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frail people improved overall functional capacity and cognition during acute hospitalisation when compared with usual care after an individualised multicomponent exercise training programme. The usual‐care group received habitual hospital care, which included physical rehabilitation when needed. For the intervention group, exercise training was programmed in two daily sessions (morning and evening) of 20 minutes duration over 5–7 consecutive days (including weekends), supervised by a qualified fitness specialist. Each session was performed in a room equipped ad hoc in the acute care of elderly (ACE) unit. Exercises were adapted from the Vivifrail multicomponent physical exercise programme to prevent weakness and falls^143‐145 (www.vivifrail.com). The resistance exercises were tailored to the individual’s functional capacity using variable resistance training machines aiming at 2 to 3 sets of 8 to 10 repetitions with a load equivalent to 30 to 60% of the 1‐repetition maximum. Participants performed three exercises involving mainly lower‐limb muscles (squats rising from a chair, leg press, and bilateral knee extension) and one involving the upper‐body musculature.¹³⁶ This contrasts with an earlier RCT showing no significant benefit of a simple in‐hospital mobility programme and a behavioural strategy to encourage mobility in older patients and their ability to perform ADLs after acute hospitalisation.¹⁸¹ These findings suggest that interventions beyond walking stimulation are needed to preserve or increase functional capacity in older patients during acute hospitalisation. This is likely because muscle mass tends to decrease in the elderly during hospitalisation, and muscle strength and muscle mass are associated with disability, morbidity, and mortality.¹⁹³ Therefore, an individualised physical exercise intervention including low‐moderate intensity progressive resistance training is an effective therapy to counteract the loss of muscle strength and mass that frequently occurs during hospitalisation.^179,180,194 Once discharged, however, progression to moderate‐high intensity resistance training is required to achieve the benefits shown in many of the randomised controlled trials referred to above,^{7,70,74,75,195,196} given the well‐described dose‐response effects related to intensity and adaptations to anabolic exercise.

Summary of exercise recommendations

There are sufficient data from both epidemiological studies and experimental trials to warrant the training of all physicians, including geriatricians, in the basics of exercise prescription for health‐related and quality of life benefits, as outlined in Tables 7.9. There is also strong evidence that exercise training is an effective intervention for improving the hallmarks of frailty, including muscle strength, muscle mass, incidence of falls, and gait ability.

      Screening for sedentary behaviour and insufficient physical activity (including aerobic, strength, and balance‐enhancing structured and incidental activities) should take place at all major encounters with healthcare professionals, given their roles as potent risk factors for all‐cause and cardiovascular mortality, obesity, sarcopenia, hypertension, insulin resistance, cardiovascular disease, diabetes, stroke, colon cancer, depression, dementia, osteoarthritis, osteoporosis, recurrent falls, frailty, and disability, among other conditions. Exercise recommendations should be integrated into the mainstream of other healthcare recommendations, rather than being marginalised as at present. Exercise advice should be specific in modality, frequency, duration, and intensity and accompanied by practical implementation solutions and behavioural support systems to monitor progress and provide feedback. Ultimately, the penetration of these recommendations into the most inactive cohorts in the community, who have the most to gain from increases in levels of physical activity and fitness, will depend on a combination of evidence‐based guidelines^86,153 coupled with health professional training and behavioural programmes tailored to age‐specific barriers and motivational factors. One of the main challenges for the future is to integrate exercise programmes as a mandatory part of the care of frail and pre‐frail older patients in hospital and aged care settings to prevent more severe physical declines and disability. Considering the current evidence of the benefits of exercise in frail older adults, it is not ethical to not prescribe physical exercise to these individuals,¹⁶ as this means doing harm by withholding evidence‐based and effective treatment.

It is quite likely that after initial screening, many barriers and difficulties with adherence will be identified in the typically sedentary older individual. Therefore, it becomes important to know how to deliver the prescription in logical stages that are palatable and feasible and have some likelihood of successful implementation. Current position stands and consensus guidelines for physical activity in older adults^7,86,197 generally recommend a multi‐modal exercise prescription including aerobic, strengthening, balance, and flexibility training, via a combination of structured and incidental (lifestyle‐integrated) activities. However, it is usually best to start with only one mode of exercise and let the older adult get used to the new exercise routine before adding other components, or optimal adherence and adaptation may be compromised.¹⁹⁸ This approach obviously requires attention to risk factors, medical history, and physical exam findings, as well as personal preferences, to prioritise prescriptive elements, and will be different for each individual. If significant deficits in muscle strength or balance are identified, then these should be addressed prior to the initiation of aerobic training. Prescribing progressive aerobic training in the absence of sufficient balance or strength is likely to result in knee pain, fear of falling, falls, fractures, and limited ability to progress aerobically and is not recommended. A few generalisations can be made, as follows:

Table 7.9 Exercise recommendations for optimal ageing and prevention and treatment of disease in older adults.

Modality	Resistance training	Aerobic exercise training	Balance training
Dose
Frequency (days per week)	2–3	3–7	1–7
Volume	1–3 sets of 8–12 repetitions, 8–10 major muscle groups	20–60 min per session	1–2 sets of 4–10 different exercises emphasising static and dynamic posturesa
Intensity	15–18 on Borg Scaleb (70–80% 1 RM) 6 s per repetition, 1 min rest between sets	12–14 on Borg Scaleb (40–60% heart rate reserve or maximum exercise capacity)	Progressive difficulty as toleratedc

      ^a Examples of balance‐enhancing activities include Tai Chi movements, standing yoga or ballet movements, tandem walking, standing on one leg, stepping over objects, climbing slowly up and down steps, turning, standing on heels and toes, walking on a compliant surface such as foam mattresses, and maintaining balance on a moving vehicle, such as a bus or train.

      ^b Scale of perceived exertion from 6 (easy) to 20 (maximal).

      ^c Intensity is increased by decreasing the base of support (e.g., progressing from standing on two feet while holding on to the back of a chair to standing on one foot with no hand support); by decreasing other sensory input (e.g., closing eyes or standing on a foam pillow); by perturbing the centre of mass (e.g., holding a heavy object out to one side while maintaining balance, standing on one leg while lifting the other leg out behind the body, or leaning forward as far as possible without falling or moving feet); or by dual‐tasking (adding a secondary cognitive [e.g. naming animals] or physical [e.g., juggling] task while tandem walking).

       Sequence

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