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Increasing Physical Activity in Frail, Older Adults: Guidance for Clinicians

Karen S. Feldt, PhD, APRN, BC, GNP   Disclosures

Introduction

Despite the reported benefits of exercise on physical and psychological well-being, Americans have grown increasingly sedentary. Morethan 70% of older adults could be classified as sedentary, defined as having no regular moderate physical activity or exercise.^[1-3] This concern was the focus of a symposium on prescribing and monitoring exercise in frail persons. Researchers described the current knowledge about the benefits of exercise, identified barriers to exercise for older adults, and discussed individual and national strategies to improve and promote exercise in frail elders.

Aerobic Exercise: Modifying Sedentary Lifestyles

Jerome Fleg, MD,^[4] Director of the Laboratory of Cardiovascular Science at the National Heart, Lung and Blood Institute, Bethesda, Maryland, presented a review of the research on what happens when older adults become sedentary. "We know that peak cardiovascular oxygen consumption declines in sedentary persons. Body composition changes with a sedentary lifestyle, increasing the fat in the abdominal area. We also see increases in blood pressure, insulin resistance, and cholesterol, specifically a decrease in HDL, the good cholesterol."^[4-5]

Fleg emphasized that increasing exercise may have more "health" benefitsthan actual "fitness" benefits. Fitness is related to a person's maximal capacity and has been linked to lower mortality rates. However, exercise, especially aerobic exercise, can improve health even if the person does not achieve maximal fitness. Some clear health benefits include improved cardiac function, better functional capacity, enhanced psychosocial well-being, improved mental status, and modification of coronary risk factors. Older studies have already demonstrated that people who walked 1-2 miles per day had similar reductions in mortality as did those who walked more than 2 miles, when compared with sedentary individuals. "That means, the worse off you are, the more you have to gain," even if the exercise is not maximal, says Fleg.

There are a number of salutary effects of aerobic exercise training in older adults, including:

1. Reduction in blood pressure, both systolic and diastolic. This decrease in BP has been shown to occur in both low-intensity and high-intensity exercise groups;

2. Improved peak oxygen consumption^[6];

3. Changes in glucose metabolism.^[7] Aerobic exercise improves insulin response and the body becomes more sensitive to insulin; and

4. Decreases in total cholesterol and improvements in HDL.

Fleg also pointed out that weight loss in combination with exercise may have an additive effect on lowering morbidity and mortality.^[7] Programs for elders should start with lower-intensity exercise and advance in small increments. Fleg pointed out that "We don't really have data yet on the optimal exercise program for frail elders." He identified the need for further research on frail elders with heart failure, including exercise and resistance training for this population.^[8]

Resistance Training

Resistance training is being increasingly evaluated to identify specific benefits for older populations. Joseph Signorile, PhD,^[9,10] Associate Professor in Exercise and Sport Sciences atthe University of Miami, Miami, Florida, discussed the effects of specific resistance training techniques on strength, power, and functional performance in frail older individuals.

"We selectively lose Type II skeletal muscle fibers with increasing age," noted Signorile. These fast-contracting fibers may be essential in helping persons to right themselves quickly as they begin to fall. His research has demonstrated that elders improved their strength with low-speed resistance training, but elders who do high-speed resistance training performed betteron activities of daily living. Muscle strength declines by 15%-30% per decade after age 70 years, but resistance training can result in huge gains for elders, including improved functional performance.^[3,11]

Exercise should be individualized after an extensive evaluation of the patient's particular needs. This model may not be possible for clinicians to implement with patients in their daily clinical visits. Signorile recommends that elders combine resistance training with flexibility exercises, endurance exercises, and balance exercises so that older adults can improve in several areas of function. Clinicians need to be aware that very frail elders with osteoporosis may not be able to do power training because of the possibility of spontaneous fractures. Careful screening and counseling of patients is essential before weight and resistance training programs are initiated.^[12]

A Seven-Step Approach to Exercise

Learning how to initiate exercise programs for elders can be challenging. "Most older people don't jump at the chance to exercise," says Barbara Resnick, PhD, CRNP, FAAN, FAANP, Associate Professor, University of Maryland, Department of Adult Health Nursing, Baltimore, Maryland. She presented findings from her study of 175 older adults living in a continuing-care retirement community.^[13] Over half of the elders initially interviewed in that study performed zero hours of moderate exercise weekly.^[14] She became particularly concerned about howto motivate older adults to exercise.

Resnick has used Bandura's social cognitive theory to shape her work on exercise in older adults. This theory identifies that motivation is really related to both intrinsic and extrinsic factors of the individual.^[15] The intrinsic portion of motivation is linked tothe older adult's beliefs. That is, the more the individual believes he or she is capable of performing an activity, the more likely she or he will do it. The extrinsic portion of motivation can be identified as the person's outcome expectancies, or the beliefs that a certain consequence will be produced by personal action. From this initial work, Resnick developed a 7-step approach to help motivate older adults to exercise.^[16]

Step 1: Education. Education should include the:

• Anticipated benefits of exercise (decreasing joint stress, pain, riskof falling, improve mood and sleep)

• Anticipated responses to exercise in someone who has been sedentary (increased heart rate and awareness of heartbeat, increased breathing rate, perspiration, mild muscle aches)

• Warning signs of excessive exercise (severe dyspnea, wheezing, coughing, chest pain or discomfort, dizziness, or marked fatigue).^[3,16]

Older adults who are aware of both the benefits and the changes they will have during exercise are better prepared to start a program.

Step 2: Exercise Prescreening. Screening is important because it establishes where to begin and it offers guidance on level of ability to manage an exercise program. Individuals who start at levels that are too difficult may develop more serious health problems, or become discouraged by their inability to perform adequately. Older adults with very limited functional capacity may believe that they are not suited for exercise, even though they may have the most to gain.^[8] Prescreening should include a history and physical examination directed at identifying cardiac risk factors and physical limitations. Most elderly can begin a low-to-moderate exercise program (such as a walking program) without cardiac stress testing if they start slowly and gradually increase their activity level.^[3]

Step 3: Goal Setting. Older adults should be assisted in setting clear, specific, attainable goals that can fit into their life or schedule. Realistic goals might include: being able to walk without becoming short of breath, eventually walking without an assistive device, being to able to walk farther without needing to rest, taking less medication, having less knee pain, and feeling better psychologically.^[16] If older adults set their only goal as losing weight, they may stop exercising without realizing the other benefits they have already achieved. Resnick advises that at first, older adults can be encouraged to focus on the amount of time they spend exercising, not the degree of intensity of the exercise.

Step 4: Exposure to Exercise. This step requires a careful review of all of the barriers that elders identify. Solutions to each of the barriers must be addressed or elders may not begin or continue in any exercise program. Healthcare providers need to offer solutions to barriers includinglack of time, pain, fear of hurting or injuring joints, fear of falling during exercise, fear of having a cardiac arrest, no place to exercise, sensory deficits, fatigue, or comments that the patient really doesn't want to increase his life expectancy.^[3,16,17] Logistical problems also need to be solved. These can include the lack of transportation, caregiving for a dependent spouse, or lack of community areas for exercise.^[3,8]

Step 5: Exposure to Role Models. Other older adults who exercise can provide a great source of encouragement for newcomers to activity. However, this really means that the healthcare provider must be aware of the active older adults or programs in the community that can be resources to beginners. Church-centered, faith-based programs of exercise may offer motivating social, spiritual, and clinical benefits.^[18]

Steps 6 & 7: Verbal Encouragement and Verbal Rewards. Resnick describes encouragement for beginning a program of activity as letting patients know that they really are capable of doing this activity. Encouragement to continue exercise can emphasize the goals established previously. Verbal rewards are the praise and congratulations on efforts thus far. Patients can feel rewarded by the genuine enthusiasm or congratulations from a primary care provider.^[16] Graphs or charts with stickersor stars that reward mobility or distance walked can be as appealing to older adults as they are to younger persons.

Developing a National Blueprint for Physical Activity

The symposium wrap-up was a discussion of the current work of the National Blueprint Project for Increasing Physical Activity Among Adults Aged 50 and Older. Wojtek Chodzko-Zajko, PhD,^[19,20] Professor and Head of the Department of Kinesiology at the University of Illinois at Urbana-Champaign, reviewed the goals and findings of the Blueprint Partners project. This project represents the combined effects of 46 national organizations to develop a document to serve as a guide for organizations and agencies concerned with the need for improving regular physical activity of older Americans.

"The data about the benefits of exercise are clear, but the challenges to implementing exercise programs are huge," explained Chodzko-Zajko. This project is the first large attempt to include all the stakeholders and organizational issues involved in helping older Americans become physically active. It takes into account the comprehensive health issues, medical systems, marketing, transportation, environmental issues, education, and research that must be addressed for successful implementation of exercise programs.

Several examples of the barriers to sustaining physical activity for older adults have been identified. These are listed more comprehensively at the National Blueprint Web site.^[21] Some of the barriers discussed at the meeting include^[17,21]:

• Lack of evidence-based research to provide guidance on the type and amount of physical activity that would be needed to produce a specific outcome for older adults;

• Few research studies that have identified strategies on how to sustain activity programs for older adults;

• Research studies are rarely translated into practical interventions that could be carried out in any home or community setting;

• Home and community barriers such as poorly designed or unsafe neighborhoods that discourage physical activities by older adults. Many suburban neighborhoods lack sidewalks, while personal safety may be more of a concern in urban neighborhoods;

• Health professionals are not often sought to give recommendations to the professionals in community planning/urban design, transportation, or recreation;

• Older adults simply do not know how to start a community-based exercise program;

• Even if elders know of potential community activity sites, they may lack transportation or the financial resources to participate in planned community programs;

• Physicians receive very little education on disease prevention or exercise (however, nurse practitioner education generally stresses disease prevention strategies);

• Age-specific patient education materials on physical activity need tobe available to healthcare providers;

• There is no easy-to-use, evidence based, physical activity prescription protocol for older adults;

• Healthcare providers need to be aware of the type and quality of community activity programs and resources available for older adults;

• There are not good economic models that clearly illustrate the cost benefits of increasing physical activity for persons over the age of 50 years and especially the cost benefit for persons age 75 years and older;

• Many of the marketing or public messages about physical activity and exercise have been unclear, inconsistent, and confusing to older adults and health professionals;

• There is minimal marketing research to define perceptions, beliefs, and concerns about physical activity or exercise of the 50-years-and-older age group; and

• There have not been enough effective messages developed and tested to communicate information about physical activity.

Although these barriers seem formidable and discouraging, there is already work being done to overcome them. The task force identified numerous strategies to address these issues and improve the physical activity levelsof older Americans.

Blueprint on Strategies for Improving Physical Activity of Older Adults

The National Blueprint Project suggests several strategies to increase physical activity, many of which are already under way. The strategies are divided into 5 categories or areas: research, home/community, workplace, medical systems, and public policy.^[20,21]

Strategies for research identify steps needed in research, including medical, social, behavioral, policy, and marketing research. These recommendations include:

• Developing profiles of elders who are active to better understand the characteristics of the active population;

• Developing longitudinal studies of activity-friendly communities to determine impact on reducing disease;

• Developing more research to understand what motivates elders to startand continue physical activity;

• Developing more appropriate and valid measures of physical activity and outcomes; and

• Conducting research related to HCFA/Medicare guidelines for physical activity in older populations.

The home/community strategies take into account the nature of how people live and carry out the normal tasks of daily life. These strategies include:

• Developing professionals who can act as information resources in the community;

• Providing a template to community organizations for physical activityfor older persons; and

• Designing "health-impact" assessments for communities (similar to environmental impact assessments).

Workplace strategies recognize that people generally work in or near the community in which they live, and worksites can often operate as a community resource or center. These strategies were not discussed at the symposium because of the focus on frail older adults, but are available at the National Blueprint Web site.^[21]

The Blueprint document identifies medical systems in a broadly defined way, to include healthcare delivery centers, such as clinicians' offices, clinics, medical centers, hospitals, and healthcare reimbursement organizations. The strategies highlighted in this section include:

• Establishing methods for physical activity assessment, counseling, and follow-up for older adults;

• Incorporating "best practices" on physical activity into educational programs for all healthcare providers and professionals;

• Developing evidence-based practice guidelines for physical activity for older adults and distributing information to healthcare professionals;

• Providing health professionals with education on how to promote physical activity in older adults; and

• Developing standards to improve physical activity in long-term-care environments.

Public policy and advocacy strategies were also established in these guidelines. The focus of these strategies was for initiatives to be developed at the local, state, and national levels. The Blueprint group recognized that effective policy or advocacy initiatives needed to include coordination and collaboration among organizations and associations that share priorities and objectives.^[20,21] Examples of these strategies include:

• Providing incentives to states and communities that achieve measurable improvements in the physical activity of older adults;

• Educating policy makers of the social, economic, and health benefits of physical activity of older adults;

• Conducting policy analysis of health plans that offer benefits related to physical activity for older adults; and

• Outlining characteristics that make a community "activity-friendly" for older adults.

Summary

Encouraging physical activity among older adults is an important and challenging task. Leaders at this symposium indicate that clinicians can look forward to guidelines and educational materials that will help them encourage and implement these programs for the frail population they serve. Several additional resources, Web links, and information on physical activity programs for older adults are available through the National Blueprint Web site.^[21]

References

1. Clark D. Physical activity and its correlates among urban primary care patients aged 55 years or older. J Gerontology. 1999; 54B: S41-S48.
2. Jones DA, Ainsworth BE, Croft JB, Macera CA, Lloyd EE, Yusuf HR. Moderate leisure- time physical activity: who is meeting the public health recommendations? A national cross- sectional study. Arch Fam Med. 1998;7:285-289.
3. Nied R, Franklin B. Promoting and prescribing exercise for the elderly. Am Fam Physician. 2002;65:419-428.
4. Fleg J. Salutary effects of aerobic exercise training in older adults. Program and abstracts of the American Geriatrics Society 2002 Annual Scientific Meeting; May 8-12, 2002; Washington, DC.
5. Katzel LI, Sorkin JD, Fleg JL. A comparison of longitudinal changes in aerobic fitness in older endurance athletes and sedentary men. J Amer Geriatr Soc. 200149:1657-1664.
6. Talbot LA, Metter EJ Fleg JL. Leisure-time physical activities and their relationship to cardiorespiratory fitness in healthy men and women 18-95 years old. Med Sci Sports Exerc. 2000;32:417-425.
7. Ross R, Dagnone D, Jones PJ, et al. Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men: a randomized, controlled trial. Ann Intern Med. 2000;133:92-103.
8. Fleg JL. Can exercise conditioning be effective in older heart failure patients? Heart Fail Rev. 2002;7:99-103.
9. Signorile J. The effects of specific resistance training techniques on strength, power, and functional performance in frail older individuals. Program and abstracts of the American Geriatrics Society 2002 Annual Scientific Meeting; May 8-12, 2002; Washington, DC.
10. Signorile JF. Sport-specific training techniques in an older population. Rehab Manag. 1997;10: 64-65.
11. Slade JM, Miszko TA, Laity JH, Agrawal SK, Cress ME. Anaerobic power and physical function in strength-trained and non-strength-trained older adults. J Gerontol A Biol Sci Med Sci. 2002;57:M168-M172.
12. Chakravarthy M, Joyner M, Booth F. An obligation for primary care physicians to prescribe physical activity to sedentary patients to reducethe risk of chronic health conditions. Mayo Clin Proc. 2002;77:165-173.
13. Resnick B. Seven step approach to motivate older adults to exercise. Program and abstracts of the American Geriatrics Society 2002 Annual Scientific Meeting; May 8-12, 2002; Washington, DC.
14. Resnick B. Testing a model of exercise behavior in older adults. Res Nurs Health. 2001;24:83-92.
15. Bandura A. Self-efficacy: The Exercise of Control. NewYork: W.H. Freeman; 1997.
16. Resnick B. Managing arthritic with exercise. Geriatr Nurs. 2001;22:143-150.
17. Cooper KM, Bilbrew D, Dubbert PM, Kerr K, Kirchner K. Health barriersto walking for exercise in elderly primary care. Geriatr Nurs. 2001;22:258-262.
18. Yanek LR, Becker DM, Moy TF, Gittelsohn J, Koffman DM. Project Joy: faith based cardiovascular health promotion for African American women. Public Health Reports. 2001;116(suppl):68-81.
19. Chodzko-Zajko W. Guidelines for physical activity in aging persons (WHO) guidelines. Program and abstracts of the American Geriatrics Society 2002 Annual Scientific Meeting; May 8-12, 2002; Washington, DC.
20. Chodzko-Zajko W, Ohta T, Faes MM, et al. Responses to publication of the WHO Heidelberg Guidelines for promoting physical activity among older persons. J Aging Physical Activity. 1997;5:79-86.
21. The National Blueprint: Increasing Physical Activity Among Adults Age50 and Older. Available at: www.agingblueprint.org. Accessed June 12, 2002.