Age Related Disease

Module 2Age Related Disease

Objectives:

After studying this module, you should be able to:

• Understand common age-related diseases• Recognize special considerations when working with the aging population• Understand exercise recommendations for many age-related diseases.

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Module 2

Introduction

Aging is often accompanied with degeneration and limited functionality. The amount of degeneration isn’t necessarily age related as discussed in Module 1, however influenced

by an individual’s activity levels, nutritional habits and lifestyle choices. As America’s population ages, they are facing issues of longevity, mortality and enhancing their quality of life. These issues are important when discussing age related diseases that can be slowed – and in some cases reversed – by engaging in regular exercise. Older clients suffering from one or more of these condi-tions are often limited in their ability to perform Activities of Daily Living (ADLs) such as bathing, eating, getting dressed and mov-ing around. Second to that, aging clients with various age-related diseases can lose their ability to perform Instrumental Activities of Daily Living (IADL), like taking medication, preparing meals, man-aging finances and doing housework. This loss of independence can be devastating for an aging client. Exercise will be an import-ant factor in increasing health and longevity.

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Age Related Disease

SarcopeniaTo be fair, sarcopenia is not a disease. However, various dis-eases affecting older individuals can be attributable to sarco-penia. As such, it is worth discussion here. Sarcopenia is sim-ply defined as muscle loss. This form of muscle atrophy how-ever, cannot be reversed in the aging population. Sarcopenia is not just loss in muscle size, the muscle fiber characteristics alter, the muscle metabolism is reduced, tissue is replaced with fat and fibrous tissue and there is altered neuromuscu-lar function – such as reduced proprioceptive capabilities. (1) Sarcopenia is a gradual and eventual occurrence, however the onset and magnitude are determined by an individual’s phys-ical activity habits. Constantly stressing the muscles though cardiovascular or resistance training can greatly deter the progressive muscle loss patterns in older adults. (1) However, in the sedentary population, advanced Sarcopenia can lead to various comorbidities such as frailty, obesity and diabetes.

Exercise Considerations and Sarcopenia

Resistance training is a powerful tool in helping to reduce and treat sarcopenia. Research indicates that resistance train-ing can increase motor neuron firing rates and muscle fiber recruitment which leads to faster reaction times and increased force production. (1, 2) Both of these are essential for the aging client in helping them prevent or avoid devastating falls. Progressive resistance training combining low-level, multi-joint exercises within a pain-free range of motion is recom-mended. Starting slow with one set of exercises per major muscle group and keeping a higher repetition scheme are more ideal for the aging client who has lost a large amount of muscle mass. In addition, it is recommended that profes-sionals avoid one repetition maximum testing along with eccentric training due to extreme muscle soreness and poten-tial injury. (3,4) Refer to Table 2.1 for a summary of exer-cise guidelines clients suffering from severe sarcopenia.

2.1 Sarcopenia

Modes Modality Intensity/Duration

Flexibility Foam Rolling; Static stretching; PNF stretching

Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds

Cardio Water; recumbent bike, elliptical, treadmill, walking

Duration: Begin with as little as 5 minutes based on previous activity level – build to 20 minutes. Intensity: Use RPE scale for intensity – start low 7-9 Fre quency: 2-3 days/week.

Balance & Coordination

Chair sits/chair stands; stair climbing; 1-leg balance – supported; balloon activity

Based on need

Resistance Bands; free weights (light); Sets: 1-3 Reps: 10-15 Intensity: low to 40% in the beginning, progress as capable. Frequency: 2-3 days/week

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Module 2

FrailtyFrailty is not necessarily age specific. It can occur within the entire age spectrum however older adults are more prone to succumb to becoming frail. Frailty is identified as a com-bination of extreme old age, one or more chronic diseases present and some form of disability. The combination of the normal aging process, disease and disability are contribu-tors to becoming frail. Those who suffer from frailty encoun-ter more problems like loss of independence, slower recovery from illness, prone to more falls and injuries and are disposed to more disease states like obesity and diabetes. The combi-nation of these factors increases the risk of mortality. (5)

Exercise Considerations and Frailty

Exercise is an important ingredient to delaying chronic dis-ease and increasing function in the elderly. Exercise has

been shown to increase muscle strength, coordination and balance in frail individuals. The primary goal of an exer-cise program should be to increase function and develop more independence for the client. While the assessment process will be the most important factor in developing a comprehensive program (which we will discuss in Module 5), exercise recommendations include cycling (recumbent bike), swimming and chair-based activities to help devel-op base level strength and aerobic capacity. Low intensity programs are ideal for this population along with long-term progressive programming that includes weights and weight bearing activity once a baseline level of strength and aer-obic capacity is attained. Focusing on coordination, bal-ance and fall prevention will be ideal in helping these older adults gain back some independence and be able to partici-pate in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). (6) Refer to Table 2.2 for a summary of exercise guidelines for the frail client.

2.2 Frailty


Flexibility Static stretching; Yoga Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 seconds

Cardio Water/swimming; recumbent bike, elliptical, treadmill, walking, Upper body ergometer

Duration: Begin with as little as 5 minutes based on previous activity level – build to 20 minutes. Intensity: Use RPE scale for intensity: 7-9 Frequency: 1-3 days/week.


Chair sits/chair stands; stair climbing; 1-leg balance – supported; balloon activity

Resistance Bands; free weights (light); Sets: 1-2 Reps: 10-15 Intensity: progress to 40% in beginning stages, based on capability. Frequency: 2-3 days/week

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Age Related Disease

OsteoporosisBone loss is inevitable in the aging process. In fact, every individual encounters some degree of bone loss after the age of 35. (7, 8) Dietary habits and physical activity pat-terns can delay the rate or amount of bone loss, howev-er current statistics show that about 18 million Americans have osteopenia (a precursor to osteoporosis) and 10 mil-lion more have osteoporosis. (7) (ACSM) Osteoporosis is divided into two forms, type I and type II. Type I osteopo-rosis is often first diagnosed in post-menopausal women aged 50-75 due to estrogen deficiency. The hormonal chang-es at menopause increases bone reabsorption and as a result bones become more brittle (thin and weak). While women are more inclined to bone loss, men are not exempt from the disorder. Men below their seventies experience type I osteo-porosis less frequently than women, however disease, life-style and medications can induce early bone mass loss.

Persons over the age of seventy and those who suf-fer from hyperthyroidism and vitamin D deficiency are commonly diagnosed with Type II osteoporosis. The severity of bone loss in this group makes them high-ly susceptible to bone fractures and require more cau-tion when determining exercise capability. (7-9)

Exercise Considerations for Osteoporosis

Those with osteoporosis require more caution based on the type of osteoporosis they present with. Limitations will exist in whether they can participate in more vigorous or medium

to high impact exercises. Care should be taken as well with those who present with a co-existing condition such as osteoarthritis. The primary goals for exercise recommenda-tions should be to maximize mobility, increase coordination, provide incremental increases in strength and help individu-als prevent falls. Those who suffer from type II osteoporosis may be more weak then those with type I and require more time to progress within a resistance training program. In addition, orthopedic limitations may require slower progres-sions and assistance in movements. This group will require low-impact exercises; often chair based programming and water-based activities in the beginning. Bending, flexing and twisting are not recommended with severe cases of type II osteoporosis due to increased risk of vertebral fractures.

Individuals with type I osteoporosis may have less limitations, however caution should be taken when initiating a program with them. Weight bearing activities and resistance train-ing are highly recommended for this group, requiring indi-viduals to participate in these activities 2-4 times a week. Progressive programming is recommended taking this group from low-level intensities like 40% of 1 repetition maximum and higher repetition schemes, to higher intensities such as 75% of 1 repetition maximum and lower repetition schemes to improve muscle mass and strength. (8,9) Refer to Table 2.3 for a summary of exercise guidelines for osteoporosis.

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Module 2

OsteoarthritisOsteoarthritis is a degenerative joint disease. Osteoarthritis is localized to affected joints and begins with deterio-ration in articular cartilage. Commonly affected joints include the hands, spine, hips and knees. Osteoarthritis is accom-panied by joint pain, stiffness and a wearing down of associated cartilage. Rheumatoid arthritis is a multi-joint, inflammatory disease. Rheumatoid arthritis is multisystem, which means it can affect several joints that become inflamed as well as organs. Rheumatoid arthritis can be disabling during flare-ups. Areas commonly affected are hands, wrists, knees, feet and cervical spine. This form of arthritis is accom-panied by elongated joint stiffness, inflammation, chronic pain and joint lax-ity. It is important to know the difference between these two forms of arthri-tis as each presents with slightly different exercise precautions. (10)

2.3 Osteoporosis


Flexibility Foam Rolling; Static stretching; Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds Frequency: 5-7 days/week

Cardio Water/swimming; cycling, elliptical, treadmill, walking

Duration: Begin with as little as 5 minutes based on previous activity level – build to 20 minutes. Intensity: Use RPE scale for intensity: 9-15 based on conditioning levels Frequency: 3-5 days/week.


Balance exercises; multi-joint exercises within resistance programming to help with coordination

Resistance Bands; free weights; body weight; machines

Avoid increased load and spinal flexion/rotation in those with more severe Osteoporosis. Sets: 2-3 Reps: 8-10 Intensity: 40% in the beginning – 75% 1RM, progress as capable. Frequency: 2-3 days/week

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Age Related Disease

Exercise Considerations for Osteo- and Rheumatoid Arthritis

Individuals who have either form of arthritis are encouraged to participate in regular exercise. Improved, strength, flexi-bility and cardiovascular fitness will help those affected by arthritis to improve function, decrease joint swelling and joint pain. One note of caution for rheumatoid arthritis sufferers is to avoid strenuous exercise when they are in the midst of a flare-up or acute joint inflammation. Rheumatoid arthritis can affect both cardiac and pulmonary function along with vasculitis, which is an inflammation of blood vessels. When blood vessels become inflamed they become weakened and stretch or increase or decrease in size. Stretching or bulging of blood vessels is called an aneurysm and if the blood vessels ruptures in rare occasions it can lead to death. If the blood vessels narrow, they can limit or cut off needed blood supply and the associated tissues will die. This can affect organs such

as the heart (heart attack), brain (stroke) or kidneys (kid-ney failure)– making this a very dangerous situation. A low to moderate exercise program is suggested with slow, grad-ual progressions in exercise intensity. Exercise recommen-dations include low-impact activities like biking and swim-ming with shorter duration sessions for those new to exercise. The fitness professional will want to avoid over stretching – although improving range of motion through self-applied static stretching is recommended. Cross training and circuit training have also been found beneficial for both types of arthritis sufferers. (10-14) Refer to Table 2.4 for a summa-ry of exercise guidelines for osteo and rheumatoid arthritis.

2.4 Osteoarthritis & Rheumatoid Arthritis


Flexibility Foam Rolling*; Static stretching; PNF stretching

Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds Frequency: 1-2 sessions/day

Cardio Walking, swimming, water aerobics, dance, cycling, rowing

Duration: 5-30 minutes Intensity: Use RPE scale for intensity: 9-15 (higher levels only if no inflammation) Frequency: 3-5 days/week.

Coordination Individualized to client based on assessment

Resistance Circuit training; bands; free weights; body weight; machines

For those with Rheumatoid arthritis – exercise is contraindicated if there is a flare up or acute joint inflammation! Sets: 2-3 Reps: 12-15; 8-12 with intensity progression Intensity: 40% in the beginning, progress to 75% Frequency: 2-3 days/week

*Foam rolling is for those whom their arthritis is under control and individuals should avoid foam rolling if having inflammation or flare ups.

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Module 2

ObesityObesity is considered a metabolic disorder. Determining if an individu-al is considered overweight or obese is accomplished through the use of the body mass index (BMI). BMI is calculated by dividing one’s body weight in kilograms by their height in meters squared, or by dividing one’s body weight in pounds by height in inches squared, multiplied by 703.

BMI = kg/m2 or BMI = lbs./in2 x 703

A BMI of 18.5 to 24.9 is considered within normal limits, 25 to 29.9 is consid-ered overweight, and 30 or greater is obese. Once in this category, one may fall into one of three different obesity classes dependent on the BMI. A BMI of 30.0 to 34.9 would be considered class I obesity, 35.0 to 39.9 would be considered class II, and 40.0 and higher would be considered class III. (15) As the BMI increas-es in both adults and adolescents, so too does the risk of developing chronic dis-eases. While the main culprit of obesity may be poor diet and physical inactivity (increased intake versus decreased energy output), in the aging population obesi-ty can be a result of sarcopenia, decreased metabolic rate, decreased insulin sen-sitivity, decreased growth hormone, and osteoarthritis. In addition, the existence of obesity greatly increases the risks of comorbidities like diabetes, cardiovascular disease, hypertension and stroke within this population. With the aging popula-tion, obesity is more difficult to define by BMI, even the smallest individuals can be classified as obese if their percentage of body fat is higher than their percent-age of lean muscle mass. There is an inherent complexity to treating obesity in the aging population as the co-existence of various disease states and degenerative conditions may be present to provide multiple barriers to implementing an exer-cise program. Be cautious of any co-morbidities while developing an exercise plan.

Exercise Considerations for Obesity in Older Clients

An exercise regimen will be increasingly important for obese individuals. Because many obese or overweight individuals may be new to exercise, it will be import-ant to start out slow. For cardiorespiratory exercise, choose low impact modes of exercise (16), such as the elliptical trainer, stationary bike, or walking on a tread-mill. These low-impact modes of exercise can help to take the stresses off joints while exercising. Many obese and overweight individuals spend a good part of their day sitting, so if there are no pain barriers (arthritis, for example) choose exercis-es that force them to stand (elliptical trainer, treadmill); however, depending on their physical capabilities, starting on seated exercises (i.e. stationary bike) may be the only option. Flexibility activities will also be important to help improve joint range of motion. Caution should be taken when performing stretches that require the individual to kneel or lay on the floor, as this could place excessive stress on the joints or put stress on the cardiovascular system, particularly for those with hypertension. It may also be difficult to get down and up off the floor. Use stretches that can be performed in either a seated or standing position. Due to the lack of activity, obese and overweight individuals may possess weakness in their core and poor balance capabilities, making core and balance exercise important. However, as with flexibility exercises, caution should be taken with exercises that require the individuals to be in prone and supine positions. Choose core exercises that can be done in modified, seated, and/or standing positions. Resistance train-ing will be important to help preserve (or increase) muscle during a weight loss

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Age Related Disease

program. Beginning with machine-based exercises may be a good starting point to develop basic control and strength; however, the trainer should keep in mind that some machines may be difficult to use and uncomfortable for the obese or overweight clients. In such cases, considerations should be made regarding the use of basic bodyweight exercises (ex. body weight squats), tubing, cable, and/or dumbbell exercises that may be easier for the individual to perform. Table 2.5 provides a summary of exercise guidelines when working with an obese client.

2.5 Obesity


Flexibility Static stretching; PNF stretching Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds Frequency: 3-5 days/week


Duration: Begin with as little as 5 minutes based on previous activity level – build to 60 minutes. Intensity: Use RPE scale for intensity: 7-9 Frequency: 2-5 days/week.

Coordination Chair sit/stand; balloon activity

Resistance Bands; free weights; machines Sets: 1-3 Reps: 10-15 Intensity: < 40% in the beginning, progress as capable. Frequency: 3-5 days/week

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Module 2

DiabetesDiabetes mellitus is a metabolic disorder characterized by the body not producing enough insulin (type 1 diabe-tes), or the body cannot respond normally to the insulin that is made (type 2 diabetes). Insulin is a hormone pro-duced by the pancreas and is needed by muscle fat and the liver to utilize glucose. When insulin production is lack-ing, this can result in hyperglycemia (high blood sugar). Individuals with diabetes have an increased risk of devel-oping microvascular (small vessel) diseases, macrovascu-lar (large vessel) disease, and various neuropathies (disease affecting the nerves). Type 2 diabetes (also called non-insu-lin-dependent diabetes) is closely associated with adult-on-set obesity.(17) This is the form of diabetes fitness profes-sionals will encounter more with the aging population.

Exercise Considerations and Diabetes

Exercise is a crucial component in the management of type 2 diabetes, as the act of exercise itself can improve insu-lin resistance and glucose control. Many individuals with type 2 diabetes may also be overweight or obese, making weight loss another goal with exercise. For those with type 2 diabetes, it is recommended that they work to expend a minimum total of 1000 calories per week through aer-obic and resistance training activities to help to achieve weight reduction (18). Walking has been the most com-mon form of activity for a diabetic individual to maximize caloric expenditure (19). For those with peripheral neurop-athy (loss of sensation in the feet and hands), more non-weight bearing activities (ex. stationary bike) may be war-ranted (18). Circuit weight training may also be an option to help improve strength while enhancing cardiorespiratory fitness and caloric expenditure. (20, 21) Refer to Table 2.6 for a summary of exercise guidelines for the diabetic client.

2.6 Diabetes


Flexibility Static stretching; PNF stretching Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds Frequency: 2-3 days/week


Duration: 20-60 minutes/session Intensity: Use RPE scale for intensity: 9-15 Frequency: 4-7 days/week.

Coordination Based on individual assessment and if there are co-morbidities that need to be addressed.

Resistance Bands; free weights; machines; body weight; circuit training

Sets: 2-4 Reps: 15-20 Intensity: 40% -60% 1RM Frequency: 2-3 days/week

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Age Related Disease

HypertensionHypertension (or high blood pressure) is the most com-mon condition seen in primary care today (22) and can lead to heart disease, heart failure, stroke, and kidney failure if not treated appropriately. A healthy blood pressure read-ing is a resting systolic number (top number) of less than 120 mm Hg and a resting diastolic number (lower num-ber) of less than 80 mm Hg. One is considered pre-hyper-tensive with a blood pressure reading between 120/80 and 139/89. An individual with a blood pressure above these pre-hypertensive values would be considered hyperten-sive (23). Some of the most common causes of hyperten-sion include smoking, a diet high in fat (particularly sat-urated fat), and excess weight. Treatment typically comes in the form of medications to control one’s blood pressure; however, lifestyle changes (exercise, diet, smoking cessation) have also shown to be effective in lowering blood pressure, with the potential of eliminating the use of medications.

Exercise and Hypertension

Cardiorespiratory exercise is often recommended for those with high blood pressure, as it has been shown to be most effective in lowering blood pressure in comparison to

resistance training (6). It has also been shown that exercis-ing at low to moderate intensities is as effective, if not more effective, than high intensity exercise. This becomes import-ant for older or overweight clients who may be hypertensive. It should also be noted that individuals with hypertension are typically using some form of antihypertensive medica-tion (beta blockers), which can reduce the heart rate response during submaximal and maximal cardiorespiratory exercise (6). Because of this, exercise intensity may be best moni-tored through the use of the Ratings of Perceived Exertion or Talk Test versus traditional heart rate monitoring. Caution should be taken when performing exercises (flexibility, core, resistance training) in supine and prone positions, as these positions can increase blood pressure. Going from these posi-tions back to a standing position can also cause one’s blood pressure to dramatically drop (hypotension), leading to weak-ness, dizziness, and fainting. Although resistance training is recommended for hypertensive clients, it is not recommend-ed as the only form of exercise unless used in a circuit format. Traditional resistance training alone has not been shown to lower blood pressure, and should be used in conjunction with cardiorespiratory exercise (22). Proper breathing should also be practiced during resistance training to decrease the risk of the Valsalua maneuver, which can increase blood pressure dramatically. Table 2.7 provides a summary of exercise guide-lines when trainers are working with a hypertensive client.

2.7 Hypertension


Flexibility Foam Rolling; Static stretching; PNF stretching

Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds

Cardio Recumbent bike, elliptical, treadmill, rowing

Duration: 30-60 minutes/session Intensity: Use RPE scale for intensity: 9-13 Frequency: 3-7 days/week.

Coordination Based on individual assessment and if there are co-morbidities that need to be addressed.

Resistance Bands; free weights; machines; body weight; circuit training

Sets: 2-4 Reps: 15-20 Intensity: 40%-60% Frequency: 2-3 days/week

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Module 2

StrokeA stroke is considered a cerebrovascular accident commonly caused by thrombosis (blood clot), embolism (blood clot, fat globule or gas bubble) or hemorrhage. (24) The elderly are at greater risk of developing a stroke than their younger counter-parts. Hypertension, diabetes coronary artery disease, smoking and alcoholism are contributing risk factors. When a stroke occurs, the resulting neurological impairments could occur:

• Impaired communication ability

• Confusion

• Movement impairment on the upper or lower body or confined to the side affected by the stroke

• Uncoordinated voluntary movement

These consequences may impair typical exercise capabili-ties and the ability to participate in exercise will be depen-dent on the severity of the stroke and the co-morbidities.

Exercise Considerations for Stroke Victims

A stroke may greatly affect an individual’s ability to exer-cise. Muscle weakness, impaired sensation, impaired bodily control and coordination, lack of balance and trouble fol-lowing directions will create some barriers to participation in an exercise program. If an individual is capable of partic-ipating in an exercise program, begin with low-level, sim-ple exercises that do not require too much instruction. The recumbent bike, upper body ergometer or seated stepper may be utilized for building a cardiovascular base condition-ing. Short sessions starting with as little as five minutes may be necessary for beginning clients. Weight machines, tub-ing or bands and light free weights are appropriate modal-ities for resistance training. Muscle imbalances may need to be adjusted for – whether reducing load on the affected side or only working on the unaffected side. Seated resis-tance training may be necessary for those whose balance is lost. Focusing on improving balance and coordination will be important components to an exercise program to help stroke victims increase their ADLs. (24) Table 2.8 pro-vides a summary of exercise guidelines for stroke victims.

2.8 Stroke


Flexibility Static stretching Table, standing or chair stretches might be preferable to floor stretches; Hold each stretch for 30 -60 seconds Frequency: 2-3 days/week

Cardio Upper or lower body ergometer; seated stepper; elliptical; treadmill*

Duration: Begin with as little as 5 minutes based on previous activity level – build to 30+ minutes. Can split into shorter sessions throughout the day. Intensity: Use RPE scale for intensity: 7-11 Frequency: 3-5 days/week.

Coordination Dependent on affected side or mobility issues. Chair sit/stand; balloon activity

Resistance Bands; free weights; machines Sets: 1-3 Reps: 8-12 Intensity: low to 40% in the beginning, progress as capable. Frequency: 2 days/week

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Age Related Disease

Alzheimer’s DiseaseAlzheimer’s disease is the primary cause of dementia, a long term and gradual decrease in the ability to think clearly and remember things, which affects about 4 million Americans. It is a degenerative disease that rips away an aging person’s independence and ability to perform ADLs. Unusual losses of memory, poor perception, behavioral changes like aggression and agitation, and an inability to use clear language are side effects that should be noted and considered when creating an exercise program. Most exercise programs developed today focus on prevention and numerous studies support the theory that exercise helps delay or prevent the onset of the disease. (24-26) Exercise recommendations for those with Alzheimer’s disease will be based upon the stage of the disease.

Exercise Considerations for Clients with Alzheimer’s Disease

Based on the progression of the disease, the limitations to exercise will not necessarily be physical, but rather psycholog-ical. In the early stages memory loss will be the main prob-lem faced by the client. It will be increasingly important to be patient, understanding and keep all exercises simple and enjoyable. In progressive stages of the disease, professionals will be faced with physical and mental deterioration, behav-ioral changes that might include aggression or agitation, and since the client will rely heavily on their support system, the time and willingness of the caregiver to continue bringing the client to the sessions. These factors require the professional to be open and flexible, extremely understanding and focus the program mainly on activities that would allow the client to perform ADLs. Constant supervision and verbal support is required for clients suffering from this disease. Exercise guidelines are very general and as mentioned above, enjoy-ment of the activities should be of utmost importance. (24)

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Module 2

SummaryAge related diseases present the fitness professional with various considerations that must be understood to properly recommend the appropriate exercise pro-gramming. Fitness professionals must be aware of how to safely and effective-ly work with people who have special needs. Although there are many different age related diseases that could have also been covered in this chapter, we reviewed some of the most common situations a personal trainer may be confronted with. In all situations, when working with a client with special needs or difficult con-ditions, it is recommended that the individual obtain a physician’s release before engaging in exercise. It may also be appropriate for the trainer to partner with the appropriate medical professional(s) to help provide guidance when working with these individuals. The fitness professional can also refer clients to these experts as resources if the client’s needs are beyond the scope of the trainer’s practice.

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References

1. Roth, S.M., Ferrel, R.E., & Hurley, B.F. 2000. Strength training for the prevention and treatment of sarcopenia. Journal of Nutrition, Health & Aging, 4 (3), 143-55.

2. Roubenoff, R. 2001. Origins and clinical relevance of sarcopenia. Canadian Journal of Applied Physiology, 26 (1) 78-89.

3. Porter, M.M. 2001. The effects of strength training on sarcopenia. Canadian Journal of Applied Physiology, 26 (1), 123-41.

4. Porter, M.M. 2000. Resistance training recommendations for older adults. Topics in Geriatric Rehabilitation, 15 (3), 60-9.

5. Fried, L.P. 1994. Frailty. In Principles of geriatric medicine and gerontology, edited by W.R. Hazzard, E.L. Bierman, J.P. Blass, W.H. Ettinger, and J.B. Halter, 1149-55. New York: McGraw-Hill.

6. American College of Sports Medicine. 2001. ACSM’s resource manual for guidelines for exercise testing and prescription. Edited by J. Roitman, M. Herridge, M. Kelsey, T. LaFontaine, L. Miller, M. Wegner, M. Williams, and T. york. 4th ed. Philadelphia: Lippincott Williams & Wilkins.

7. National Institutes of Health, Osteoporosis and Related Bone Diseases National Resource Center. www.osteo.org.

8. Kanis, J.A., L.J. Melton III, C. Christiansen, C.C. Johnston and N. Khaltaev. 1994 Perspective: The diagnosis of osteoporosis. Journal of Bone Mineral Research. 9: 1137-41.

9. Bonnick, S.L. 2001. The osteoporosis handbook. 3rd ed. Dallas, TX: Taylor.

10. Fisher, N.M. 2002. Osteoarthritis, rheumatoid arthritis, and fibromyalgia. In ACSM’s resources for clinical exercise physiology: Musculoskeletal, neuromuscular, neoplastic, immunologic, and hematologic conditions. Edited by J.N. Meyers, W.G. Herbert, and R. Humphrey. 111-24. Philadelphia: Lippincott Williams & Wilkins.

11. Fransen M1, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;4:CD007912.

12. Fransen M1, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee.

13. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376. [Epub ahead of print]

14. Stenström CH. Therapeutic exercise in rheumatoid arthritis. Arthritis Care Res. 1994 Dec;7(4):190-7.

15. Ehrman, J.K., Gordon, P.M., Visich, P.S., & Keteyian, S.J. (2009). Clinical exercise physiology. Champaign, IL: Human Kinetics.

16. Mathus-Vliegen, E.M. (2012). Obesity and the elderly. Journal of Clinical Gastroenterology, 46(7), 533-544.

17. Colberg SR1, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, Chasan-Taber L, Albright AL, Braun B; American College of Sports Medicine; American Diabetes Association. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010 Dec;33(12):e147-67.

18. American Diabetes Association. (2002). Diabetes mellitus and exercise. Diabetes Care, 25(Suppl 1), s64-s68.

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19. Estacio, R.O., Regensteiner, J.G., Wolfel, E.E., et al. (1998). The association between diabetic complications and exercise capacity in NIDDM patients. Diabetes Care, 21, 291-295.

20. Sukla P1, Shrivastava SR1, Shrivastava PS1. A longitudinal study to assess the impact of exercise on clinical, biochemical, and anthropometric parameters among the type 2 diabetes patients of South India. Avicenna J Med. 2015 Jan-Mar;5(1):16-20.

21. Teixeira-Lemos E1, Nunes S, Teixeira F, Reis F. Regular physical exercise training assists in preventing type 2 diabetes development: focus on its antioxidant and anti-inflammatory properties. Cardiovasc Diabetol. 2011 Jan 28;10:12.

22. James, P.A., Oparil, S., Carter, B.L, et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee. The Journal of the American Medical Association, 311(5), 507-520.

23. American Heart Association. (2014). Understanding blood pressure readings. Retrieved from: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp

24. Rimmer, J., and T. Nicola. 2002. Stroke. In ACSM’s resources for clinical exercise physiology: Musculoskeletal, neuromuscular, neoplastic, immunologic, and hematologic conditions. Edited by J.N. Meyers, W.G. Herbert, and R. Humphrey. 3-15. Philadelphia: Lippincott Williams & Wilkins.

25. Cho J1, Shin MK, Kim D, Lee I, Kim S, Kang H. Treadmill Running Reverses Cognitive Declines due to Alzheimer’s Disease. Med Sci Sports Exerc. 2015 Jan 8. [Epub ahead of print]

26. Varma VR1, Chuang Y, Harris GC, Tan EJ, Carlson MC. Low-intensity daily walking activity is associated with hippocampal volume in older adults. Hippocampus. 2014 Dec 7.

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Age Related Disease