Pathy's Principles and Practice of Geriatric Medicine. Группа авторов

exercise Resistance training Balance training High‐impact, high‐velocity activity (e.g., jumping) is potent if tolerable; avoid if osteoarthritis is present. Resistance training effects are local to muscles contracted. Balance training should be added to prevent falls and must be challenging. Peripheral vascular disease Aerobic Resistance training Vascular effect is systemic; upper limb ergometry may be substituted for leg exercise if necessary. Resistance training has a similar effect on claudication as aerobic exercise. Low‐intensity resistance training is ineffective. Exercise only to the onset of claudication; rest and repeat. Venous stasis disease Aerobic Resistance training Local muscle contractions stimulate the return of fluid via the lymphatic system. Utilise lower body training; elevate legs when possible.

An alternative approach to aerobic exercise recommendations for adults with diabetes is the use of progressive resistance training. Insulin resistance is worsened by loss of muscle mass, decreased glucose transport into skeletal muscle and subsequent glycogen storage, catabolic/inflammatory mediators, inactivity, visceral fat, and related inflammatory cytokines such as IL‐6 and C‐reactive protein. The specific indications for resistance training in older adults with diabetes include its ability to combat age and diabetes‐related sarcopenia¹⁵⁵; prevent loss of muscle and bone mass and reduced resting metabolic rate, which otherwise accompanies hypocaloric dieting; increase glucose uptake and storage in skeletal muscle; reduce visceral fat depots; and reduce C‐reactive protein,^155,156 as well as its beneficial effects on resting blood pressure, functional status, mobility, sleep,¹⁵⁷ and depressive symptoms. The effects on muscle mass are unique to high‐intensity resistance training and clearly distinguish it from aerobic exercise. For this reason, current recommendations include both aerobic and resistance training as well as dietary modification for type 2 diabetes. A summary of the major trials on which such recommendations to include resistance training for treatment of type 2 diabetes have been based is presented in Table 7.8.

Table 7.8 Major randomised controlled trials including resistance training in type 2 diabetes.

Study	N (average age)	Duration of training (months)	Resistance training intensity	Other additional intervention	Significant improvement in insulin sensitivity or glucose homeostasis
Dunstan et al.33,34	36 (60–80 years)	2 (6 months supervised)	High	Moderate weight loss programme	Yes, for supervised phase but not home‐based, free‐weight phase
Balducci et al.158	120 (60.9 years)	12	Moderate	Aerobic at 40–80% HR	Yes
Baldi and Snowling159	18 (46.5 years)	2.5	Moderate	None	Yes
Cuff et al.160	28 (60.0 years)	4	Low	Aerobic at 60–75% HR	Yes
Loimaala et al.161	50 (53.8 years)	11	High	Aerobic at 65–75% HR	Yes
Castaneda et al.77	62 (66 years)	4	High	None	Yes
Dunstan et al.162	27 (51 years)	2	Moderate	Low‐intensity cycling between each set	Yes
Ibañez et al.78	9 (66.6 years)	4	High	None	Yes
Rodriguez‐Mañas et al.163	964 (78.4 years)	4	High	Nutritional and educational programme	Yes
Mavros et al.164	103 (65 years)	12	High, power training	None Control = low‐intensity resistance training	No, but metabolic benefits proportional to body composition changes

      Evidence for exercise interventions in frail older adults with diabetes

Ageing patients with type 2 diabetes exhibit greater declines in muscle strength and functional capacity and more rapid loss of muscle mass than normoglycaemic controls.^165,166 Indeed, diabetes complications such as peripheral vascular disease and peripheral neuropathy are associated with poor gait ability, impaired balance, and increased risk of falls.^165,166 In frail patients with diabetes, enhancement in functional capacity is crucial and may be more beneficial than attention to metabolic control alone.¹⁶⁷ Accordingly, an important conceptual idea is that the focus in older people with diabetes should be on functionality.¹⁶⁸ Therefore, in addition to metabolic control, effective strategies are needed to prevent the exacerbated loss of strength and functional capacity in ageing adults with diabetes because these individuals exhibit an increased risk of the development of frailty syndrome, institutionalisation, and disability.^{11,59,126‐127}

      Thus, exercise interventions, including resistance training, together with pharmacological and dietary interventions, represent the cornerstones of type 2 diabetes mellitus management.^151,169 Along with the beneficial effects of exercise interventions for older adults with diabetes on glycaemic control,^151,169 increased insulin sensitivity, decreased amount of intra‐abdominal adipose tissue and muscle fat infiltration,⁷⁸ and the cardiovascular risk factors associated with diabetes,²² physical exercise improves muscle mass, strength, power output, cardiovascular function, and functional capacity,⁷⁸ as it does in healthy elders. It may also help prevent dementia in older adults with diabetes,⁴ although systematic review indicates more study is needed.¹⁷⁰ In frail older people with diabetes with functional decline, multicomponent exercise programmes composed of resistance, endurance, balance, and gait retraining should be employed to increase functional capacity and quality of life and avoid falls,