Training with Common Chronic Conditions

Most older adults live with one or more chronic health conditions. As a senior fitness specialist, you'll regularly work with clients managing conditions like hypertension, diabetes, arthritis, and heart disease. This lesson covers exercise modifications and considerations for the most common chronic conditions affecting older adults.

The Reality of Chronic Conditions

Prevalence in Older Adults

• 80% of adults 65+ have at least one chronic condition
• 68% have two or more chronic conditions
• Multiple conditions require careful program design
• Exercise benefits most chronic conditions

General Principles

When working with chronic conditions:

1. Obtain medical clearance when appropriate
2. Understand basic pathophysiology
3. Know contraindications and precautions
4. Modify exercises as needed
5. Monitor appropriate variables
6. Communicate with healthcare team
7. Stay within scope of practice

Cardiovascular Conditions

Hypertension (High Blood Pressure)

Definition: Consistent blood pressure ≥130/80 mmHg

How exercise helps:

• Acute reduction in BP after exercise (post-exercise hypotension)
• Chronic training reduces resting BP 5-7 mmHg
• Improves vascular function
• Reduces medication needs in some cases

Programming guidelines:

Precautions:

• Avoid Valsalva maneuver (breath-holding with straining)
• Isometric exercises can spike BP—use caution
• Stop if BP exceeds 220/105 during exercise
• Extended cool-down prevents rapid BP drop
• Monitor for symptoms of uncontrolled hypertension (severe headache, visual disturbances, chest pain)

Medication considerations:

• Beta-blockers blunt heart rate response—use RPE
• Diuretics may cause dehydration—ensure hydration
• Some medications cause orthostatic hypotension—careful transitions

Coronary Artery Disease

Definition: Atherosclerotic plaque in coronary arteries, reducing blood flow to heart muscle

How exercise helps:

• Improves cardiac efficiency
• Promotes collateral blood vessel development
• Reduces risk factors (BP, cholesterol, weight)
• Improves functional capacity

Programming guidelines:

• Medical clearance required
• May have specific HR limits prescribed
• Start conservatively, progress gradually
• Aerobic exercise primary focus
• Resistance training beneficial but secondary

Precautions:

• Know warning signs (chest pain, unusual shortness of breath, dizziness)
• Follow prescribed heart rate limits
• Avoid exercising in temperature extremes
• Extended warm-up and cool-down essential
• Stop immediately if symptoms occur

Heart Failure

Definition: Heart cannot pump adequately to meet body's demands

How exercise helps:

• Improves exercise tolerance
• Reduces symptoms (shortness of breath, fatigue)
• Improves quality of life
• Reduces hospitalization risk

Programming guidelines:

• Medical clearance essential
• Start very conservatively
• Interval training may be better tolerated than continuous
• Low-moderate intensity
• Short sessions initially (10-15 min)
• Monitor for fluid retention (weight gain)

Precautions:

• Watch for decompensation signs (increased swelling, weight gain, worsening shortness of breath)
• Avoid exercise during acute flares
• May need to modify based on daily symptoms
• Know client's "dry weight" baseline

Metabolic Conditions

Type 2 Diabetes

Definition: Impaired insulin production and/or insulin resistance leading to elevated blood glucose

How exercise helps:

• Improves insulin sensitivity (acute and chronic)
• Lowers blood glucose during and after exercise
• Reduces HbA1c
• Manages weight
• Reduces cardiovascular risk

Programming guidelines:

Blood glucose considerations:

Hypoglycemia awareness:

• Symptoms: shakiness, sweating, confusion, rapid heart rate, irritability
• Have fast-acting carbohydrate available (glucose tablets, juice)
• Risk higher with insulin or sulfonylureas
• Delayed hypoglycemia can occur hours post-exercise

Precautions:

• Foot care is essential—check feet, proper footwear
• Peripheral neuropathy may affect balance
• Retinopathy may contraindicate high-intensity exercise
• Nephropathy may require modified intensity
• Avoid exercise if BG very high with ketones

Obesity

Definition: BMI ≥30 kg/m²

How exercise helps:

• Increases energy expenditure
• Preserves lean mass during weight loss
• Improves metabolic health
• Enhances psychological well-being
• Improves functional capacity

Programming guidelines:

• Focus on movement enjoyment and sustainability
• Gradual progression of volume
• Non-weight-bearing options may be needed (swimming, cycling)
• Strength training to preserve muscle
• Emphasize functional capacity over weight loss

Considerations:

• Joint stress may limit some exercises
• Thermoregulation challenges—monitor for overheating
• May need equipment modifications (wider chairs, appropriate benches)
• Psychological sensitivity—focus on ability, not weight
• Movement quality over quantity

Musculoskeletal Conditions

Osteoarthritis

Definition: Degenerative joint disease with cartilage breakdown

Common sites: Knees, hips, hands, spine

How exercise helps:

• Strengthens muscles supporting joints
• Maintains joint mobility
• Reduces pain and stiffness
• Improves function
• Helps manage weight (reducing joint stress)

Programming guidelines:

• Low-impact aerobic exercise
• Resistance training (crucial for joint support)
• Flexibility work
• Aquatic exercise often well-tolerated

Modifications:

• Avoid deep squatting if knee OA is severe
• Limit high-impact activities
• Exercise when joints feel best (often after warming up)
• Modify range of motion as needed
• Ice after exercise if needed

Precautions:

• Distinguish between exercise discomfort and joint flare
• Acute joint inflammation = reduce intensity
• Work within "pain envelope" (mild discomfort OK, sharp pain not)
• May need periodic deload when symptoms flare

Rheumatoid Arthritis

Definition: Autoimmune inflammatory joint disease

How exercise helps:

• Maintains joint mobility
• Strengthens muscles
• Reduces fatigue
• Improves cardiovascular health
• Enhances psychological well-being

Programming guidelines:

• Exercise during remission/low disease activity
• Gentle ROM exercises even during flares
• Low-impact activities
• Balance strength and flexibility

Precautions:

• No exercise of actively inflamed joints (red, hot, swollen)
• May need frequent program modifications based on symptoms
• Systemic nature—fatigue is common
• Coordinate with rheumatology team

Osteoporosis

Definition: Bone mineral density ≥2.5 standard deviations below young adult mean

How exercise helps:

• Weight-bearing exercise stimulates bone formation
• Resistance training loads specific bone sites
• Balance training reduces fall/fracture risk
• Maintains muscle mass and strength

Programming guidelines:

• Weight-bearing aerobic activity
• Resistance training targeting hip and spine
• Balance training essential
• Modify based on severity and fracture history

Critical precautions:

• Avoid loaded spinal flexion (crunches, toe touches with weight)
• Avoid excessive spinal twisting
• High-impact activities may be inappropriate
• Fall prevention is paramount
• Know fracture history and locations

Neurological Conditions

Parkinson's Disease

Definition: Progressive neurodegenerative disorder affecting movement

Symptoms: Tremor, rigidity, bradykinesia (slowness), postural instability

How exercise helps:

• Improves motor function
• Reduces bradykinesia
• Improves balance (critical for fall prevention)
• Enhances quality of life
• May have neuroprotective effects

Programming guidelines:

• Large amplitude movements (LSVT BIG concepts)
• Balance training (high priority)
• Gait training
• Flexibility to counter rigidity
• Exercise when medication is working ("on" periods)

Precautions:

• Fall risk is very high—safety first
• Symptoms fluctuate—adapt accordingly
• Freezing episodes can occur—have strategies
• Orthostatic hypotension common
• Cognitive issues may affect learning and following instructions

Stroke History

Definition: Brain damage from interrupted blood supply (ischemic) or bleeding (hemorrhagic)

How exercise helps:

• Improves cardiovascular fitness
• Enhances motor recovery
• Improves function on affected side
• Reduces secondary complications
• Reduces risk of recurrent stroke

Programming guidelines:

• Work with physical therapy team
• Include both affected and unaffected sides
• Aerobic, resistance, and flexibility
• Balance and gait training

Precautions:

• Know extent and location of deficits
• Fall risk on affected side
• May have visual field deficits
• Cognitive/communication issues may be present
• Blood pressure management important

Pulmonary Conditions

Chronic Obstructive Pulmonary Disease (COPD)

Definition: Chronic bronchitis and/or emphysema causing airflow limitation

How exercise helps:

• Improves exercise tolerance
• Reduces dyspnea (shortness of breath)
• Improves quality of life
• Strengthens respiratory and peripheral muscles
• Reduces hospitalizations

Programming guidelines:

• Pulmonary rehabilitation programs optimal
• Interval training may be better tolerated
• Upper and lower body exercise
• Breathing techniques during exercise

Precautions:

• Pursed-lip breathing during exertion
• Allow adequate recovery between efforts
• Monitor oxygen saturation if available
• Know when supplemental oxygen is needed
• Avoid exercise during respiratory infections

Multiple Chronic Conditions

Managing Complexity

Most older adults have multiple conditions. Approach:

1. Prioritize safety: Address most restrictive condition first
2. Find common ground: Many modifications benefit multiple conditions
3. Start conservatively: When uncertain, less is more initially
4. Monitor closely: Watch for unexpected interactions
5. Communicate: Ensure healthcare team is aware of exercise program

Example: Client with Diabetes, Hypertension, and Knee Osteoarthritis

Considerations:

• Blood glucose monitoring (diabetes)
• Avoid Valsalva, extended cool-down (hypertension)
• Low-impact, modify knee exercises (OA)

Sample program:

• Cycling or swimming for aerobic (low-impact, good for all three)
• Resistance training with blood pressure awareness
• Flexibility and balance with OA modifications
• Monitor blood glucose before/after

Key Takeaways

1. Most older adults have chronic conditions—expect and prepare for them
2. Exercise benefits almost all chronic conditions—it's not a reason to avoid activity
3. Medical clearance is important for uncontrolled or complex conditions
4. Know the red flags and contraindications for each condition
5. Modify appropriately—there's almost always a way to exercise safely
6. Monitor relevant variables (BP, blood glucose, symptoms)
7. Communicate with healthcare providers when concerns arise
8. Stay within scope of practice—you modify programs, not treat diseases