The Surgeon General has issued a report warning people - including older adults - that physical inactivity is a major risk to their health.
The aging of the American population has created a large group of older adults who are even more susceptible to the detrimental effects of physical inactivity than younger people. This is not news to those of us in the fitness industry, but many of us are not prepared to deal with this growing segment of the population.
So, first let’s look at a few statistics. In the year 2000, roughly 35 million people (13 percent of the population) were age 65 or older. By 2030, the number is expected to double to 70 million. According to the Active Aging Partnership National Blueprint, 88 percent of these people have at least one chronic health condition that in many cases may be improved or managed with physical activity. They also report that 35 to 50 percent of women age 70 to 80 have difficulty with general mobility tasks like walking a few blocks, climbing a flight of stairs or doing housework. Dr. Mark Williams, professor at Creighton University of Medicine in Omaha, says this statistic reports a disproportionate amount of women because, although women make up about 60 percent of the elderly population (>65 years), the female predominance increases exponentially after age 65 since women tend to live longer than men. Women who reach age 65 have an additional life expectancy of 19 years, compared with less than 16 years for men of the same age.
Once adults pass the physical prime of their teens and 20s, they lose an average of 10 ounces of lean body mass a year, and this is mostly in the form of muscle tissue. And since few people actually lose 10 ounces of weight a year (instead, most gain about a pound a year), the loss of lean tissue is masked. Another way to look at this is the average person gains about one pound and 10 ounces of body fat per year. It is a process that is more insidious and crippling than osteoporosis but one few people notice until they realize it is getting difficult to climb the stairs or heft themselves off the sofa. Unchecked, the gradual loss of muscle strength is the main reason elderly Americans have difficulty performing the tasks of daily living, and ultimately, they lose their independence. This phenomenon, which we call sarcopenia, derived from Greek words for “vanishing flesh,” is NOT an inevitable consequence of aging. It is instead an inevitable consequence of disuse.
Another important reason for older people to strength train is that evidence suggests that exercise may decrease the rate of bone loss associated with osteoporosis and reduce the likelihood of falls that result in hip fractures. A frightening statistic is that almost 24 percent of people over age 50 who have hip fractures die within a year. Falling is a serious public health concern among elderly people because of its frequency, the morbidity associated with falls and the cost of the necessary healthcare. According to Dr. Mary Tinetti, professor at Yale University, approximately 30 percent of the people who live in the community fall each year. Unintentional injury, which most often results from a fall, ranks as the sixth leading cause of death among people over 65 years of age. Muscle weakness has been identified as one of the biggest potentially modifiable risk factors for falling. In the late 80s and early 90s, studies found that despite a decrease in muscle fibers and strength, muscle function can be maintained and/or improved with training, even in the very old.
A slight increase in muscle strength at any age can improve quality of life and stave off the fraility that used to be considered a normal part of getting old. While strength training is not the only important type of exercise for older adults, it should be easy to understand that the frailer a person becomes, the greater the importance of strength training. And sometimes, strength training and flexibility are the only types of exercise in which the elderly can engage until they gain enough muscle strength to allow them to work on their endurance or aerobic capacity and balance. In an article by Wayne Westcott, PhD, published in the October 1995 issue of American Fitness Quarterly, 12 health and fitness benefits were outlined that result from strength training by older adults. They were: avoid muscle loss, avoid metabolic rate reduction, increase muscle mass, increase metabolic rate, reduce body fat, increase bone mineral density, increase glucose metabolism, increase gastrointestinal transit, reduce resting blood pressure, improve blood lipids levels, reduce low back pain and reduce arthritic pain.
Although the benefits of strength training have been discussed exclusively to this point, older inactive adults also lose ground in three other areas that are important for staying healthy and independent. These are endurance, balance and flexibility. Endurance training can maintain and improve cardiovascular function and can reduce risk factors associated with chronic diseases associated with aging such as diabetes, colon cancer, heart disease, stroke and others. It can also reduce overall death and hospital rates. Balance exercises help to prevent falls, and flexibility training helps to keep the body limber by stretching muscles and tissues that hold the body’s structure in place. Flexibility may also play a part in preventing falls.
Some types of exercise improve just one area of health or ability, but more often, an exercise has many different benefits. So, elderly adults should be encouraged to increase both the types and amounts of exercise and physical activity they do. According to an article in the winter 2002 newsletter, Aging Successfully, published by the St Louis School of Medicine and Geriatric Research, the goals of exercise for older adults should be to minimize the effects of aging and chronic diseases, reverse the effects of disuse and maximize psychological health. This is different than those of younger adults for whom exercise helps prevent disease and increase life expectancy.
So, contrary to traditional thinking, regular exercise helps - not hurts - most older adults. Older people become sick or disabled more often from not exercising than from exercising. Almost all older adults, regardless of age or condition, can safely improve their health and independence through exercise and physical activity. There are few reasons to keep them from exercising, and “too old” and “too frail” are not among them!!
Barriers to exercise among older adults include personal factors such as discomfort, fear of injury, social isolation, and environmental difficulties (such as lack of access to an exercise facility or unfavorable weather conditions). In 1985, Dishman and his colleagues classified determinants of exercise participation into three broad categories: personal, environmental and exercise-specific. The personal and environmental barriers are most relevant for us.
The barriers to regular physical activity vary with age. In an Australian survey, the main barriers among adults 60 to 78 years old were injury and poor health. Among adults 18 to 39 years old, they were child care responsibilities, lack of time and lack of motivation. The barriers are essentially the same for those 40 to 59 years old, but these clients begin to have chronic diseases and injuries. Let’s look in detail at some common personal barriers.
- Temperament. A person’s attitude reflects self esteem, overall outlook and health beliefs. The best predictors of intention to exercise are different for men and women. In women, participation is best predicted by attitude towards exercise, perceived control over their lives in general (voluntary vs. involuntary action), their assessment of the benefits of exercise and self efficacy (the confidence to initiate exercise). In men, attitude towards exercise is the only predictor.
- Popular Press. The press influences attitudes as well. They depict slender, young individuals exercising and seldom portray older people doing so. Such depictions reinforce the perception that older people do not belong in gyms, group exercise or swim classes.
- Time. People are busy. Because couples are having children later in life, child-rearing acts as a barrier to individuals who are well into their 50s. The daily routine of waking early, preparing children for school or day care, commuting to work, working a full day and then returning home does not leave much time for traditional exercise. Often, parents fulfill their family's commitments at the expense of their own health. Others simply place work goals ahead of regular physical activity. Retirees might have more discretionary time, but they frequently are busy caring for grandchildren and doing volunteer work.
- Discomfort. Many surveys have revealed that the most common barriers to exercise are physical ailments, rapid fatigue and fear of injury. In a Canadian survey of 199 people, at least 50 percent listed these factors as barriers. Within groups whose physical ailments (such as low back injuries, knee joint degeneration or restrictive and obstructive lung or heart disease) limit physical activity, pain is a common reason for remaining inactive. In addition, many sedentary adults tire easily. This is particularly true for overweight individuals.
- Fear of injury. Fear of injury is an understandable impediment to exercise for many older people. Patients with diabetes and peripheral neuropathy might be afraid of exacerbating foot pain, inducing fractures or triggering hypoglycemia. Patients sometimes fear falling and breaking a hip. They often have friends who started a new activity, were injured and incurred a lasting disability.
- Inertia. "I don't know how/I don't like it/I get bored/I'm too busy." Inertia has many possible causes, but the most likely one is a lifetime of little exertion. Older people might perceive that exercise is not socially acceptable and will not take advantage of the opportunity to participate in any type of activity. Most adults who have never exercised will never start, even if counseled.
- Isolation. Many adults do not want to exercise alone, and program compliance without social support is poor. Motivating older people to exercise can be particularly difficult if they have lost a spouse or have a spouse whose disability limits exercise options. Divorce or the demands of work can also impede exercise participation.
- Misconceptions. People often have a narrow view of what exercise is. They might think that jogging is the only exercise that exists or that all forms of exercise are repetitive and boring. Many blue-collar workers mistakenly feel that their jobs provide enough exercise. An old quote suggests that "animals sweat, men perspire, women do neither." Many women who grew up receiving such advice in the 1930s to 1950s lack the knowledge or skills to engage in regular physical activity.
The first step in alleviating fear of discomfort is to provide options for its prevention or relief. People with chronic pain can move more freely when the pain is properly managed. Thus, once pain control is achieved, exercise can begin. Potential clients with other chronic conditions (e.g., diabetes, hypertension, asthma, arthritis) that are poorly controlled might benefit from multidisciplinary approaches, depending upon their individual goals. Although the presence of an unstable medical condition is a contraindication to vigorous exercise, low intensity exercise and flexibility training can help control symptoms and facilitate the progression towards more moderate intensity activity.
Motivation can be a significant barrier to initiating exercise among the elderly, even after treatment of conditions like anemia, diabetes, depression or dementia. While educating clients about the general benefits of exercise is an important starting point, it is often insufficient. A better alternative is to identify unmet personal goals that can aid in developing appropriate exercise recommendations. For instance, the client who wants to be able to play on the floor with grandchildren will need flexibility and strength as well as some aerobic capacity. This goal is very different from that of a severely impaired person who merely wishes to be fit enough to independently use the toilet.
While group activity commonly motivates the elderly to exercise, studies show that group participation does not necessarily increase long-term exercise frequency among sedentary elderly women. Their expectation of health benefits, however, is an important motivating factor, and this underscores the importance of explaining the health benefits when counseling elderly women.
The risk of injury with low level exertion is small, so explaining the benefits of exercise, such as improved function and increased mobility, might offset fear of injury. Once those with fears and physical ailments have been given permission to exercise and information on maximizing existing health, specific program suggestions and follow up plans can be made. People do get injured, but the number of these injuries can be reduced. Overuse and inadequate warm ups are the most frequent causes, so tailor your exercise prescriptions to address these issues.
External environmental barriers are quite common and might be among the most seductive reasons for nonparticipation. Individuals cannot control environmental barriers but can use them to rationalize why they do not exercise.
- Physician advice. Occasionally, physicians unwittingly impede lifestyle changes. A survey by the CDC revealed that physicians inquired about diet and exercise less than one third of the time, which might give patients the impression that exercise is unimportant. This could change with all the publicity that Metabolic Syndrome is getting from the medical community (and the CDC).
- Lack of coaching. In addition, busy practices allow little time for counseling since counseling is often uncompensated. Lack of follow up to monitor progress and attainment of exercise goals reinforces the notion that exercise is unimportant.
- Access and cost. Many people consider health clubs to be too expensive. Some live in dangerous neighborhoods, while others lack community recreational resources or transportation to an exercise facility. Although most studies that show access, transportation and cost as significant barriers were conducted among minority groups, these problems are probably common for all older populations.
- Climate. In northern climates, inclement weather and unsafe outdoor conditions due to ice and snow often cause individuals to go without regular physical activity for months at a time. For those living in warmer regions, extremes of heat and humidity are obstacles to activity.
Interventions that involve modifying the environment have been effective over the short term. For example, posting signs to encourage use of stairs seems to increase this activity in seniors. Other helpful modifications include improved lighting, wheelchair access, use of indoor malls, use of senior citizen centers, programs that have specific exercise routines designed for seniors...and access to personal trainers who know how to design safe and effective programs for seniors (i.e., YOU!).
When selecting tactics to overcome these barriers, consider the client’s current position within the six stages of behavior change. Key measures include controlling pain, managing chronic conditions, explaining the benefits of exercise, dispelling misconceptions, identifying realistic personal goals and following up.
Many barriers to exercise are not easily addressed. The act of starting an exercise program (or of changing any high risk behavior) has been described to progress through a series of stages: precontemplation, contemplation, preparation, action, maintenance and termination. In the precontemplative stage, the person has no interest in starting to exercise. In the contemplative stage, the person is thinking about starting but has made no specific plans. The preparation stage involves planning to exercise; the action stage, starting a program; and the maintenance stage, continuing it. Unfortunately, many exercisers drop out, entering the undesired termination stage, in which they can either remain mired (precontemplative) or cycle again through the stages. Most of the people we will be seeing should be in the preparation or action stage. Some of the clients you initially see are going to be in the contemplative or even the precontemplative stage, so it is important to know what to do to move them to the stage of action.
Success is more often achieved when clients actually progress from one stage to the next rather than jump right into an exercise program. The personal trainer’s goal, therefore, should be to move the client through the stages to the maintenance stage. To facilitate this, strategies should match the person’s stage of change. Research has shown that stage-matched programs for cardiovascular disease prevention can achieve participation rates as great as 85 percent, compared with one to five percent for traditional programs.
Stages of Exercise Initiation and Matched Strategies
|Stage of Change
- Elicit reasons and barriers to exercise
- Provide simple educational information
- Talk about a program when the client is ready
- Motivate (describe benefits, specify goals, involve family)
- Elicit commitment
- Identify goals
- Plan (date, equipment, etc)
- Follow up
- Review goals
- Suggest strategies to overcome fatigue, discomfort, and bad weather. Identify and address possible “roadblocks”
- Follow up
- Review coping strategies
- Reassess goals
- Reassess fitness levels to see progress
Exercise Counseling Guidelines
The US Preventive Services Task Force has developed some simple, practical suggestions for counseling that are readily adaptable for your clients.
- Frame the teaching to match the perceptions. Inquire about the person’s beliefs and concerns, including thoughts on exercise.
- Help clients set goals. Help clients identify long-term goals and then develop intermediate, more easily attainable goals. Some people want to run in a marathon. Some wish to gain independence (e.g., be able to get out of chairs and beds and to go to the toilet unassisted). By identifying goals, you can help design a goal-congruent exercise program.
- Let them know what to expect. Fully inform clients of the expected benefits and the necessary time required to realistically achieve them. Giving clients a timeframe as to when to expect observable results might prevent discouragement when immediate results are not seen. Focus on intermediate goals rather than on long-term goals. Tell clients about common pitfalls that frequently occur in the beginning stages of an exercise program, ways to avoid these problems and simple remedies to solve them. In addition, clients should be informed of the symptoms of exercise intolerance.
- Suggest small changes rather than large ones. Ask clients to progressively do more: "It is great you are walking 10 minutes in the morning. Could you add an additional five minutes?" This reinforces their ability to achieve goals.
- Provide specific, informative instructions. For example, ask how much they are comfortable doing now, then ask them to do this activity more often (e.g., three times a week) and for a longer time (by 10 to 25 percent per week) until they are doing 20 to 30 minutes of any aerobic exercise, three to four times a week. Behavioral change is enhanced if the regimen and its rationale are explained, demonstrated as appropriate and given in written form.
- Adding new behaviors is sometimes easier than eliminating established behaviors. For instance, if weight loss is a concern, suggest that the person begin moderate physical activity rather than suggesting a drastic change of diet.
- Link new behaviors to old behaviors. For example, suggest to clients that they exercise before eating lunch or use an exercise bike while watching the news.
- Use the power of the profession. Clients view you as health experts and regard what you say as important. Don't be afraid to use direct messages such as, "I want you to start an exercise program." Simple and specific messages are particularly powerful.
- Get explicit commitments. Ask clients to describe what they plan to achieve this week (i.e., what, when and how often). The more specific the commitment, the more likely it is to be honored. After getting commitments, ask how sure they are that they will execute them. Those who express more assurance are more likely to meet the commitment.
- Use a combination of strategies. Programs can be tailored to individual needs. Written materials strengthen the message and can be personalized if you jot pertinent comments in the margins. Printed materials, however, cannot substitute for oral communication with clients!
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