Senior Fitness Test Manual

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.

Most of us would agree that quality of life in later years depends to a large degree on being able to do the things we want to do, without pain, for as long as possible. Because we are living longer, it is becoming increasingly important to pay attention to our physical condition. Ironically, the numerous technological advances in recent years have had mixed benefits for people relative to quantity and quality of life. Whereas medical technology has contributed to a longer life expectancy, computer technology and greater automation are contributing to increasingly sedentary lifestyles and to an increased risk for chronic health and mobility problems. Statistics suggest that in the United States, the health care cost associated with technology-induced inactivity approaches $1 trillion per year (Booth, Gordon, Carlson, & Hamilton, 2000). Very few jobs or household activities these days provide enough energy expenditure to meet people's physical activity needs. Pushing a button to open the garage door, rolling a trash can out to the curb, or driving through an automated car wash, for example, contributes little to our physical strength, health, and functional mobility.

Several recent publications describing national and international physical activity guidelines (e.g., Canadian Physical Activity Guidelines, 2011; Physical Activity Guidelines for Americans, 2008; Start Active, Stay Active, published by the UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; and the World Health Organization's Global Recommendations on Physical Activity for Health, 2010) provide excellent overviews of the benefits of exercise for older adults as well as the relationship between sedentary lifestyles and the onset of a number of chronic conditions that can lead to frailty and disability in later years. Unfortunately, statistics suggest that most older adults do not get the amount of exercise they need and that 42 percent of those over 65 are experiencing functional limitation in common everyday activities, statistics that have not improved over the past decade (Federal Interagency Forum on Aging-Related Statistics, 2010). As a result, although average life expectancy continues to increase, so too does the possibility of living more years with physical limitations. Many older adults, often because of their sedentary lifestyles, are functioning dangerously close to their maximum ability during normal activities of daily living. Climbing stairs or getting out of a chair, for example, often requires near-maximal efforts for older people who are not very physically active. Any further decline or small physical setback could easily cause them to move from independent to disabled status in which assistance is needed for daily activities.

The good news, though, is that much of the usual age-related decline in physical fitness is preventable and even reversible through proper attention to our physical activity and exercise levels. Especially important is the early detection of physical weaknesses and appropriate changes in physical activity habits. The SFT, therefore, was developed specifically to evaluate and monitor the physical status of older adults so that evolving weaknesses might be identified and treated before resulting in overt functional limitations.

Rationale for Developing the SFT

With the rapid growth of the older population, finding ways to extend active life expectancy and reduce disability has become the goal of government agencies, gerontology researchers, and health practitioners throughout the world. Physical frailty in later years is costly both in terms of the resources spent on medical care and the diminished quality of life for these people.

Figures show that it costs the United States $54 billion a year to care for people who have lost their independence, and these figures are expected to increase drastically as the size of the older population continues to grow unless the proportion of those with disabilities is reduced (National Institutes of Health, 2012). The annual health care cost per person jumps drastically as an older adult progresses from independent to dependent status.

Although a number of conditions (e.g., mental confusion, visual loss) can rob people of their independence, problems with physical mobility rank at the top of the list (U.S. Department of Housing and Urban Development, 1999). Luckily, studies suggest that physical function is preserved at a much higher level for those who are active and physically fit, with improvements possible at any age, even for many of those with chronic health conditions (American College of Sports Medicine [ACSM], 2009; Physical Activity Guidelines Advisory Committee, 2008). Research clearly shows that it is never too late to improve one's physical fitness and functional ability; even people in their 90s have experienced dramatic benefits from beginning a physical exercise program (Fiatarone Singh, 2002).

In earlier years, because of the lack of available fitness tests for older adults, health professionals were limited in their ability to evaluate clients and make recommendations based on objective data. Instead, program leaders generally had to rely on their own subjective judgment in evaluating older people's physical condition and in planning exercise programs. The SFT was developed to address the need for improved ways of assessing fitness in older adults. Specifically, it was designed to assess the physical capacity of the large proportion of older adults who are still living independently within the community, but because of their declining fitness levels may soon be at risk for losing their functional independence.

As indicated in the physical function continuum presented in figure 1.1, approximately 65 percent of the older adult population fits into this independent but generally low-fit category. At the high end of the continuum are approximately 5 percent of older adults who are considered to be at a high-fit or elite level, such as those athletic older people who continue to engage in strenuous exercise or perhaps still participate in athletic competitions. At the lower end are those people (representing about 30 percent of the older population) who already have progressed into the physically frail and dependent categories and need assistance with common activities of daily living. Although the test items are suitable for use with most frail older adults at the low end of the continuum, they were primarily designed to evaluate fitness in the larger midsection of independent-living adults so that any evolving weaknesses could be detected and treated before causing loss of function and frailty. Cost savings in health care expenses and in diminished quality of life would be substantial if we could prevent, or at least delay, older adults' progression from the independent to the frail and dependent category.

Identifying Criterion Fitness Scores Associated With Maintaining Functional Mobility and Independence

As is typical in the process of establishing criterion-based standards, a combination of processes—subjective reasoning, data-based statistics, and literature review—was involved in arriving at the recommended fitness standards (cut-point scores) for the SFT test items that would be associated with the ability (or projected ability) to function independently in later years. More specifically, fitness standards were developed based on the fitness scores achieved by the 2,140 moderate-functioning participants in the previously described normative database, with adjustments made as needed to reflect other relevant information from the literature regarding anticipated age- and gender-related patterns of decline over the 30-year period from the 60s to the 90s. Naturally, the 3,126 study participants who are rated as high functioning would also meet the criteria for independent functioning in later years. However, fitness scores for this group of study participants were not considered in the analysis when establishing minimum fitness standards for independent functioning because it was assumed their performance, being much higher than what is needed to meet minimum requirements, would have an inflationary effect on the fitness standards being proposed.

The strategy followed in arriving at the recommended fitness standards for older adults as presented in chapter 5 ( volved three stages, with the first step being to set fitness standards for 90- to 94-year-olds, utilizing the actual scores obtained by the moderate-functioning (independent) 90- to 94-year-old participants in the normative study database. This was considered a logical first step since the goal of maintaining the level of fitness needed for independent functioning had already been met by this group. Because there is no evidence in the literature suggesting that thresholds for maintaining physical independence should be different for men than for women, the same fitness standards are proposed for those over 90 for both sexes on all test items, standards that are based on the average scores obtained by moderate-functioning 90- to 94-year-old male and female study participants, but with some rounding off and minor smoothing of numbers to make them consistent with SFT scoring procedures and convenient for use by the public.

Previous reports suggest that the proposed standards for the 90- to 94-year-olds are reasonable and in line with other findings concerning the level of fitness needed for independent functioning. The 400-yard (366 m) standard for 90- to 94-year-olds on the 6-minute walk, for example, is within the range of the 360- to 600-meter recommendation that has been previously proposed as the minimum walking distance needed to function independently—that is, to be able to navigate within the community to do one's own shopping and errands (Cohen, Sveen, Walker, & Brummel-Smith, 1987; Lerner-Frankiel, Vargas, Brown, Krusell, & Schoneberger, 1986). Also, the 400-yard standard on the 6-minute walk is close to the quarter-mile (440 yard) criteria used by Medicare as a cut point for defining mobility limitation and disability (U.S. Department of Health and Human Services, 2006). The proposed fitness standard of 8.0 seconds for 90- to 94-year-olds to complete the 8-foot up-and-go test is similar to, but appropriately below, the 8.5-second cut point that has been identified as a predictor for falling in older adults, using the same testing protocol (Rose et al., 2002). Performing below the 8.5 cut point for predicting falls is an especially important consideration, given that falls and fall-related injuries are a major cause of loss of independence and escalating health care costs (Centers for Disease Control and Prevention,
2011).

The second stage in the process involved determining appropriate fitness standards for age groups younger than 90 based on how much anticipated physical decline needed to be planned for over the 30-year period between the ages of 60 and 64 and 90 and 94. It was important that standards be set high enough to allow people to experience normal rates of age-related decline and not progress below that required for independent functioning at age 90. In estimating the rate of decline that needed to be planned for on each of the fitness variables, we first considered the actual scores obtained by the 2,140 independent-functioning participants in the normative database, then we calculated the percent decline seen over the 30-year period from 60 to 64 and 90 to 94. Next, we made adjustments in this figure (percent decline) based on information from the literature showing a greater rate of decline (approximately 1.25 as great) when performance is tracked longitudinally (in the same people from one age to the next) versus cross-sectionally, which occurred in the normative study when different age groups were measured at the same time. Therefore, the standards presented in table 5.5 for 60- to 64-year-olds reflect an anticipated rate of age-related decline that is approximately 1.25 times greater than what was observed in the normative study participants. See Rikli and Jones (2012) for additional
details.

Once fitness standards were developed for the oldest (90 to 94) and youngest (60 to 64) age groups, we established standards for the remaining in-between ages based on the best knowledge available concerning patterns of declines across these age groups, paying particular attention to the fact that the rate of decline tends to be greater for men than women (Doherty, 2003; Hughes et al., 2001); that lower-body strength tends to decline faster than upper-body strength (Paterson, Jones, & Rice, 2007; Vandervoordt, 2002); and that there is a well-recognized curvilinear pattern of age-related decline, with an acceleration in decline in later years (ACSM, 2009; Doherty, 2003; Macaluso & De Vito, 2004; Paterson et al., 2007; Vandervoordt, 2002).

As mentioned previously, the ultimately proposed standards of fitness for all age groups reflect rounded-off numbers to make them consistent with SFT scoring procedures and to make them more user-friendly and convenient for use by practitioners who work with older adults and by older adults themselves. All standards for the chair stand, arm curl, and step test have been reported in whole numbers to be consistent with the SFT scoring instructions for these tests, with standards for the 6-minute walk reported in 5-yard increments, also consistent with scoring instructions on the SFT.

As discussed in chapters 2 and 3, maintaining an adequate amount of lower- and upper-body strength is necessary for executing a variety of common tasks associated with physical independence such as climbing stairs, walking distances, getting out of a chair or the bathtub, standing up from the floor, lifting and lowering objects, and reducing risk for falls. Reminding participants about the health-related benefits of strength training is also important—such as reducing risk of obesity, bone loss, low-back pain, osteoarthritis, cardiovascular disease, and diabetes. In the SFT, lower-body strength is assessed using a 30-second chair stand; upper-body strength is measured using the arm curl. Any form of exercise that stresses a person's muscles, including many common types of housework and yardwork activities, will help maintain strength. However, if your client scored low on either or both of the 30-second chair stand and arm curl test items and wishes to increase his strength, a particular regimen of progressive resistance exercises will need to be followed.

Briefly, strength is increased by gradually increasing the resistance placed on a muscle (i.e., by applying what is called the overload principle). Overloading a muscle means making it do more than it is accustomed to doing. This can be accomplished using free weights (similar to the dumbbells used to test arm strength in the SFT), elastic exercise bands, Velcro strap-on weights, exercise machines that are designed for specific muscle groups, or a person's own body weight and gravity. A suitable resistance for stimulating strength depends on the participant's health and fitness status. Generally, according to national recommendations previously mentioned, a beginner should start out with a load of 50 percent of one-repetition maximum (1RM), gradually increasing to approximately 70 to 80 percent of 1RM. A load of 70 to 80 percent of 1RM should cause the lifter to reach fatigue within 8 to 12 repetitions, with fatigue meaning the muscles cannot perform another repetition using proper form. Using a leg press as an example, lower-body strength can be increased by selecting a resistance (load) that can be pressed at least 8 times, but no more than 12 times, before the muscle is too fatigued to continue. Then, as muscle strength improves (as it becomes possible to press the selected weight more than 12 times before fatigue), the resistance should be increased, thus causing the muscle to again be overloaded (i.e., to do more than it was accustomed to). This process is repeated throughout the strength development program—as strength improves to the point where the new resistance can be performed more than 12 times without fatigue, it is again replaced with a heavier
resistance.

When recommending strengthening exercises that do not use traditional weight machines, such as the standing squat, which uses body weight and position as a form of resistance, the aforementioned guidelines do not directly apply. Although the goal is to complete 8 to 12 repetitions to fatigue, some participants will at first be able to complete only 1 or 2 repetitions. If this is the case, gradually increase the repetitions (not the resistance) until participants are able to complete the exercise between 8 and 12 times. Also, when performing nonequipment exercises (e.g., calisthenics), increasing the load (resistance) is achieved by increasing the challenge, such as changing body position, gripping up on (shortening) a resistance band, using a thicker resistance band, or adding dumbbells. Refer to the sections To Increase the Challenge throughout the chapter for more exercise examples.

Strength training guidelines for older adults recommend performing at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week. Important muscle groups for older adults are those needed for lower-body functioning (hip extensors, knee extensors, and ankle plantar flexors and dorsiflexors), for upper-body functioning (biceps, triceps, shoulders, and back extensors), and for trunk and core stability (abdominals and lower back). Strengthening exercises can also be performed more than two times a week, with at least 48 hours between sessions.

Strength Conditioning Guidelines

• Always include a short warm-up (including dynamic flexibility exercises) before doing strength exercises to raise body temperature and get more blood to the extremities.
• Progress slowly, and cautiously increase both the range of motion and the amount of weight for people with chronic conditions or who are frail or less fit.
• The goal is to perform at least one set of 8 to 12 repetitions, to the point of fatigue, for each of the major muscle groups twice a week.
• Rest time between exercises depends on exercise type and resistance level. Participants should rest for 1 to 2 minutes after most exercises and 2 to 3 minutes after multiple-joint exercises using heavy
  resistance.
• Place exercises using larger muscle groups (e.g., leg press, bench press, seated row, standing squat, chest press, and wall push-up) at the beginning of the workout; place single-joint and isolated muscle actions (e.g., triceps extensions, biceps curls, knee extensions, and leg curls)toward the end of the session.
• Both concentric (shortening) and eccentric (lengthening) muscle actions are recommended.
• Increase weight (progression) by about 2 to 10 percent when the desired number of repetitions is met (larger muscle groups generally can handle a greater increase in load).
• If using a resistance band, switch to another band that provides more resistance after the participant can do 8 to 12 repetitions.
• Exercises should be conducted through the full range of motion.
• Remind participants to breathe throughout the movement (generally exhale during the exertion phase and inhale during the release phase).

Strength Conditioning Precautions

• Participants should talk with their doctors if they are unsure about doing a particular exercise, especially if they have had joint surgeries.
• Use only resistance levels that allow the participant to keep proper body alignment and form during the exercise.
• For the less conditioned and people with chronic pain disorders, stretch the same muscle group after each resistance exercise.
• Remind participants to avoid hyperextending or locking the joints.
• Remind participants to avoid jerking or thrusting the weight.
• Participants should always stay within their pain-free range.
• Allow 48 hours between moderate- to high-intensity workouts.

It has been our experience that both practitioners and researchers generally find it preferable to administer the SFT to several people at a time. In fact, group testing is preferred when the goal is to compare performance to the normative data, because all normative scores were collected in a group setting where there tends to be more social interaction and encouragement than when tests are given in an isolated environment. Although the SFT is especially suitable for group administration, careful planning and organization are needed for the testing to run smoothly and efficiently. With the help of six or seven trained assistants, it is possible to test up to 24 participants at a time in a 60- to 90-minute period using a circuit-style setup. If all tests, including the 6-minute walk test, are to be administered indoors, a large community center or gymnasium (approximately 50 feet by 100 feet, or 15 m by 30 m) will be needed. However, a much smaller area will work if the 6-minute walk test can be administered outdoors or if the 2-minute step test is substituted for the 6-minute walk test as the measure of aerobic endurance. Included in this section are instructions for setting up the stations for testing, a list of equipment and supplies that will be needed at each station, guidelines for selecting and training testing assistants, and step-by-step procedures for administering the test items on test day.

Station Setup

For the most efficient use of time and to minimize the fatigue effect for participants, testing stations should be set up circuit-style in the following order: (1) chair stand test, (2) arm curl test, (3) height and weight and 2-minute step test (if 6-minute walk test is not used as the aerobic endurance test), (4) chair sit-and-reach test, (5) back scratch test, and (6) 8-foot up-and-go test. As indicted in the diagram in figure 4.3, the stations should be set up around the periphery of the room, allowing space in the center for the pretest warm-up exercises and for the 6-minute walk if there is room. This type of station setup allows participants to begin their testing at any point in the circuit and then rotate in order to the next station.

When the 6-minute walk test is used, it should always be administered after all other tests are completed. If it is not possible to give the 6-minute walk test (e.g., because of space limitations, bad weather), then the 2-minute step test is administered at station 3 along with the height and weight measurements. If you want to administer both the 2-minute step test and the 6-minute walk test, we recommend including the 2-minute step test as part of the regular circuit and giving the 6-minute walk test on a separate day. For many older adults, it is too exhausting to complete both aerobic tests on the same day. Doing so could result in unsafe conditions as well as inaccurate
scoring.

For group testing, the specific procedures for administering each of the test items within the circuit is the same as those described in the preceding section on official SFT protocols. However, additional equipment and supplies will be needed, as well as trained assistants to help at each of the stations.

Testing Equipment, Supplies, and Assistants

For group testing to run smoothly, each station should be properly set up in advance with all the required equipment and supplies. Although a special feature of the SFT is that it does not require extensive equipment, you should not underestimate how long it takes to gather the needed items. Table 4.2 lists the specific equipment and supplies, as well as the number of assistants, needed at each station. Brief organizational instructions are also provided. Recall that table 4.1 provides suggested vendors and sources for obtaining the equipment and supplies.

Although not absolutely necessary, it is convenient to have a small table (such as a card table) set up at each testing station, or, if possible, to arrange the testing stations near a counter, a table, a bench, or a ledge of some type that can provide a place to lay out the testing supplies (scorecards, pencils, stopwatches). To facilitate assigning and rotating participants, it is also helpful to post station signs indicating the test name and number of each station. Sample copies of station signs with brief test descriptions are included in appendix G. The signs can be copied, mounted, and laminated to make them more durable for repeated use.

As an aid in organizing and keeping track of all supplies and equipment, and in ensuring they are readily available at each station on test day, we have found it helpful to use numbered containers (e.g., gift bags or shopping bags) to collect and transport the items for each station. For example, a small bag labeled Station 1 would contain all the items needed to conduct the chair stand test: a stopwatch, scorecards, and pencils. Similarly, a somewhat larger bag labeled Station 6 would contain the items needed for the 8-foot up-and-go: a stopwatch, tape measure, cone (or similar marker), scorecards, and pencils. In fact, if you plan to conduct the tests on multiple occasions, it is helpful to list the contents on the outside of each bag, making it easy to double-check to see that all equipment and supplies are available each time they are needed.

After administering the SFT to your clients or program participants, we suggest that you meet with them, either individually or as a group, to give them their feedback. This provides an ideal time to educate and motivate about the importance of being physically active and fit in later life. You especially should point out the strong relationship between people's activity level and their fitness scores (surprisingly, many people are not aware of this) and the fact that as much as half of the typical decline associated with aging may not be due to aging at all, but rather to disuse—that is, people's tendency to become less and less active as they age.

Point out to your clients that as people are living longer, it is becoming increasingly important that they pay attention to their fitness level if they want to remain healthy and independent during their later years. Learning that participation in physical activity can help delay the onset of physical frailty and extend their physical independence can be very motivating. Statistics indicate that many older adults by their late 70s or early 80s, particularly those with sedentary lifestyles, will lose the strength and endurance they need to perform common everyday activities, such as climbing stairs, walking to the store, and taking care of their own personal and household activities, unless steps are taken to increase their activity level. For many, maintaining a physically active lifestyle can easily add 10 years or more to their functional or active life span, thus significantly delaying the onset of physical frailty.

It is especially critical for older people to understand the importance of preventing the viciouscycle that occurs for so many—the cycle that begins with becoming less active as they age, which in turn leads to lower energy levels (less desire to be active), which then results in even further reductions in activity, then further declines in energy levels, and on and on. Eventually, this downward spiral can result in people's strength and endurance declining to the point that it is hazardous to their health and their ability to carry out normal everyday activities. Scores obtained on the SFT items can provide important feedback about the strengths and weaknesses of older adults and whether or not their physical declines are placing them at risk for losing their functional mobility.

The good news that you can share with your clients, however, is that no matter what their age or current physical condition, it is always possible to improve their level of fitness by increasing their activity level. You can tell them, citing research reported in national and international physical activity guidelines, that people of all ages—even into their late 80s and 90s—have experienced significant gains in fitness after beginning exercise programs, gains that have led to improved functional performance (e.g., walking and balance) and, for some, the ability to discard their canes and walk without assistance. Such guidelines have recently been developed by the World Health Organization and by researchers in the United States, Canada, the United Kingdom, and elsewhere (ACSM, 2009; Canadian Society for Exercise Physiology, 2011; U.S. Department of Health and Human Services, 2008; UK Department of Health, Physical Activity, Health Improvement and Protection, 2011; World Health Organization, 2010).

You can also motivate your clients by sharing success stories from your own program. Older people are interested in the activities of their peers and are often motivated by their successes. In our program, for example, a 79-year-old woman who had several chronic health conditions and was on 13 medications scored below average on most test items when she first came in to be tested. She was so surprised at how poorly she scored compared with others her age that she immediately hired a personal trainer. Six months later, when she came back for a reevaluation, she not only scored in the normal range on most tests but was also down to taking only 4 medications and saying she felt like a new person. She also looked like a new person—full of energy and smiles. Certainly we are not suggesting that exercise can be used to cure medical problems, but we do know it can help in managing numerous conditions.

Even relatively small success stories can be interesting and meaningful. One woman, after 8 weeks in our program, was thrilled when she found she had gained enough upper-body strength to be able, for the first time, to pull down the back door (hatch) in her minivan without having to ask for help. Another woman reported a tremendous gain in self-confidence when her lower-body strength (and balance) improved to the point she could get up from the floor easily without help, something she had been unable to do for some time. We could go on and on with stories about how increased physical activity level has improved people's quality of life.

Beginning or modifying an exercise program, however, generally takes more than a motivational talk about the value of exercise and a few motivational stories. Changing behavior in people is difficult and almost always requires applying some type of behavior modification strategy. One behavior modification technique that has been successful in changing exercise behavior, especially for those who have already expressed a desire to change, is goal setting.