Physical Activity in Older Adults

Original Editor - Caroline Greenwood

Top Contributors - Wendy Walker, Kim Jackson, Admin, Vidya Acharya, Giulia Neculaes, Bhanu Ramaswamy, Lucinda hampton, Evan Thomas, Simisola Ajeyalemi, Christina Nowak, Shaimaa Eldib, Rucha Gadgil and Carina Therese Magtibay  

Introduction

Physical activity (PA) in older people is critically important in the prevention of disease, maintenance of independence, and improvement of quality of life. Despite the obvious benefits to older people from being active, for example, preventing falls, remaining independent, reducing isolation, and maintaining social ties in order to improve mental health, women and men become less active as they age across all WHO regions.

• Regular physical activity (PA) has the potential to provide substantial health advantages to individuals across all age groups. It is important to note that for PA does not diminish in later stages of life. In fact, there is mounting evidence suggesting that engaging in PA can prolong the duration of active independent living, decrease disability, and enhance the overall quality of life for older individuals.
• The significant increase in the global aging population has presented new challenges in promoting the health of older individuals. It is crucial to not only extend their lifespan but also enhance the "quality" of their extended years. Encouraging older people to increase their level of physical activity is one effective approach to achieve this goal.

What is Ageing?

Aging is an inevitable process that manifests differently in each individual. The rate at which aging occurs and the specific areas of the body that are affected can vary greatly from person to person. Initially, the signs of aging may be subtle and have minimal impact on a person's daily life. However, as time goes on, these changes accumulate and eventually impact all systems within the body. It is important to note that the aging process encompasses both biological and psychosocial changes.

• Psychosocial changes occur as individuals navigate through different roles in society. They often adapt their goals and priorities, which can make it challenging for some older individuals to accept the need for assistance or to recognize the importance of self-care. This can lead to feelings of sadness and frustration. Consequently, older individuals often require additional motivation and support.
• Biologically changes occur at a molecular and cellular level, resulting in a decline in physiological reserve and an increased susceptibility to various diseases. Even in individuals who maintain a healthy and active lifestyle, there is a gradual decline in strength, endurance, bone density, and flexibility, typically at a rate of approximately 10% per decade. Muscle power, in particular, diminishes at a faster rate of about 30% per decade. These changes can significantly impact a person's overall level of functioning.

The physical functioning of older individuals has been the subject of a recent study utilizing the International Classification of Functioning, Disability, and Health (ICF) framework. The findings revealed a significant decline in muscle strength, including hip abductors and knee extensors, as well as various aspects of physical performance such as walking capacity, speed, mobility, sit-to-stand performance, upper extremity function, and balance performance after one year. However, there were no notable changes observed in the levels of participation in activities of daily living, activities related to balance, or physical activity.

We live in an ageing population with the majority of people now are expected to live beyond 60 years.  

• In 2015, 8.3% of the world’s population was older than 65, an increase of 1% from 2005. 
• This population is often seen as having poor health, this doesn’t need to be the case.  
• Many chronic conditions and non-communicable diseases can be prevented or delayed, by engaging in healthy behaviours. 
• Despite this, studies have found that this age group spend on average 10.7 hours per day sitting, with 40% of this age group living a sedentary lifestyle.  
• It is crucial that this is addressed, and that older adults are encouraged to be more active. 

Benefits of Exercise

As is commonly known, there are many health benefits of exercise and this stands true for adults of all ages. Systematic review and meta-analyses among Japanese community-dwelling older adults suggest the prevalence of sarcopenia (9.9%  overall: 9.8% among men, and 10.1% among women), providing valuable information in addressing sarcopenia prevention in the older community.

Resistance training will improve strength and can reverse or delay the decline of muscle mass and strength that occurs with ageing. Aerobic exercise can help to improve endurance by increasing the capillary density, mitochondrial and enzyme levels in the skeletal muscles. Together, this can help older adults to maintain their participation in ADLs and therefore maintain independence. Randomized Controlled trial demonstrated that Augmented Prescribed Exercise Program (APEP) enhances outcomes in weak older medical patients in the acute setting as compared to the usual care, thus suggesting that this intervention is valuable to frail medical inpatients.

Exercise can also help to reduce the risk of many non-communicable diseases. Exercise has been shown to:

• Reduce the risk of coronary heart disease, stroke, certain types of cancers and diabetes. 
• Prevent post-menopausal osteoporosis and therefore reduce the risk of osteoporotic fractures. 
• Reduce the complications of immobility 
• Reduce the risk of accidental falls
• Improve mental/cognitive function, reduces stress/anxiety and improve self- confidence

Being active from an early age can help prevent many diseases just as regular movement and activity can help relieve the disability and pain associated with these conditions. Importantly, the benefits of physical activity can be enjoyed even if regular practice starts late in life. It has been suggested that older adults engaged in regular physical activity demonstrate improved:

• Balance
• Strength
• Coordination and motor control
• Flexibility
• Endurance.

What Exercise is Appropriate for Older Adults?

The exercise regimen and level of intensity will vary based on the individual's capabilities. Physical activity options for older adults are diverse and include activities like walking, swimming, stretching, dancing, gardening, hiking, cycling, or participating in organized exercise sessions. However, there are specific factors to consider when recommending physical activity for older adults:

• The intensity of aerobic activities should be adjusted according to the older adult's aerobic fitness level.
• It is recommended to engage in activities that maintain or enhance flexibility.
• Balance exercises are beneficial for older adults who are at risk of falling.
• Older adults with medical conditions or disabilities that may impact their ability to be physically active should consult with a doctor for guidance

It is crucial to acknowledge that some older individuals may have limited range of motion, reduced muscular strength and mass, or stiff joints due to disabilities. In such cases, manual handling and passive exercises can be utilized to maintain their well-being, while also encouraging active exercises.

Clinical Guidelines

The current international recommendations for physical activity in adults vary slightly across different countries.

• In Australia, it is recommended that individuals aged 65 years and over engage in at least 30 minutes of moderate-intensity physical activity on most, if not all, days. If starting with 30 minutes seems challenging, one can begin with just 10 minutes once or twice a day and gradually increase the duration over time. Incorporating different types of activities throughout the week is also encouraged, while minimizing sedentary behavior..
• In Canada, the recommendation is to aim for at least 30 minutes of moderate-intensity physical activity on most, if not all, days. Similarly, in the United States, it is advised that all adults accumulate a minimum of 30 minutes of at least moderate-intensity physical activity on most, if not all, days of the week..
• In the United Kingdom, the guideline suggests that adults should strive for a total of at least 30 minutes of at least moderate-intensity physical activity on five or more days of the week for general health benefits.

It is important to note that these recommendations serve as a guideline and individuals should consult with healthcare professionals for personalized advice based on their specific circumstances.

Falls Prevention

Approximately 30% of adults over the age of 65 experience at least one fall each year. Studies have shown that exercise is an effective way to decrease the number of falls and injuries resulting from falls. This exercise regimen can be done at home or in a center, either individually or in a group setting. It should include a combination of balance, gait training, and strength training. The exercises should be challenging but safe, achieved by reducing the participant's base of support, shifting their center of gravity, or removing hand support. Ideally, individuals should aim to complete at least 3 hours of exercise per week to achieve the greatest reduction in the risk of falls.

Physical Activity in Dementia

• Studies show that patients with dementia or mild cognitive impairments have better cognitive scores after 6 to 12 months of exercise compared with sedentary controls.
• Telomere length is an indicator of biological aging, and short telomere length is associated with various geriatric diseases, such as cancer, dementia, osteoporosis, and mortality. Recent systematic review and meta-analysis of randomized controlled trials suggests that exercise positively affects the telomere length compared to usual care or inactivity, and aerobic exercise performed at moderate intensity over six months or longer is the most effective in slowing the rate of telomere shortening.

• Meta-analyses of RCTs of aerobic exercise in healthy adults were also associated with significantly improved cognitive scores, concluding " physical exercise may also attenuate cognitive decline via mitigation of cerebrovascular risk, including the contribution of small vessel disease to dementia".
• In 2018, a study came to a different conclusion regarding the effects of exercise on people with dementia. The Dementia and Physical Activity trial studied 494 people with dementia, with a 2:1 random allocation to exercise versus control. The study found that people with dementia who were assigned to a year of vigorous exercise had a worse mean score on the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-cog) than those who kept to their usual routines. The study also found that a four-month aerobic and strengthening exercise program did not slow cognitive decline in people with mild to moderate dementia, and there is a possibility that the intervention could worsen cognition.
• However, a randomized control trial suggests that home-based exercise and nutrition strategies have a positive outcome on the frailty score and physical performance in pre-frail or frail older adults.
• Another single-blind randomized clinical trial evaluating the effects of usual care and early structured exercise intervention on 370 elderly hospitalized patients showed improvement in muscle power output of lower limbs at submaximal loads and maximal muscle strength.
• A systematic review shows the advantages of brain health with exercise training in older adults due to the changes in brain structure and function.
• Additionally, another systematic review suggests that e-health strategies are effective in enhancing physical activity in older patients.

Designing an Exercise Program

WHO has published specific guidelines (2020) for people older than 65 and recommended that both aerobic exercise and strength training should be carried out.

• Adults and older adults (>65) should do at least 150–300 min of moderate-intensity aerobic physical activity, or at least 75–150 min of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate-intensity and vigorous-intensity activity throughout the week for substantial health benefits;
• Adults and older adults (>65) should also do muscle-strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week, as these provide additional health benefits.
• Older adults, as part of their weekly physical activity, should do varied multicomponent physical activity that emphasises functional balance and strength training at moderate or greater intensity on 3 or more days a week, to enhance functional capacity and to prevent falls.

1. Aerobic exercise- Older persons should build up to at least 30 minutes of aerobic exercise – for example walking, swimming, water exercises, and stationary cycling – on most, if not all, days. Studies show that a treadmill-walking program has positive effects on the postural balance of institutionalized older adults.
2. Strength training- The following regimen allows the individual to maintain bone and muscle strength. In order to continue to strengthen muscle and bone, one should steadily increase the intensity (weight) of the workout. Recommendations are:
   1. Strength training 2 to 3 days a week, with a day of rest between workouts
   2. When repetitions can be made in good form with ease, weight lifted should be increased

The exact exercise chosen will, of course, vary from person to person. It is important that medical conditions are considered, as well as the patients' fitness and level of function. If exercise is new to someone, it should be first discussed with their health care provider and then a program of gradual increase should be implemented. As recommended by WHO, exercise should include both aerobic and strength training, but it should also ideally include a component of balance training and flexibility work. Options may include hiking, walking, swimming, gym, dancing, tai chi, or chair exercises. It is important to find something that each person enjoys and can continue with independently.

A qualitative study exploring how older people participating in an evidence-based exercise intervention describing their relationship with their therapists and how this relationship might contribute to their motivation for exercise, suggests that 'Therapeutic Alliance' is an essential part of therapy and relational knowledge and competence are necessary for transferring professional knowledge in therapy. The findings are useful to therapists involved in clinical practice, especially to those working with vulnerable groups.

How to Promote Positive Health Message

The WHO 2020 guidelines reaffirm messages that some physical activity is better than none, that more physical activity is better for optimal health outcomes and recommend reducing sedentary behaviours.

In order to successfully engage older adults, it is important to frame the message in the correct way. It has been found that gain-framed messages, ie. Messages that highlight the benefits of engaging in a particular behaviour, are significantly more likely than loss-framed messages to promote prevention behaviour. For example, the message ‘exercising regularly can help you to lose weight’ would be more effective than the message ‘not exercising regularly can make you gain weight'.

Links to healthy living campaigns:

• Make your move- sit less- be active for life 
• Growing stronger- strength training for older adults

• Living Longer Living Stronger


Related pages

• Age and Exercise
• Falls in the elderly