Benefits And Methods Of Increasing Physical Activity In The Elderly
Introduction
The elderly make up a significant proportion of the worldwide population at present. This portion of the population is set to increase significantly of the next few decades due to reduced fertility rates, migration and increased life expectancy. As this this part of populations grows all parts of society but will have to adapt, particularly the health care sector. Older populations require greater medical and social support. Individuals experience greater disability and dependence. Models predict that ageing will result in moderate increases in expenditure in acute care and even greater increase in long-term care.
Increasing physical activity (PA) in the elderly is one means of reducing future health care burden. The health benefits of PA in the elderly are well established. It is an important part of positive ageing and should be promoted to maintain the health and wellbeing of this section of the population. Physiotherapists are placed to promote physical activity in the elderly. This essay will discuss means by which physiotherapists can increase PA in older adults and how this is currently achieved.
Physical Activity in the Elderly
PA refers to “body movement that is produced by the contraction of skeletal muscles that increases energy expenditure. Increased PA is associated with increased rates of survival in older people. While it was originally thought frailty and comorbidities would increase as a result but this has not proven to be the case. Levels of frailty are reduced and a general improvement in health status is observed with increasing levels of activity. It is an important factor in the prevention of chronic conditions. It also improves cognitive health and reduces the risk of developing dementia. Older individuals have improved physical function, increased independence and quality of life. Increased mobility is also seen. Rates of falls are also reduced in older person with increased PA. Falls is a significant cause of hospital admissions and this contributes health care costs. Similarly, increased PA is associated with reduced hospital stays and reduced use of health care resources in older persons. The benefits described are seen in both healthy older adults and those with functional limitations and disabilities.
The Role of Physiotherapists
Physiotherapists are an essential source of health information to the public. They have long been involved in various means of health promotion. Surveys suggest that the overwhelming majority of physiotherapists consider it their role to provide PA to patients, even where it is not a specific treatment for a patient. Physiotherapists are experts in exercise and movement in individuals of all age groups. Physiotherapy practice typically involves regular and prolonged patient contact. This makes them ideally placed to promote PA in the elderly. Many patients have long-term chronic conditions and multimorbidities that contribute to PA. Physiotherapists understand have the expertise to help patients overcome these barriers.
Assessment, screening and monitoring
Assessment and screening during clinical sessions is an important part of health care contacts. Physiotherapists can screen for many risk factors for diseases including PA. Levels of are often asked about in response to the presenting complaint for example for those presenting with musculoskeletal disorders.
Single-question screening questions are effective
Screening can even be performed by asking a single question on the topic individuals. This method has been shown to be specific, sensitive and reliable in identifying physically inactive individuals. Where more detail of PA is required, a number of outcome measures can be used. Both direct and indirect methods of ascertaining PA exist. Indirect forms include diaries and logs of PA although questionnaires are most often used. Questionnaires specific to older persons include the Physical Activity Scale for the Elderly (PASE), Community Healthy Activity Model Program for Seniors Activities Questionnaires for Older Adults (CHAMPS). Direct methods of determining patient PA include wearable technology such as pedometers. One downside of such devices is that they may not accurately record PA as users often significantly increase their PA in response to wearing them. This in itself may be a good reason to recommend wearable technology. Some walking programmes specifically work around using wearable technology and are effective. A more recent development in this area is the use of smartphones. Smartphones are effective tools at monitoring PA levels. While use amongst older adults has not increased to the same levels as younger generations, use has grown. Focus groups show that older persons are interested in using smartphones for health benefits. Applications on these devices are effective at monitoring and increasing PA in the older population although larger randomly controlled trials are still required.
Education of benefits and recommended levels of physical activity
Despite the clear benefits, the majority older adults do not reach recommended levels of physical activity. The benefits of PA for older persons are clear. It is important that patients are aware of the same and the levels of activity required to gain these benefits. Current guidelines recommended a minimum amount of exercise per week for older adults. The American Sports College of Medicine and American Heart Foundation recommend 150 minutes of moderate intensity or 75 minutes of vigorous PA per week. Resistance exercise for major muscle groups is also recommended at least twice per week. At present, the majority of older adults fall short of the recommended levels of PA. 40% of older adults meet aerobic activity guidelines and only 15% percent meet both aerobic and strength guidelines.
However PA intensity decreases as individual’s age. In recent years, there has been increased focus on low to moderate levels of PA but lower levels of PA have not yet been incorporated into guidelines. Firstly, it is important to educate older patients about the recommended level of exercise. Secondly, it is important to discuss barriers to reaching those levels and possible find a way to work around those barriers. Finally, where it is not possible to meet the recommendations it is important to let patients know that some exercise is better than none, even if recommended levels are not met.
Physiotherapists can often provide written material and brochures regarding this area and often they will provide informal education and advice. They even refer elderly patients to physical activity classes and gyms.
Exercise Prescription
Exercise a subset of PA, refers to “planned, structured and repetitive movement to improve or maintain one or more components of physical fitness. ” Physiotherapists are well equipped to prescribe exercise to patients. One study found that when healthy adults are prescribed physical activity by a physiotherapist or medical doctor, they tended to significantly change PA behaviour. Self-reported measures of PA indicate that this increase activity persists.
Physiotherapists can prescribe and recommend a number of forms of exercise that have been shown to be effective in older adults. Endurance training is overwhelmingly beneficial to older adults. For example, walking is a common form of exercise that a physiotherapist can prescribe to their patient. Physiotherapists can encourage walking by using walking diaries and using pedometers. Group walking programmes are also an effective and enjoyable means of increasing PA. Walking and similar types of interventions are cost-effective and efficacious means of increasing PA. The cost of moving into the ‘active’ category was found to be €331 to €3673 after 12 months in one systematic review. Resistance training is another form of exercise that physiotherapists can recommend for older adults. It is both safe and effective at improving health. Physiotherapists can also prescribe balance exercises to elderly patients. Such exercises improve mobility but they are of particular benefit to those who are at an increased risk of falls. Additionally, balance exercises improve quality of life and reduce fear of falling.
Another recent development in exercise for older adults is the use of virtual reality-based exercise (VRE). A recent study showed that VRE increased both physical and cognitive scores. Physical measures were improved, albeit not as much as physical exercise. However, measures of falling and perceived exertion were reduced more so with VRE. Importantly, the VRE was considered more enjoyable than standard exercise. This form of exercise may be a useful option for older adults, particularly when many older individuals’’ PA is affected by the state of the weather!
Health Behaviour Modification
Physiotherapists are well-suited to modifying patients’ health behaviours. In addition to being able to find solutions to common barriers to increasing PA they are also familiar with various models of health behaviour change. These include the Stages of Change, Transthoretical and Health Belief models. While lack of skill, lack of resources, lack of time, lack of energy and social influence have been noted by patients as barriers to increasing PA, lack of willpower was identified as the most significant barrier. It is important that physiotheraposts recognise the readiness of their patients to change health behaviours such as physical activity. This better enables practitioners to use their intervention strategies to increase PA.
Make Every Contact Count
Every health care contact is an opportunity to improve a patient’s health whether this is in an inpatient, outpatient or community setting. Patient’s can be screened for provided with brief interventions. Health care workers can raise awareness about health behaviours and encourage a patient to consider improving them. For example, alcohol awareness and smoking cessation are often targeted with brief interventions. Worker’s speciality and the purpose of the contact do not matter. Such interventions are increasingly used to increase PA in all age groups, including older adults. They are an effective and cost-effective means of increasing PA. Traditionally, health promotion has been seen more often in primary care settings. Secondary care settings were seen as too busy for such discussions. However recently hospital policies have been changing to encourage health promotion by health care workers in the hospital setting.
Current Physiotherapy Practice
While many tools are available for physiotherapists to assess and promote PA in the elderly, recent surveys indicate that promotion of PA is inconsistent. While physiotherapists discuss PA during clinical sessions with their patients, this is done so inconsistently. Brief interventions are inconsistently used and there is no common framework by which physiotherapists can provide PA education to patients. Similarly, PA guidelines are not consistently used in practice. The 2017 survey carried out by Lowe et al of 522 physiotherapists found that 88% of respondents are aware of PA guidelines. However, when asked three basic questions about endurance and strength guidelines, only 16% of respondents answered correctly. This indicates that there is inadequate knowledge of the guidelines. An earlier review of the Irish undergraduate curricula found that there is a dearth of information regarding PA and exercise education taught to undergraduates, particularly with regarded to public health and lifestyle-related disease. These findings are at odds with physiotherapists own point of view. An earlier review that found physiotherapists feel confident in their expertise to promote physical activity. A concern regarding the lack of knowledge of these guidelines is that interventions regarding PA may actually meet best clinical practice.
Lowe also found that assessment and screening of PA was often absent or informal. This is in line with previous findings that found PA is often assessed on an ad hoc basis or when it relevant to the presenting complaint. Given that physical activity is a risk factor for many conditions and confers many health benefits in the elderly, these results are disappointing.
A number of barriers to assessing PA were also identified. The most consistent barrier appeared to be the complexity of the patients. This primarily refers to their comorbidities but socioeconomic factors also contributed. Other barriers included working in an acute setting, the culture of the physiotherapy team and lack of time. Given the recent efforts to encourage PA promotion in health care and in the acute setting, this is surprising. Further to this, time-constraints should not be a barrier to assessing PA in patients. Studies show that single-question screening is effective and reliable at identifying physically inactive individuals.
Conclusion
The benefits of PA are clear and increasing levels of the PA will help reduce the probably increased health care burden that will come with ageing populations. Physiotherapists are in the ideal position to assess PA of the public and they have a number of tools by which they can promoted PA. The number of tools available is ever increasing as technology provides more and more options. However, surveys of practicing physiotherapists indicate that the promotion of PA in patients is inconsistent and knowledge of PA is lacking. Furthermore, a cohesive framework that physiotherapists can encourage PA in clinical practice is not currently available.
