adults are currently participating in an exercise program and are asymptomatic, medical clearance is not necessary before altering or continuing the program as long as it is done at a light to moderate intensity. All exercise participants should be educated as to the importance of chest, arm, or jaw discomfort; abnormal shortness of breath; or heart palpitations as symptoms of cardiac dysfunction (Riebe et al., 2015). If any cardiac symptoms become apparent with exercise, that exercise should be stopped and the individual should be referred to their physician for further follow-up and testing. An exercise stress test is recommended prior to the start of any vigorous exercise program for anyone with a known metabolic (such as type 2 diabetes), cardiovascular, or renal disease (Riebe et al., 2015). It is important that all patients be educated on the difference between moderate and vigorous exercise so that appropriate screening and testing can be completed as needed for the safety of the patient. of Sports Medicine, 2020). The FITT principle for exercise prescription is generally appropriate for older adults with diabetes without complications. Exercises should be modified as appropriate for other conditions and complications. However, because type 2 diabetes is characterized by abnormal glycemic control, exercise may cause swings in blood glucose levels, resulting in either hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose; Liguori & American College of Sports Medicine, 2020). While hyper- and hypoglycemia have many symptoms in common, in general hypoglycemia develops more quickly than hyperglycemia and is considered to be more immediately dangerous. Symptoms of both hyper- and hypoglycemia can be found in Table 15. When developing an exercise prescription for a person with type 2 diabetes, occupational and physical therapy practitioners must be aware of the individual’s current medications. Individuals on some oral blood glucose lowering drugs and individuals on insulin should monitor their blood sugar before and after each exercise session to ensure that they do not become hyper- or hypoglycemic during or after exercise (American Diabetes Association, 2016). Adjustments may also need to be made to eating habits before and/or after exercise to avoid these swings in blood glucose levels, such as having 10–15 grams of carbohydrate intake immediately prior to the proprioceptive and balance exercise described below (Demir et al., 2022). Older adults with blood glucose below 100 mg/dL should not start an exercise session unless they have had a small snack to prevent hypoglycemia (American Diabetes Association, 2016). Table 15: Signs of Hyperglycemia and Hypoglycemia Hyperglycemia Hypoglycemia • Confusion. • Increased thirst. • Headaches. • Blurred vision. • Frequent urination. • Fatigue. • Confusion. • Irritability. • Headache. • Sweating. • Increased heart rate. • Weakness. • Poor coordination. • Poor concentration. • Coma. Note : Adapted from Ahren (2013). If a patient’s blood sugar is consistently above 250 mg/dL, they may require referral back to their physician to discuss other control options (American Diabetes Association, 2016). Older adults with diabetes should also be screened for peripheral neuropathy and educated about the need • Nausea and vomiting. • Shortness of breath. • Coma.
An exercise stress test is not a necessary screening tool for everyone prior to the start of exercise (Liguori & American College of Sports Medicine, 2020; Riebe et al., 2015). In general, healthy older adults with no comorbid conditions and no signs of symptoms suggestive of comorbid conditions do not require medical clearance prior to initiating a light to moderate exercise program (Riebe et al., 2015). Further, these participants may progress to vigorous exercise if desired if the above guidelines are followed. Older adults with known cardiovascular, metabolic, or renal disease should seek medical clearance from their physician prior to starting a new exercise program (Riebe et al., 2015). Medical clearance is left to the discretion of the physician and may include a resting electrocardiogram, an exercise stress test, or even an angiography if warranted. Close communication should be maintained between the practitioner and the physician in case new signs or symptoms develop during the exercise program. If older Special populations Safety should always be the practitioner’s primary concern when establishing an exercise program for an older adult. To ensure safety, all older adults' vitals should be taken before and after all exercise sessions. Many older adults have comorbid conditions—such as diabetes, osteoarthritis (OA), or dementia—that warrant specific recommendations or adjustments for exercise. While most individuals with comorbid conditions will still be able to fully participate in an exercise program, some adjustments to the exercise prescription may be necessary to ensure safety. Such adjustments will ensure that older adults with these conditions are able to safely complete both aerobic and resistance training. In general, any progressive, degenerative neurological disorder such as multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson’s disease will require adjustments to the exercise plan. Such adjustments may include a slower progression or a decrease in the intensity of exercise. Acute musculoskeletal conditions or extreme deconditioning will also require adjustments to the exercise plan. Any individual who has recently undergone surgery should also be carefully evaluated prior to starting an exercise program due to the potential of stress on healing tissues. While a full review of all comorbid conditions likely to be seen in clinical practice is beyond the scope of this course, a brief discussion of diabetes, OA, and dementia follows. Diabetes Diabetes is a group of systemic metabolic disorders that are characterized by an elevated blood glucose concentration (Liguori & American College of Sports Medicine, 2020). It is most often chronic, its prevalence increases with age, and the most common cause is obesity (Demir et al., 2022; Devine et al., 2022). Obesity affects 604 million adults worldwide (Devine et al., 2022). Worldwide, 9.3% of adults live with diabetes, and it is predicted that by 2030 there will be 578 million people with diabetes (Demir et al., 2022). Older adults with diabetes are at an increased risk for heart disease and stroke as a result of vascular changes that occur with a sustained increase in blood glucose levels. Neuropathy (peripheral and autonomic), coronary artery disease (CAD), retinopathies, cataracts, peripheral artery disease, obesity, and joint pain are common comorbidities with type 2 diabetes (Demir et al., 2022; Devine et al., 2022; Liguori & American College of Sports Medicine, 2020). As discussed earlier, both aerobic and resistive exercise have numerous benefits for insulin sensitivity and glucose control, and they are key for managing diabetes, type 2 diabetes progression, prediabetes, and many diabetes- related health complications (Liguori & American College
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