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........................................................................................................................................................................ hypoglycaemia in the event of inadequate caloric intake. Importantly, all patients with diabetes should be aware of warning symptoms and attention should be given to chest discomfort or unusual breathlessness during exercise as this may be indicative of CAD.

4.3 Exercise and sports in ageing

4.3.1 Introduction The elderly are defined as adults aged above 65 years. Similar to the general population, higher exercise capacity in this age group is also associated with reduced mortality.179 A physically active lifestyle maintained through middle and older age translates into better health180 and longevity.181185 Commencing a new exercise regimen among sedentary elderly individuals has shown significant health improvements180,186 including cognitive capacity.187190 Moreover, regular exercise exerts beneficial effects in reducing the risk of developing CV and metabolic disease through improved control of CV risk factors,191,192 also preserving cognitive function.187190 Importantly, exercise helps to preserve neuromuscular competence,193,194 thus maintaining balance and coordination, which reduces the risk of falling.195,196 4.3.2 Risk stratification, inclusion/exclusion criteria Moderate-intensity exercise is generally safe for older healthy people and medical consultation before starting or progressing the level of exercise programme is not usually required.81,197 The general recommendation for exercise implementation for the general population also applies to healthy elderly people.

Nevertheless, due to potential risks of exercising among the elderly (Table 6), the European Association of Preventive Cardiology (EAPC) recommends self-assessment by a brief questionnaire81 to determine the need for advice from health professionals, but this approach has not been tested prospectively. Community-dwelling frail or sedentary older adults may have a slightly increased risk of falls during exercise; however, there is no evidence of serious adverse outcomes, injury, or CV events.195,196,198,199 Exercise interventions to improve balance in those diagnosed with dementia bring numerous benefits without an increased risk of adverse outcomes.200 Resistance exercise in older adults is rarely associated with adverse events.201,202 No major risks have been reported in older individuals performing low- and moderate-intensity aerobic exercise, and even more intense aerobic activities are associated with a relatively small risk.203205 CV events during intense exercise occur at a rate of around 1 event per 100 years of vigorous activity.206 Risks are highest during the first few weeks of beginning vigorous exercise; therefore both exercise intensity and duration should be increased gently (for example, every 4 weeks).81,197,207210 Among older individuals who are well prepared and accustomed to intense exercise, participation in competitive vigorous sports does not confer higher risk compared with younger adults.38,211

4.3.3 Exercise modalities and recommendations for exercise and sport in the elderly The physical exercises for elderly persons should be designed according to their biological age, exercise experience, functional capacity, safety, ageing trajectories, comorbidity, lifestyle habits, and previous experience of exercise. Elderly people should perform endurance and strength exercise, and specific exercises for flexibility and balance (Table 7).201,212,213 Endurance exercise exerts beneficial effects on the cardiorespiratory system and resistance exercise prevents the decrease in muscle mass and sarcopenia.192 Achieving >150 min/week moderate-intensity aerobic exercise (i.e. walking or other moderate intensity aerobicstype activities) is associated with at least 30% lower risk of morbidity, mortality, disability, frailty, and dementia compared with being inactive.212,214,215 The strength exercises for the major muscle groups should be performed at least twice a week (810 different exercises, 1015 repetitions). Accustomed senior athletes should continue performing exercise and sports activities, without any predetermined age limit.38,211,216 Sports activities for older people according to exercise type and intensity are reported in Table 8. Annual clinical assessment including a maximal exercise test (preferably with simultaneous CPET) is recommended in master athletes performing a high level of sports and exercise programmes.217

Special considerations for individuals with obesity, hypertension, dyslipidaemia, or diabetes

Recommendations Classa Levelb In obese individuals (BMI>_30 kg/m2 or a waist circumference >80 cm for females or >94 cm for males) resistance training >_3 times per week, in addition to moderate or vigorous aerobic exercise (at least 30 min, 57 days per week) is recommended to reduce CVD risk.121 I A In individuals with well-controlled hypertension, resistance training >_3 times per week in addition to moderate or vigorous aerobic exercise (at least 30 min, 57 days per week) is recommended to reduce blood pressure and CVD risk. 132 I A Among individuals with diabetes mellitus, resistance training >_3 times per week in addition to moderate or vigorous aerobic exercise (at least 30 min, 57 days per week) is recommended to improve insulin sensitivity and achieve a better CVD risk profile.176,178 I A Among adults with well-controlled hypertension but high risk and/or target organ damage, high-intensity resistance exercise is not recommended. III C In individuals with uncontrolled hypertension (SBP>160 mmHg) high-intensity exercise is not recommended until blood pressure has been controlled. III C

CVD = cardiovascular disease; SBP = systolic blood pressure. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026