Population ageing is one of the
most discussed global phenomena in the present century. Countries with a large
population like India have a large number of people now aged 60 years or more.
The population over the age of 60 years has tripled in last 50 years in India
and will relentlessly increase in the near future. According to census 2001,
older people were 7.7% of the total population, which increased to 8.14% in
census 2011. The projections for population over 60 years in next four censuses
are: 133.32 million (2021), 178.59 (2031), 236.01 million (2041) and 300.96
million (2051).
Frailty is a state of vulnerability that carries
an increased risk for adverse outcomes. It can be viewed as a transition phase
in older people between good health and poor health. Frail older adults are
less capable of tolerating the stress of medical illness, hospitalization, and
immobility. Common signs and symptoms are fatigue, weight loss, muscle
weakness, and progressive decline in function. Frailty is more prevalent in
older people and in those with multiple medical conditions. Frail in Elderly is
usually manifested as weakness, impaired mobility, balance and minimal reserve.
It is seen in the older population as unintentional weight loss, fatigue,
exercise intolerance, weakness, slowed motor performance and low physical
activity.
Concomitant with age, there is decline in
voluntary physical activity which is associated with decrease in numerous
measures of exercise capacity including peak oxygen consumption (VO2pea),
muscle strength, and fatigability which ultimately leads to frailty. Recently
it has been recognized that older adults who are obese also meet criteria for
frailty because of decrease muscle mass and strength that occurs with aging
(sarcopenia) and a need to carry greater body mass due to obesity. This is
associated with an increased risk of fall, ADL disability, hospitalization and
death and at times with Chronic Health diseases like Osteoarthritis, Diabetes Mellitus,
Hyper Tension, angina, Congestive Cardiac Failure, pulmonary disease or Cancer.
Frailty due to alteration in multiple physiological systems (including
inflammatory, skeletal muscle, endocrine, clotting, and haematological) and
dysregulation of mechanisms between these systems to maintain homeostasis
With increasing age, there is a well-described decline in voluntary
physical activity which is associated with decreases in several measures of
exercise tolerance including maximal aerobic capacity, muscle strength, and
fatigueability, leading to an increase risk of frailty.
Frailty increases the risk for loss of functional
independence and decrease in quality of life, the identification of
cost-effective interventions to prevent or ameliorate frailty is one of the
most important public health challenges.
In recent years, increased physical activity or
regular exercise training has been proposed as preventive strategies for
frailty and its adverse outcomes, as it can target four of the frailty criteria:
weakness, low physical activity, slowed motor performance, and exercise intolerance.
Epidemiological studies suggest that regular physical activity is associated
with a decreased risk of ADL disability in older adults, which is an adverse
outcome of frailty.
Frailty is not a contra-indication to physical activity, rather it maybe
one of the most important indications to prescribe physical exercise.
Longitudinal studies have demonstrated that regular physical activity extends
longevity and reduces the risk of physical disability. In fact, cardio-respiratory
fitness has been found to be a significant mortality predictor in older adults,
independent of overall or abdominal obesity
Benefits of Exercises:
With age, there is a decline in the muscle mass and strength and it is
even more distinct in frailty. Studies show that exercise is favourable in older
adults, even in the frailest subset benefit from it. The benefits of exercise
in the elderly are numerous and include increased mobility, improved performance
of activities of daily living (ADL), better gait, less incidence of falls, increased
bone mineral density, and improvements in overall wellbeing.
Aerobic/endurance exercise training
Aerobic capacity often measured as VO2peak
declines with age and contributes to a decrease in the older adult’s ability to
perform activities of daily living. This is largely due to three major causes:
1) A decline in the ability of the cardiopulmonary
system to deliver O2
2) A decline in the ability of the working muscle to
extract O2, and
3) A decline in metabolic muscle mass and parallel
increase in metabolically inactive fat mass.
Indeed, probably one of the most notable effects of
endurance training is on VO2peak which is an important determinant
of frailty in older adults. The improvement in VO2peak with
endurance exercise training would be thought to reduce frailty in older adults
and thus counter the decline in VO2peak with aging and physical
inactivity. There are two mechanisms by which aerobic exercise is thought to
alter the frailty phenotype: improvement in the maximal oxygen uptake (VO2
peak) and increased muscle mass. VO2 peak is defined as the
maximum rate of oxygen consumption measured during vigorous exercise and is
closely related to sub-maximal endurance exercise capacity and exercise
tolerance. Another important adaptation to endurance exercise training is an
increase in muscle oxidative capacity, which results in fatigue resistance or
increased muscle endurance.
Progressive Resistance exercise training
There is well-documented evidence that muscle strength and mass decreases
with advancing age.
Muscle strength decreases approximately 12% to 15% per
decade after the age of 50 years in both males and females going up to a 30%
decrease by 70 years age. Most of the decline in strength can be explained by
selective atrophy of type II muscle fibres and the loss of neuronal activation.
Despite these age-related effects on muscle,
resistance exercise training still has been found to increase strength in older
adults. Motor performance in older adults has also been shown to improve after
resistance training. Several studies have shown that resistance exercise
training increases muscle mass and thus muscle strength in both younger and
older adults. However, the response to resistance training appears to be
attenuated in older adults with mobility limitations or other co-morbidities.
In healthy older adults, four months of progressive resistance training
increased muscle mass by 16 to 23%, whereas it increased muscle mass by 2.0–9%
in frail older adults
Combined aerobic and resistance exercise
Given the beneficial results seen with aerobic or
resistance exercise alone and that both types of exercise target specific
distinct features of frailty, there has been recent interest in whether an
intervention with both components is beneficial for frail older adults.
Therefore, the few exercise interventions conducted in frail older populations
have mostly used combined aerobic and resistance exercise and found to have a
much promising effect than isolated aerobic or resistance training alone.
Effect of exercise interventions on the adverse outcomes of frailty
Several studies have examined the effect of exercise on falls, a common
adverse outcome of frailty. After a single fall, the risk of skilled nursing
facility placement in older adults increases three-fold, after adjustment for
cognitive, psychological, social, functional and medical factors. In addition
to falls, ADL disability is of major concern in frail individuals as it is
associated with higher rates of mortality. Combined resistance exercise
training with balance training and home safety and assistive device
evaluations, rates of ADL disability decreased only in those with moderate
frailty, but not in those with not in those with severe frailty. Moderate
frailty was defined as either the inability to perform a rapid gait test
(requiring more than 10 seconds to walk a 3 meter course) or stand up from a
chair with arms folded, and severe frailty was defined as having both
characteristics
Adverse outcomes of exercise
Most exercise intervention trials studied the effects
on features of frailty and the adverse outcomes of frailty. Physical exercise can reverse frailty (frail
reverse to non-frail) or if older adults can convert from a greater state of
frailty to a lesser state of frailty with exercise suggesting that it is
possible to successfully “treat” frailty.
Molecular and cellular mechanisms underlying exercise training
Aging and physical inactivity are associated with
increased levels of chronic inflammation. Inflammatory cytokines have direct
catabolic effects on skeletal muscle. These cytokines also induce insulin
resistance, which contributes to sarcopenia and frailty by reducing muscle
protein synthesis. Accordingly, an important mechanism by which exercise
training reduces frailty is by suppressing muscle inflammation and promoting
anabolism which leads to an increase in muscle protein synthesis
Future Directions
Exercise and physical activity are promising interventions
for frailty, and several studies are currently underway to examine their
impact. Adherence to an exercise regimen is key to its beneficial effects, and
strategies to overcome this barrier need to be developed before exercise as treatment
modality is implemented on a wide scale.
Although exercise uniformly had a positive impact on
functional measurements, exercise seemed to be more beneficial in frail people
living in long-term care facilities compared to the community (probably due to
floor and ceiling effects of some outcome measurements) and in the earlier
stages of frailty compared to the later stages of frailty (probably due to less
ability to exercise with greater degree of frailty). With respect to specific
type of exercise program, a multi-component training was found to have a more
positive effect on the functional ability and adverse health consequences of
the frail people. Interventions lasting longer than five months seemed to
result in greater benefits on the adverse health consequences of the frail
people. The duration for each session of exercise that was most beneficial was
30–60 minutes, which is less than what is usually recommended for healthier
older adults. In addition, cognition is a factor that should be considered. A significant
proportion of older adults are cognitively impaired, which may impact their
ability to properly adhere to a regular exercise regimen. However, if
caregivers are involved, this may not be such a barrier.
Based on currently available evidence, a multi-component exercise
program that includes aerobic activity, strength exercises, and flexibility is
recommended in frail older adults
Recommendations:
In older adults of the 60 years and above age group, physical activity
includes leisure time physical activity, transportation (e.g. walking or
cycling), occupational (if the individual is still engaged in work), household
chores, play, games, sports or planned exercise, in the context of daily,
family, and community activities.
The recommendations in order to improve cardio-respiratory and muscular
fitness, bone and functional health, reduce the risk of NCDs, depression and
cognitive decline are:
1. Older adults should do at least 150 minutes of moderate-intensity
aerobic physical activity throughout the week or do at least 75 minutes of
vigorous intensity aerobic physical activity throughout the week or an
equivalent combination of moderate- and vigorous-intensity activity.
2. Aerobic activity should be performed in bouts of at least 10 minutes
duration.
3. For additional health benefits, older adults should increase their
moderate intensity aerobic physical activity to 300 minutes per week, or engage
in 150 minutes of vigorous-intensity aerobic physical activity per week, or an
equivalent combination of moderate-and vigorous-intensity activity.
4. Older adults, with poor mobility, should perform physical activity to
enhance balance and prevent falls on 3 or more days per week.
5. Muscle-strengthening activities, involving major muscle groups,
should be done on 2 or more days a week.
6. When older adults cannot do the recommended amounts of physical
activity due to health conditions, they should be as physically active as their
abilities and conditions allow.
Inactive people should start with small amounts of physical activity and
gradually increase duration, frequency and intensity over time. Inactive adults
and those with disease limitations will have added health benefits when they
become more active.
Exercise Recommendations for frail older adults:
|
Aerobic exercise: Moderate to
vigorous activity enough to raise the pulse rate to 70–80% of the maximum
heart rate. Activity performed for a minimum of 20–30 minutes at least three
days per week
 |
|
Resistance exercise: The
progressive resistance program should involve all major muscle groups of the
upper and lower extremities and trunk. One set of 8 to 10 different exercise,
with 10 to 15 repetitions per set, performed 2–3 non-consecutive days per
week. Moderate-high intensity training is recommended, in which moderate
intensity is 5 or 6 on a 0 to 10 scale.
 |
|
Flexibility and balance exercise: Stretching
to the point of tightness and holding the position for a few seconds.
Flexibility activities are performed on all days that aerobic or muscle
strengthening activity is performed. Balance training exercise 2–3 times per
week.
  |
|
Modified Wall Suryanamaskar: Hypothesised
to be a good exercise for improving balance and reaction time in the
community dwelling elderlies. Also can be a good combination of aerobic and
resistance training for improving strength, endurance, flexibility and
aerobic capacity in this population.
  |
|
Virtual Reality Training: Virtual reality
game exercise have been found to improve balance and gait of elderly
individuals in community dwelling elderlies.
  |
Conclusion: An exercise “prescription”
Majority of studies suggest that clinicians should recommend regular
physical activity or exercise training to frail older adults. All adults over 60
years should participate in 150 minutes (2 hours and 30 minutes) of moderate
aerobic exercise per week. Although most trials studied resistance exercise
training, we would encourage frail older adults to start with an aerobic
activity such as walking, as it is more accessible. If possible, resistance
exercise training should be added. Depending on the degree of frailty,
supervision may or may not be required. For individuals with severe frailty,
evaluation by a rehabilitation profession is recommended.
The majority of evidence shows that regular physical activity or
exercise is beneficial for older adults who are frail or at high risk of
frailty. Studies have shown the number adverse events are minimal, and the
gains of regular exercise clearly outweigh the risks.
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2. Aguirre LE, Villareal
DT. Physical Exercise as Therapy for Frailty. Nestle Nutr Inst Workshop Ser.
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Ministry
of health and family welfare. New Delhi: Director General of Health
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Statistics Office. New Delhi: Central Statistics Office Ministry of
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(AoP)
