Exercise: A Guide from the National Institute on Aging

Introduction

Welcome to one of the healthiest things you can do for yourself. Exercise! Regular exercise and physical activity are very important to the health and abilities of older people. In fact, studies suggest that not exercising is risky behavior. That is why we wrote this book. We are the National Institute on Aging, part of the National Institutes of Health, and our research is aimed at improving the health of older people.

For the most part, when older people lose their ability to do things on their own, it doesn't happen just because they have aged. More likely, it is because they have become inactive. Older inactive adults lose ground in four areas that are important for staying healthy and independent: endurance, strength, balance, and flexibility.

Fortunately, research suggests that you can maintain or at least partly restore these four areas through exercise -- or through everyday physical activities (walking briskly or gardening, for example) that accomplish some of the same goals as exercise. What may seem like very small changes resulting from exercise and physical activity can have a big impact.

Getting Past the Barriers

You may be reluctant to start exercising, even though you've heard that it's one of the healthiest things you can do. You may be afraid that physical activity will harm you; or you might think you have to join a gym or buy expensive equipment in order to exercise. Or, you may feel embarrassed to exercise because you think it's for younger people or for people who look great in gym clothes. You may think exercise is only for people who are able to do things like jogging.

In fact, just about every older adult can safely do some form of physical activity at little or no cost. And you don't have to exercise in a public place or use expensive equipment, if you don't want to.

Even household chores can improve your health. The key is to increase your physical activity, by exercising and by using your own muscle power.

Who Can Exercise?

Studies show that, in the long term, older adults in all age groups hurt their health far more by not exercising than by exercising. As a rule, older people should stay as physically active as they can.

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What can Exercise do for Me?

Most people know that exercise is good for them. Somehow, though, older adults have been left out of the picture -- until recently. Today a new picture is emerging from research: Older people of different physical conditions have much to gain from exercise and from staying physically active. They also have much to lose if they become physically inactive.

Exercise isn't just for older adults in the younger age range, who live independently and are able to go on brisk jogs, although this book is for them, too. Researchers have found that exercise and physical activity also can improve the health of people who are 90 or older, who are frail, or who have the diseases that seem to accompany aging. Staying physically active and exercising regularly can help prevent or delay some diseases and disabilities as people grow older. In some cases, it can improve health for older people who already have diseases and disabilities, if it's done on a long-term, regular basis.

What Kinds of Activities Improve Health and Ability?

Four types of exercises help older adults gain health benefits:

Endurance exercises increase your breathing and heart rate. They improve the health of your heart, lungs, and circulatory system. Having more endurance not only helps keep you healthier; it can also improve your stamina for the tasks you need to do to live and do things on your own -- climbing stairs and grocery shopping, for example. Endurance exercises also may delay or prevent many diseases associated with aging, such as diabetes, colon cancer, heart disease, stroke, and others, and reduce overall death and hospitalization rates.

Strength exercises build your muscles, but they do more than just make you stronger. They give you more strength to do things on your own. Even very small increases in muscle can make a big difference in ability, especially for frail people. Strength exercises also increase your metabolism, helping to keep your weight and blood sugar in check. That's important because obesity and diabetes are major health problems for older adults. Studies suggest that strength exercises also may help prevent osteoporosis.

Balance exercises help prevent a common problem in older adults: falls. Falling is a major cause of broken hips and other injuries that often lead to disability and loss of independence. Some balance exercises build up your leg muscles; others require you to do simple activities like briefly standing on one leg.

Flexibility exercises help keep your body limber by stretching your muscles and the tissues that hold your body's structures in place. Physical therapists and other health professionals recommend certain stretching exercises to help patients recover from injuries and to prevent injuries from happening in the first place. Flexibility also may play a part in preventing falls.

Which Ones Should I Do, and How Much Should I Do?

Some types of exercise improve just one area of health or ability. More often, though, an exercise has many different benefits.

In other words, exercise as much as you can. It's best to increase both the types and amounts of exercises and physical activities you do. Gradually build up to include: endurance, strength, balance, and flexibility exercises.

Now that you have read about all the benefits of exercise, we hope you are enthusiastic about getting started. However, it's important to start at a level you can manage and work your way up gradually.

For one thing, if you do too much too quickly, you can damage your muscles and tissues, and that can keep you on the sidelines. For another, your enthusiasm needs to last a lifetime. The benefits of exercise and physical activity come from making them a permanent habit. Start with one or two types of exercises that you can manage and that you really can fit into your schedule, then add more as you adjust to ensure that you will stick with it.

How much you exercise depends on you and on your unique situation. For some, muscle-building exercise might mean pushing more than a hundred pounds of weight at the local gym to keep your legs in shape for hiking or jogging. For others, it might mean lifting 1-pound weights to strengthen your arm muscles enough to use a washcloth. That might mean the dignity that comes from being able to wash yourself, instead of having someone else do it for you. The goal is to improve from wherever you are right now.

Some people are reluctant to start exercising because they are afraid it will be too strenuous. Researchers have found that you don't have to do strenuous exercises to gain health benefits; moderate exercises are effective, too.

Is it Safe for Me to Exercise?

"Too old" and "too frail" are not, in and of themselves, reasons to prohibit physical activity. In fact, there aren't very many health reasons to keep older adults from becoming more active.

Most older people think they need their doctor's approval to start exercising. That's a good idea for some people. Your doctor can talk to you not only about whether it's all right for you to exercise but also about what can be gained from exercise.

Chronic Diseases: Not Necessarily a Barrier

Chronic diseases can't be cured, but usually they can be controlled with medications and other treatments throughout a person's life. They are common among older adults, and include diabetes, cardiovascular disease (such as high blood pressure), and arthritis, among many others.

Traditionally, exercise has been discouraged in people with certain chronic conditions. But researchers have found that exercise can actually improve some chronic conditions in most older people, as long as it's done when the condition is under control.

Congestive heart failure (CHF) is an example of a serious chronic condition common in older adults. In people with CHF, the heart can't empty its load of blood with each beat, resulting in a backup of fluid throughout the body, including the lungs. Disturbances in heart rhythm also are common in CHF. Older adults are hospitalized more often for this disease than for any other.

No one is sure why, but muscles tend to waste away badly in people with CHF, leaving them weak, sometimes to the point that they can't perform everyday tasks. No medicine has a direct muscle-strengthening effect in people with CHF, but muscle-building exercises (lifting weights, for example) can help them improve muscle strength.

Having a chronic disease like CHF probably doesn't mean you can't exercise. But it does mean that keeping in touch with your doctor is important if you do exercise. For example, some studies suggest that endurance exercises, like brisk walking, may improve how well the heart and lungs work in people with CHF, but only in people who are in a stable phase of the disease. People with CHF, like those with most chronic diseases, have periods when their disease gets better, then worse, then better again, off and on. The same endurance exercises that might help people in a stable phase of CHF could be very harmful to people who are in an unstable phase; that is, when they have fluid in their lungs or an irregular heart rhythm.

If you have a chronic condition, you need to know how you can tell whether your disease is stable; that is, when exercise would be OK for you and when it wouldn't.

Chances are good that, if you have a chronic disease, you see a doctor regularly (if you don't, you should, for many reasons). Talk with your doctor about symptoms that mean trouble -- a flare-up, or what doctors call an acute phase or exacerbation of your disease. If you have CHF, you know by now that the acute phase of this disease should be taken very, very seriously. You should not exercise when warning symptoms of the acute phase of CHF, or any other chronic disease, appear. It could be dangerous.

But you and your doctor also should discuss how you feel when you are free of those symptoms -- in other words, stable; under control. This is the time to exercise.

Diabetes is another chronic condition common among older people. Too much sugar in the blood is a hallmark of diabetes. It can cause damage throughout the body. Exercise can help your body "use up" some of the damaging sugar.

The most common form of diabetes is linked to physical inactivity. In other words, you are less likely to get it in the first place, if you stay physically active.

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If you do have diabetes and it has caused changes in your body -- cardiovascular disease, eye disease, or changes in your nervous system, for example -- check with your doctor to find out what exercises will help you and whether you should avoid certain activities. If you take insulin or a pill that helps lower your blood sugar, your doctor might need to adjust your dose so that your blood sugar doesn't get too low.

Your doctor might find that you don't have to modify your exercises at all, if you are in the earlier stages of diabetes or if your condition is stable.

If you are a man over 40 or a woman over 50, check with your doctor first if you plan to start doing vigorous, as opposed to moderate, physical activities. Vigorous activity could be a problem for people who have "hidden" heart disease -- that is, people who have heart disease but don't know it because they don't have any symptoms.

How can you tell if the activity you plan to do is vigorous? There are a couple of ways. If the activity makes you breathe hard and sweat hard (if you tend to sweat, that is), you can consider it vigorous.

If you have had a heart attack recently, your doctor or cardiac rehabilitation therapist should have given you specific exercises to do. Research has shown that exercises done as part of a cardiac rehabilitation program can improve fitness and even reduce your risk of dying. If you didn't get instructions, call your doctor to discuss exercise before you begin increasing your physical activity.

For some conditions, vigorous exercise is dangerous and should not be done, even in the absence of symptoms. Be sure to check with your physician before beginning any kind of exercise program if you have:

  • abdominal aortic aneurysm, a weakness in the wall of the heart's major outgoing artery (unless it has been surgically repaired or is so small that your doctor tells you that you can exercise vigorously)
  • critical aortic stenosis, a narrowing of one of the valves of the heart.

Most older adults, regardless of age or condition, will do just fine in increasing their physical activity. You might want to show your doctor this book, to open the door to discussions about exercise.

Checkpoints

You have already read about precautions you should take if you have a chronic condition. Other circumstances require caution, too. You shouldn't exercise until checking with a doctor if you have:

  • chest pain
  • irregular, rapid, or fluttery heart beat
  • severe shortness of breath
  • significant, ongoing weight loss that hasn't been diagnosed
  • infections, such as pneumonia, accompanied by fever
  • fever, which can cause dehydration and a rapid heart beat
  • acute deep-vein thrombosis (blood clot)
  • a hernia that is causing symptoms
  • foot or ankle sores that won't heal
  • joint swelling
  • persistent pain or a problem walking after you have fallen
  • certain eye conditions, such as bleeding in the retina or detached retina. Before you exercise after a cataract or lens implant, or after laser treatment or other eye surgery, check with your physician.

How to Keep Going

"Definitely NOT!" That's what 75-year-old Emma King told us when we asked her if she ever intended to stop exercising. Ms. King lives in Durham, North Carolina, and has taken long walks at least 4 or 5 days a week, for years. Recently, she took part in a study of exercise for older adults and added stretching to her weekly routine. "I can really tell the difference if I miss 2 or 3 days. I don't know what it would be like not to exercise," she said.

For many older adults, motivation to keep exercising and doing physical activities isn't a problem. They say that regular physical activity makes them feel so much better that it would be hard to stop.

Others say that, while physical activity makes them feel better, a little extra motivation helps them get going. For example, Georgia Burnette, 68, of Amherst, New York, told us that she used to put on headphones and listen to recorded books borrowed from the library to make her 40-minute walks more interesting. Now, she mall-walks for an hour, 5 days a week, with a friend. Having that companionship is a good motivator, says Ms. Burnette.

We have included this section on motivation because physical activity needs to be a regular, permanent habit to produce benefits. So does staying motivated!

Recording your scores and watching them improve can be an excellent motivator to exercise, and we have included charts at the end of this booklet so you can do that. But don't get discouraged if you see that your scores have improved by only a few seconds or just one or two lifts of a weight. In terms of real-life benefits, those slight improvements are multiplied many times over as you include them in your everyday activities. You incorporate that extra little bit of endurance and strength into everything you do, and it adds up to a lot.

But no matter how enthusiastic you are about exercise, there may be times when you need extra motivation. It's common for beginning exercisers, especially those who are frail, to make fast progress at first. You might get discouraged when the improvements you were making taper off at times.

These leveling-off periods are normal. Often, they mean that it's time to gradually make your activities more challenging. If you have any doubts about whether you are doing the right things to progress, check with your doctor or a qualified fitness professional.

When you need extra motivation, try the following:

  • Ask someone to be your exercise buddy. Many older adults agree that having someone to exercise with helps keep them going.
  • Follow Georgia Burnette's advice: Listen to recorded books or music while you do endurance activities.
  • Set a goal, and decide on a reward you will get when you reach it.
  • Give yourself physical activity homework assignments for the next day or the next week.
  • Think of your exercise sessions as appointments, and mark them on your calendar.
  • Keep a record of what you do and of your progress. Understand that there will be times that you don't show rapid progress and that you are still benefiting from your activities during those times.
  • Plan ahead for travel, bad weather, and house guests. For example, an exercise video can help you exercise indoors when the weather is bad.

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Sticking With It: What Works

According to the U.S. Surgeon General's report, you are more likely to keep doing physical activities if you:

  • think that, overall, you will benefit from them
  • include activities you enjoy
  • feel you can do the activities correctly and safely
  • have regular access to the activities
  • can fit the activities into your daily schedule
  • feel that the activities don't impose financial or social costs you aren't willing to take on
  • have few negative consequences from doing your activities (such as injury, lost time, or negative peer pressure)

In other words, set yourself up to succeed right from the start. Choose realistic goals, learn to do the exercises correctly and safely, and chart your progress to see your improvement.

Sample Exercises

Many different physical activities can improve your health and independence. Whether you choose to do the exercises shown in this chapter or other activities that accomplish the same goals, gradually work your way up to include endurance, strength, balance, and stretching exercises.

Here are some points to keep in mind as you begin increasing your activity:
  • If you stop exercising for several weeks and then return, start out at about half the effort you were putting into it when you stopped, then gradually build back up. Some of the effects of endurance and muscle-building exercises deteriorate within 2 weeks if these activities are cut back substantially, and benefits may disappear altogether if they aren't done for 2 to 8 months.
  • When an exercise calls for you to bend forward, bend from the hips, not the waist. If you keep your entire back and shoulders straight as you bend forward, that will help ensure that you are bending the right way, from the hips. If you find your back or shoulders humping in any spot as you bend forward, that's a sign that you are bending incorrectly, from the waist. Bending from the waist may cause spine fractures in some people with osteoporosis.
  • It's possible to combine exercises. For example, regular stair-climbing sessions improve endurance and strengthen leg muscles at the same time.

How Hard Should I Exercise?

We can't tell you exactly how many pounds to lift or how steep a hill you should climb to reach a moderate or vigorous level of exercise, because what is easy for one person might be strenuous for another. It's different for different people.

We can, however, provide some advice based on scientific research: Listen to your body. The level of effort you feel you are putting into an activity is likely to agree with actual physical measurements. In other words, if your body tells you that the exercise you are doing is moderate, measurements of how hard your heart is working would probably show that it really is working at a moderate level. During moderate activity, for instance, you can sense that you are challenging yourself but that you aren't near your limit.

One way you can estimate how hard to work is by using the Borg Category Rating Scale, shown on the next page. It was named after Gunnar Borg, the scientist who developed it. The numbers on the left of the scale don't indicate how many times or how many minutes you should do an activity; they help you describe how hard you feel you are working.

Food Pyramid

  • Fats, oils & sweets
    • use sparingly
  • Milk, yogurt & cheese group
    • 2-3 servings
  • Meat, poultry, fish, dry beans, eggs & nuts group
    • 2-3 servings
  • Vegetable group
    • 3-5 servings
  • Fruit group
    • 2-4 servings
  • Bread, cereal, rice & pasta group
    • 6-11 servings

For endurance activities, you should gradually work your way up to level 13 - the feeling that you are working at a somewhat hard level. Some people might feel that way when they are walking on flat ground; others might feel that way when they are jogging up a hill. Both are right. Only you know how hard your exercise feels to you.

Strength exercises are higher on the Borg scale. Gradually work your way up to level 15 to 17 - hard to very hard - to build muscle effectively. You can tell how hard an effort you are making by comparing it to your maximum effort. How hard does your current effort feel compared to when you are lifting the heaviest weight you can lift? Once you start exerting more than a moderate amount of effort in your muscle-building exercises, your strength is likely to increase quickly.

As your body adapts and you become more fit, you can gradually keep making your activities more challenging. You might find, for example, that walking on a flat surface used to feel like you were working at level 13 on the Borg scale, but now you have to walk up a mild hill to feel like you are working at level 13. Later, you might find that you need to walk up an even steeper slope to feel that you are working at level 13.

The Borg scale is simple to use. But if your level of effort doesn't match the numbers you see on the Borg scale - for example, if you think you are doing the exercises correctly, but you aren't progressing or you are exhausted by your effort - check with a fitness professional. These experts are likely to understand the science that went into developing the Borg scale, and they can teach you how to match your level of effort with the right number on the scale.

How am I Doing?

There are ways to tell when it's time to move ahead in your activities, and we have mentioned some of them in the preceding chapter. For example, when you can lift a weight more than 15 times, you know it's time to add more weight in your strength exercises. And when endurance activities no longer feel somewhat hard to you, it's time to exercise a little longer, then to add a little more difficulty, like walking up steeper hills.

As you progress, you can do some simple tests, shown in this chapter, that will tell you just how far you have come. These tests also can help you assess how fit you are before you start exercising. After that, try them again every month. Record your scores each time, so you can see your improvement the next time you test yourself.

You might be interested in doing these tests for a couple of reasons. For one, most people make rapid progress soon after they start exercising, and you might find the improvement you see in your scores after just a month encouraging.

For another, these tests are a good way of letting you know if you really are progressing. Although it's normal for your improvement to slow down at times, your test scores should get better overall (unless you have reached your goal and are maintaining your current level).

If you are not in condition to do these tests right now, keep working on your current exercises and activities until you are. Whether you are testing or actually exercising, your pace should never make you feel dizzy, lightheaded, or nauseated, and you shouldn't feel pain. If you have a chronic medical condition, or are at risk of developing one, follow the guidelines in "Is it Safe for Me to Exercise?" before testing yourself.

  1. Endurance: See how far you can walk in exactly 6 minutes. Write down how far you walked (in feet, blocks, laps, miles, number of times you walked up and down a long hallway, or whatever is convenient for you). Do this test every month. As your endurance improves, you should find that you can walk farther in 6 minutes.
  2. Lower-Body Power: Time yourself as you walk up a flight of stairs (at least 10 steps) as fast as you safely can. Record your score. Repeat the test, using the same stairs, one month later. It should take you less time.
  3. Strength: Each time you do your strength exercises, use the chart in the back of this book to record how much weight you lift and how many times you lift that weight. Another chart shows how much more weight you can lift, and how many more times you can lift it, compared to the month before.
  4. Balance: Time yourself as you stand on one foot, without support, for as long as possible (stand near something sturdy to hold onto, in case you lose your balance). Record your score. Repeat the test while standing on the other foot. Test yourself again in one month. The amount of time you can stand on one foot should increase.

What Should I Eat?

Your body needs fuel for exercises and physical activities, and that fuel comes from food. Eating the right nutrients from a balanced diet helps build muscle and energy. But just what does "balanced diet" mean? What should you eat, and exactly how much of it should you eat?

Food Pyramid

Fats, oils & sweets use sparingly
Milk, yogurt & cheese group 2-3 servings
Meat, poultry, fish, dry beans, eggs & nuts group 2-3 servings
Vegetable group 3-5 servings
Fruit group 2-4 servings
Bread, cereal, rice & pasta group 6-11 servings

This diagram is the U.S. Department of Agriculture (USDA) food pyramid. If you use it as a guideline, you will be following a balanced diet. It tells you how many servings of each kind of food you should eat each day. We have also included a chart that shows you what, exactly, counts as one serving of each kind of food.

If you use the food pyramid as a guideline, you may also be helping to prevent or delay some of the diseases associated with growing older. For example, by cutting down on fats, you will be reducing your risk of getting cardiovascular diseases like high blood pressure. By increasing the amount of fruits and vegetables you eat, you will be lowering your risk of getting some types of cancer.

Looking at the guidelines, you will see that the biggest part of the calories you take in each day should come from grains, and the smallest amount should come from fats, oils, and sweets. The guidelines put heavy emphasis on vegetables and fruits, and less on meat and dairy products.

Some older adults are on restricted diets because of certain health conditions. Kidney disease is just one example of a condition that often requires restrictions of certain foods or fluids. If your doctor or nutritionist has asked you to follow a special diet, please follow his or her advice.

The Big Picture

Often, people decide to exercise and eat a balanced diet because they want to control their weight. For many people, these healthy habits do result in weight loss...but that's only part of the big picture. Exercise and a healthy diet can help make you healthier. But they are just one part of becoming physically fit. Think about other lifestyle changes you can make, too. For example, smoking contributes to a variety of serious diseases and can keep you from exercising. So does excessive alcohol. Together, habits like exercise, a balanced diet, and giving up smoking will help you achieve what we wish for you: the best of health.

Target Heart Rate

Target Heart Rate (THR) is a common way of judging how hard you should exercise during endurance activities. It tells you how fast the average person should try to make his or her heart beat during endurance sessions. It's not always the best way for older adults to decide how hard to exercise, though, because many have long-standing medical conditions or take medications that change their heart rate. We recommend using the Borg scale shown in Chapter 4 instead. However, some older exercisers who are in basically good health and who like taking a "scientific" approach to their endurance activities may find the THR method useful. Others should check with their doctors first.

For those of you who can use THR, the chart below shows an estimate of how fast you should try to make your heart beat, once you have gradually worked your way up to it. "Gradually" is an important word here. Going immediately from an inactive lifestyle to exercising at the rate shown in the chart is not advised.

One way to reach your THR gradually is to take your pulse during an endurance-type activity that is already a part of your life (walking, for example.) Do it at the pace you normally do it, and record your heart rate, from session to session (or over several sessions), increase how hard you work, so that your pulse rate gradually gets faster, over time.

Eventually, you can try to get your heart rate up to 70 to 85 percent of its maximum ability (the rate shown in the chart). Making it beat faster than this is not advised.

Note: The goal is not for your heart rate to be faster all the time - just when you do your endurance activities. In fact, you should find that, as your heart becomes more efficient from endurance exercise, your resting pulse rate is slower than it was before you took up this healthy habit.

How to Take Your Pulse

To take your pulse, press the tips of your index and middle fingers against the inside of the opposite wrist, just below the mound at the base of your thumb, and count how many pulsations you feel in a 10-second period. Multiplying this number by 6 will give you your heart rate. (Note: Don't count your pulse for an entire minute. During the minute that you have stopped exercising to take your pulse, your heart will have slowed down, and you won't get an accurate reading.

DO NOT Use the THR Method If...

  • You take medications that change your heart rate
  • You have a pacemaker for your heart
  • You have an irregular heart rhythm called "atrial fibrillation"
  • You have any other condition that affects your pulse rate.

All of these situations can give you inaccurate readings.

Many older adults take medications in a class called "beta blockers" for high blood pressure or some heart conditions. Your doctor can tell you if your heart or blood-pressure medicine is a beta blocker, or if you have other conditions or medications that will affect your pulse rate during exercise. Some eye drops used to treat glaucoma also contain beta blockers.

Your heart rate is a reflection of how hard your body is working. Beta blockers tend to keep your heart rate slower, so no matter how hard you push yourself, you might never reach the heart rate you are trying for. You might end up exerting yourself too much, as you try in vain to reach a heart rate that your beta blockers won't allow. Being on beta blockers doesn't mean you can't exercise vigorously; it just means you can't rely on your heart rate or on your pulse rate, to judge how hard you are working.

Age Desired Range for Heart Rate During Endurance Exercise

(beats per minute)

40 126-153
50 119-145
60 112-136
70 105-128
80 98-119
90 91-111
100 84-102

How Much Exercise Should I Get Each Week?

When you first start out, you might have trouble keeping up with even the minimum amount of exercise we suggest in the chart at the bottom. Start out with a schedule that your body can tolerate and that you think you really can manage, and build up from there.

Note that the schedules are arranged so that you are never doing strength exercises of the same muscle groups on any two days in a row. If you want to do strength exercises every day, alternate muscle groups. For example, do strength exercises of your upper-body muscles on Monday, Wednesday, and Friday and of your lower-body muscles on Tuesday, Thursday, and Saturday. Or you can do strength exercises of all of your muscle groups up to every other day.

Begin exercising gradually. Once you have worked your way up to a regular schedule...

...get at least this much exercise each week:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Stretching Endurance Strength/balance,

all muscle groups

Endurance

Stretching

Strength/balance,

all muscle groups

Endurance Stretching

Charts

  1. Weekly Schedule
  2. Daily Endurance and Flexibility Exercise Record
  3. Balance Exercises, Anytime, Anywhere - Weekly Schedule
  4. Strength and Balance Exercises : Daily Record
  5. Exercise: Monthly Progress Record

Source: National Institutes of Health (www.nih.gov)

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Last Editorial Review: 7/14/2005

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