Physiotherapists have a key role to play in promoting positive ageing and maintaining the health and well-being of the elderly.
The theme covered is in relation to Physical Activity of older adults in order to help promote positive ageing and well-being.
The purpose of this assignment is to investigate the role of Physiotherapists in maintaining the health and well-being of older adults to encourage positive ageing through the promotion of physical activity. Physical activity (PA) is defined as “any bodily movements that allow energy expenditure such as walking, shopping, housework or planned exercise” (Taylor et al, 2014). The World Health Organization (WHO, 2010) recommend at-least 150 minutes moderate intensity exercise weekly in addition of two sessions of strength training and two sessions of balance training to minimize falls risk in older adults over the age of 65.
Successful/Positive/healthy ageing terms have been used interchangeably in previous research yet there has been no agreed-upon set definition. The WHO defined healthy ageing as “the process of developing and maintaining the functional ability that enables wellbeing in older age” (WHO, 2009). For older adults, extending life is an important factor, but the maintenance of functional independence is also of high priority, to preserve the quality of life.
Physiotherapists routinely offer exercise prescription for patients and it is imperative this practice is carried over for the ageing population and adapted for their functional capabilities. The UK Chartered Society of Physiotherapists recently developed a campaign to promote PA in older adults called “Never too late”, it has been shared on social media and with patients to promote awareness of PA and its benefits, to enhance both functional independence and the well-being of older adults (CSP, 2018). This is one example of the many initiatives that have been implemented in order to target the ageing population.
The problematic area found in previous literature is the adherence rates of PA in older adults. A recent UK study indicated only 12.7% of those over the age of 65 meet PA recommendations (Clarke et al, 2017). These findings suggest older individuals may need interventions focusing on cognitive processes, such as PA education, but also behavioural strategies to improve PA adherence (Lachman et al, 2018). Research has also suggested that focusing on the benefits of PA is more effective for behaviour change rather than presenting risks of a sedentary lifestyle (Notthoff & Carstensen, 2014). The discussion will aim to provide useful interventions that can guide Physiotherapy practice in order to promote PA in older adults for their health and wellbeing.
Physiotherapists have a key role to obtain information regarding patients’ PA during assessments. This can be achieved subjectively or objectively. Subjective usually involves questionnaires such as the PASE (Physical activity scale for elderly) or the 7-day PA recall questionnaire, which have both been validated in elderly populations (Watts et al, 2013). However, these subjective measures have areas for recall bias especially if patients have cognitive issues. Objective measurement can be gained by use of pedometers or accelerometers but also have limitations depending on adherence rates of wearing them or on the type of activity i.e. cycling may not have accurate representation due to lack of gait pattern (Sylvia et al, 2014). A study illustrated that older adults who received PA advice from their physician performed more moderate-to-vigorous intensity activity than those who did not receive advice. However, evidence suggested that general practitioners (GPs) did not discuss PA with all relevant patients (Noordman et al, 2010). In a 2014 study, approximately 95% of older adults visited their GP in the previous year, yet only about 62% reported receiving advice about PA (Taylor et al, 2014). Therefore Physiotherapists have a responsibility to ask all relevant patients about their daily PA and especially to target those at risk of inactivity.
A number of PA barriers have been identified in older people, including low self-efficacy, low motivation, depression, lack of interest, fear of falling, poor health status, physical ability, low expectations and exercise programme characteristics (Room et al, 2017). Many sedentary adults have negative views about PA and their ability to exercise as they assume they are too old, or PA may lead to falls/injury, therefore behavioural change is important to reduce any misconceptions and encourage changes in activity (Lachman et al, 2018). Engagement in PA has also shown to improve mental wellbeing of older adults and indeed reduce and prevent the reoccurrence of depression (Zubala et al, 2017).
Exercises adherence is known to be poor in older adults and can be affected by health status and long-term conditions (Room et al, 2017). A previous review evaluated adherence of self-management strategies prescribed by Physiotherapists (Peek et al, 2016). Results indicated that interventions using activity monitors, feedback systems, written instructions and behavioural exercise programmes were effective in promoting adherence rates in the general population. A more recent systematic review established some interventions that improved adherence of prescribed exercise in older adults (Room et al, 2017). Eleven studies were included in the review and interventions were classified into the following categories: comparison of behaviour, feedback and monitoring, social support, natural consequences, identity and goal planning. Four studies illustrated promising results from the feedback and monitoring category, which demonstrated an increase in exercise adherence post interventions. The interventions consisted of community base class settings, supervised exercise, motivation classes and graphic feedback. Four of the studies also used behavioural theories to justify the chosen interventions such as social cognitive theory (SCT), cognitive behavioural therapy and self-efficacy. The SCT suggests that people learn not only from their own experiences but also from observation of others, their behaviours and outcomes of behaviour (Bandura, 1971). Of the behavioural strategies used, only one study reported significant improvement in exercise adherence with use of the SCT (Duncan & Pozehl, 2003). However, the studies were of moderate to high risk of bias due to small sample sizes and the lack of sample justification, which limits generalisation of the results. The data nevertheless, indicated that adherence rates were generally better in supervised programmes. This may help overcome barriers such as motivation and low self-efficacy for older adults, which can be utilised by Physiotherapists when designing group exercise programmes (Room et al, 2017).
A Recent study looked at behavioural changes in response to interpersonal and intrapersonal strategies to improve PA in older adults (McMahon et al, 2017). The Otago programme was used as an evidence-based protocol for PA uptake along with the Fitbit used objectively and the CHAMPS (Community healthy active model programme for seniors) questionnaire as a subjective measure. The interventions were over an eight-week period and also included a six-month follow-up. The interpersonal behavioural strategies required dialogue between group members about PA-related ideas, experiences, and knowledge to elicit individual change. Intrapersonal behaviour strategies required review of key PA concepts followed by individual reflection and discussion with the inclusion of personally meaningful, realistic, and specific PA goals.
The findings of the study suggest, interpersonally orientated behaviour change strategies enhanced the effects of an evidence-based PA programme (Otago) for older adults. The total PA increased by three hours per week compared to those that did not receive any strategies and were maintained six months post-intervention. However, intrapersonal behaviour strategies had no significant effect on the quantity of PA at either time point. The study also indicated that 85% of the increase in PA was light intensity which does not meet current WHO recommendations. However previous research has shown, PA of all intensities has benefits for older adults in terms of wellbeing contributing to positive ageing (Loprinzi et al, 2015). A limitation of the study was the chances of recall bias for the CHAMPS questionnaire as there were higher PA levels reported than objectively measured by the Fitbit, which may have interfered with results. The study only illustrated PA changes with interpersonal behavioural techniques. Conversely, recent literature suggests that intrapersonal orientated strategies such as barrier identification and feedback are associated with greater effects on PA (French et al, 2014). The study was a factorial experiment with no level of blinding and therefore results were at risk of bias.
Many interventions have targeted exercise in later life, but they typically do not achieve sustained behaviour change (Lachman et al, 2018). Most interventions are based on formal exercise programmes in the community, which may not be accessible for all patients. An alternative approach is to integrate PA into daily life routines based on personalised goals and interests, as suggested by the National Institute of Ageing Go4Life Program (NIA, 2018) which offers online resources to provide self-management skills for PA. A personalised approach allows for realistic goal setting and inclusion of beliefs and expectations about exercise, which can encourage participants to think about the future and motivate behaviour change (Lachman et al, 2018).
Chase et al (2014) concluded that theory-based exercise interventions were more effective than those without a reported theoretical basis. Most commonly reported were the Transtheoretical Model and SCT. Self-efficacy, or beliefs about one’s abilities to carry out desired behaviours, is a major component of both theories, which affects motivation and actions of PA. There are ongoing Government Incentives such as “Make Every Contact count” which has incorporated the Health Behaviour Change Framework and Implementation Plan in Ireland. This allows Physiotherapists along with other Clinicians to promote PA as both primary and secondary preventative measures for the ageing Irish population along with utilisation of behavioural strategies as the core concept for change (HSE, 2016).
A recent study evaluated the use of behavioural strategies in fitness applications (Sullivan & Lachman, 2017). Some behaviour change techniques are included in fitness technology such as goal setting, feedback, rewards and self-monitoring. However, few fitness apps included behavioural strategies such as action planning, attitude adjustment, and barrier identification, which may be most relevant to inactive populations. Beyond measuring PA, if used correctly and for long enough, fitness trackers have the potential to facilitate long-term behaviour change through use of self-monitoring data (Cadmus-Bertram et al, 2015). However few interventions using fitness technology have reported follow-up data, and consequently little is known about the duration of the change in activity (McMahon et al, 2016). Future research should aim for longer follow-up periods and evaluate the features associated with long-term PA increases. Fitness trackers are also not accessible for the majority of the elderly population due to their high cost. However, it may be beneficial for Physiotherapists to recommend them to suitable patients. Trackers can also be used to monitor patients’ heart rate and blood pressure and the newer versions even have built-in sensors to detect falls. This daily monitoring has the potential to personalize healthcare tracking and recommendations for both GPs and Physiotherapists (Sullivan & Lachman 2017).
In addition to individual behaviour change techniques for increasing PA, the use of social factors have also been explored in group walking programmes for older adults in a recent review (Victor et al, 2016). Social factors such as social support and competition had increased engagement, adherence, and completion of PA and were especially effective in previous unmotivated and sedentary participants. Competition also increased PA involvement when participants aimed to accumulate more steps or daily activity than their peers. Competition allowed for encouragement of one another to meet their goals. This is a strategy that Physiotherapists can utilize when recommending PA for older adults by offering rewards for the highest PA increases (Smith et al, 2017).
Finally, the types of exercise recommended for older adults are functional and weight-bearing exercises where safe and possible to do so (Sparling et al, 2015). Seated exercises have also been recently evaluated and results indicated that it had cognitive benefits and improvements in quality of life for those who cannot exercise in upright positions due to other co-morbidities (Sexton & Taylor, 2018). However, it should not be used as an alternative therapy to upright exercises if patients are able to do so. Physiotherapists must ensure safety when recommending PA uptake. Use of the Physical Activity Readiness Questionnaire is advised before recommending PA increase, as older adults may need screening from a GP to ensure safety (ACSM, 2014). Physiotherapists may implement a thorough subjective and objective exam looking at balance and mobility levels before recommending PA depending on the patient’s condition (Shanahan et al, 2016).
Physiotherapists have an important role to play in PA promotion in older adults. Addressing barriers to PA is imperative to ensure long-term exercise adherence. This subsequently will help optimise the quality of life and cater for successful and positive ageing. Physiotherapists that are currently running exercises classes should be aware of potential behavioural techniques that can be used to increases PA levels and adherence. There are still some gaps in the literature in regards to long-term follow-up after exercise promotion interventions and therefore future research such aim to produce more longitudinal studies to measure adherence rates and behavioural change strategies to ensure evidence-based practice during PA promotion. Physiotherapists should stay up to date with Government and local initiatives in order to help optimise delivery of PA information to their patients. Majority of the elderly population are not meeting recommended PA guidelines so it is important that Physiotherapists utilise every interaction with patients to promote PA and address any concerns patients may have. Physiotherapists should be aware of potential co-morbidities that may effect PA recommendations and therefore screening should be included before any information is provided.
Word Count: 2178
1) American College of Sports Medicine (2014).The Basics of Personal Training for Seniors Available at: https://certification.acsm.org/blog/2014/january/the-basics-of- personal-training-for-seniors [Accessed on: 04 Jan 2019]
2) Bandura. A Social learning theory. Soc Learn Theory 1971;1:46
3) Cadmus- Bertram LA, Marcus BH, Patterson RE, Parker BA, Morey BL.(2015) Randomized trial of a Fitbit-based physical activity intervention for women. Am J Prev Med 49(3):414–8.10.1016/j.amepre.2015.01.020
4) Chase, J. (2014). Interventions to Increase Physical Activity Among Older Adults: A Meta-Analysis. The Gerontologist, 55(4), pp.706-718.
5) Clarke T. C., Norris T., & Schiller J. S. (2017). Early release of selected estimates based on data from the 2016 National Health Interview Survey Washington, DC: National Center for Health Statistics; Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/Earlyrelease201705.pdf
6) Duncan K, Pozehl B. Effects of an exercise adherence intervention on outcomes in patients with heart failure. Rehabil Nurs 2003; 28:117–22.
7) French, D. P., Olander, E. K., Chisholm, A. & McSharry, J. (2014). Which Behaviour Change Techniques Are Most Effective at Increasing Older Adults’ Self-Efficacy and Physical Activity Behaviour? A Systematic Review. Annals of Behavioral Medicine, 48(2), pp. 225-234. doi: 10.1007/s12160- 014-9593
8) Go4Life. (2018). Go4Life. [online] Available at: https://go4life.nia.nih.gov [Accessed 4 Jan. 2019].
9) Health Service Executive (2016). Making Every Contact Count: A Health Behaviour Change Framework and Implementation Plan for Health Professionals in the Irish Health Service. Health Service Executive. ISBN No 978-1-78602-038-3
10) Lachman, M., Lipsitz, L., Lubben, J., Castaneda-Sceppa, C. and Jette, A. (2018). When Adults Don’t Exercise: Behavioral Strategies to Increase Physical Activity in Sedentary Middle-Aged and Older Adults. Innovation in Aging, 2(1).
11) Lachman, M., Lipsitz, L., Lubben, J., Castaneda-Sceppa, C. and Jette, A. (2018). When Adults Don’t Exercise: Behavioral Strategies to Increase Physical Activity in Sedentary Middle-Aged and Older Adults.
12) Loprinzi PD, Lee H, Cardinal BJ. (2015) Evidence to support including lifestyle light-intensity recommendations in physical activity guidelines for older adults. American Journal of Health Promotion.29 (5):277–284.
13) McMahon, S., Lewis, B., Oakes, J., Wyman, J., Guan, W. and Rothman, A. (2017). Assessing the Effects of Interpersonal and Intrapersonal Behavior Change Strategies on Physical Activity in Older Adults: a Factorial Experiment. Annals of Behavioral Medicine, 51(3), pp.376-390.
14) McMahon SK, Lewis B, Oakes M, Guan W, Wyman JF, Rothman AJ.( 2016) Older adults’ experiences using a commercially available monitor to self-track their physical activity. JMIR MHealth UHealth 4(2):e35.10.2196/mhealth.5120
15) Noordman J, Verhaak P, van Dulmen S. (2010) Discussing patient’s lifestyle choices in the consulting room: analysis of GP-patient consultations between 1975 and 2008. BMC Fam Pract; 11:87.
16) Notthoff N, Carstensen LL. (2014) Positive messaging promotes walking in older adults. Psychol Aging 29(2):329–41.10.1037/a0036748
17) Peek, K., Sanson-Fisher, R., Mackenzie, L. and Carey, M. (2016). Interventions to aid patient adherence to physiotherapist prescribed self-management strategies: a systematic review. Physiotherapy, 102(2), pp.127-135.
18) Room, J., Hannink, E., Dawes, H. and Barker, K. (2017). What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review. BMJ Open, 7(12), p.e019221.
19) Shanahan, D.F., Franco, L., Lin, B.B., Gaston, K.J. and Fuller, R.A., (2016). The benefits of natural environments for physical activity. Sports Medicine, 46(7), pp.989-995.
20) Smith GL, Banting L, Eime R, et al. The association between social support and physical activity in older adults: a systematic review. Int J Behav Nutr Phys Act. 2017;14:56. doi: 10.1186/s12966-017-0509-8.
21) Sparling, P.B., Howard, B.J., Dunstan, D.W. and Owen, N., (2015). Recommendations for physical activity in older adults. BMJ: British Medical Journal (Online), 350.
22) Sullivan, A. and Lachman, M. (2017). Behavior Change with Fitness Technology in Sedentary Adults: A Review of the Evidence for Increasing Physical Activity. Frontiers in Public Health, 4.
23) Sylvia, L.G., Bernstein, E.E., Hubbard, J.L., Keating, L. and Anderson, E.J., (2014). A practical guide to measuring physical activity. Journal of the Academy of Nutrition and Dietetics, 114(2), p.199.
24) Taylor D. (2014) Physical activity is medicine for older adults. Postgrad Med.;90:26–32.
25) The Chartered Society of Physiotherapy. (2019). Never too late. [online] Available at: https://www.csp.org.uk/public-patient/keeping-active-and-healthy/staying-healthy-you-age/staying-strong-you-age/strength [Accessed 3 Jan. 2019].
26) Victor CR, Rogers A, Woodcock A, Beighton C, Cook DG, Kerry SM, et al. (2016) What factors support older people to increase their physical activity levels? An exploratory analysis of the experiences of PACE-Lift trial participants. Arch Gerontol Geriatr (2016) 67:1–6.10.1016/j.archger..06.006
27) Watts AS, Vidoni ED, Loskutova N, Johnson DK, Burns JM. (2013) Measuring physical activity in older adults with and without early stage Alzheimer’s disease. Clin Gerontol.;36(4):356–374. 10.1080/07317115.2013.788116
28) World Health Organisation (2010). Physical Activity and Older Adults. Available at: http://www.who.int/dietphysicalactivity/factsheet_olderadults/e n/ [Accessed on 29 Dec 2018]
29) World Health Organization. (2009). What is Healthy Ageing?. [online] Available at: https://www.who.int/ageing/healthy-ageing/en/ [Accessed 3 Jan. 2019]
30) Zubala, A., MacGillivray, S., Frost, H., Kroll, T., Skelton, D., Gavine, A., Gray, N., Toma, M. and Morris, J. (2017). Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews. PLOS ONE, 12(7), p.e0180902.