Journal of Gerontology: MEDICAL SCIENCES Copyright 1989 by The Cerontologic(il Society of America

1989, Vol. 44. No. 5. M147-157

Cardiovascular and Behavioral Effects of Aerobic

Exercise Training in Healthy Older Men and Women
James A. Blumenthal,12 Charles F. Emery,1 David J. Madden,3
Linda K. George,3 R. Edward Coleman,2 Margaret W. Riddle,1
Daphne C. McKee,4 John Reasoner,2 and R. Sanders Williams2

'Department of Psychiatry, department of Medicine, and

3
Center for the Study of Aging and Human Development, Duke University Medical Center.
"North Carolina Spine Center, Chapel Hill.

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The cardiovascular and behavioral adaptations associated with a 4-month program of aerobic exercise training
were examined in 101 older men and women (mean age = 67years). Subjects were randomly assigned to an Aerobic
Exercise group, a Yoga and Flexibility control group, or a Waiting List control group. Prior to and following the 4-
month program, subjects underwent comprehensive physiological and psychological evaluations. Physiological
measures included measurement of blood pressure, lipids, bone density, and cardiorespiratory fitness including direct
measurements of peak oxygen consumption (VO2) and anaerobic threshold. Psychological measures included
measures of mood, psychiatric symptoms, and neuropsychological functioning. This study demonstrated that 4
months of aerobic exercise training produced an overall 11.6% improvement in peak VO2 and a 13% increase in
anaerobic threshold. In contrast, the Yoga and Waiting List control groups experienced no change in cardiorespira-
tory fitness. Other favorable physiological changes observed among aerobic exercise participants included lower
cholesterol levels, diastolic blood pressure levels, andfor subjects at risk for bone fracture, a trend toward an increase
in bone mineral content. Although few significant psychological changes could be attributed to aerobic exercise
training, participants in the two active treatment groups perceived themselves as improving on a number of
psychological and behavioral dimensions.

PHYSICAL exercise has become increasingly popular as a

method of health enhancement. Epidemiologic and lab-
oratory studies have shown that increased levels of physical
activity are associated with longevity and reduced risk for
cardiovascular disease (1-3). Lack of activity, on the other
hand, has been shown to be associated with decreased
exercise capacity, cardiovascular deconditioning, and mus-
cle atrophy (4,5). Most research on exercise has focused on
young and middle-aged male subjects, however. In an edito-
rial appearing in the journal of the American College of
Sports Medicine, Holloszy (6) noted that the positive atten-
tion that exercise has received is based "largely on emo-
tional reactions and on wishful thinking." In particular, he
cited the paucity of data on older persons and stated that
"such a recommendation [to exercise] cannot be made
lightly in view of the potential hazards of unsupervised
exercise for older individuals" and noted "the unresolved
questions regarding the effect of exercise on the aging
process" (p. 2).
It is especially important to evaluate the effects of exercise
on elderly persons because aging is associated with declines
in physical and mental functioning that may be modifiable by
exercise. Previous studies have documented impaired car-
diovascular performance for older individuals as compared
to younger persons in terms of maximum oxygen consump-
tion (V02max), heart rate, cardiac output, and left ventricu-
lar ejection fraction during exercise (7-10). Furthermore,
these changes are not due simply to the increased prevalence
of specific cardiovascular disease states in the elderly, but
also occur in elderly individuals without overt disease (10).
The decline in cardiovascular performance that is typi-
cally associated with aging is attributable to changes both in
peripheral circulation and intrinsic myocardial systolic and
diastolic function (11,12). However, the degree to which
these decrements represent the inevitable biologic sequelae
of normal aging or represent changes that may be potentially
modifiable with exercise training has not been systematically
studied in a large sample of older men and women.
There is considerable support for the hypothesis that habit-
ual rigorous physical exercise may enhance cardiovascular
functioning in elderly persons. First, sociocultural features of
modern industrial society have resulted in declining levels of
habitual physical activity among adults, suggesting that
physical deconditioning, which is potentially reversible,
could contribute to a decline in cardiovascular function (13).
Second, with the exception of peak heart rate, all the parame-
ters of cardiovascular function that have been observed to
decline with advancing age are known to be favorably modi-
fied by aerobic exercise training in young populations
(14,15). Several studies have suggested that similar effects
occur in the elderly (16-18), although results have been
inconsistent (19-21) and are plagued by methodological
limitations. These limitations have included cross-sectional
comparisons that are potentially confounded by genetic dif-
ferences between sedentary and active groups as well as by
selection bias; exercise programs of insufficient duration and
intensity to assess adequately the effects of exercise training;
non-random comparison groups; and small sample sizes.
In addition to decrements in cardiovascular function,
declines in psychological function including decreased cog-

M147
M148 BLUMENTHAL ET AL.
nitive efficiency and increased prevalence of psychiatric
symptoms have been found among older adults (22,23). In
traditional tests of cognitive function, for example, there are
age-related impairments in the acquisition and manipulation
of unfamiliar material (24), and declines in some forms of
memory performance (25). Disturbances of mood are also
prevalent among the elderly population (26). A number of
studies in younger and middle-aged subjects have shown that
aerobic exercise may improve mood (27-29) and may im-
prove performance on various cognitive tasks (30,31). Re-
cently these observations have been extended to the elderly
(32-34), although methodological problems and inconsis-
tent results have made it difficult to draw any firm conclu-
sions for older people (35-37).
The purpose of this study was to provide a comprehensive
assessment of the cardiovascular, psychological, and behav-
ioral effects of aerobic exercise training in a group of healthy
older (greater than 60 years) men and women. The study was
designed to improve upon the methodological shortcomings
of previous research by (a) using a longitudinal design in
which a large cohort of subjects undergo intensive exercise
training; (b) precisely measuring changes in aerobic fitness
using measures of direct oxygen consumption; (c) including
randomized control groups to identify nonspecific factors
(e.g., attention, expectations, enhanced self-efficacy, etc.)
that may contribute to changes in physical and psychological
functioning; and (d) evaluating concurrent changes in behav-
ioral and psychological characteristics, as well as changes in
cardiovascular function among study participants.
METHOD
One hundred thirteen men and women were initially
recruited as subjects for the study through television, radio,
and newspaper advertisements. Twelve subjects were subse-
quently excluded because of positive ECG during exercise
testing (n = 5), moving from the area (n = 2), evidence of
coronary artery disease (n = 1), asthma (n = 1), previous
pulmonectomy (n = 1), uncontrolled hypertension (n = 1),
or concurrent beta-blocker therapy (n = 1). All remaining
101 subjects (51 women, 50 men) were judged to be free of
clinical manifestations of coronary disease by medical his-
tory, physical examination, and bicycle ergometry exercise
testing performed under continuous electrocardiographic
monitoring. The subjects ranged in age from 60 to 83 years
(mean = 67.0 ± 4.9 years). All subjects had at least a high
school education, and 96% were white.
Procedures. — Subjects were randomly assigned to an
Aerobic Exercise (AE) group (n = 33), a Yoga and Flexibil-
ity (YO) control group (n = 34), or a Waiting List (WL)
control group (n = 34) following the completion of an
extensive assessment battery.
Subjects in the AE group attended three supervised exer-
cise sessions per week for 16 consecutive weeks. Based on
maximum heart rate achieved during the bicycle exercise
test, subjects were assigned six-beat training ranges equiva-
lent to 70% maximum heart rate reserve (38). Each aerobic
exercise session began with a 10-minute warm-up exercise
period followed by 30 minutes of continuous bicycle ergom-
etry at an intensity that would maintain heart rate within the
assigned training range. The subjects then engaged in brisk
walking/jogging and arm ergometry for 15 minutes. The
exercise session concluded with 5 minutes of cool-down
exercises. Heart rates were monitored via radial pulses and
were recorded, along with ratings of perceived exertion (39),
three times during each exercise session.
Subjects in the YO group participated in 60 minutes of
yoga exercises at least two times a week for 16 weeks. The
supervised yoga classes provided a control for the effects of
social stimulation and attention from trainers, without pro-
ducing an aerobic training stimulus.
Subjects randomized to the WL control group did not
receive any form of treatment between Time 1 and Time 2
evaluations. They were instructed not to change their physi-
cal activity habits and specifically not to engage in any
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aerobic exercise for the 4-month period. Subjects in all three
groups were told to maintain their regular dietary habits until
completion of the study. No suggestions for dietary modi-
fication were offered to any subjects.
Assessment Procedures
All participants underwent comprehensive physiological
and psychological evaluations that were conducted prior to
the beginning of the exercise program (Time 1) and after
four months (Time 2).
Physiological measures. — Blood pressure was obtained
by standard cuff sphygmomanometry with the subject in a
sitting position. Body weight was obtained by a standard
balance scale. Plasma triglycerides, total serum cholesterol
(TC), high-density lipoprotein cholesterol (HDL-C), and
low-density lipoprotein cholesterol (LDL-C) were deter-
mined from blood samples drawn between 0700 and 0900
hours following a 14-hour fast. Blood was withdrawn by a
one-syringe, 15 cc vacutainer tube, anticoagulated with
3.5% sodium citrate, and centrifuged at 6000 x g for 15
minutes prior to analysis by a commercial laboratory. Al-
though assays from commercial laboratories may be variable
(40), the quality control data from Smith Klein Laboratories
(Atlanta, GA) between January 1986 and June 1987 were
excellent (r > .90).
Measurement of bone density by single photon absorp-
tiometry with 1-125 was performed using a Bone Densitome-
ter (Norland Corporation, Fort Atkinson, WI). The bone
mineral content (mg/cm2) was obtained from the distal radius
of the non-dominant arm by locating the position at which
the radius and ulna were separated by 5 mm. This site has
been demonstrated to contain 50% trabecular bone (41). The
subject was seated and the arm studied in slight pronation
(1-10 degrees).
In order to measure cardiorespiratory fitness, subjects
underwent bicycle ergometry testing. Each subject per-
formed two maximum effort exercise tests following an
initial practice test on a Fitron cycle ergometer (Cybex
Lumex, No. F1000750). The graded exercise protocol con-
sisted of 3-minute stages starting at 150 kpm and increasing
150 kpm at each stage. Subjects maintained a pedaling rate
of 50 rpm. Subjects exercised until exhaustion or standard
clinical endpoints. A 12-lead EKG (Hewlett Packard, No.
1517A) was employed to provide continuous electrocardio-
 EFFECTS OF AEROBIC EXERCISE TRAINING
graphic monitoring. Heart rates were recorded every minute.
Blood pressure was measured by cuff sphygmomanometry
at 3-minute intervals. Respiratory and oxygen consumption
measurements were obtained using a System 4400 metabolic
system (Alpha Technologies, Laguna Hills, CA). Measure-
ments of VO2, expired ventilation (VE), and respiratory
exchange ratio (RER) were obtained every 15 seconds.
Anaerobic threshold (AT) was determined as the degree of
oxygen consumption (VO2, ml/min) at which there was a
nonlinear increase in VE; an increase in VE/VO2 without a
simultaneous increase in VE/VCO2; an increase in PETO2
without a simultaneous decrease in PETCO2; or an increase
in respiratory gas exchange ratio. The details of this proce-
dure are described elsewhere (42). Multigated angiography
was also performed on a subset of subjects. These data will
be reported elsewhere.
Psychological measures. — A comprehensive psycholog-
ical test battery including measures of mood, psychiatric
symptoms, and neuropsychological functioning was admin-
istered before and after the exercise program.
Anxiety, depression, and overall mood were assessed by
questionnaires. Anxiety was assessed by the State-Trait
Anxiety Inventory (43), a 40-item questionnaire that mea-
sures levels of anxiety at the time of the assessment (state)
and in general (trait). Depression was measured by the
Center for Epidemiological Studies Depression Scale (44),
which is a 20-item scale that assesses how many days in the
past week the subject experienced symptoms associated with
depression. The Affect Balance Scale (45), a 10-item mood
survey, was used to measure global positive and negative
emotional states. Life satisfaction was assessed by the 20-
item Life Satisfaction Index (46), and a 10-item Self-Esteem
Scale (47) was used to measure perceived self-confidence.
Psychiatric symptoms were assessed from the Hopkins
Symptom Checklist (SCL-90-R) (48), a 90-item question-
naire designed to assess the degree of emotional distress and
psychopathology. For the purposes of this study, five scales
were selected to measure psychiatric symptoms including
the Somatization, Obsessive Compulsive, Phobic Anxiety,
Paranoid Ideation, and Psychoticism scales.
Neuropsychological functioning was assessed in several
behavioral areas. Two tests were used to assess strength and
motor function:
(a) The Finger Tapping Test (49) requires the subject to
tap the index finger of each hand as quickly as possible for
two 30-second trials alternating between dominant and non-
dominant hands.
(b) The Strength of Grip Test (49) requires the subject to
squeeze a hand dynamometer (Smedley Inc., Chicago) for
four trials. The first and third trials were performed with the
dominant hand, and the second and fourth trials were per-
formed with the nondominant hand.
Four procedures were used to assess memory function:
(a) The Short Story Module of the Randt Memory Test
(50) requires subjects to recall the details of a short story
immediately after it has been read to them and after a 30-
minute delay.
(b) The Digit Span Subtest of the WAIS-R (51) requires
subjects to repeat a series of digits that have been orally
M149
presented to them both forward and, in an independent test,
in reverse order.
(c) The Benton Revised Visual Retention Test (52) re-
quires subjects to draw from memory a series of geometric
shapes following a 10-second exposure.
(d) The Selective Reminding Test (53) requires subjects
to read a list of words and then to recall as many as possible.
Three procedures were used to assess psychomotor
function:
(a) The Digit Symbol Subtest of the WAIS-R (51) is a
paper-and-pencil task that requires subjects to reproduce,
within 90 seconds, as many coded symbols as possible in
blank boxes beneath randomly generated digits, according to
a coding scheme for pairing digits with symbols.
(b) The Trail Making Test (Part B) (49) requires subjects
to connect, by drawing a line, a series of numbers and letters
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in sequence (i.e., 1-A-2-B, etc.) as quickly as possible.
(c) The 2 & 7 Test (54) is a timed visual scanning task in
which subjects must identify "target" stimuli (the digits 2
and 7) from an array of visually presented distractors.
Several other tests were also included as general measures
of psychomotor function.
(a) The Nonverbal Fluency Test (55) requires subjects to
draw as many original, nonrepetitive designs as possible in a
five-dot matrix within a two-minute time limit.
(b) The Verbal Fluency Test (56) includes two one-
minute trials in which subjects are asked to generate as many
words as possible that begin with a given letter.
(c) The Stroop Color-Word Test (57) measures the ease
with which subjects can shift their perceptual set by accu-
rately naming the color of the ink that the words red, blue, or
green are printed in. Each word is printed in a different color
ink than the color it represents.
A Perceived Change Questionnaire was administered at
Time 2 only, and was designed to measure subjects' self-
ratings of perceived change in mood, personality, physical
and social functioning. Nineteen dimensions were included,
and each was rated on a 7-point Likert-type scale, from
"much worse" to "much improved."
Data Analyses
The principal mode of data analysis was a repeated mea-
sures multivariate analysis of variance (MANOVA). Group
(AE, YO, or WL) and Sex (Male or Female) served as
between-subject factors, while Time (Time 1 and Time 2 or
Pre- and Post-Treatment) served as a within-subject factor.
In order to control for the numerous instruments that were
used, variables were clustered into various conceptual units
(e.g., exercise performance, lipids, mood, psychiatric
symptoms, strength and motor function, memory, etc.)
whenever possible. Univariate analyses were examined
when significant multivariate effects were observed. In cases
where data could not be clustered (e.g., body weight), data
were analyzed by ANOVA.
RESULTS
Comparability of groups. — Table 1 shows the character-
istics of the subjects in the three groups. Among the 101
subjects who completed the Time 1 baseline assessments,
M150 BLUMENTHAL ET AL.
Table 1. Baseline Characteristics
Aerobic
(n = 33)
Age (years) 66.5 ± 4.3
Sex (M/F) M = 17 F = 16 M = 17
Education (years) 15.2 ± 2.0
V02max (ml/min) 1454.9 ± 538.0 1354.2
SCL-GS1 51.1 ± 3.6
Vocabulary 60.3 ± 6.9
Note: Values are means ± SD
there were no significant group differences in demographic,
physiological, or psychological characteristics.
The subjects in this study population were characterized
by educational levels above those in the United States
population as a whole. The incidence of psychopathology
was low and the level of intellectual functioning (inferred
from the Vocabulary subtest of the WAIS-R) was above
average as compared to published normative data (51).
Adherence to randomization procedure. — Of the 101
subjects who entered the study, 97 completed both Time 1
and Time 2 testing. Only four subjects failed to complete
their respective programs and were not available for the
Time 2 assessments. Of the four subjects who dropped out of
the study before the Time 2 assessments, two subjects
dropped out of the AE group because they moved from the
area, and two subjects dropped out of the WL group because
of family illness. This left a sample of 48 men and 49 women
for an overall adherence rate of 96%.
Assessment of subject participation indicated that the AE
and YO participants were highly compliant with their re-
spective programs. Subjects assigned to the AE group exer-
cised for a mean ( ± SD) total of 46 ± 2 exercise sessions
(out of a possible 48) while the YO group attended 32 ± 3
exercise sessions (out of a suggested 32) during the 16-week
period. Review of the daily exercise logs indicated that the
AE group subjects were within or above their prescribed HR
training range 88% of the time. Perceived exertion ratings
(RPE) during the aerobic exercise classes were in the "mod-
erate" range (13.4 ± 1.8).
Changes in cardiorespiratory fitness. — Heart rate at rest
and submaximal (300 kpm) workload, duration of exercise
on the bicycle ergometer, and peak VO2 were all considered
together in a MANOVA. The MANOVA for the measures of
cardiorespiratory fitness revealed significant multivariate
main effects for time, F(3,86) = 10.25, p< .001, and sex,
F(3,86) = 66.83, p < .001, and a significant multivariate
Group x Time interaction, F(6,172) = 7.69, p< .001.
Comparison of peak VO2 data revealed that men had
higher initial fitness levels (21.7 ± 4.2 ml/kg/min) than
women (16.0 ± 2.9 ml/kg/min). However, both men and
women in the AE group experienced comparable improve-
ments in aerobic capacity. Univariate analysis of the peak
VO2 revealed a significant Time x Group interaction,
F(2,90) = 6.89, p < .01. Figure 1 shows that subjects in the
AE group experienced an overall 11.6% increase in peak
VO2. Men achieved a 14.4% improvement in peak VO2 and
Yoga Wait List Total
(n = 34) (n = 34) (n = 101)
67.8 ± 5.9 66.8 ± 4.3 67.0 ± 4.9
F = 17 M = 16 F = 18 M = 50 F = 51
15.6 ± 2.6 14.6 ± 2.6 15.2 ± 2.4
± 438.9 1345.6 ±436.2 1376.6 ±471.6
52.1 ± 4.7 53.7 ± 6.6 52.3 ± 5.2
59.7 ± 8.1 57.7 ± 8.2 59.2 ± 7.8
women achieved an 8.6% improvement. AE participants
increased from 19.4 ± 5.3 to 21.4 ± 5.8 ml/kg/min. The
respiratory exchange ratios (RER) at Time 1 (1.30) and Time
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2 (1.33) were not significantly different, suggesting that
exercise tests at Time 1 and Time 2 were comparable. In
contrast, subjects in the YO and WL groups experienced a
nonsignificant 1-2% reduction in aerobic capacity (Yoga:
18.8 ± 4.7 to 18.7 ± 4.8 ml/kg/min; Wait List: 18.5 ± 4.0
to 17.9 ± 4.2 ml/kg/min). The success of the AE interven-
tion in inducing a cardiovascular training effect is also
reflected by their lower heart rates at rest and at submaximal
exercise workloads (i.e., 300 kp) and by the longer exercise
times during ergometry testing for the AE group only (see
Figure 1).
Anaerobic threshold (AT) was considered separately in an
ANOVA as an index of submaximal exercise performance.
The ANOVA revealed a significant sex main effect, F(l ,76)
= 123.71, p < .001, with men having significantly higher
ATs (955 ± 2 1 7 ml/min) than women (579 ± 93 ml/min).
There was also a significant Time x Group interaction,
F(7,79) = 3.23, p< .04. Figure 2 shows that the anaerobic
threshold increased 13% for the AE group, F(l,28) = 7.64,
p < .01, but did not change for the YO and WL control
groups.
Changes in lipids. — A MANOVA for the lipid values
revealed a significant multivariate sex main effect, F(4,89)
= 15.26, p < .001. Univariate analyses indicated that
women had higher HDL-cholesterol levels (60.6 ± 14.3
mg%) than men (44.5 ± 8.7 mg%). There were no sex
differences for total cholesterol or triglycerides, however.
The MANOVA also revealed a marginally significant multi-
variate effect for Time, F(4,89) = 2.34, p < .07 and a sig-
nificant multivariate Time x Group interaction, F(8,178)
= 2.29, p<. 03.
The univariate Time X Group interaction was significant
for total cholesterol, F(2,92) = 6.95, p < .002, and for
LDL-cholesterol, F(2,92) = 6.37,/? < .01. Figure 3 shows
that cholesterol levels for the AE group were reduced after
training, F(l,30) = 5.38, p < .05, while the cholesterol
levels for the YO group increased and the cholesterol levels
for the WL group remained unchanged.
Changes in weight and blood pressure. — An ANOVA
for body weight revealed significant main effects for sex,
F(l,87) = 67.9, p < .001 and time, F(l,87) = 4.30, p <
.05, and a Time x Sex interaction, F(l,87) = 7.87, p <
.01. Subjects in all three groups, particularly the men, lost a
 EFFECTS OF AEROBIC EXERCISE TRAINING M151

Heart Rate Heart Rate Males Only Females Only

(rest) (300 kpm)
115 Timel
Trne2
110 o-

105 B

100
3"M
95
u
2
BO

1700

1600 B
1500
B
Aerobic Yoga Wait List Aerobic Yoga Wait List
1400

1300
Aerobic Yoga Wait List Yoga Figure 4. Mean ( ± SE) values for bone mineral content in men and
women.
Figure I. Mean ( ± SE) values of cardiorespiratory training effects.

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700
Aerobic Yoga
Figure 2. Mean ( ± SE) values for anaerobic threshold (AT) obtained
during bicycle ergometry studies.
Cholesterol Triglycerides
Aerobic Vbga Wait List Aerobic Yoga
Figure 3. Mean ( ± SE) values for blood lipid levels.
small but statistically significant amount of weight (Aerobic:
0.4 kg; Yoga: 0.6 kg; Wait List: 0.2 kg).
A MANOVA for blood pressure (systolic and diastolic)
revealed a significant time main effect, F(2,91) = 5.61, p<
.01. The ANOVA for diastolic blood pressure (DBP) re-
vealed a significant time main effect, F(\ ,92) = 11.23, p <
.01, with all three groups showing a reduction of 2-4 mm Hg
in DBP (Aerobic: 79-75; Yoga: 79-77; Wait List: 79-75
mm Hg). There was not a significant univariate time main
effect for systolic blood pressure.
Changes in bone density. — An ANOVA for bone mineral
content revealed significant main effects for time, F(3,85) =
3.09,/? < .05, and sex, F(3,85) = 18.91,/? < .001. Figure4
shows that the sex main effect was observed because women
had lower mineral content values than men. The time main
effect was a result of the lower overall mineral content values
at Time 2 compared to Time 1 for all subjects.
Previous studies have used a ratio of bone mineral content
to bone width, and have found that women with a ratio <
.325 tend to be at risk for subsequent bone fracture (58).
Consequently, the sample was partitioned into High and
Low risk group categories based upon the suggested .325
cutoff. A 3 (Treatment group) x 2 (Risk group) x 2 (Time)
ANOVA revealed a marginally significant 3-way interaction
F(2,85) = 2.32, p < .10. The high-risk subjects who
Wait List participated in the AE group experienced an increase in bone
mineral content (0.47 ± .20 to 0.56 ± .18), while the high-
risk subjects in the YO and WL group experienced no
change.
Changes in mood. — The State-Trait Anxiety Inventory
(STAI), CES-Depression Scale, and Affect Balance Scale
were considered together in a MANOVA. Results revealed a
significant Time X Group x Sex interaction, multivariate
F(8,170) = 2.00,/? < .05. Examination of the univariate
effects revealed a significant Time x Group x Sex interac-
tion for the CES-Depression Scale, univariate F(2,88) =
5.39, p < .01. Examination of the right panel of Figure 5
reveals that the men in the AE group experienced a signifi-
Wait List
cant reduction in their depression scores, F(l,15) = 8.69,/?
< .01. The women in the AE group, however, did not
experience a statistically significant change in their depres-
sion scores and neither men nor women in the control groups
changed significantly between assessments.
The univariate ANOVA for trait anxiety revealed a mar-
ginally significant Time x Group x Sex interaction,
F(2,88) = 2.42,/? < .09. Examination of Figure 6 revealed
that men in the AE group tended to achieve lower trait
anxiety scores at Time 2 compared to the men in the other
groups, and women in the AE group tended to achieve lower
state anxiety scores than women in the other groups. The
ANOVA for the Life Satisfaction and Self-esteem scales
revealed no significant main effects or interactions.
Changes in psychiatric symptoms. — Five scales from the
SCL-90 were considered in a MANOVA for psychiatric
symptoms including Somatization, Obsessive-Compulsive,
Phobic Anxiety, Paranoid Ideation, and Psychoticism (see
Table 2). The results of this MANOVA revealed a multivari-
ate time main effect, F(5,86) = 3.56, p < .006. Significant
M152 BLUMENTHAL ET AL.

All Subjects Males only Males Only Females only

Aerobic Yoga Wait List Aerobic Yoga Wait List

Yoga Wait List Aerobic Yoga Wait List

Figure 5. Mean (± SE) values for CES-Depression in all subjects and in Figure 6. Mean (± SE) values for state anxiety (females) and trait
males only. anxiety (males) from the STAI.

Table 2. SCL-90 Psychiatric Symptoms

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Aerobic Yoga Wait List
Male Female Male Female Male Female
SCL-90 Scales Tl T2 Tl T2 Tl T2 Tl T2 Tl T2 Tl T2
Somatization 50.4 50.6 49.9 50.0 50.4 52.1 50.1 50.8 53.1 53.3 49.2 50.1
± 3.5 ± 3.3 ± 2.6 ± 2.9 ± 4.0 ± 5.7 ± 3.5 ± 5.8 ± 6.4 ± 7.4 :t 4.2 i: 4.6
Obsessive- 57.2 56.8 54.9 53.3 55.8 54.7 57.8 55.2 60.4 58.7 54.0 53.0
compulsive ± 5.6 ± 5.8 ± 4.7 ± 3.9 ± 8.7 ± 9.5 ± 8.4 ± 6.6 ± 7.7 ± 9.5 :t 4.8 ±: 5.2
Phobic anxiety 49.6 49.2 49.5 49.3 49.8 49.7 50.0 50.2 52.3 51.3 50.8 50.0
± 1.2 ± 0.8 ± 0.9 ± 1.0 ± 2.0 ± 2.8 ± 2.2 ± 2.9 ±6.5 ± 4.4 :± 4.1 i: 2.3
Paranoid 51.1 50.1 50.0 50.6 49.9 49.1 51.9 50.6 53.1 52.4 51.6 50.4
ideation ±4.2 ±4.1 ±2.3 ± 6.3 ±4.1 ±3.6 ± 5.2 ± 4.6 ± 4.0 ± 5.8 :t 5.0 ±: 4.5
Psychoticism 52.3 51.1 50.7 50.9 51.3 50.7 52.4 51.4 53.1 52.4 53.5 50.3
±3.9 ±3.4 ±2.1 ± 3.1 ± 3.0 ± 4.7 ± 4.6 ± 2.4 ±4.1 ±5.0 ± 10.2 i: 3.0

Note. Tl = Time 1; T2 = Time 2. Values are means ± SD.

Table 3. Strength and Motor Function

Aerobic Yoga Wait List

Male Female Male Female Male Female
Measures Tl T2 Tl T2 Tl T2 Tl T2 Tl T2 Tl T2
Tapping 139 .3 131.6 116.3 115.1 130.6 128.2 114.3 112 .5 137.1 131.4 112.4 116 .5
(dominant) ± 15 .2 ±: 14.3 ±: 15.1 ± 14.4 ± 17.5 i: 19.7 ± 21.6 ± 17 .8 ± 14.2 ± 17.5 ± 17.5 ± 19 .1
Tapping 123 .7 110.3 105.5 103.4 115.9 110.7 99.8 99 .2 118.4 113.0 102.2 98 .7
(nondominant) ± 16 .6 ±: 12.8 ±: 12.2 ± 14.0 ± 18.9 i: 18.3 ± 13.2 ± 13 .1 ± 15.3 i: 14.0 ± 17.3 ± 14 .7
Grip strength 49 .8 47.2 24.9 24.3 48.0 46.8 26.5 24 .3 44.8 43.5 27.3 26 .4
(dominant) ±9 .9 ±: 10.1 ± 6.7 ± 7.4 ± 7.7 ± 7.9 ± 3.8 ± 4 .0 ± 9.3 ± 8.7 :t 5.3 ± 5 .4
Grip strength 44 .7 42.3 21.4 21.3 42.3 41.3 23.8 22 .5 40.2 39.4 23.9 23 .3
(nondominant) ± 10 .5 ±: 10.3 ± 4.9 ± 5.9 ± 9.0 ± 9.5 ± 3.9 ± 4 .3 ± 8.3 ± 7.9 :t 6.1 ± 6 .0

Note. Values are means ± SD.

univariate time main effects were observed for obsessive-
compulsive, F(l,90) = 6.36, p < .01 and psychoticism,
F(l,90) = 4.15, p < .05, with subjects in all three groups
reporting fewer symptoms. No other significant multivariate
main effects or interactions were observed.
Changes in strength and motor functioning. — Strength
and motor function were assessed by tapping speed and grip
strength. Results of the MANOVA revealed a significant
time main effect, multivariate F(4,86) = 10.78, p < .001
and a sex main effect, multivariate F(4,86) = 48.85, p <
.001. Examination of Table 3 shows that men accomplished
more total taps for both the dominant hand, F(l,89) =
30.94,/? < .001 and nondominant hand, F( 1,89) = 22.28,/?
< .001, than women. Similarly, men achieved greater grip
strength for the dominant hand, F( 1,89) = 200.39,/? < .001
and nondominant hand, F(l,89) = 156.42, p < .001, than
women. Table 3 also shows that both men and women
tended to display decreased grip strength at Time 2 relative
to Time 1.
 EFFECTS OF AEROBIC EXERCISE TRAINING M153

Changes in memory. — Memory function was assessed by
the Digit Span Subtest of the WAIS-R, Benton Visual
Retention Test, the Randt Short Story Subtest, and the
Selective Reminding Test. Results of the MANOVA re-
vealed significant multivariate main effects for sex, F(7,84)
= 2.55, p < .02, and time, F(7,84) = 2.57, p < .02.
Examination of the scores in Table 4 indicates that men
scored higher on Digit Span than women, F( 1,90) = 7.82,/?
< .01, whereas women achieved higher scores than men on
the Selective Reminding Test, F(l,90) = 5.09, p < .03.
Significant univariate time main effects were found only for
two summary scores from the Selective Reminding Test,
greater long-term cumulative recall, F(l,90) = 4.17, p <
.05, and number of intrusions, F(l,90) = 4.47, p < .04.
Psychomotor function. — Psychomotor functioning was
and Digit Symbol Subtest from the WAIS-R. Results of the
MANOVA revealed a significant multivariate main effect
for time, F(4,87) = 3.97, p < .01. Univariate analyses
indicated a significant time main effect for Digit Symbol,
F( 1,90) = 15.11, p < .001. Table 5 shows that all subjects
performed better at Time 2 compared to Time 1.
Additional procedures included the Stroop Test and the
Nonverbal Fluency and Verbal Fluency tests. These data
were analyzed by a MANOVA that revealed significant
multivariate main effects for sex, ^(4,87) = 3.21, p < .02,
and time, F(4,87) = 12.71,/? < .001. Results are displayed
in Table 6. The univariate ANOVAs for Nonverbal Fluency
revealed a significant time main effect, F(l ,90) = 46.55, p
< .001. In addition, there was a significant sex main effect,
with men achieving higher scores than women, (1,90) =
8.39,/? < .01. Subjects in all three groups achieved a signifi-

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assessed with the 2 and 7 Test, Trail Making Test (Part B), cant increase in mean total productions at Time 2 relative to

Table 4. Memory Function

Aerobic Yoga Wait List
Male Female Male Female Male Female
Measures Tl T2 Tl T2 Tl T2 Tl T2 Tl T2 Tl T2
Digit span 9.3 9.8 8.6 8.0 9.8 9.3 7.4 7.9 8.4 9.3 8.4 8.3
(forward) ± 2.7 ± 2.8 ± 2.5 ± 2.3 ± 2.2 ± 2.4 ± 2.2 ± 1.6 ± 2.4 ± 2.4 d: 2.1 ± 2.0
Digit span 7.9 7.9 7.1 7.8 7.4 7.4 6.2 6.4 7.4 7.6 6.8 7.1
(backward) ± 2.9 ± 2.9 ± 1.8 ± 2.8 ± 2.8 ± 2.8 ± 1.7 ± 1.6 ± 2.3 ± 2.6 d: 1.9 ± 1.8
Benton 6.6 6.3 6.2 6.2 5.6 7.0 5.8 5.8 6.0 5.9 6.1 6.9
(correct) ± 1.8 ± 1.9 ± 2.0 ± 1.8 ± 2.2 ± 1.9 ± 2.3 ± 1.9 ±1.5 ±2.0 d: 2.0 ± 2.1
Benton 4.9 5.4 5.5 5.7 6.8 4.9 6.6 6.3 5.9 5.9 5.6 4.7
(error) ± 2.9 ± 3.2 ± 3.0 ± 3.5 ± 4.5 ± 3.8 ± 5.0 ± 3.5 ±2.7 ±3.1 ±3.4 ± 3.2
Story recall 9.6 11.4 11.1 10.7 10.4 9.8 9.7 9.8 9.7 11.9 10.3 10.6
(immediate) ±2.5 ±4.1 ± 4.1 ± 3.6 ± 2.6 ± 3.4 ± 3.8 ± 3.5 ± 3.5 ± 3.4 d: 3.5 ± 4.2
Selective 9.3 9.7 9.7 9.6 6.8 8.2 8.0 8.9 7.8 7.5 9.7 10.2
reminding ± 2.8 ± 2.9 ± 2.3 ± 3.0 ± 2.3 ± 3.2 ± 2.5 ± 3.0 ± 3.4 ± 3.0 d: 2.5 ± 2.2
(total cumula-
tive recall)
Selective 3.2 4.4 1.7 2.9 5.2 4.8 3.5 4.1 3.5 3.4 1.6 3.8
reminding ± 2.8 ± 5.2 ± 1.6 ± 2.4 ± 7.8 ± 6.9 ± 3.4 ± 3.3 ± 3.5 ± 2.3 d: 1.4 ± 3.8
(number of
intrusions)

Note. Values are means ± SD.

Table 5. Psychomotor Function

Aerobic Yoga Wait List
Male Female Male Female Male Female
Measures Tl T2 Tl T2 Tl T2 Tl T2 Tl T2 Tl T2

Trails (B) 83.8 76.1 81.3 83.1 88.2 87.4 90.9 94.9 83.9 85.5 78.8 77.9
± 34.2 d: 22.8 ±: 24.3 ± 32.0 ± 31.5 ±: 37.5 ± 43.0 ± 30.1 ± 45.2 ±: 44.1 ± 27.5 ± 27.7
Digit symbol 50.1 50.5 52.1 54.6 45.7 48.1 47.0 49.2 44.2 46.2 48.3 49.9
± 9.9 ± 9.3 ± 8.5 :t 8.6 ± 7.2 ± 8.5 ± 10.7 ± 11.3 ± 8.7 ±: 10.9 :± 9.7 :t 9.5
2 +7 9.9 8.8 10.7 7.5 11.2 12.6 8.4 8.8 6.8 7.2 7.9 8.0
(digits) ± 5.1 ± 7.5 ± 6.6 :t 4.6 ± 11.1 ±: 10.6 ± 5.4 :t 7.7 ± 4.0 ± 4.1 :± 6.3 :t 6.3
2 + 7 5.9 5.7 8.7 5.1 4.6 8.1 5.7 6.9 5.5 5.1 6.5 5.9
(letters) ± 4.6 ± 3.8 ± 6.6 :t 4.1 ± 3.6 ±: 11.4 ± 4.4 :t 6.5 ± 5.4 ± 5.3 :± 7.6 :t 4.1

Note. Values are means ± SD.

M154 BLUMENTHAL ET AL.

Table 6. Additional Psychomotor Tests

Aerobic Yoga Wait List
Male Female Male Female Male Female
Measures Tl T2 Tl T2 Tl T2 Tl T2 Tl T2 Tl T2
Stroop color 74.4 76.9 72.7 71.5 71.9 68.8 71.4 68.2 73.0 70.7 77.4 72.8
± 10.4 ±: 10.7 ± 11.1 ± 10.5 ± 11.2 ± 9.7 ± 14.0 ± 13.3 ± 10.9 ±: 11.4 ± 8.1 ± 11.8
S troop - 1.0 0.8 2.8 2.6 1.7 1.5 - 1.9 1.0 1.1 2.2 3.5 6.6
interference ± 7.1 ± 5.9 ± 6.1 :t 6.7 ± 5.2 ± 6.8 ± 5.5 :t 5.4 ± 5.5 ± 5.7 ± 7.5 ± 7.4
Verbal 44.8 43.7 43.8 45.2 46.4 45.8 44.1 42.9 45.7 46.2 43.1 45.6
fluency ± 12.6 ±: 13.2 ± 12.6 ± 10.5 ± 14.6 d : 13.3 ± 14.3 ± 12.9 ± 13.1 ±: 11.0 ± 14.7 ± 11.1
Nonverbal 17.3 19.2 14.4 15.5 16.1 17.5 11.9 14.2 15.4 16.6 15.2 17.2
fluency ± 3.8 ± 3.3 ± 3.8 :t 3.7 ± 4.0 ± 4.4 ± 3.4 :t 4.2 ± 4.6 ± 4.5 ± 4.3 :t 4.3
Note. Values are means ± SD.

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Table 7. Perceived Changes (in %) Among Study Subjects 60 minutes three times a week was associated with an overall
11.6% improvement in directly measured peak VO2 and a
Better Same Worse
13% increase in anaerobic threshold. This level of improve-
AE YO WL AE YO WL AE YO WL ment of cardiorespiratory fitness is generally consistent with
Overall Health Status 94 74 4 6 25 96 0 3 0 previous studies of older subjects that reported increases of
Sleep 39 41 0 55 59 100 6 0 0 V02max from 5-20% (59). For example, these data are
Energy 74 74 0 26 26 92 0 0 8 consistent with the recent 1-year trial of exercise among
Mood 71 76 12 29 21 85 0 3 4 retired men reported by Cunningham et al. (18). Moreover,
Self-confidence 55 68 19 45 32 81 0 0 0 the present results indicate that women participating in
Life-satisfaction 65 76 8 35 24 92 0 0 0 aerobic exercise are able to achieve similar levels of im-
Bowel function 26 38 4 74 59 92 0 3 4
provement in cardiorespiratory fitness. Posner et al. (60)
Memory 39 38 4 61 56 92 0 6 4
also reported recently a comparable improvement in
Ambition 58 44 8 42 53 92 0 3 0
Social life 39 38 0 58 59 100 3 3 0 V02max and maximal work rate in their sample of 28 elderly
Eating habits 42 35 12 58 62 88 0 3 0 men and women participating in four months of aerobic
Flexibility 84 91 0 16 9 100 0 0 0 exercise. Schocken et al. (61) also reported a 10% improve-
Physical endurance 100 76 4 0 24 92 0 0 4 ment in functional capacity, although VO2 was not measured
Loneliness 32 41 0 65 59 100 3 0 0 directly. It should be noted that reports by Seals et al. (21)
Weight 52 38 19 39 59 81 10 3 0 and Dustman et al. (33) found a two- to threefold larger
Appearance 61 38 4 39 59 96 0 3 0 improvement in aerobic capacity, however. These latter two
Family relations 35 38 0 65 62 100 0 0 0 studies differ from ours in several important respects: their
Concentration 58 38 4 39 59 88 3 3 8 samples were considerably smaller, subjects in their study
Sex life 45 24 0 55 74 100 0 3 0
included more men, and samples included subjects who
were less fit initially than subjects in the present study.
DeVries (62) also reported a 15.8% improvement in physical
Time 1. There were no significant main effects for Verbal work capacity after 42 weeks of exercise but reported data on
Fluency, however. Examination of the univariate time main only eight of an initial group of 112 male subjects aged 52 to
effects for the Stroop test revealed that performance im- 88. Dustman et al. (33) reported a 27% improvement in
proved both in terms of color performance, F(l ,90) = 4.65, V02max in 13 study subjects. Although our 4-month exer-
p < .04, and interference scores, F(l,90) = 5.08, p < .03, cise training protocol was similar to that of the Dustman et
for all three groups. al. study, subjects in the present study experienced less than
50% of the improvement in V02max reported by Dustman et
Perceived change in quality of life. — Examination of al. However, the Dustman sample was younger than the
Table 7 reveals that both the AE and YO groups reported present sample (60 vs 67 years) and predominantly male (9
comparable changes in social, personal, and physical func- of 14 subjects vs 50 of 101 subjects). Furthermore, our use
tioning. In contrast, the WL showed little perceived change of ergometry testing rather than treadmill testing may have
on any of the measures. The active treatment groups reported limited our VO2 values, since bicycle values may be 5-10%
more positive changes (chi square/? < .001) than the waiting lower than treadmill values (63,64). The significant 13%
list group on 17 of 19 variables. improvement in AT is also noteworthy. Changes in AT may
be more meaningful than improvements in V02max, as
DISCUSSION subjects' daily activities seldom require maximum effort
The results of this study indicate that four months of (65). Our data indicate that subjects in the AE group were
aerobic exercise training elicited significant increases in able to perform more work before exercise-limiting ventila-
tory and metabolic changes occurred and suggest greater
cardiorespiratory functioning in healthy older men and
submaximal, as well as peak, work capacity.
women. A moderate intensity aerobic exercise program of
 EFFECTS OF AEROBIC EXERCISE TRAINING
In addition to aerobic fitness, other favorable physiologi-
cal changes were observed among aerobic exercise partici-
pants including lower cholesterol levels and, for subjects at
risk for bone fracture, an increase in bone mineral content.
Previous studies have associated increased levels of physical
activity with higher bone mineral content (66-71). Talmage
and colleagues (71), for example, reported that the most
active women in a cohort of over 1,200 subjects had greater
bone mass than the sedentary women. In another cross-
sectional study, Jacobsen et al. (70) concluded that regular
exercise may reduce bone loss accompanying aging, espe-
cially post-menopausally. These cross-sectional studies con-
tain inherent biases, however (72). Our longitudinal data
indicate that four months of aerobic exercise may increase
bone mineral content in individuals who have low bone
density and who are apparently at risk for fracture. Although
the mechanisms for this observation are unknown, radial
measurements may reflect overall skeletal status in healthy
adults (73), and suggest that exercise may actually increase
bone density.
Although the relationship between exercise and serum
lipid levels has not been definitively established, decreases
in the total cholesterol and LDL-cholesterol and increases in
HDL-cholesterol have been reported (74). Our data are
consistent with recent reviews that suggest that reductions in
total cholesterol may be likely especially accompanying
weight loss (75). In the present study, weight loss was small
and consistent across the three groups, suggesting that re-
ductions in cholesterol may have been induced by the spe-
cific effects of the aerobic exercise. Although lipid assays
performed by commercial laboratories have been suspect
(40), our lipid assays were performed by the same commer-
cial laboratory throughout the duration of the study, and we
are unaware of any systematic source of bias that may have
selectively reduced the cholesterol levels in the aerobic
exercise group.
The representativeness of our study sample is also impor-
tant to consider in interpreting our data. For example, it has
been noted that 85% of all older persons have at least one co-
existing chronic medical condition. Our sample was healthy
with no concomitant illness. In addition, our subjects were
highly motivated to participate in our study, hence a 96%
compliance rate, and had a higher than average education.
The general lack of significant change using standard psy-
chlogical instruments may be due to the relatively high level
of functioning of our program participants. For example,
Himmelfarb and Murrell (76) reported a mean CES-D score
of 10.11 in their sample of 279 community elderly aged 54—
100 and 36.43 on the STAI trait anxiety scale. The mean
scores for our sample were 5.3 and 31.3 respectively.
Similarly, our subjects performed at a relatively high level
on the neuropsychological procedures and may have had
little room for improvement.
There were few psychological changes that could be
clearly attributed to a specific treatment condition. There
was a tendency for aerobic exercise to be associated with
improved mood, in that men experienced reduced depres-
sion scores and tended to have lower trait anxiety scores, and
women tended to have lower state anxiety scores. However,
the improved performance on the various neuropsychologi-
M155
cal tests was not unique to a particular group, and changes
were probably the result of practice and increased familiarity
with the tasks.
Two final points are worth noting. Despite the absence of
objective changes on the majority of the psychological
measures, subjects in the aerobic exercise and yoga groups
perceived themselves as changing on a number of important
psychological, social, and physical dimensions. In the phys-
ical area, subjects felt in better health, felt that they looked
better, and that they had more energy, endurance, flexibility,
and better sleep; socially, subjects reported improved family
relations, better sex life, less loneliness, and a better social
life; psychologically, subjects reported improved mood,
self-confidence and life satisfaction, and that they had better
memory and concentration. In contrast, the wait list control
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group perceived relatively little change over four months.
These differences may be due to the demand characteristics
of the study and may simply reflect the fact that subjects in
the two active treatment groups expected to feel better.
However, it is also possible that subjects' own self-percep-
tions may be more sensitive to change (on at least some
measures) than the standard psychometric instruments. Both
active treatment groups may have experienced an increased
sense of self-efficacy which, along with social support, may
have served to enhance their feelings of self-confidence and
self-esteem.
Second, it should be emphasized that these results repre-
sent changes in physical and psychological functioning after
only four months of treatment. It is possible that a longer
exercise program may be needed for significant psychologi-
cal changes to occur. We are currently investigating this
possibility in follow-up studies of this cohort.
ACKNOWLEDGMENTS
This research was supported by grant AG-04238 from the National
Institute on Aging and grant HL-30675 from the National Heart, Lung, and
Blood Institute.
The authors thank Janet Simon, Robin Pomeroy, Susan Schniebolk,
Julia Whitaker, Cheri Rich, Sally Schnitz, and Carol Cracchiolo for
technical assistance; Drs. Fred Cobb, Martin Sullivan, and Michael Higgin-
botham for ergometry testing; and Janet Ivey for secretarial assistance.
Address correspondence and requests for reprints to Dr. James A.
Blumenthal, Duke University Medical Center, Box 3119, Durham, NC
27710.
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Sports Exer 1984:16:223-7. Accepted September 30, 1988

INTERNATIONAL PERSPECTIVES ON CANCER IN THE AGED:

PREVENTION, RECOGNITION AND TREATMENT
FEBRUARY 21-23,1990
The Wyndham Harbour Island Hotel • Tampa, Florida

PRESENTED BY: The University of South Florida

• International Exchange • College of Medicine -
Center on Gerontology Dept. of Internal Medicine
• College of Public Health • College of Nursing
The primary focus of the Conference is on recent advances in the prevention,
etiology, detection and treatment of cancer among older persons. Important age-related
issues, the efficacy of various treatment modalities, the role of nutrition and psycho-
social factors and future trends in prevention and treatment will be explored. Twenty
hours (20) of Category ICME credits have been approved.
REGISTRATION
Pre-registration is required as registration is limited. The registration fee of
$175.00 is due by no later than December 15th, 1989 and includes attendance at all
scientific meetings and social events.
FOR INFORMATION
Contact: Colleen A. Cuervo, MJ>.A., Conference Development Director, (813) 974-3468
1ECG, University of South Florida, Box 3208, Tampa, Florida 33620