Making the case for physical activity and older people

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Active for Later Life
Making the case for physical activity and older
people
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• What do we mean by older people?
• The benefits of physical activity for older
  people
• How active are older people?
• How active should older people be?
• Can we help to change matters?
• What helps older people to become active?
• Older people and physical activity strategic
  connections

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What do we mean by older people?
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We all age, but we all age differently
What do we mean by older people?

• Not a homogeneous group
• Traditionally defined as those aged over 50
• Significant variations in health and functional
  capacity
• Improvements in health and longevity
• Self-identification often most important

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Hierarchy of physical function
What do we mean by older people?
Physically fit
Physically unfit
Physically unfit frail
Group 1
Healthy
Unhealthy independent
Group 2
Unhealthy dependent
Group 3

• (World Health Organization, 1997)

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Hierarchy of physical function
What do we mean by older people?

• (Adapted from Spirduso, 1995)

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National Service Framework for Older People
What do we mean by older people?

• Entering old age
• Transitional phase
• Frail older people
• (Department of Health, 2001a)

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Older people and physical activity
What do we mean by older people?

• Entering old age
• Making Activity Choices
• To promote and extend healthy active life and
  compress morbidity
• Transitional phase
• Increasing the Circle of Life
• To maintain independence and reduce long-term
  dependency
• Frail older people
• Moving in the Later Years
• To maintain independence and improve quality of
  life

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The benefits of physical activity for older
people
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The benefits of physical activity for older people

• Increasing evidence in relation to
• Disease prevention and management, psychosocial
  benefits and complications of immobility
• Maintaining independence, improving the quality
  of life, and successful ageing
• Opportunities for significant savings to health
  and social care services
• Benefits can be achieved by healthy older
• people as well as the frail and very old.

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Prevention and management of disease
The benefits of physical activity for older people

• Coronary heart disease
• Stroke
• Increased blood pressure
• Late onset (Type 2) diabetes
• Osteoporosis
• Colon cancer
• Weight control
• Reduction in accidental falls
• Effects apparent even among those taking up
• activity at a later age.

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Psychological benefits
The benefits of physical activity for older people

• Reduction in stress and anxiety
• Reduction in depression
• Improvement in overall psychological well-being
• Improvements in cognitive function
• Improvements in self-esteem and self-worth
• Reduction in isolation and loneliness
• Effects apparent even among those taking up
• activity at a later age.

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Reducing the complications of immobility
The benefits of physical activity for older people

• Deep vein thrombosis
• Gravitational oedema
• Intermittent claudication
• Contractures
• Pressure sores
• Faecal impaction
• Effects apparent even among those taking up
• activity at a later age. Movement can be
• passive and aided.

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Improvements in independence, quality of life
and successful ageing
The benefits of physical activity for older people

• Maintenance of social networks
• Continued independent living
• Improved quality of sleep
• Sustained performance of activities of daily
  living
• Effects apparent even among those taking up
• activity at a later age.

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Potential social benefits
The benefits of physical activity for older people

• Enhanced social integration
• Formation of new friendships
• Widening of social networks
• Role maintenance and new role acquisition
• Empowerment
• Enhanced inter-generational activity
• Positive images of older people
• Maintenance of caring skills
• Reduced health and social care costs

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Reduction in health and social care costs
The benefits of physical activity for older people

• Accidental fractures among women (1.8 billion)
• CHD and stroke (1.6 billion for health care
  alone)
• Diabetes (5 of NHS resources)
• Obesity (2.5 billion)
• Poor mental health (32 billion)

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Changing the focus of physical activity promotion
The benefits of physical activity for older people
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How active are older people?

• Levels of physical activity,
• fitness and functional capacity

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Regular physical activity amongMEN aged 50,
England
How active are older people?
80
60

• participating at least five times a week

40
20
0
50-54
55-59
60-64
65-69
70-74
75-79
80
(Skelton, Young et al, 1999)
Age
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Regular physical activity amongWOMEN aged 50,
England
How active are older people?

• participating at least five times a week

(Skelton, Young et al, 1999)
Age
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Regular physical activity among minority ethnic
groups aged 55, England
How active are older people?

• Those participating in activity 5 x 30 minutes a
  week

Men Women
African-Caribbean Indian Pakistani Bangladeshi Chi
nese
20 22 15 7 13
14 2 6 1 14
(Erens et al, 2001)
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Levels of sedentary behaviour among MEN aged
50, England
How active are older people?

• participating less than once a week

(Skelton, Young et al, 1999)
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Levels of sedentary behaviour among WOMEN aged
50, England
How active are older people?

• participating less than once a week

(Skelton, Young et al, 1999)
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Levels of sedentary behaviour among minority
ethnic groups aged 55, England
How active are older people?

• Those participating less than once a week

Men Women
African-Caribbean Indian Pakistani Bangladeshi Chi
nese
57 67 73 85 68
59 78 85 92 64
(Erens et al, 2001)
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Participation in walking among MEN aged 70,
England
How active are older people?

• able to walk for different periods of time and
  length of walk, without discomfort

(Skelton, Young et al, 1999)
Age
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Participation in walking among WOMEN aged 70,
England
How active are older people?

• able to walk for different periods of time and
  length of walk, without discomfort

(Skelton, Young et al, 1999)
Age
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Older people living in care and residential
settings
How active are older people?

• 86 of women and 78 of men in care homes are
  sedentary.
• Sedentary behaviour in care homes is double that
  in private households (at age 65).
• Half of all men and women in local authority
  residential homes never or very occasionally take
  trips outside the home.
• (Department of Health, 2002b)

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Thresholds for quality of life
How active are older people?

• Exercise performance

Threshold value necessary for performance of an
everyday task
Age
Adapted from Young (1986)
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Aerobic capacity in MEN and WOMEN aged 50-74
(mean 2sd)
How active are older people?

• Maximum oxygen uptake (ml/kg/min)

(Skelton, Young et al, 1999)
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Knee extension strength inMEN and WOMEN aged
50-74 (mean 2sd)
How active are older people?

• Isometric knee extension strength (N/kg)

(Skelton, Young et al, 1999)
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Shoulder flexibility inMEN and WOMEN aged 50
(mean 2sd)
How active are older people?

• Shoulder abduction (degrees)

(Skelton, Young et al, 1999)
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Functional capacity
How active are older people?

• Even healthy older people lose functional
  capacity.
• Muscle strength lost at 1-2 per year
• Muscle power lost at 3-4 per year
• Aerobic capacity lost at 1 per year
• Bone density lost at 1 in men and 2-3 in
  women after menopause
• Flexibility and balance
• Proprioception and kinesthetic awareness
• Co-ordination and reaction
• Thermo-regulation
• Sedentary behaviour increases loss of
  performance.
• (Skelton and Dinan, 1999)

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Functional decline and frailty
How active are older people?

• (Spirduso, 1995)

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Inactivity-related disease?
How active are older people?

• Disuse rather than disease?
• One weeks bed rest reduces strength by up to
  20 spine bone mineral content by 1.
• Nursing home residents spend 80-90 of their
  time seated or lying down leading to
  inactivity-related disability.
• Those who are less active and weaker will enter
  nursing homes earlier than those who maintain
  their fitness.

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Physical activity is disappearing from everyday
life
How active are older people?

• Labour-saving devices
• Transport patterns
• Concerns over safety in public spaces
• Sport as entertainment
• The impact of information technology
• Leading to an increase in sedentary and
  physically
• less demanding lifestyles

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How active should older people be?

• Current recommendations

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Recommendations for all adults
How active should older people be?

• 30 minutes of moderate physical activity, on at
  least five occasions a week.
• (Department of Health, 1999b)
• Activities like brisk walking, cycling, swimming,
  dancing and gardening are good options.

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Working towards the recommended levels
How active should older people be?

• Those who cannot achieve the recommended 30
  minutes should build towards that target, e.g. 2
  x 15 minutes and smaller bouts of activity on a
  regular basis.
• Even the smallest amounts will bring some
  benefit, e.g. walking to the post box on the
  corner of the street or to the bottom of the
  garden.

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How active should older people be?

• Physical activity for the older person should
  also include
• muscle strength and endurance (resistance)
  exercises for all major muscle groups
• balance exercises
• flexibility (stretching)
• (American College of Sports Medicine, 1998)

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Physical activity opportunities for older people
How active should older people be?

• Continued or renewed sports participation and
  active recreation as well as fitness, exercise
  and dance activities and groups
• Active Living including walking, cycling,
  swimming and gardening
• Playing with grandchildren, posting a letter,
  walking in shopping centres
• Chair-based activities
• Assisted corridor and ward walking, or activities
  in the bath and at bedtime

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Can we help to change matters?

• Evidence of effectiveness and successful
  interventions

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Evidence of effectiveness
Can we help to change matters?

• From a critical review of 29 physical activity
  interventions
• Increased activity levels over a longer period of
  time
• Group/class-based and home-based activity were
  effective
• Tailored to individual needs
• Cognitive-behavioural strategies and goal-setting
• Telephone support and continued contact
• (King et al, 1998)

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Evidence of effectiveness
Can we help to change matters?

• Strength Fiatarone et al, 1990
• Functional capacity Skelton et al, 1995
• Bone density Rutherford, 1999
• Depression Blumenthal et al, 1999
• Blood pressure Young et al, 1999
• Mental health Fox, 1999
• Cardiac rehabilitation Jolliffe et al, 2001

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Evidence of effectiveness falls prevention
Can we help to change matters?

• FICSIT Trials Province et al, 1995
• Tinetti et al, 1996
• Wolf et al, 1996
• Campbell et al, 1997
• PROFET Close et al, 1998
• Gardner et al, 2000
• FaME Skelton, 2001
• Day et al, 2002

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Evidence of effectiveness duration vs outcome
Can we help to change matters?

• Gait (8 weeks)
• Balance (Static 8 weeks Dynamic 8 weeks)
• Muscle strength (8-12 weeks)
• Muscle power (12 weeks)
• Endurance (26 weeks)
• Transfer (6 months)
• Postural hypotension (24 weeks)
• Bone strength (1 year for femur and lumbar spine)
• (Skelton and McLaughlin, 1996)

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Promoting physical activity through primary
health care
Can we help to change matters?

• Physical activity advice/counselling can increase
• physical activity.
• King et al, 1995
• Riddoch et al, 1998
• PAL Goldstein et al, 1999
• Eakin, 2001

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Home-based programmes
Can we help to change matters?

• Improve health and function in older people
  living in the community
• Some studies show higher rates of adherence to
  prescribed exercise compared with group
  activities.
• Telephone-based counselling improves
  participation and adherence.
• Improvements in muscle strength and functional
  capacity.
• (Atienza, 2001)

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Community-based physical activity programmes
Can we help to change matters?

• Reviews
• King et al, 1998 Stewart, 2001
• Interventions
• CHAMPS Stewart, 2001
• GALM Stevens et al, 1999
• On the Move Cassady et al, 1999
• Dunn et al, 1999
• There is a need for differentiation.

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Best practice for promoting physical activity
with older people
Can we help to change matters?

• Use of a health educator and extended
  consultation time
• Agreement of problem areas
• Goals agreed by both older person and
  professional
• Identification and recognition of social and
  environmental barriers
• Tailored action plan
• Choice and range of accessible local activities
• Supplementary educational materials
• Systematic follow-up and support over time

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What helps older people to become active?

• Barriers, beliefs, attitudes
• and motivation

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Barriers to activity
What helps older people to become active?

• Intrinsic barriers
• Those that relate to the beliefs, motives and
  experiences of the individual, e.g. previous
  experiences at school, concerns about
  over-exertion, or perceptions of physical
  activity.

• Extrinsic barriers
• Those that relate to the broader physical
  activity environment, e.g. skills and attitudes
  of others, the types of opportunities available,
  access and safety.

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Previous experiences
What helps older people to become active?

• Opportunities in school
• Activity not associated with fitness and health
• Armed forces
• Limited experiences of sport
• All aspects of life were more physically demanding

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Older peoples sources of beliefs
What helps older people to become active?

• The media (radio, TV, magazines, newspapers)
• Workplace, leaflets
• Common sense
• Personal experiences (and experiences of others)
• Medical and health professionals
• (Finch, 1997)

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Beliefs about activity
What helps older people to become active?

• Its good for you.
• Its common sense.
• General health benefits
• Specific health benefits e.g. weight control,
  mental well-being, specific conditions
• Maintenance of function
• Onset of ageing
• (Finch, 1997)

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Moderation at our age
What helps older people to become active?

• You can overdo it.
• Gentler activities are more suitable.
• It depends on the individual.
• Fears over breathlessness and increased heart
  rate.
• (Finch, 1997)

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Beliefs exceptions to the positive view
What helps older people to become active?

• The health lottery
• A fashion for exercise nowadays
• You need to be fit to do physical activity.
• Too late to start
• Dangers when you stop
• It can become an obsession.
• (Finch, 1997)

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Overcoming barriers
What helps older people to become active?

• The association between physical activity and
  exercise and sport
• Frequency
• Intensity
• Old age is a time to slow down.
• Reassurance and education
• (Finch, 1997)

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Beliefs about activity the underlying
motivators
What helps older people to become active?

• To maintain suppleness and agility, and control
  weight
• Feeling better
• Enjoyment
• Prevent future illness
• Manage existing health problems
• To keep going, be independent (live longer rare)
• Adventure/challenge, new learning
  
• (Finch, 1997)

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Overcoming concerns about being active
What helps older people to become active?

• I dont think I should start at my age.
• Im worried I might hurt something.
• I have to take it easy at my age.
• My aches and pains will get worse.
• Can I do exercise with my blood pressure?
• Health concerns need the advice of a GP.

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Triggers and life events
What helps older people to become active?

• Wanting to play with grandchildren
• Physiological signs of ageing
• Retirement, children leaving home
• Onset of ailment or illness
• Moving home
• Bereavement
• Maintaining independence
• (Finch, 1997)

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Extrinsic barriers
What helps older people to become active?

• Skills and attitudes of others, e.g. exercise
  instructors, GPs, leisure/recreation managers
• Appropriate programming
• Accessible opportunities (transport)
• Safe activity environments (parks, well-lit
  streets)
• Positive images of older people

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A different spin on fitness
What helps older people to become active?

• Strength to lift household objects
• Flexibility to wash hair, tie shoes
• Balance and agility to climb stairs
• Co-ordination and dexterity to open a door with
  a key
• Speed to cross the road at pedestrian traffic
  lights
• Muscular endurance to walk to the shops

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Older people and physical activity Strategic
connections
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National Service Framework for Older People
Strategic connections

• Standard 8
• The promotion of health and active life in old
  age
• Increasing physical activity
• Improved nutrition and diet
• Immunisation and management of influenza
• Other areas of health promotion e.g. smoking
  cessation

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National Service Framework for Older People
Strategic connections

• Standard 1 Age discrimination
• Standard 5 Stroke
• Standard 6 Falls
• Standard 7 Mental health

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National Service Frameworks
Strategic connections

• Preventative aspects of
• NSF for Coronary Heart Disease
• NSF for Mental Health
• NSF for Diabetes
• NHS Cancer Plan
• National osteoporosis strategy

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Other strategic connections
Strategic connections

• Successful ageing and Ageing Well
• Independent living
• Cultural strategies and sports development e.g.
  Active Communities
• Neighbourhood regeneration and renewal
• Human transport
• Lifelong learning

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Active for Later Life Summary

• Physical activity can contribute significantly
  towards successful ageing.
• Although physical activity can confer a wide
  range of benefits, the majority of older people
  remain inactive.
• Even modest amounts of activity can be
  beneficial.
• There are many opportunities to enable older
  people to become Active in Later Life.