Geriatric Nursing 2001 • Volume 22 • Number 1 43

Caring for the Aging Athlete

Catherine Hill, RN, MSN, CS, ONC, CEN

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The myth of the “golden years” as a time ofinactivity and confinement is no longervalid with 85% of elders 65 and older re-porting their health as good, very good, orexcellent.1 Eighty percent of seniors also re-

ported no difficulty with any activities of daily living(ADL).1 Exercise, leisure physical activities, and com-petitive sports are an important part of the life of manyretired elders. Although chronic conditions, such asarthritis (47.7% of seniors) and heart disease (59.8% ofseniors), frequently occur in this age group, they are notcontraindications to regular activity, especially the con-tinuation of modified forms of prior exercise.

Long-term exercise does not appear to cause ex-cessive degenerative joint disease, reduces systolic anddiastolic blood pressure, and improves blood lipid pro-files. Fall risk and injury are lower in elders who partic-ipate in resistance training, according to the President’sCouncil on Physical Fitness and Sports. Leisure activityand sports injury trends in the aging athlete are similarto younger adults—20% are strain/sprain in nature, and15% are skin problems.

Today, we define and monitor senior exercise regi-mens as aerobic or strength, endurance, and flexibilitytraining in addition to the traditional measures of ADLand instrumental ADL. Aerobic exercise includes light,moderate, or vigorous physical activity for at least 30minutes per day five or more times per week. In 1985,12% of seniors met this definition;2 currently, that figureis 20% to 30%.3 Strength, endurance, and flexibilitytraining include a combination of components that im-prove ADL performance, functional independence, andsocial integration. Although weight training can in-crease muscle strength and endurance, other activitiescan accomplish the same goals.

Technically, leisure physical activities are a subsetof general exercise patterns. A review of 1992 data from

the Healthy People 2000 report reveals that more than60% of adults 65 and older engage in leisure-time phys-ical activity. Leisure activities are affected by strength,endurance, flexibility, and personal interest. The inten-sity of participation tends to be less than in exercise andcompetitive sports but helps maintain fitness nonethe-less. Physically active hobbies, surveyed in the 1990-1991 Health Promotion and Disease Preventionsupplement to the National Health Interview Survey, in-cluded gardening, dancing, golf, hunting, fishing, wood-working, tennis, bowling, biking, and swimming.

The variability of senescence and the range of phys-ical activity levels seen in elder athletes make aging phys-iology important in their assessment and treatment.Cardiopulmonary and musculoskeletal systems have in-trinsic changes related to aging, some of which are slowedby fitness activities, whereas others may increase or affectspeed of recovery from injury. The interplay of these sys-tems often is measured by maximum oxygen consump-tion (VO2 max) to quantify cardiopulmonary enduranceas a marker of fitness. As people age past their 30s, theirmaximum work capacity declines at a rate of about 1%per year.4 A person’s highest level of conditioning influ-ences his or her final level of decline. Therefore, athletesand untrained or sedentary seniors will have very differ-ent functional abilities. Unfortunately, the inactive seniorwill decline twice as fast as his physically active counter-part.4 Table 1 summarizes the cardiopulmonary changesthat affect physical exercise.

Musculoskeletal changes, like cardiopulmonarychanges, can be minimized by fitness training. However,given the physical loading forces, musculoskeletal in-juries are the most common in the aging athlete. Herewe need to understand the structural changes that affectthe balance of fitness activity versus injury risk. In 1998,the U.S. Consumer Product Safety Commission (CPSC)reported a 54% increase in the number of active sports-

Feature Article

related injuries to people 65 and older between 1990and 1996. This increase occurred with an age-specificpopulation growth of only 8%. Injuries associated withaerobics and weight training were up 173%, whereasless active sports, such as golf and bowling, showed verylittle increase.5 These statistics have prompted theCPSC to team up with the American Academy ofOrthopedic Surgeons to promote a sensible approach tophysical activity. Table 2 summarizes the physiologicchanges that affect exercise.

The musculoskeletal declines of aging can be min-imized—and in some cases eliminated—by sensiblestrength and endurance training. The difference be-

44 Geriatric Nursing 2001 • Volume 22 • Number 1

tween Gordie Howe, a hockey star playing exhibitiongames in his 70s, and your typical nursing home residentis the result of not only good genetics but life choices infitness activities.6

According to a 1990 report from the CPSC thatsamples the National Electronic Injury SurveillanceSystem, Americans are remaining physically active intotheir 70s, 80s, and 90s. In actual numbers, 34,000 sportsinjuries occurred in the 65 and older age group, whichrose to 53,000 in 1996. This 54% increase is quite a con-trast to the 18% increase in sports injuries among 25- to64-year-olds. Interestingly, sports injuries occurred notonly among the youngest of the 65-plus population butincreased by 29% for people 75 and older.

Although more injuries are occurring, on the aver-age, they are less costly and severe. Injuries from leisureactivities have remained relatively constant. A fascinatingbut small number of injuries have been seen for the firsttime in 1996 involving such “extreme” sports as snow-boarding and in-line skating. Most (60%) geriatric sportsinjuries in both 1990 and 1996 occurred in men.

Overuse injuries (62%) are most common, ofteninvolve the lower extremities, and frequently compoundpre-existing arthritis in the 50- to 80-year-old popula-tion,7 according to private practice physician Warren A.Scott. No evidence exists that moderate exercise like bi-cycling, skiing, rowing, swimming, or golf increases therisk of developing osteoarthritis, but research on run-ners reveals an acceleration of pre-existing disease withcontinued running.8 Likewise, previous joint injury orabnormal joint alignment increases the risk of degener-ative joint disease.

Given that 40% to 60% of elders have some arthri-tis of the hip or knee activity and 81% of aging athletesinjure themselves, moderation is critical to injury avoid-ance. Golf and tennis are the most common sportsplayed by American elders. These sports produce manyof the rotator cuff injuries and meniscal tears encoun-tered in ambulatory care.6

Because aging is associated with progressivechanges in cardiopulmonary function, many health careproviders are concerned about appropriate recommen-dations and monitoring of recreational and competitiveathletics in elders. Research has shown exercise trainingcan delay and partially reverse some of the age-relateddecline in cardiac functional capacity.9 Although themagnitude of benefit is related to baseline status andactivity frequency and intensity, increased blood flowand shear stress actually inhibit athrogensis.10 In pa-tients with coronary heart disease, exercise has similarbenefits in exercise tolerance, muscle strength, de-creased blood pressure, improved blood lipids, de-creased cigarette smoking, enhanced psychologicwell-being, and stress reduction.11

In older athletes, the primary focus is on individualefforts instead of team sports, such as long distance run-

Cardiovascular changes

Decline in cardiac output (approximately 30%)

Decline in maximum heart rate (max 10 beats/min/decade)

Decline in VO2 max (9%/decade after age 25)

Decreased capillary-to-muscle peripheral blood flow

Decreased myocardial muscle mass

Increased time for return to resting heart rate

Pulmonary changes

Decreased lung compliance

Decreased static and dynamic lung function

Decreased vital capacity (50%)

Increased forced residual capacity (30%)

Table 1. Physiological Changes of theCardiopulmonary System that Affect Exercise

Decreased collagen water content (decreased flexibility)

Decreased glycosaminoglycan in tendons (stiffer)

Decreased intervertebral spinal disc water/cells/proteins

Decreased lean body/muscle mass (up to 35%/decade)

Decreased ligament tensile strength (by 50%)

Decreased strength (10%/decade)

Decreased Type II (fast twitch) muscle fibers (by 50%)

Decreased Type XI articular cartilage

Increased body fat

Increased muscle collagen (decreased flexibility)

Loss of bone mass (men: 0.4%/year, women: 1%-7%/year)

Lower articular cartilage chondrotin sulfate/chonodrocyte content (decreased strength)

Table 2. Physiogical Changes in MusculoskeletalSystem that Affect Exercise after Age 50

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ning. A 5-year retrospective study conducted on 155YMCAs and Jewish Community Centers throughoutthe United States concluded that the greatest risk ofcardiovascular complications occurred in racquetball,handball, squash, and jogging.12 Swimming, basketball,calisthenics, soccer, and walking, on the other hand, hadmuch lower cardiovascular risk.

The most important variable associated with riskof cardiovascular event was the person’s normal activitypattern. This research has spawned the evaluation em-phasis of previously sedentary older adults—men olderthan 40 and women older than 50—before they begin avigorous physical activity program. In patients olderthan 65, an energy expenditure greater than 500 caloriesover basal requirements per week should be the goal.Rhythmic activities, such as walking or swimming, per-formed three to four times per week for 5 to 30 minutesat intensities of 50% to 60% of maximum heart rate issafe and easily maintained by most elders.

Table 3 summaries the guidelines for fitness andrehabilitation for adults that have been developed andpublished by the American Heart Association,American College of Sports Medicine, the Centers forDisease Control, and the American Association forCardiovascular and Pulmonary Rehabilitation.

Exercise in the elderly is not a single entity but acollection of leisure time activities, sports participation,and conditioning exercise. Older individuals who haveremained active throughout their lives maintain muchof their strength and stamina. Regardless of age or ini-tial fitness level, these activities should be assessed, en-couraged, and monitored because of their physical andpsychologic benefits. The benefits and risks of regularexercise in older and elderly adults are similar to thosein younger people. Regular exercise not only lengthensthe number of years of life but also its quality by ame-liorating many age-related declines in the muscu-loskeletal and cardiovascular systems. An awareness ofthe prevalence, importance, and guidelines for exercise

in older people should be reflected in our assessmentand counseling.

Seniors generally possess significant time to act onbehalf of their health. Their commitment to exercise pat-terns can be easily reinforced because of the rapid bene-fits, such as enhanced functional independence andself-esteem.

REFERENCES

1. Schick FL, Schick R. Statistical handbook on aging Americans. Phoenix: OryxPress; 1994.

2. U.S. Department of Health and Human Services. Healthy People 2000:National Health Promotion and Disease Prevention Objectives.Washington (DC): Public Health Service; 1990. p. 97-106.

3. U.S. Department of Health and Human Services. Healthy People 2000:Midcourse Review and 1995 Revisions. Washington (DC): Public HealthService; 1996. p. 23.

4. Williams RA. The athlete and heart disease. Philadelphia: LippincottWilliams & Wilkins; 1999. p. 110.

5. Available from: http://www.nisu.flinders.edu.au/pubs/monitor16/moni-tor1619.htm.

6. Rodeheffer RJ, et al. Exercise cardiac output is maintained with advancingage in healthy human subjects: cardiac dilatation and increased stroke vol-ume compensate for diminished heart rate. Circulation 1984;69:203-13.

7. Scott WA, Couzens GS. Treating injuries in active seniors. Phys Sports Med1996;24(5).

8. Krcik JA. Geriatric athlete: musculoskeletal problems. Geriatric GrandRounds 1999.

9. Hagberg JM. Effect of training on the decline of VO2 max with aging. FedProc (1987);46:1830-3.

10. Niebauer J, Cooke JP. Cardiovascular effects of exercise: role of endothelialshear stress. J Am Coll Cardiol 1996;28:1652-60.

11. Wegner NK, Froelicher ES, et al. Cardiac rehabilitation. Clinical practiceguideline No. 17. AHCPR Publication No. 96-0672. Washington (DC): U.S.Department of Health and Human Services; 1996.

12. Vander L. Cardiovascular complications of recreational physical activity.Phys Sports Med 1982;10:89-97.

CATHERINE HILL, RN, MSN, CS, ONC, CEN, is a nurse practitionerwith the Medical Group of Texas and a faculty member at theUniversity of Texas at Arllington School of Nursing.

Copyright © 2001 by Mosby, Inc.0197-4572/2001/$8.00 + 0 34/1/114423doi:10.1067/mgn.2001.114423

Geriatric Nursing 2001 • Volume 22 • Number 1 45

American Association American Heart American College of Centers for for Cardiovascular and

Exercise Type Association Sports Medicine Disease Control Pulmonary Rehabilitation

AEROBIC

Frequency per week ≥ 3 3-5 Daily 3-5

Intensity 50%-60% heart rate 55%-90% heart rate Moderate 50% VO2 max

Duration 30 minutes 15-16 minutes 30 minutes 30-45 minutes

RESISTANCE

Activity 8-10 reps 8-12 reps No recommendation 12-15 reps

Frequency 2-3 ≥ 2 Most days 2-3

Table 3. Guidelines for Exercise TrainingN

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