

Smoking cessation has been shown to significantly increase bone mineral density in older seniors (Vondracek and Linnebur, 2009). Quitting smoking has also been found to reduce the risk of hip fracture. Notably, the health benefits of smoking cessation for the decreased risk of cardiovascular and pulmonary disease make this behavior change essential for older adults.

All seniors with osteoporosis should receive adequate vitamin D and calcium. Supplementation is almost always recommended since diet alone isn't usually satisfactory. Vondracek and Linnebur (2009) summarize that research has shown that calcium and vitamin D supplementation has been found to significantly reduce fracture risk and bone loss in the spine. The authors recommend 1200-1500 mg of calcium divided two to three times daily. To avoid deficiency in vitamin D the authors propose that 800-1000 IU vitamin D3 daily OR 50,000 IU vitamin D2 every 2-4 weeks. To treat vitamin D deficiency, the authors recommended 50,000 IU of vitamin D2 every week.
Practical Application: Based on the existing data that shows older adults are at high risk for osteoporosis, personal trainers and exercise professionals are advised to use the current older adult guidelines summarized by Vondracek and Linnebur (2009) (also refer to Side Bar 2) to help their senior clients fully enjoy the benefits of an active physical lifestyle.

Does Flexibility Training Improve Balance and Functional Activity in Seniors?
Ceceli, E., Gokoglu, F., Koybasi, M, Cecek, O., and Yorgancioglu, Z.R. (2009). The comparison of balance, functional activity, and flexibility between active and sedentary elderly. Topics in Geriatric Rehabilitation, 25(3), 198-202.
With aging, many seniors begin to adopt a sedentary lifestyle, which results in some deleterious health effects (i.e., cardiovascular disease, type 2 diabetes, some cancers). The authors explain that aging (and inactivity) also results in connective tissue changes in muscle that reduce a person's range of motion. The purpose of this study was to see if performing flexibility exercises has any effect on balance and functional ability. The study subjects (primarily women &Mac179;65 years of age) included 25 seniors in the flexibility group and 21 subjects in the sedentary control. All subjects were leading functionally independent lives. The flexibility exercises were led and supervised by a physiotherapist. All upper- and lower-body flexibility stretches were preformed in a supine position (on a mat), with 10 repetitions of each stretch. All exercises were performed to the subject's endpoint range of motion (i.e., full range of motion). Sessions were held three times/week for 20 minutes and were completed over a period of 4 months. Balance was tested with a one-legged stance test and a Sharpened Romberg (SR) test. The SR test involves the subject standing for 60 seconds in a heel-to-toe position with the dominant foot behind the nondominant foot. With this assessment, the arms remain by the subject's side as he/she tries to keep from moving the feet (eyes closed in one trial and open in a second trial). With the one-legged stance (eyes closed in one trial and open in a second trial), the arms are kept by the sides. Subjects are allowed to move arms (for balance) during the sustained (up to 30 seconds) testing period. Functional activity was evaluated with a 30-meter walking test and a functional reach test. Anterior trunk flexion and left/right lateral trunk flexion were also measured pre- and post-training. The study results indicate that flexibility training had a significant positive effect on functional ability and flexibility. Results also showed a positive (though not statistically significant) increase in balance ability.
Practical Application: Currently, much of the research for seniors is on cardiorespiratory fitness and resistance training, which are indeed critical components of fitness. However, it is praiseworthy to see a modern, data-based control training study that documents the benefits of full-range of motion flexibility training for seniors. Hopefully, when exercise professionals share the meaningful outcomes of this flexibility training study, senior clients will be inspired to adhere to their daily stretching exercises.

Is There Really Such a Thing as Successful Aging?
Article Reviewed: Yaffe, K, Fiocco, A.J., Vittinghoff, E., Simonsick, E.M., Newman, A.B., Satterfield, S., et al. (2009). Predictors of maintaining cognitive function in older adults: The Health ABC Study, Neurology, 72, 2029-2035.
One unique area of scientific query is involved with understanding, defining and predicting successful aging. However, most investigators in this area have focused on understanding healthy aging from a physical health perspective and have largely ignored cognitive health. Yaffe and colleagues (2009) focused their research on cognitive function with a sample population of 2,509 elder men and women (70-79 years of age at the start of the study) over a period of 8 years. The results of this study showed that doing moderate to vigorous exercise, not smoking, and volunteering in the community were major predictors of optimal cognitive function. Interestingly, volunteering with older adults has been demonstrated to reduce mortality and increase a person's sense of well-being. Yaffe et al. suggest that volunteering provides great emotional gratification for older adults while also increasing their social network. In fact, the authors affirm that those seniors with positive cognitive function typically do not live alone. As well, higher levels of educational attainment throughout life are associated with optimal cognitive function as well.
Practical Application: Personal trainers and exercise professionals have the unique advantage of providing social network opportunities (group workout on the beach, golf course or park; theme training events for all clients {e.g., New Years Eve 5K race, Halloween costume workout, etc.}, and partner or small group personal training.) As well, encouraging clients to learn more about exercise, nutrition, and metabolism may beneficially help them challenge their mind, while concomitantly increasing their cognitive health.

What are the Current Aging Statistics on Education, Income, Health Care, Physical Activity, Obesity and Leisure Time Use?
Source: Aging Statistics from the Administration on Aging, Department of Health and Human Services : Retrieved 11/13/2009
The following is a synthesis of current information from the Administration of Aging (Department of Health and Human Services) web site, which brings together a wide variety of up-to-date statistical information about the growing senior population of men and women (&Mac179; 65 years of age).
Education: In 1965, 24% of seniors had graduated from high school, and 5% had bachelor's degrees. By 2007, 76% were high school graduates, and 19% had at least a bachelor's degree.
Income: Incomes of older adults gradually rose between 1974 and 2006. The percentage of seniors with incomes below the poverty line went from 15% to 9%; those categorized with low income dropped from 35% to 26%; those with high incomes increased from 18% to 29%. More older people, especially women, continue to work past the age of 55 years.

Health Status: “While older people experience a variety of chronic health conditions that often accompany aging, the rate of functional limitations among people age 65 and older has declined in recent years.” However, the life expectancy in the U.S. is lower than that of many high-income countries, such as France, Japan, Sweden, and Canada. Americans who survive to age 65 can expect to live an average of 18.7 more years.

Physical Activity and Obesity: There was no significant change in the percentage of older people engaged in physical activity between 1997 and 2006 with 22% of people age 65
and over engaging in regular leisure time physical activity. The proportion of leisure time devoted to sports, exercise, recreation and travel declines with age. On an average day, most Americans &Mac179;65 years of age spend at least half of their leisure time watching television. The percentage of people &Mac179;65 years of age that are obese increased from 22 percent to 31 percent over the course of 12 years (from 1994 to 2006 data).

Health Care: Health care costs, particularly for prescription drugs, have risen dramatically for older Americans. In 2004, over half of out-of-pocket health care spending (excluding health insurance premiums) by community-dwelling older people was for purchase of prescription drugs. These costs are expected to decline because of the savings available through the Medicare prescription drug program.

Leisure Time Use: The fraction of leisure time that older Americans spend socializing, such as visiting friends or attending social events, modestly declines by age, from 13% in those ages 55 to 64 to 10% for those 75 and over.

Side Bar 1: What are the Current Theories How People Age?
Taylor and Johnson (2008) present a perceptive overview of the current theories how people age. These theories of aging are divided into seven broad categories and discussed below.
Wear and Tear Theories: The wear and tear theories suggests that all cells, tissues, organs and systems of the body wear out with their continual use through life. The theory also states that internal bodily damage may enhance the aging process from sites within the body. For instance, free radicals (which are scavenger molecules seeking electrons from other molecules) and cell disease are internal mechanisms that may promote cell aging and death. As well, environmental agents, such as carcinogens, pollutants, viruses, and environmental radiation are external agents that may advance cellular demise.
Genetic Theories: The genetic theories propose that all genes in the human body are age-coded from birth to death. This theory supports the concept that cells have a biological clock of life. Supporters of this theory suggest that the changes observed in chronological aging such as puberty and menopause are examples of the conjectures in this theory. However, the theory notes that cellular errors or mutations are examples of complications that may occur during life, which will alter the biological clock of a cell, organ or body system.
General Imbalance Theories: The general imbalance theories suggest that the brain, endocrine glands, and/or immune system (or any combination of these) gradually start to dysfunction, leading to the aging process. The failure of an organ or body system will vary throughout the body and may be upsurged by infection and disease.
Accumulation Theories: The accumulation theories propose that the functional decline correlated to aging is the result of an accumulation of certain chemical that result in a cell's dysfunction, damage and death. For instance, with this theory it is felt that free radicals may continually accumulate and hasten the death of certain cells and tissues.
Dysdifferentiative Hypothesis of Aging and Cancer: Differentiation is a process describing that all cells in the human body are very specialized in their function and structure. The dysdifferentiative hypothesis proposes that cells gradually (with aging) begin to lose their highly specific mechanisms, which leads to a cascade of age-related changes in the body organ.
Caloric Restriction Hypothesis: Quite a few scientists are presently doing investigations to understand the cellular and molecular basis how calorie restriction retards aging in selected animals. Research has demonstrated that some animals (i.e., rats) can consume 30% to 50% fewer calories (while getting the satisfactory amounts of protein, fat, vitamins and minerals) and increase their life span. In fact, with rodents, low-calorie diets can actually postpone some of the major diseases observed in late life (Weindruch, 2006). No controlled data-based long-term study has yet to be completed with healthy adults. The underlying mechanism of this theory is that calorie restriction limits injury to the cells mitochondria (ATP power plant of the cell) from highly reactive free radicals (Weindruch).

Side Bar 2: What are the Highlights of the 2009 ACSM/AHA Physical Activity Recommendations for Older Adults?
The following are the current health, frequency, intensity and duration guidelines for older adults from the AHA and ACSM. For older adults who are unable to meet these guidelines, ACSM/AHA recommend performing physical activity that can be safely endured by the senior.
Health: The ACSM/AHA recommendation for health is a minimum of 150 minutes of physical activity per week. For greater health benefits, increases in duration, frequency, and intensity of exercise are recommended.
Endurance Exercise for Older Adults
Frequency and Duration: With moderate-intensity activities, accumulate a total of 150-300 minutes a week in bouts of 10 minutes or more (up to 60 for greater benefits) per day. With vigorous-intensity exercise activities, complete a total of 75-150 minutes per week in 20 to 30-minute work bouts.
Intensity: Utilizing a subjective assessment range from 0 to 10, let 5 to 6 represent the moderate-intensity exertion and 7 to 8 signify the vigorous-intensity effort.
Type: Use any exercise mode that does not trigger orthopedic stress to the body. For persons with lower extremity limitations, aqua exercise, walking, elliptical training and stationary cycling may be more advantageous due to their minimal impact stresses on the body.
Resistance Training for Older Adults
Frequency and Intensity: Complete resistance training at least 2 times per week at a moderate (5 to 6 intensity on a 10-point scale) or vigorous (7-8) intensity.
Type: Progressive weight training of 8 to 10 exercises involving the major muscles of the body is advised. Weight bearing calisthenics and stair climbing are also beneficial.
Flexibility Exercise for Older Adults
Frequency and Intensity:
Do stretching exercises at least 2 days/week at a moderate (5-6) intensity on the 0-10 scale.
Type: Perform static stretches that maintain and/or increase the desired joint range of motion for the selected joint or group of joints.
Balance Exercise For Frequent Fallers and Older Adults with Mobility Problems
At this time, the research does not provide an optimal dose (frequency, intensity, time, duration) for balance exercises. That said, the ACSM/AHA guidelines for balance include gradually increasing challenges that reduce the base of balance support (e.g., two-legged stationary stand with different widths of legs apart, shifting weight from one leg to the other leg, one-legged stand), dynamic movements that challenge the center of gravity (i.e., walking in a circle or figure eight and changing direction and speed), exercises that challenge the posture muscles (e.g., heel stands and toe stands), and movements that challenge sensory input (e.g., standing movements with the eyes closed).
Source: Chodzko-Zajko, W.J., Proctor, D.N., Fiatrone Singh, M.A., Minson, C.T., Nigg, C.R., et al. (2009). Exercise and physical activity for older adults. Medicine & Science in Sports & Exercise, 41(7), 1510-1530.

Side Bar 3: Special Focus: What Are Some Special Nutrient Needs for Seniors?
Impaired absorption of certain micronutrients is commonly observed in the elderly. Elmadfa and Meyer (2008) propose that nutrient needs in the elderly should optimize immune function and help reduce disease risk. While caloric needs of seniors are lower than healthy young adults, the demands for most vitamins, minerals, and trace elements are not (or are modestly reduced). Iron needs appear to be somewhat lower after a woman goes through menopause. Vitamin B12 can be meaningfully reduced in a senior adult (Elmadfa & Meyer). As well, Elmadfa and Meyer contend that calcium and vitamin D absorption are also reduced in seniors (as discussed thoroughly in the osteoporosis article above). Predictably, the skin's ability to synthesize vitamin D decreases with advancing age. Deficiencies in vitamin B12, B6 and folate are considered to be contributing risks for cardiovascular disease (Elmadfa & Meyer). Prominently, foods rich in antioxidants (e.g., beta-carotene and ascorbic acid) are recommended because they can improve the oxidative (balance of free radical and antioxidant molecules) balance within cells.

The response to vaccination is also lower in seniors and thus makes them more vulnerable to infections (Elmadfa & Meyer, 2008). Adequate supply of all essential nutrients may help control this impairment. Lastly, Elmadfa and Meyer (2008) note that many seniors have a weakened thirst perception and thus do not drink enough water. This can depress renal function and other bodily processes. Therefore, the importance of drinking water throughout the day needs to be a regular reminder to older males and females.

Senior Research Round-Up Summary
Older adults are the most physically inactive group of any population (Chodzko-Zajko et al., 2009). While every person has a biological clock, the health benefits of a physically active lifestyle for seniors clearly indicate that many age-related illnesses and diseases can be impressively slowed down. Personal trainers and exercises professions are exemplary role models to advocate, inspire and promote physical activity and exercise in this special population. Take charge and do it!

Additional References:
Centers for Disease Prevention: Retrieved 11-11-09

Elmadfa, I. and Meyer, A.L. (2008). Body composition, changing physiological functions and nutrient requirements of the elderly. Annals of Nutrition & Metabolism, 52(suppl 1), 2-5.

Taylor, A.W. and Johnson, M.J. (2008). Physiology of exercise and healthy aging. Human Kinetics.

Weindruch, R. (2006). Calorie restriction and aging. Scientific American, Inc. December, 2006.