Chinese expert consensus on prevention and control interventions for older adults with physical functional impairment (2022)

Abstract

Older adults are at high risk for functional impairment, which is closely related to sarcopenia, falls, and frailty. This seriously affects their quality of life and health, and places a heavy burden on society and families. Although domestic and foreign sports recommendations and prevention and control guidelines/expert consensus have been issued for healthy older adults and functional impairment‐related diseases, there is no guidance on prevention and control interventions for older adults with physical functional impairment. In China, there is insufficient understanding of the importance of prevention and control interventions for functional impairment in older adults, and there are many drawbacks, such as unstandardized diagnosis and treatment, and relatively simple intervention methods. Therefore, the consensus expert group formulated a consensus based on domestic and foreign guidelines related to functional impairment in older adults to provide guidance for Chinese medical professionals working in the field of geriatrics.

The risk factors for functional impairment are complex, including age, gender, chronic diseases, daily behavior, psychological factors, socioeconomic conditions, and many others. Elderly adults suspected of functional impairment should be intervened after being assessed and diagnosed of functional impairment. It is recommended to adopt a multidisciplinary team cooperation model, educate patients, and individualized exercise programs.

1. INTRODUCTION

In 2001, the World Health Organization (WHO) officially adopted the International Classification of Functioning, Disability, and Health (ICF) standard, which provides a framework for determining and classifying an individual's overall functioning based on three aspects: body structure and function, activity, and social participation.

Functional impairment is a broad description of functional limitations, including functional decline, impairment, disability, and handicap. Functional impairment is the comprehensive result of a decline in internal abilities (physical strength, mental power, etc.) and external environmental influences, and is widespread among older adults. Affected by individual, social, environmental, and other factors, it manifests as a decline in the ability to perform basic/instrumental daily activities, physical activity ability, emotional and cognitive function, social participation, and communication, adaptive, and other multidimensional abilities. Physical functional impairment in older adults refers to functional changes, such as decreased muscle strength, mobility and balance ability, impaired gait, and other functional changes related to aging or chronic diseases.

This consensus provides technical guidance for prevention and control interventions for physical functional impairment in older adults.

2. EPIDEMIOLOGY OF FUNCTIONAL IMPAIRMENT AND BACKGROUND TO THE DEVELOPMENT OF THIS CONSENSUS

According to the latest authoritative demographic data published by China CDC Weekly, a publication of the Chinese Center for Disease Control and Prevention, in 2020, there were 108.67–108.79 million individuals with disability in China, of which 52.71 million were older adults. It is estimated that this population will increase to 136.24–136.74 million by 2030, and the number of older adults with disabilities will exceed 77 million, accounting for more than 57% of the total population with disability, with an estimated duration of the disability period of 7.44 years. ¹ If prevention and control measures are not applied, the disability rate will exceed 70% by 2050. ¹ In addition to older adults with disabilities, those with functional impairment, such as partial disability, functional decline, and handicap, comprise a large proportion of functionally restricted individuals, posing a heavy burden on society and families.

Early screening, assessment, and diagnosis of the functional state of older adults, as well as timely intervention and management, are the main measures to prevent the occurrence and delay the progression of disability in this population. ² , ³ In recent years, in addition to traditional intervention techniques, new intervention techniques are emerging, bringing new hope to older adults with functional impairment.

Based on evidence‐based methodology and guided by the Delphi method, the consensus expert group searched relevant domestic and foreign literature in the last 10 years on the prevention and control of physical functional impairment, conducted literature quality evaluation, and summarized relevant evidence by integrating domestic and foreign consensus recommendations of guidelines related to functional impairment in older adults. The expert group assembled several times to reach a consensus. After several rounds of feedback based on international consensus standards, and in consideration of the national conditions and characteristics of older adults in China, as well as previous results of the project team, this consensus has been formulated as a reference for medical professionals working in geriatrics.

Recommendation 1: The prevalence of physical functional impairment in older adults remains high. Prevention, early identification, and scientific intervention are helpful to improve the prognosis and quality of life of older adults.

3. RISK FACTORS FOR FUNCTIONAL IMPAIRMENT

Most domestic and foreign studies suggest that the factors influencing physical functional impairment are complex, ⁴ including age, gender, chronic diseases, daily behavior, social economy, marriage, education, family status, and psychological factors. ⁵

3.1. General individual factors

Age is one of the main risk factors for functional impairment. The rate of impaired ability to perform daily activities is significantly higher in older adults than in younger individuals, and the disability rate increases significantly with the increase in age, particularly among individuals aged 75 years and older.

Weight is another important risk factor for impaired functioning, with a higher risk for disability in overweight, underweight, and older adults with obesity. The muscle mass and function in older adults with a low body weight are decreased, making them prone to falls, fractures, and other adverse outcomes. In overweight and older adults with obesity, the burden on the skeletal system is increased, resulting in an increased risk for falling and disability.

Additionally, women tend to be at a higher risk for disability than men.

3.2. Chronic disease factors

Chronic underlying diseases and geriatric syndromes, such as frailty, malnutrition, and sarcopenia, are important risk factors for functional impairment. The higher the comorbidity index, the higher the incidence of functional impairment. ⁶ , ⁷ , ⁸ Cardiovascular, cerebrovascular, neuropsychiatric, respiratory, endocrine, and musculoskeletal diseases are the main causes of functional impairment, including Alzheimer's disease (AD), Parkinson's disease (PD), chronic obstructive pulmonary disease, diabetes, stroke, and depression. In addition, sarcopenia, frailty, and other aging‐related pathophysiological states resulting in physiological functional decline can lead to a decline in the body's ability to maintain homeostasis, leading to a significant increase in the incidence of falls, disability, hospitalization, home care, death, and other adverse prognoses.

3.3. Behavioral factors of daily life

Personal living habits, nutritional status, and participation in social activities are closely related to the incidence of functional impairment in older adults. Good lifestyle habits, such as regular physical exercise, and avoidance of bad habits, such as tobacco or alcohol consumption, reduce the risk of functional impairment. Poor nutritional status and low degree of participation in social activities are closely related to decline in physical functioning, quality of life, and activities of daily living, and significantly increase the risk of falls, fractures, bed rest, and disability in older adults.

3.4. Environmental factors

The medical and health service status, regional medical conditions and resource distribution, living environment, caregivers' caring ability, and community and social public environments are closely related to the self‐care ability of older adults. Regular physical examinations and medical services, good living environment, abundant regional medical resources, and excellent professional and technical services are important guarantees for reducing the occurrence of disability.

3.5. Other factors

Educational level, family harmony, income level, mental health, and marital status are also closely related to the risk for functional impairment in older adults. This risk is significantly higher in older adults with low educational and income levels, poor family relationships and psychological status, and divorced or widowed individuals living alone.

Recommendation 2: The risk factors for functional impairment are complex, including age, gender, chronic diseases, daily behavior, psychological factors, socioeconomic conditions, marriage, educational level, family status, and many others.

4. COMMON ASSESSMENT TOOLS FOR FUNCTIONAL IMPAIRMENT

Currently, there is no specific assessment scale for functional impairment in older adults. The common indicator used to evaluate the functional status of this population is the ability to perform basic and instrumental activities of daily living. The Barthel and Katz indices and PULSES profile, and the Functional Activity Questionnaire, Lawton Instrumental Activities of Daily Living Scale, and Functional Independence Measure are widely used to assess basic and instrumental activities of daily living, respectively.

In terms of balance, gait, and strength assessment, widely used tools include the Berg Balance Scale, Tinetti Balance and Gait Assessment Tool, Fugl‐Meyer Assessment, Four‐stage Balance Test, Timed Up & Go Test, and 30‐Second Chair Stand Test. The Morse Fall Scale and Hendrich II Fall Risk Model are the most widely used screening tools to assess the risk for falls. Among these, the Four‐stage Balance Test, Timed Up & Go Test, and 30‐Second Chair Stand Test are recommended by the Centers for Disease Control and Prevention as convenient, effective, and accurate assessment tools for evaluating gait, muscle strength, and balance function in older adults, with strong operability and great significance for guiding precise intervention. ⁹

Based on the initial Function in Sitting Test (FIST) scale established using the Delphi expert consultation method in the earlier stage, the project team further selected items and constructed the first formal FIST scale suitable for older adults in China. ¹⁰

Recommendation 3: Presently, there is no domestic or foreign specific assessment scale for functional impairment in older adults. It is recommended to select the corresponding assessment scale based on the clinical symptoms and reference the first constructed FIST scale suitable for older adults in China.

5. INTERVENTIONS FOR FUNCTIONAL IMPAIRMENT

5.1. Integrated management by multidisciplinary teams for older adults

Considering that functional impairment in older adults is caused by a variety of factors, the adoption of a multidisciplinary management model is suggested. Geriatric multidisciplinary teams comprise geriatric physicians, psychologists, dietitians, rehabilitation therapists, pharmacists, nurses, related specialists, and social workers. According to the screening and evaluation results, the wishes of patients and their families should be respected to select an appropriate intervention/treatment to delay functional decline or improve organ function status and quality of life.

5.2. Health education

Regular health education should be performed for older adults with functional impairment and relevant interventional practitioners, to include matters needing attention in daily activities, advantages and disadvantages of exercise and rest, and basic knowledge and formulation of exercise programs, to improve the awareness of patients and medical staff on the harm of functional impairment, intervention methods, and their importance. Currently, the most popular method is to rate the risk degree according to age, family environment, educational level, disease status, and other factors, and provide different levels of education according to the risk degree.

Recommendation 4: Functional impairment of older adults is caused by a variety of physiological and pathological factors. It is recommended to adopt the comprehensive management mode of multidisciplinary approach, and regularly educate patients and interventional practitioners about relevant health knowledge to improve their understanding and the intervention technical level.

5.3. Exercise therapy

Older adults have age‐related cumulative decline in multiple physiological systems, reduced body reserve capacity, decreased ability to resist stress and maintain homeostasis, and progressive loss of muscle mass and strength, which manifest as low muscle mass, muscle strength, and physical strength, ¹¹ , ¹² and result in decreased body function and significantly increased risks for falls, fractures, incapacitation, and death. ¹³ Underlying chronic diseases additionally contribute to functional impairment in this population.

Exercise is the best way to delay the decline in skeletal muscle content and delay or reverse functional impairment, including resistance, balance, aerobic, structured, and other forms of exercise. ¹⁴ A complete exercise program comprises warm‐up, strength, finishing, and stretching exercises (Table 1). An ideal exercise program should meet the individual's requirements for health and physical fitness. Exercise program contents include the type, mode, intensity, duration, frequency, notice, volume, and progression of exercise. Individualized exercise programs should be developed for older adults according to their degree of functional impairment.

TABLE 1.

Composition of a complete exercise program.

Elements of an exercise program	Content of exercises	Function and efficacy
Warm‐up exercise	5–10 minutes of small‐to‐moderate‐intensity cardiopulmonary and muscle endurance activities	Adjusting the body's physiological function to meet the needs of intense exercise and reduce the risk for injury
Intensity exercise	20–60 minutes of aerobic, moderate resistance, and/or competitive exercise (aerobic exercise can be divided into multiple exercises totaling 20–60 minutes, but each exercise should last no less than 10 minutes)	Improving muscle strength, explosive power, gait, balance, sports endurance, activity, and other performance of the main movement
Finishing exercise	5–10 minutes of small‐to‐moderate‐intensity cardiopulmonary and muscle endurance activities	Physical indicators, such as heart rate and blood pressure, can be gradually restored to normal levels, and metabolites produced by muscles when the body exercises with greater intensity can be eliminated
Stretching exercise	Stretching for at least 10 minutes after warm‐up or finishing exercises	Warm‐up and finishing exercises are not a substitute for stretching, and stretching exercises are usually performed after warm‐up or finishing exercises, or after warm compression of a muscle

Recommendation 5: Exercise rehabilitation, including resistance, balance, aerobic, structured, and other forms of exercise, is an ideal way to delay or reverse functional impairment and improve the prognosis and quality of life of older adults.

Recommendation 6: The ideal exercise rehabilitation program should meet the individual's requirements for health and physical fitness. Exercise program contents include the mode, intensity, duration, frequency, notice, volume, and progress of exercise. The specific program selection should be adjusted according to the actual status and tolerance of older adults with functional impairment.

5.3.1. Exercise intervention therapy for age‐related physical functional impairment

(1) Warm‐up exercise. Compared with young individuals, older adults are more likely to experience injuries during high‐intensity or high‐speed exercise. Therefore, older adults should adhere to the principle of gradual exercise and must be fully warmed up before exercise. This can be achieved by jogging, fast walking, or gymnastics for approximately 5–10 minutes, resulting in slight sweating and heart rate increase. This cannot only reduce the possibility of muscle, ligament, and joint injury during exercise, but also adjust the body function and condition, thus increasing the efficiency of exercise.

(2) Resistance exercise. Resistance exercise is an effective way to improve muscle mass and strength. ¹⁵ Small amounts and repeated exercise of various muscle groups through medium and high resistance can cause ultrastructural muscle damage and release inflammatory cytokines and growth factors, such as insulin‐like growth factor‐1, fibroblast growth factor, and mechanical growth factor, thus stimulating the differentiation and proliferation of myosatellite cells. ¹⁶ , ¹⁷ The incorporation of new nuclei from satellite cells into existing muscle fibers increases the number of myonuclear domains, that is, anatomic and functional units consisting of nuclei and surrounding sarcoplasm, thereby increasing muscle mass and strength ¹⁸ and improving sarcopenia and physical function. Improved muscle mass and strength reduce the risk of fractures and falls and prevent incapacitation. Furthermore, resistance exercise can reduce the risk of fractures and falls by improving bone mineral density. ¹⁹ Simple medium‐to‐high‐intensity resistance exercise can improve exercise endurance, muscle function, and activity ability in older adults. ²⁰

For older adults who cannot walk safely or cannot walk at all, resistance exercise of the upper limbs and sit‐down resistance exercise under supervision are also feasible exercise methods. Resistance exercise should be performed 2–3 days/week, starting from to one to two sets/day and gradually increasing to two to three sets/day, with 8–12 exercises for each major muscle group. It should target the main muscle groups for functional activity of the limbs and trunk, including large multi‐joint muscle groups (such as the pectoralis major, latissimus dorsi, hamstrings, and triceps surae) and single‐joint muscle groups (such as the triceps brachii, quadriceps femoris, gluteus maximus, and gluteus medius). Dumbbell and elastic band are better methods of resistance exercise for older adults. It is recommended to rest for at least 1 day between exercise courses of the same muscle group to recover muscle function. ²¹ It is of great benefit to the recovery of the functional ability of individuals with functional impairment and debilitation to add sit‐stand movement or acceleration movement in resistance exercise. Evidence‐based medical studies have shown that resistance exercise with 70%–80% intensity of 1RM (weight of maximum number of repetitions per session) has better effects than exercise with light (<50% 1RM) and moderate (<70% 1RM) intensity. ²² , ²³ The selection of exercise method, intensity, and duration can be adjusted according to the actual status and subjective fatigue degree of older adults. ²⁴

(3) Balance and gait exercise. Factors associated with falls in older adults include reduced self‐efficacy, mobility difficulties, and poor balance. ²⁵ , ²⁶ Once older adults have sufficient strength and endurance, they can maintain their individual standing ability and avoid falls and injuries. Fall prevention is an important part of the intervention measures for impaired body function, and mainly relies on balance and gait stability exercise.

5.3.1.1. Balance exercise

Balance exercise includes Tai Chi, ²⁷ Otago, ²⁸ elastic belt, ²⁹ and balance exercises on smooth ground, and postural control exercise. ³⁰ Among them, as a traditional Chinese martial art and fitness exercise, Tai Chi emphasizes slow and continuous movement, with smooth integration of trunk, upper limb, and lower limb rotation, which has been proven to be beneficial in improving the flexibility, balance, lower limb strength, and postural stability of older adults and has become one of the common fall prevention methods.

Invented at the University of Otago in New Zealand and widely used, the Otago exercise program consists of strength and balance exercises. Strength exercises include flexion and extension of the knees, ankles, and toe joints, and hip joints opening to strengthen the sides of the pelvis, whereas balance exercises include walking in a figure of eight, heel or toe walking, moving from sitting to standing position, and exercise with one‐leg support. Exercises are performed three times per week under the supervision of a therapist. Each session lasts for 40 minutes, with 5‐minute warm‐up and 5‐minute relaxation exercises. Otago exercises can significantly improve balance and walking speed in older adults, and adding cognitive function exercise based on balance exercise can improve gait and motor coordination in older adults with balance disorders. ³¹

In addition to professional clinical balance exercise, safe and simple family balance exercise programs can also improve mobility, balance, and gait, and reduce the risk for falls in older adults, and have greater adherence and sustainability among older adults. ³² Balance exercise aims to improve the body's dynamic stability and maintain good activity. It is recommended to perform one to two sets of dynamic or static balance exercises one to seven times/week. Balance exercises should be used as auxiliary exercises before formal aerobic exercise. Appropriate methods should be selected according to the actual status of older adults, and protective measures should be taken to avoid accidental injuries.

5.3.1.2. Gait stability exercise

Gait stability exercise is very important for older adults to have sufficient muscle strength and balance to walk independently. The basic principles of gait exercise are as follows: starting from a stable position and progressing gradually to an unstable position; gradually reducing the body support area and improving the center of gravity; transition from eye opening to eye closing; progress from static to dynamic balance; and gradually increasing the control of head, neck, torso, and limbs under the premise of maintaining stability. Although gait stability can be improved by only lower limb and trunk motion speed exercise, the combination with upper limb motion speed exercise is better. ³³ , ³⁴

Aerobic exercises, such as walking and jogging, are a better way to improve gait and mobility, and weight‐bearing exercises are often more effective. Exercises such as spa treatment or cycling may be considered for individuals with severe arthritis or balance problems. For individuals with low strength, resistance and balance exercise can be performed before aerobic or weight‐bearing aerobic exercise. Exercise intensity and duration should be gradually increased. In the first week of exercise, the exercise duration should start from 5–10 minutes and gradually increase to 20–30 minutes, whereas exercise intensity should gradually increase from moderate to high (Table 2). When the heart rate cannot be used as a measure of exercise intensity due to arrhythmia, use of beta‐blockers, or presence of pacemakers, subjective fatigue can be assessed. Cognitive impairment can be assessed by observing the individual's breathing rate, speech ability, sweating, or facial expression.

TABLE 2.

Intensity of aerobic and resistance exercise.

Intensity	Aerobic exercise intensity				Relative strength of resistance motion
	Relative strength			Absolute strength
	%HRmax	%VO2max	RPE	MET	%1RM
Minimum	≤ 57	≤ 37	≤ 9	< 1.6	< 30
Low	57–64	37–45	10–11	1.6–3.2	30–50
Medium	64–76	45–64	12–13	3.2–4.8	50–70
High	76–96	64–91	14–17	4.8–6.8	70–85
Highest	≥ 96	≥ 91	≥ 18	≥ 6.8	≥ 85

Abbreviations: HR_max, maximum heart rate; MET, energy metabolic equivalent, also known as metto; RM, weight of maximum number of repetitions; RPE, subjective fatigue; VO₂max, maximum oxygen uptake.

(4) Aerobic exercise. The main function of aerobic exercise is to improve muscle mass. Repeated use of large muscle groups can improve the quality and quantity of mitochondria, increase capillary density, and inhibit skeletal muscle degradation, thereby generating greater oxygen extraction and improving muscle metabolic function. ¹⁵ Studies have shown that 50‐minute walking three times/week (150 minutes/week) can increase the oxygenation capacity of older adults. ³⁵ Furthermore, this 150 minutes/week walking exercise has an intensity of approximately 55%–65% of the heart rate reserve, corresponding to moderate‐intensity exercise, can improve the adherence of older adults, and is conducive to long‐term aerobic exercise. Dancing, cycling, hiking, jogging, and swimming can also be used as aerobic exercises.

The specific exercise method is selected based on the individual's preference, feasibility, cognition, and underlying diseases. It is recommended that exercise duration in the first few weeks should start from 5–10 minutes/day, gradually increase to 15–30 minutes/day, and finally reach 20–60 minutes/day, with a frequency of 3–7 days/week. Moderate‐intensity continuous exercise and high‐intensity interval exercise have a good effect on improving aerobic capacity and endurance performance (Table 2).

(5) Structured exercise. For older adults who lack walking ability, a phased intervention method should be adopted. For older adults with functional impairment and mild‐to‐moderate frailty, three forms of structured exercise (resistance, balance, and aerobic) can be conducted at the same time under the premise of ensuring safety. This exercise mode is better than the single unstructured exercise mode. ³⁶ Studies have shown that structured exercise can reverse acute physical impairment and reduce the risk for severe physical impairment in older adults with mild and moderate frailty. ³⁷ Family‐based structured exercise can help improve adherence, ³⁸ and cognitive function can be improved through structured functional exercise. ³⁹ For older adults with mild and moderate frailty, it is recommended to conduct a structured exercise intervention as early as possible, before obvious physical functional impairment. Early intervention with structured exercise is also recommended for older adults at a risk of physical functional impairment. Based on evidence‐based plans, the VIVIFRAIL multicomponent exercise program is a typical structured exercise to prevent frailty and reduce the risk for falls in older adults. The program's guidelines (http://vivifrail.com) include lower extremity (squats, leg lifts, and knee extensions), upper body (sitting bench press), balance, and gait exercises (half‐tandem line walking, one‐leg standing, stride exercises, and small obstacle walking). VIVIFRAIL plans to evaluate the functional capacity level of older adults (mild, moderate, and severe impairment) using the Short Physical Performance Battery and Walking Speed Test, and to develop personalized structured exercise programs based on their functional state and fall risk. ⁴⁰ , ⁴¹

The above are intervention measures for older adults with different degrees of physical functional impairment. For healthy older adults and those at risk of physical functional impairment, the WHO has put forward guidelines for the exercise level, ⁴² which not only introduces the content and mode of physical exercise for older adults in detail, but also recommends the frequency and intensity of exercise, as follows: (1) total exercise: more than 150 minutes/week of moderate‐intensity or more than 75 minutes/week of high‐intensity aerobic exercise, or a combination of moderate‐ and high‐intensity exercise for the same time; (2) minimum exercise duration: aerobic exercise should last at least 10 minutes/time; (3) maximum continuous exercise: 300 minutes/week of moderate‐intensity or 150 minutes/week of high‐intensity aerobic exercise, or the same time of medium‐ and high‐intensity exercise combination; (4) fall prevention exercise: balance exercise ≥ 3 times/week; resistance exercise ≥ 2 times/week; (5) exercise for older adults with chronic diseases: older adults limited in exercise due to their health conditions should perform physical activity as much as possible; and (6) personalized intervention: age‐related physical functional impairment currently mainly relies on exercise for intervention, and older adults with different mobility abilities have their corresponding appropriate exercise types and modes. Improving the monotonous exercise mode and adherence and persistence of older adults will be the focus of future intervention method research. Community aging in place‐advancing better living for elders (CAPABLE) individualized and comprehensive intervention measures are implemented according to the functional and psychological state, preference, and family environment of older adults. ⁴³ The preliminary research results of this project team suggest that individualized comprehensive prevention and control intervention measures integrating patient education, exercise, and rehabilitation training are beneficial for improving the functional status of older adults with functional impairment.

Recommendation 7: Warm‐up exercise is particularly important for older adults. It cannot only reduce the risk of muscle, ligament, and joint injury, but also increase the efficiency of exercise.

Recommendation 8: Resistance exercise is the most effective way to improve muscle mass and strength. It can improve bone density, reduce the risk for fractures and falls, improve sarcopenia and muscle function, and prevent incapacitation in older adults.

Recommendation 9: Balance and gait exercises are important means to prevent falls and an important part of intervention measures for impaired body function.

Recommendation 10: Aerobic exercise can effectively improve muscle mass and exercise endurance of older adults with functional impairment. Moderate‐intensity continuous exercise and high‐intensity interval exercise have good effects on improving the aerobic exercise capacity and exercise endurance of older adults with functional impairment.

Recommendation 11: Multicomponent structured exercise, including resistance, balance, and aerobic exercise, has better intervention effects than a single, unstructured exercise mode, and should be implemented as early as possible. However, the selection of specific exercise combinations should be comprehensively considered in accordance with the individual's preferences, disease status, and tolerance. The VIVIFRAIL multicomponent structured exercise program is a typical case for reference.

Recommendation 12: Personalized intervention with the goal of improving adherence and continuity of the intervention is a relatively ideal and easy to popularize exercise method. CAPABLE interventions implement individualized and comprehensive interventions based on factors such as individual functional status, psychological emotions, preferences, and family environment.

5.3.2. Exercise intervention therapy for physical functional impairment related to chronic diseases

In addition to age‐related factors, older adults often have a variety of chronic diseases. Among the chronic diseases that cause disability in this population, nearly half are diseases of the nervous system. ⁴ The 2020 WHO Guidelines on Physical Activity and Sedentary Behavior and the 2021 International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines strongly recommend that appropriate exercise programs are implemented in all older adults with these chronic diseases after excluding exercise contraindications. ⁴⁴ , ⁴⁵ It is recommended to perform 150–300 minutes of moderate‐intensity or at least 75–150 minutes of high‐intensity aerobic exercise per week. On this basis, resistance exercise should be performed for at least 2 days/week, and the intensity of balance exercise should be appropriately increased.

(1) Parkinson's disease. PD is a neurodegenerative disease primarily affecting older adults. Affected individuals often experience lower extremity motor dysfunction and myotonia. Owing to decreased muscle strength and balance ability and increased muscle tension, these individuals are prone to falls while walking.

Various exercise methods are used in traditional rehabilitation therapy, including passive drafting, muscle strength, endurance, balance, and gait exercise. Dual‐task exercise denotes simultaneous cognitive and motor function exercise. Compared with the single motor exercise method, it can improve the functional activity, balance, and gait of patients with PD. Hydrotherapy is an aerobic exercise program that has been used for rehabilitation in individuals with chronic nervous system diseases in recent years. Balance and gait exercise in water can exercise the movement and balance response of different body parts, improve the exercise ability, and thus reduce pain and the risk for falling in patients with PD. Hydrotherapy combined with water obstacle exercise is more effective than traditional hydrotherapy programs. ⁴⁶

The emergence of novel intervention technologies, such as artificial intelligence, robotics, and virtual reality (VR), has provided a new way for patients with PD to exercise. Robot‐assisted gait exercise has been applied to improve nerve plasticity through repetitive motion exercise to restore gait function. However, studies have shown that robot‐assisted gait exercise is not better than balance exercise in improving postural instability in patients with mild to moderate PD. ⁴⁷ Compared with conventional rehabilitation exercise, patients with PD could achieve the same therapeutic effect through VR rehabilitation exercise, although the VR exercise group showed better performance in gait and balance. ⁴⁸

Intervention measures, such as traditional rehabilitation therapy, hydrotherapy, and new intervention methods combined with modern technology, can improve the functional impairment of patients with PD. When traditional rehabilitation exercise is not effective for these patients, artificial intelligence, VR, and robot‐assisted rehabilitation exercise can be used as alternative or combined therapies.

(2) Alzheimer's disease. Patients with AD usually exhibit neurological symptoms and mental and cognitive dysfunction, and their ability to perform activities of daily living and social functioning gradually decline on this basis, eventually leading to irreversible progressive decline. Therefore, the intervention techniques for these patients mainly include cognitive function exercises, supplemented by physical function exercises. The combination of these two types of exercise can improve the cognitive and physical functioning of patients with AD. ⁴⁹ Moreover, in patients with AD who only exhibit cognitive dysfunction, compared with cognitive function exercise alone, combined physical and cognitive function exercise can better improve the clinical symptoms. ⁵⁰ Therefore, it is recommended to increase physical function exercise, regardless of whether patients with AD have physical dysfunction.

(3) Stroke. Stroke is a common cause of disability among older adults. In addition to traditional muscle strength and motor function exercise, mechanical and robot‐assisted gait exercise can improve the walking independence of patients with subacute stroke who cannot walk independently. The American Heart Association/American Stroke Association Guidelines for Adult Stroke Rehabilitation recommend the use of robot‐assisted exercise for patients with stroke, with a level of evidence of IIB. ⁵¹

Functional electrical stimulation, which uses low‐frequency electrical stimulation to stimulate contraction of the affected limb, can also help the damaged muscle return to normal. In addition, gait‐induced functional electrical stimulation can correct gait abnormalities in patients with stroke. ⁵² VR‐based rehabilitation therapy is more effective than functional electrical stimulation in improving the motor ability of large distal upper limb muscles after stroke, ⁵³ suggesting that VR rehabilitation therapy is also an effective intervention for post‐stroke physical dysfunction.

Recommendation 13: PD, AD, and chronic cardiovascular and cerebrovascular diseases are common causes of functional impairment in older adults. After excluding exercise contraindications, an appropriate exercise program should be implemented.

Recommendation 14: In addition to traditional rehabilitation exercise methods, such as stretching, muscle strength, endurance, balance, and gait exercise, dual‐task combined cognitive and physical exercise, functional electrical stimulation, artificial intelligence, robotics, VR, and other emerging rehabilitation exercise interventions have also achieved good intervention effects and are worth considering as intervention methods.

5.3.3. Exercise safety

Evidence‐based medicine has demonstrated that long‐term regular exercise for older adults with functional impairment can reduce the risk for falls and fall‐induced injuries; improve muscle strength, balance, body function, and cognition; and does not increase the risk for mortality, hospitalization, fractures, and other health problems. ⁵⁴ , ⁵⁵ Similarly, epidemiological data show that although the risk for myocardial infarction is higher during exercise than at rest, the overall risk for myocardial infarction in older adults who exercise regularly is significantly lower than that in non‐exercisers. ⁵⁶ Therefore, long‐term exercise is safe and effective in older adults with functional impairment. Before intervention, patients should be comprehensively evaluated by a multidisciplinary team of geriatric experts. After excluding relevant risks, appropriate individualized intervention methods should be selected according to the actual status.

Recommendation 15: For older adults with functional impairment, relevant risks and contraindications should be excluded through comprehensive assessment by a multidisciplinary team of geriatric experts, and appropriate rehabilitation exercise and related intervention programs should be selected according to the actual status. Close monitoring and timely adjustment should be made during the intervention process to ensure safety.

AUTHOR CONTRIBUTIONS

Initiated and organized this consensus: Jianqing Wu and Jinhui Wu. Wrote the initial manuscript draft (including substantive translation): Jianqing Wu, Chen, and Mao. Preparation and presentation of published reports: Li, Zhao, Meng, and Hu. Critically reviewed and revised the manuscript: Wang, Yu, Zhang, Geriatrics Branch, Chinese Medical Association, and the expert group of the Chinese Expert Consensus on Prevention and Control Interventions for Older Adults with Physical Functional Impairment.

FUNDING INFORMATION

National Key R&D Program of China (grant numbers: 2018YFC2002100 and 2018YFC2002102).

CONFLICTS OF INTEREST STATEMENT

Jianye Wang, Pulin Yu, and Cuntai Zhang are Editorial Board members for Aging Medicine and co‐authors of this article. To minimize bias, they were excluded from all editorial decision‐making related to the acceptance of this article for publication. All other authors have nothing to disclose.

Supporting information

Appendix S1

Wu J, Chen B, Mao Y, et al. Chinese expert consensus on prevention and control interventions for older adults with physical functional impairment (2022). Aging Med. 2023;6:25‐34. doi: 10.1002/agm2.12242