The Journal for Nurse Practitioners
Volume 6, Issue 3 , Pages 187-192, March 2010

Facilitating Successful Aging: Encouraging Older Adults to Be Physically Active

  • Amanda Adams-Fryatt

      Affiliations

    • Amanda Adams-Fryatt, RN, BN, MN, is a nurse practitioner at the Kildonan Personal Care Centre in Winnipeg, Canada.

Article Outline

Abstract 

Participation in regular physical activity has the potential to change the way we age. Evidence indicates that engaging in regular physical activity can provide dramatic physical, mental, and social benefits to older adults and decrease overall any-cause mortality. For older adults, the focus changes, and beside the promotion of health, maintenance of independent living becomes paramount. Nurse practitioners (NPs) must counsel older adults on the benefits of physical activity. The Stages of Change theory can be used to encourage older adults to change sedentary behavior and become more active.

Keywords:  health promotion , independence , older adults , physical activity , stages of change

 

Older adults (65 years and older) are the most rapidly growing age group. Due to advancing knowledge and technology, people are now living longer. In 2011, the baby boomers will begin turning 65 and by 2030, 20% of the American population and 13.2% to 21.2% of the Canadian population will be over 65.1, 2 This age group will become the dominant demographic category for the first time in history.

It is important to remember that physical activity is one of our most basic functions. The first step a child takes marks a milestone in development. Throughout life, physical activity provides opportunities to increase motor skills important for healthy living. As we age, physical activity becomes essential to maintain independent living and a happy and healthy life. Participation in regular activity has been heralded as one of the most important factors attributed to successful aging.3, 4 The concept of successful aging refers to a process where deleterious effects of aging are minimized and good health is maintained.5 Aging need not be accompanied by disease and disability. The Stages of Change theory is a behavioral model that the practitioner can utilize to facilitate a healthy behavior change. This facilitation is well within the scope of the advanced practice nurse.

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Health Promotion 

In a review conducted by Warburton et al,6 it was found that regular physical activity unquestionably provides primary and secondary prevention of chronic disease. Primary prevention refers to activities that are directed toward preventing disease; engaging in physical activity with the intent to prevent illness is primary prevention.7 Secondary prevention focuses on screening; the objective is early diagnosis and treatment of disease.7 With regard to primary prevention, it has been shown that regular physical activity is associated with a decreased risk of death from cardiovascular disease and is important in the prevention of type 2 diabetes mellitus, colon and breast cancer, and osteoporosis.6, 8 However, even after disease presentation, participation in regular physical activity continues to play an important role in the management of the disease, well into the retirement years; this is an example of secondary prevention.9 Older adults are a group that is particularly vulnerable to chronic disease and disability, and physical activity maintains or increases quality of life by preserving independence.5

In 2007, the American College of Sports Medicine and the American Heart Association published physical activity recommendations for older adults. These recommendations apply to all people over 65.4 Recommendations include moderate-intensity aerobic activity for a minimum of 30 minutes 5 days a week or vigorous aerobic activity 20 minutes 3 days a week. They should participate in muscle strengthening and endurance exercises a minimum of 2 days per week. Flexibility and balance exercises should be included at least 2 days every week for at least 10 minutes.4 While it is recognized that older adults should exceed these recommendations wherever possible, “There is substantial evidence that older adults who do less activity than recommended still achieve some health benefits.”(4,p8) Extremely deconditioned individuals may improve health with as little as 2 exercise sessions per week.10

Despite the abundance of evidence that regular activity contributes to primary and secondary prevention of disease, controls obesity, helps maintain independence, and is associated with an overall decrease of any-cause mortality,6 many older adults report that they have never been counseled on these benefits by their provider. Reports suggest that practitioners often miss counseling opportunities for lifestyle change.11 In the case of family physicians, researchers estimate that only 30% to 60% ask their patients about exercise.12, 13 Results may be similar for nurse practitioners (NPs).

Health promotion and disease prevention is the cornerstone of an NP's role, and physical activity counseling is an essential aspect of health promotion.7, 8, 14 Within this age group, practitioners are perceived as experts and there is often a relationship of trust; therefore, recommendations are frequently taken seriously. Evidence reveals that practitioners who invest small increments (3–5 minutes) of time per office visit help to increase their patients' activity level, at least initially. In a recent study in which patients were counseled by their physician to increase activity, Marke et al15 found that the behavior of older adults changed in half of the study participants. These patients stated that they would not have changed their behavior if not for practitioner counseling.

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Physical Activity: The Fountain of Youth? 

There is no age limit to the benefits of physical activity; it can slow and reverse age-related loss of strength, endurance, and flexibility. Further, participation in regular physical activity through the middle-age years and into retirement may delay biological aging by 10 to 12 years.9

Aging has been described as a normal and gradual physiologic process of structural and functional loss, with a decline noted in middle and late adulthood.16 Predetermined changes that occur with aging include decreasing lung capacity, flexibility, and sensorial acuity, as well as a general slowing of movement and loss of muscle tone. Physiological functions deteriorate, but decline is not considered a disease.5 Certain problems that once were considered inevitable in aging are, in reality, related to disuse; disuse actually exacerbates the naturally occurring changes.5, 17 It is known that regular physical activity increases independence and physiologic reserve, helps prevent falls and associated injuries, prevents cognitive decline, manages chronic disease and pain, and improves mental outlook, particularly in depression.4, 8, 9, 17, 18

Independence and Physiologic Reserve 

Muscle mass, strength, and aerobic capacity are typically reduced with aging.9, 17 This change in functional capacity, which contributes to the loss of physiologic reserve, affects independence. Gradually declining maximum aerobic power (or endurance) will eventually become low enough that routine activities of daily living become very fatiguing. Evidence suggests that participation in regular aerobic activity can increase endurance by 24% to 30% within 6 months of initiation. Increased leg strength helps to increase walking speed, walking endurance, and stair-climbing power. The potential reversing or at least slowing of this progression facilitates independence.5, 9

Falls and Associated Injuries 

Falls and fall-related injuries are common in this age group and are associated with increased morbidity and mortality. Hip fractures, the most common consequence of a fall, often lead to the loss of independence.17 Those who fall and are unable to get up run the risk of developing pneumonia, dehydration, pressure sores, and rhabdomyolysis.5 Although there are many reasons why older adults fall, one common reason is the lack of muscle strength in the lower limbs due to loss of muscle mass. Beginning in middle age and into the eighth decade, back, arm, and leg muscle strength decreases by 60%. Muscle endurance also decreases, leading to rapid fatigue. There is evidence to suggest that muscle strength can be improved with resistance and strength training, and the improvements are manifest well into the tenth decade. This improved strength may also assist the individual to get back on his or her feet sooner once a less serious fall has occurred.4, 17

Alzheimer Disease 

With the growing number of older adults, it is speculated that Alzheimer disease (AD) and other dementias will become a global health problem.5 Suffering loss of independence and quality of life from AD and dementia is one of the most feared consequences of growing old. Brain health is as important as heart health; what is good for the heart is also good for the brain, and this includes physical activity. Larson et al,19 in a recent study, found that although increased activity does not prevent AD, it can delay the onset. The workout must last 20 to 30 minutes, be performed at least 3 times a week, and be sufficient enough in intensity to cause breathlessness and sweating. Regular exercise improves cerebral blood flow and oxygen delivery to the hippocampus, encourages the development of new brain cells, and decreases the risk of atherosclerosis.9, 19

Chronic Disease and Pain Management 

According to a report issued by the National Institute on Aging and the U.S. Census Bureau,1 approximately 80% of older adults have 1 chronic disease, and approximately 50% have 2 chronic diseases. Aging can bring chronic disease, but living with it does not have to be debilitating. Regular physical activity is part of management of cardiovascular disease, metabolic syndrome, cancer fatigue, arthritis, osteoporosis, obesity, diabetes mellitus, and even chronic obstructive pulmonary disease (COPD).5, 6, 8, 20, 21 Moderate exercise controls the progression of coronary artery disease and atherosclerosis in general.4 It influences blood glucose levels and, together with loss of adipose, can manage insulin resistance.6 Regular activity decreases cancer fatigue and is associated with an overall improvement in quality of life of the cancer patient.6 Physical activity has been shown to be effective in the management of chronic pain in older adults, and maintains or increases bone mass.6 To be effective, a program must be tailored to suit the patient's condition.4, 22

Depression 

Because 15% to 30% of all older adults suffer from depression, it deserves special mention.18, 23 Untreated depression is associated with a decrease in physical functioning, adaptation to illness, decreased quality of life, and increased mortality (suicide). Noel et al24 found that as depressive symptoms worsened, quality of life and physical and mental functioning also declined. In addition to the chemical imbalances said to occur with serotonin and norepinephrine, depression in older adults is also associated with psychosocial factors such as spousal death, retirement, social isolation, decreased financial income, and the passing of friends and other loved ones, including pets—aging and loss go hand in hand. Losses inherent to older adult life have been found to be one of the most serious risk factors for suicide. DeLeo et al25 report that the highest suicide rates in any country are among the over 75-year-old group, particularly in older white males. Exercise, even in as low a dose as 20 to 60 minutes per week, has been shown to have a positive influence on affect and energy levels.26, 27 Because of this and because older adults are often confined to a fixed income, exercise can be considered a low-cost and accessible nonpharmacologic treatment for depression.3 Given that physical activity is often undertaken in groups, improvements in mental health may also be associated with the social relationships that are formed.3

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Recognition and Removal of Barriers 

Older adults are the most sedentary of any age group.4 In observing trends in physical activity, it has become apparent that activity decreases as people increase in age. Schutzer et al13 report that 50% of sedentary adults have no plan to change their behavior, and convincing the individuals, who may have been habitually inactive, to become active may be particularly challenging. Changing behavior in this age group may be difficult, but it is not impossible. Successful behavior change lies in the assessment of the patient's readiness to change, self-efficacy, and identifying and overcoming real and perceived barriers.22

The barriers that older adults cite most often are: ill health and change in health status (pain); unsatisfactory physical environment (poor sidewalks, high neighborhood crime rate); lack of time; lack of transportation to a recreational facility; disinterest; lack of social support; lack of funds; fear of injury; and lack of knowledge and understanding regarding the need for increased activity.3, 13 Schutzer et al13 state that some older adults find the effects of increased activity (achy muscles, perspiring, and increased breathing) to be negative.

Patients must be reminded that regular activity will help decrease pain.28 If arthritis is a problem, walking in a swimming pool can increase flexibility and resistance as well as decrease pain.28 They can be encouraged to exercise with a friend or in a group. Regular walking has been shown to significantly decrease the risk of chronic disease among older men.10 Walking can be undertaken at a shopping mall or in the halls in an apartment block. A home-based balance and strength program can be initiated by using chair exercises; balancing soup cans; and strengthening legs by leaning against the kitchen counter and doing leg raises using elastic tubing or light ankle weights.11 Exercise can be incorporated into a regular routine by walking a flight of stairs instead of taking the elevator, parking the car a block away and walking the rest of the way, or walking in 10-minute intervals. Alleviate boredom by cross-training, using music, dancing, or exercising while watching a television program.13 Pedometers can be used to reinforce gains. An exercise prescription, written on an actual prescription pad, emphasizes its importance and therapeutic value.10 The prescription must be written in partnership with the patient and tailored to suit the individual's needs, any medical conditions, and enjoyment.4

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Stages of Change 

The transtheoretical model, or Stages of Change theory, developed by Prochaska and DiClemente, is a model that can be used to assist patients to change unhealthful behaviors, such as smoking.21 People who modify their behavior progress through a series of 5 distinct stages. It can be a linear progression, but it is most often cyclic.21 These researchers, in a separate study,29 found that this theory could successfully be generalized to other behaviors such as exercising. This theory is useful to evaluate the patient's level of readiness and self-efficacy in becoming physically active and provides the practitioner with a counseling approach that assumes that patients have different counseling needs at different stages. A counseling approach can be paired with the stage the individual is in. Repeated short counseling sessions tailored to the patient's stage of change and shared decision making increases the chance of success. The 5 stages include: precontemplation, contemplation, preparation, action, and maintenance.

Precontemplation 

In this stage, changing behavior has not been considered; people are often unaware of their need to change.21 The NP can provide oral and written information on the benefits of physical activity, discuss pros and cons for changing behavior (targeting the pros), and identify potential barriers in a nonjudgmental way.29 The NP can provide an educational pamphlet that emphasizes the benefits and describes easy methods to incorporate activity into daily routines. The objective is to encourage thinking about the change on an emotional level; help the individual find his or her reasons for increasing activity. The communication techniques used during this stage are empathy and reflective listening. Empathy must be genuine.

Contemplation 

This is the first stage of change; the patient is willing to consider a behavior change but has not yet committed to taking action.21 The NP should focus on the pros of changing. Discuss with the patient the benefits that are most important and meld with his or her personal values.3 Link the benefits to an activity that he or she enjoys. The NP should enter into a discussion about the individual's present confidence level and suggest ways confidence may be enhanced, such as exercising with a friend or obtaining family support. Again, provide specific written instructions or an educational pamphlet.21 For some habitually sedentary people, this stage will likely be difficult. Some will require additional assistance and support from the NP.

Preparation 

In this stage, the patient has made the decision and is ready to undergo change within the next month.21 The NP must act to facilitate commitment and planning by working together with the patient in establishing clear, achievable, and realistic goals. Discuss potential barriers and take action to remove them. In this way, the individual can gain confidence and maintain motivation. It is essential to provide encouragement and positive reinforcement.

Action 

In this stage, the patient has implemented the agreed-upon changes and has begun to modify the behavior.21 Congratulations and positive reinforcement are crucial. Maintain or enhance the patient's self-confidence by encouraging him or her to do a little more, such as walking 5 minutes longer or trying a new sport. The NP must continue to reinforce the benefits of activity by inquiring as to other activities he or she may enjoy. Because relapse is common,21 anticipate it and work together to prevent it. Offer ongoing assistance and support.

Maintenance 

In this stage, the new behavior is well established. The NP can assist the patient to plan for times when it might be more difficult to be active, such as during vacations. Revising goals may be needed. What is important to note is that relapse is common and is not considered negative.21 The patient has learned something about himself or herself, so focus on what strategies worked and positively reinforce those behaviors.21 Continue to offer support and encouragement.

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Conclusions 

As the population continues to age, it will be more important than ever to maintain health and independence. One strategy is to promote health by increasing physical activity. Changing sedentary behavior in older adults may be difficult, but it is not impossible. Successful behavior change lies in the assessment of the patient's readiness to change, and identifying and overcoming barriers. The Stages of Change theory is a useful tool for assessing the individual's readiness to change and provides a counseling method that the NP can use to facilitate healthy lifestyle change. Older adults seek medical attention more often than younger adults; therefore, NPs are the ideal people to provide advice. There is no age limit to the benefits of physical activity; it can slow and reverse age-related changes. Any physical activity is better than no activity.

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References 

  1. National Institute on Aging and U.S. Census Bureau  . 65+ in the United States, 2005 . Available at: http://www.census.gov/prod/2006pubs/p23-209.pdf Accessed September 18, 2009.
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 In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(09)00666-7

doi:10.1016/j.nurpra.2009.11.007

The Journal for Nurse Practitioners
Volume 6, Issue 3 , Pages 187-192, March 2010

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