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Physical activity reduces morbidity in older patients

What are the benefits of increased physical activity?

What type of exercise is suitable for older people?

How can GPs support and motivate patients to be more active?

What are the benefits of increased physical activity?

What type of exercise is suitable for older people?

How can GPs support and motivate patients to be more active?

There is a strong association between severe disability and very old age. With the ageing population the burden of disability seems likely to escalate.

However, disability is not necessarily inevitable in old age and may be postponed or avoided by positive lifestyle choices. Participation in regular, moderate-intensity physical activity in old age, such as walking, can double the likelihood of dying free from disability.1

Physical activity and exercise are often used interchangeably but have different meanings. Physical activity is movement of the body by the skeletal muscles that results in energy being expended. Exercise, in contrast, is a subset of physical activity that is planned, structured, and repetitive and is done with the specific goal of improving physical fitness. Very few of us exercise regularly but most of the population are physically active to some extent as part of daily life.

Regular physical activity can significantly reduce blood pressure and has been shown to confer some protection against CHD, diabetes, osteoporosis, and breast and colon cancer, see table 1, attached. Long-term follow-up studies have also shown that older people (over 65 years of age) who exercise three or more times a week are less likely to develop dementia.2

The psychological benefits of regular physical exercise should not be underestimated. It improves self-esteem and wellbeing, and may reduce mild depression.3

Even in older patients, muscles are trainable with amounts of physical activity that fall well below currently accepted public health recommendations,4 and quite modest regular physical activity can have positive effects on physical independence.5,6

Brisk walking for as little as 2.5 hours per week has been shown to reduce the risk of cardiac events in older women by 30%.7 Activities with modest goals, such as walking, may be more achievable, sustainable, appropriate and less daunting for older people. The greatest proportionate benefit seems to occur when the least active individuals become moderately active.8

Adoption of physical activity
Health professionals can play an important role in initiating and supporting lifestyle changes. However, in order to be able to encourage older adults to be more physically active it is essential to understand the factors that may influence both adoption and adherence, see table 2, attached.

Motivators
Motivation to take up physical activities in later life seems to depend on previous experience, general health, knowledge and psychological factors.6,9 The strongest predictor of physical activity at any age is enjoyment. It is therefore important to find an activity that is done for pleasure. Continued participation in an activity is also influenced by encouragement and support from others.

Deterrents
A survey of 409 people aged 65-84 years found that deterrents to physical activity included lack of interest, physical symptoms, reluctance to join a group and mistaken beliefs about the lack of benefits of physical activity.10

Safety
For the vast majority of the population, the risk associated with sedentary behaviour substantially outweighs any risk from physical activity. Generally, older people are less likely to push themselves beyond their limits or to be more physically competitive.

Older individuals with health problems may believe that physical activity will worsen a pre-existing condition. In fact, studies have now established the feasibility and benefits of physical activity in peripheral vascular disease,11 stroke, COPD, coronary artery disease12 and arthritis. Older patients with osteoarthritis have also reported less pain and physical disability with resistance training.13,14 Exercise trials in very old people living in institutional care settings have reported no adverse events15 and the University of Dundee's over 60s exercise classes have attracted thousands of pensioners over the past three decades and, despite an open-door policy, has incurred no adverse events.

Patients can be reassured that if they are engaged in an activity that is not causing symptoms of distress, they are very unlikely to be doing themselves any harm.

Promotion
GPs are repeatedly reported as a credible and preferred source of health advice, particularly with regard to information about physical activity for older patients.16 GP support can be a powerful impetus for adopting and maintaining an active lifestyle.17,18

Where to exercise
Exercise can be conducted within a healthcare centre, in the community or at home. There is clear indication in the literature that physical activity promotion programmes, in a variety of forms, can be successful.19 However, older people may not have been exposed to these programmes in the same way that younger individuals are ie in schools or the workplace. The GP and team are uniquely placed to promote lifestyle changes.

By familiarising themselves with local exercise programmes and activities GPs can advise older patients to get involved. Various support measures and feedback relating to improved performance or general wellbeing may provide additional incentives for continued participation in these programmes. This can be provided either by the GP, practice nurse, exercise group or instructor, friends or family.

The key message for older patients is that ‘doing something is better than doing nothing'. Further advice on helping older people take up exercise is shown in box 1, attached. For many patients, walking is the ideal activity.

The type of physical activity is not important, but should leave the patient feeling uplifted and happy. The easiest way to get started is by incorporating physical activity as part of a daily routine. Older people should be encouraged to ‘get moving' by any form of activity, eg walking, gardening, dancing or playing with grandchildren.

Physical activity should challenge the body to work above the resting level and intensity is classified according to the amount of energy expended compared with the baseline energy expenditure at rest.

Public health recommendations suggest that most adults should be doing around 30 minutes of moderate-intensity activity on most days of the week.20 The recommendations for very old people (over 85 years of age) will be considerably less than this.

People who are resuming activity after a number of years should be advised to start slowly, build up gradually and stay within their own limits of comfort.

Physical activity does not need to be done in one continuous session, but can be broken down into shorter bouts. For example, a 10-minute walk for the newspaper in the morning, followed by 15 minutes of gardening at lunchtime and 10 minutes playing with the grandchildren amounts to a healthy and achievable level of activity for the day. It seems that it is the total ‘volume' of physical activity accumulated during the day that confers health benefit, irrespective of the duration or number of activity bouts.19

Conclusion
It is easy to lose sight of the fact that physical activity is a normal health-enhancing behaviour at all ages. GPs are in a position to encourage older patients to be active.

Key points Box 1: Helping patients to be more physically active Table 1: Risks associated with inactivity and benefits of physical activity Table 2: Factors influencing adoption of and adherence to physical activity Useful information

Age Concern. Keep fit
www.ageconcern.org.uk

Age Concern. Leisure and Learning. Factsheet 30. July 2008 www.ageconcern.org.uk

Directgov. Over 50s health and well-being. Staying physically active www.direct.gov.uk

NHS Choices. Fitness
www.nhs.uk

The University of Dundee's over 60s exercise classes. www.dorothydobsonsover60s.com

Authors

Dr Angela Wilkinson
MBChB MRCP
specialist registrar in medicine for the elderly

Professor Marion ET McMurdo
MBChB MD FRCP CBiol FIBiol
Professor of Ageing and Health, Medicine for the Elderly NHS Tayside and University of Dundee

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