Dawn Irwin MSc DipST

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Exercise Older People
Dawn Irwin MSc DipST Clinical Exercise
Specialist Senior Tutor / Assessor Exercise and
the Prevention of Falls and Injuries Advanced
Instructor Training HPC Registered Sports and
Manipulative Physiotherapist
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We have an ageing population
65 - 74
The number of people aged 65 and over is
projected to increase by 60 per cent by 2031
75 - 84
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OPCS Audit Commission 1995
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If Id known I was going to live this long, Id
have taken better care of myself Dubey Blake
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AGEING AND MUSCLE

• ? Muscle mass
• ? Size of Type 2 fast fibres
• ? Turnover of contractile protein
• ? Mitochondria
• ? Proprioception
• ? Connective tissue and fat
• ? heat production
• ? Susceptibility to injury and damage

• ? Max. heart rate
• ? Max. stroke volume
• ? Max. cardiac output
• ? Aerobic Power
• ? Systolic B.P.
• ? Postural Hypotension
• ? Fatigue
• ? Breathlessness

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Functional Ability in older age
EVEN HEALTHY OLDER PEOPLE LOSE...

• Strength (1 to 2 p.a.)
• Power (3 to 4 p.a.)
• Bone density (Women1 to 3, Men0.4 p.a.)
• Ligament tensile strength (50 by 60)
• VO2max (1 p.a.)
• Pacemaker cells (50 by 60)
• Motor neurones/axons (37 by 60)
• Maintenance of temperature control

Sedentary behaviour increases the loss of
performance...
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70 yr old females
active, strength-trained
sedentary
The same difference in muscle size is seen
between a 30 and an 80 yr old
(Adapted from Sipilä Suominen Muscle Nerve
199316294)
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Young muscle
Old muscle
Angular shape
Crushed and banana-shaped
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Osteoporosis
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Young healthy spine
Osteoporotic spine
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Thresholds for quality of life
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Exercise and Health

• Prevention of disease
• Osteoporosis
• Impaired glucose tolerance (mature onset
  diabetes)
• Hypertension
• Ischaemic heart disease
• Colon Cancer
• Stroke
• Anxiety
• Depression

Long-term commitment to activity
Effects apparent even when taking up activity at
a later age
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Exercise and Health

• Prevention of disability
• Intermittent claudication
• Angina pectoris
• Heart failure
• Asthma
• Chronic airflow obstruction
• Multiple disability

Long-term commitment to activity Effects apparent
even when taking up activity at a later age
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Exercise and Health

• Prevention of complications of immobility
• Faecal impaction
• Deep vein thrombosis
• Gravitational oedema
• Contractures
• Pressure sores

Effects apparent even when taking up activity at
a later age Movement can be passive and aided
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Exercise and Health

• Prevention of isolation
• Socialisation
• Touching
• Prevention of dependence
• Functional ability
• Falls
• Maintenance of Caring Skills
• Physical performance and mental health

Long-term commitment to activity Effects apparent
even when taking up activity at a later age
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BENEFITS OF REGULAR EXERCISE

• IMPROVES OR MAINTAINS
• Good posture body image
• Intake of nutrients and immunity to infection
• Cerebral function, mood, memory
• Sleep pattern and duration
• Social contacts

INDEPENDENCE AND QUALITY OF LIFE

• REDUCES OR PREVENTS
• Likelihood of falls and fractures
• Breathlessness, Obesity
• Constipation, incontinence, urinary urgency
• Anxiety, Depression, Stress

DEPENDENCE AND ISOLATION
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THE THREE DIMENSIONS OF HUMAN FRAILTY
TIME
HUMAN FRAILTY (Spirduso, 1995)
DISUSE
DISEASE
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ACTIVITY AND SURVIVAL

• Activity gt2000 calories a week (30 lower
  mortality)
• Hypertensive men who exercised had half the
  mortality rate
• Smokers who exercised had 30 lower mortality

(Paffenberger et al., 1986) - 16,936 Harvard
Graduates

• Lowest fitness category at follow-up
• died 3.5 (men) to 4.5 (women) x rate of fit
  people
• higher incidence of cancer and Cardiovascular
  disease

(Blair et al., 1989) - 13,344 healthy men and
women
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MORBIDITY AND MORTALITY

• 80 of over 80s would rather be dead than suffer
  the loss of independence that moving to a nursing
  home would bring (Salkeld, 2000).
• 7.5 years of functional disability at the end of
  life (Wilkins Adams, 1983)
• For 1 hr exercise a week - 10 increase in
  reported health status, 19 decrease in health
  risks (Fries, 1980)
• Its NEVER TOO LATE (Fiatarone, 1990)

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Sedentary vs. active lifestyles

• gt3 hrs per week targeted exercise
• myocardial infarct - 3 x less likely
• Osteoporosis - 2 x less likely
• Fall-related injuries - 2 x less likely
• Hip fracture - 2 x less likely
• WHO, 1996 regular physical activity helps to
• preserve independent living and
• postpone the age associated declines in balance
  and co-ordination that are major risk factors
  for falls

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National Service Framework For Older People 2001
- Exercise Evidence

• Standards
• 3 Intermediate Care
• 5 Stroke
• 6 Falls
• 7 Mental Health
• 8 Promotion of Health and active life in old
  age

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ACTIVITY AND OLDER PEOPLE - SPIRAL OF DECLINE
Elite Older Athlete Physically Active Independent
but Active Physically
Frail Physically Dependent Disabled
Medications Fear of Falling Ageism Disengagement O
wning Up Disability Threshold
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Routine activity 6 minutes walk or 15 minutes
wait ?
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HOW MUCH IS ENOUGH?

• Regular for health - activities are performed
  most days of the week, preferably
  daily
• (WHO, BHF, Dept. of Health)
• Adult population - physical activity of a
  moderate intensity for half an hour,
  on at least five days of the week.
• (Department of Health 1999)
• Maintenance of Independence - once/twice a week
  minimum targeted exercise
• (Consensus)

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WHATS THE DIFFERENCE?

• Physical Activity
• any bodily movement produced by skeletal muscles
  that results in energy expenditure.
• Exercise
• planned, structured and repetitive bodily
  movement undertaken to improve or maintain one or
  more components of physical fitness.
• Bouchard 1990

Gardening DIY Housework Bowling
Walking Cycling Exercise class Sports
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Physical Activity in the UK

• HEA National Survey of Activity and Health in men
  and women aged 50 (conducted in 1990 and 1991)
• Questionnaires for 50-69 year olds and for those
  aged 70

• Allied Dunbar National Fitness Survey (conducted
  in 1990 and 1991)
• Questionnaires for those aged 50-69 and for those
  aged 70
• Physical Appraisals for those aged 50-74 and for
  those aged 75

The combined samples give a nationally
representative total of 3078 people over the age
of 50. A physical appraisal was performed in
1318 people.
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SEDENTARY WAYS

• 40 of people aged 50 or over in the UK are
  sedentary
• 60-85 are sedentary in ethnic minority groups
• Between the ages of 45 and 74 the amount of
  people taking enough activity to benefit health
  declines from 1 in 3 to 1 in 7.

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Couch potatoes ?
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Couch potatoes ?
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SEDENTARY WAYS

• 1/2 of sedentary gt50s and 2/3 of gt70s
  believe they take part in enough physical
  activity to keep fit.

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Physical Appraisal - ADNFS
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Maximal oxygen consumption (VO2 max) in men and
women aged 50-74
Maximal oxygen uptake (ml/kg/min)
VO 2 max to walk comfortably at 3 mph
Age (years)
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Isometric knee extension strength in men and
women aged 50-74
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SEDENTARY WAYS

• Nursing home residents spend 80-90 of their
  time seated or lying down

• As a result of inactivity, a third of over
  70s cannot walk a quarter of a mile on their own

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Inactivity as a major risk factor
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Physical activity and public health the
benefits

• Coronary Heart Disease 10 billion
  37 attributable to inactivity
• Diabetes 5.2 billon
  - 56 preventable
• Obesity 2.5 billion to NHS and economy
• Falls and fractures among older people 1.7
  billion 46 preventable
• Mental Health - 32 billion (1996 7)

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We are all trippers.but when do we become
fallers?
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Inactivity determined disability ?
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Reported falling by distance of walking ability

Cambridge City gt75s Cohort, Fleming, 2002,
unpublished
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Falls a major problem in the UK

• 11 million people aged gt 65 yrs
• 28,000 women aged gt 90 yrs
• Fractures costs 1.7 billion
• 1 Hip Fracture every 9 mins
• Cost 12-18K
• 1 Wrist Fracture every 10 mins
• Cost 450
• 500 admitted to Hospital every day
• 33 never go home

Annual European Home and Leisure Accident
Surveillance Survey (EHLASS) Report UK 2000
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Fallers

• 1 in 3 over 65s
• 1 in 2 over 80s
• 70-80 of falls go unreported
• 40 fall at home
• 5-10 fall on the bus
• More falls in residential settings than in the
  community

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Could costs be cut ?

• Fractures, mostly due to falls in older people,
  cost the NHS 1.7 billion per year.
• One third of call-outs for London Ambulance
  Service are for people aged 65, nearly 10 are
  fallers
• 40 of these are not taken into Hospital for
  treatment
• 40 of nursing home admissions are due to falls
  or balance/mobility problems

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Inactivity related disease?

• No standing activity leads to active loss of
  bone and muscle
• 1 wk bed rest ? strength by 20
• 1 wk bed rest ? spine BMD by 1

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Determinants associated with physical activity

• Ethnicity
• Gender
• Educational level
• Smoking status
• Overweight
• Medical condition
• Perceived lack of ability
• Motives to improve appearance or fitness

• Fear of Injury
• Transportation problems
• Safety concerns
• Social Support
• GP and family advice
• Myths and mistaken beliefs

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Strength training in older people - effects on
muscle properties I
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Strength training in older people - effects on
muscle properties II
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Effects of strength training on health and
well-being
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Strength training in frail, institutionalised
older people
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CHAIR BASED EXERCISE

• Improvements in wide range of ages /settings
• Strength and Power (Fiatarone 1990, 1994 Skelton
  1995, 1996)
• Flexibility and Functional Ability (McMurdo 1993
  Skelton 1995, 1996)
• Arthritic Pain (Hochberg, 1995) and Postural
  Hypotension (Millar, 1999)
• Depression (McMurdo, 1993)
• Rehabilitation following hip fracture (Nicholson,
  1997)
• ? Risk of future falls (Allen, 1999)

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Effects of strength training on independence and
functional ability
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Specificity of training
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Bone strengthening in gt50s -1 year
(Rutherford et al., 1998)
Post-menopausal women 1 year walking, NO change
spine BMD (Cavanaugh Cann, 1988)
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Potential Risks in those with low bone density

• In those who have had spinal fractures
• Type of Exercise Reoccurrence of
  Fracture
• Back extension 16
• Flexion (abd. curls) 89
• Combined 53
• No exercise 67

Sinaki Mickelson 1982
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HRT and Exercise
Notelovitz et al, 1991
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Effective Home Exercise

• RCT - gt80 year old women
• 1 Year duration - Physiotherapist support
• home-based tailored progressive strength, balance
  and gait training (3x p/w)
• 20-30 reduction in risk
• Campbell, BMJ, 1997
• Then - Physiotherapist led nurse training
• For over 65s cost effective
• For over 80s saves money
• Robertson, BMJ. 2001

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Group based Exercise

• Randomised controlled trial
• Women aged 65 with a history of 3 or more falls
  in previous year
• Exercise-only intervention 9 months
• Falls decreased by 60
• Injurious falls decreased by 75
• 3 years from baseline
• 10 in exercise group had died, were in Hospital
  or in a nursing home compared to 33 of those not
  exercising

D.Skelton, O.Rutherford and S.Dinan
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Training Improvements in Risk Factors STRENGTH
/ POWER / ASYMMETRY

• Significant isometric and isokinetic improvements
  in the exercise group
• Ankle plantarflexion 60
• Ankle dorsiflexion 40
• Ankle Inversion 25
• Ankle Eversion 30
• Hip Flexion 20
• Lower Limb Power 25
• Asymmetry reduced 15

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Training Improvements in Risk Factors
FUNCTIONAL ABILITY BONE
Functional Reach 20 Up and go 20 Floor
rise 50 Balance 60

• Fun and social activity
• Confidence in balance
• Reduced anxiety and fear
• tripping not falling
• Playing with grandchildren
• Caring skills

Fallen Angels Club!
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SPECIALIST
Dinan Illiffe, 2001
NURSING AND RESIDENTIAL HOMES
HOSPITAL IN-PATIENTS
Unstable Ill
PRIMARY CARE
PUBLIC HEALTH
Stable Ill
Well
COMMUNITY DWELLING
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Meeting the needs of older people
NVQ3 Cardiac Rehabilitation Postural
Stability Instructors
Physically frail - housebound
NVQ3 Exercise for Special Populations Instructors
1 to 1 or home-based
Independent with human assistance
NVQ2 Exercise for Older People Instructors
Supervised sessions, health care setting
Extend
Independent with assistive aids
Chair-based Exercise, Walking and Games
Leadership Training NVQ2
Supervised sessions, community
Fully independent older people
Peer-mentor Training
Unsupervised, community
Moderate activity, half an hour, 5 x per week
Dinan, 1999
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Barriers to exercise referral

• Exercising GPs 3 x more likely to promote
  activity than sedentary GPs
• Lack of staff time and resources
• uncertainty about effectiveness
• patient resistance/reluctance to change
• insufficient knowledge
• low priority

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Do older people take up physical activity?

• King (1998) reviewed the main RCT trials
• Attendance averaged 75
• Half of the interventions used strategies to
  promote participation
• behavioural strategies
• telephone assisted
• range of activities - home, supervised
• Maintenance better than for younger adults

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Physical activity and health

• Dose response curve
• The lower the baseline level of physical
  activity, the greater the health benefit
  associated with an increase in physical activity
• (Haskell 1994)

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The Cost of Exercise

• Sedentariness appears a far more dangerous
  condition than physical activity in the very old
  American College of Sports Medicine (1998)
• Physical Activity is now rightly called the best
  buy in public health Yvette Cooper, Minister
  for Public Health (2000)

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• Man does not cease to play because he grows old.
  Man grows old because he ceases to play
• George Bernard Shaw

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Further Reading

• Taylor. A. et al (2004) Physical Activity and
  Older Adults a review of health benefits and the
  effectiveness of interventions. J Sports
  Sciences 22 703-725.
• Finch. H. (1997) Physical Activity at our age
  Qualitative research among older people. Health
  Education Authority, London.
• MacRae. P. et al. (1996) Physical activity
  levels of ambulatory nursing home residents.
  JAPA 4264-278.
• Skelton. D. et al. (1999) Physical Activity in
  Later Life Further analysis of the Allied Dunbar
  National Fitness Survey and the Health Education
  Authority Survey of Activity and Health. Health
  Education Authority, London.
• Exercise in preventing falls and fall related
  injuries in older people A review of RCTs -
  Gardner et al. (2000)

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Further Reading

• Spirduso. W. (1995) Physical Activity and
  Aging. Human Kinetics, Champaign, Illinois.
• King. A. et al. (1998) Physical Activity
  Interventions targeting older adults A critical
  review and recommendations. Am.J. Preventative
  Medicine 15316-333.
• Skelton. D. et al. (1995) Effects of resistance
  training on strength, power and selected
  functional abilities of women aged 75 and over.
  J.Am.Geriat.Soc. 431081-1087
• Skelton. D and A. McLaughlin (1996) Training
  functional ability in old age. Physiotherapy.
  82(3) 159-167
• Young. A and S.M.Dinan (2000) Active in later
  life (Chapter 11). ABC Sports Medicine, 2nd
  Edition, BMJ Publishing Group, London, p51-56.
• Physical Activity Interventions Targeting Older
  Adults a Critical Review and Recommendations
  King, A. (1999)