Applied Evidence

An FP’s guide to exercise counseling for older adults

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At what intensity and frequency should older patients exercise? This review offers guidance and resources to help you get your patients moving.


› Encourage older adults to engage in at least 150 minutes of moderate-intensity aerobic physical activity throughout the week, OR at least 75 minutes of vigorous-intensity aerobic physical activity throughout the week, OR an equivalent combination of moderate- and vigorous-intensity activity. A

› Recommend older adults perform muscle-strengthening activities involving major muscle groups on 2 or more days per week. A

› Encourage older adults to be as physically active as possible, even when their health conditions and abilities prevent them from reaching their minimum levels of physical activity. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



The health benefits of maintaining a physically active lifestyle are vast and irrefutable.1 Physical activity is an important modifiable behavior demonstrated to reduce the risk for many chronic diseases while improving physical function (TABLE 12).3 Physical inactivity increases with age, making older adults (ages ≥ 65 years) the least active age group and the group at greatest risk for inactivity-­related health consequences.4-6 Engaging in a physically active lifestyle is especially important for older adults to maintain independence,7 quality of life,8 and the ability to perform activities of daily living.3,9

Health benefits of exercise in older adults

Prescribe physical activity for older adults

The 2018 Physical Activity Guidelines for Americans recommend that all healthy adults (including healthy older adults) ideally should perform muscle-strengthening activities of moderate or greater intensity that involve all major muscle groups on 2 or more days per week and either (a) 150 to 300 minutes per week of moderate-intensity aerobic physical activity, (b) 75 to 150 minutes per week of vigorous-intensity aerobic physical activity, or (c) an equivalent combination, if possible (TABLE 22).3 It is recommended that older adults specifically follow a multicomponent physical activity program that includes balance training, as well as aerobic and muscle-strengthening activities.3 Unfortunately, nearly 80% of older adults do not meet the recommended guidelines for aerobic or muscle-strengthening exercise.3

Physical activity recommendations for healthy older adults from the US Department of Health and Human Services

Identify barriers to exercise

Older adults report several barriers that limit physical activity. Some of the most commonly reported barriers include a lack of motivation, low self-efficacy for being active, physical limitations due to health conditions, inconvenient physical activity locations, boredom with physical activity, and lack of guidance from professionals.10-12 Physical activity programs designed for older adults should specifically target these barriers for maximum effectiveness.

Clinicians also face potential barriers for promoting physical activity among older adults. Screening patients for physical inactivity can be a challenge, given the robust number of clinical preventive services and conversations that are already recommended for older adults. Additionally, screening for physical activity is not a reimbursable service. In July, the US Preventive Services Task Force (USPSTF) reaffirmed its 2017 recommendation to individualize the decision to offer or refer adults without obesity, hypertension, dyslipidemia, or abnormal blood glucose levels or diabetes to behavioral counseling to promote a healthy diet and physical activity (Grade C rating).13

Treat physical activity as a vital sign

The Exercise is Medicine (EIM) model is based on the principle that physical activity should be treated as a vital sign and discussed during all health care visits. Health care professionals have a unique opportunity to promote physical activity, since more than 80% of US adults see a physician annually. Evidence also suggests clinician advice is associated with patients’ healthy lifestyle behaviors.14,15

EIM is a global health initiative that was established in 2007 and is managed by the American College of Sports Medicine (ACSM). The primary objective of the EIM model is to treat physical activity behavior as a vital sign and include physical activity promotion as a standard of clinical care. In order to achieve this objective, the EIM model recommends health care systems follow 3 simple rules: (1) treat physical activity as a vital sign by measuring physical activity of every patient at every visit, (2) prescribe exercise to those patients who report not meeting the physical activity guidelines, and/or (3) refer inactive patients to evidence-based physical activity resources to receive exercise counseling.16,17

Screen for physical activity using this 2-question self-report

Clinicians may employ multiple tactics to screen patients for their current levels of physical activity. Physical Activity Vital Sign (PAVS) is a 2-item self-report measure developed to briefly assess a patient’s level of physical activity; results can be entered into the patient’s electronic medical record and used to begin a process of referring inactive patients for behavioral counseling.17,18 The PAVS can be administered in less than 1 minute by a medical assistant and/or nursing staff during rooming or intake of patients. The PAVS questions include, “On average, how many days per week do you engage in moderate-to-vigorous physical activity?” and “On average, how many minutes do you engage in physical activity at this level?” The clinician can then multiply the 2 numbers to calculate the patient’s total minutes of ­moderate-to-vigorous physical activity per week to determine whether a patient is meeting the recommended physical activity guidelines.16 (For more on the PAVS and other resources, see TABLE 3.)

Online physical activity resources for physicians and patients

Continue to: The PAVS has been established...


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