Active for Later Life

1. Active for Later Life Making the case for physical activity and older people

2. What do we mean by ‘older people’? • The benefits of physical activity for older people • How active are older people? • How active should older people be? • Can we help to change matters? • What helps older people to become active? • Older people and physical activity – strategic connections

3. What do we mean by ‘older people’?

4. What do we mean by ‘older people’? “We all age, but we all age differently” • Not a homogeneous group • Traditionally defined as those aged over 50 • Significant variations in health and functional capacity • Improvements in health and longevity • Self-identification often most important

5. What do we mean by ‘older people’? Hierarchy of physical function Physically fit Physically unfit Physically unfit frail (World Health Organization, 1997) Group 1 Healthy Unhealthy independent Group 2 Unhealthy dependent Group 3

6. Physically elite Physically fit Physically independent Physically frail Physical function Physically dependent Disability What do we mean by ‘older people’? Hierarchy of physical function (Adapted from Spirduso, 1995)

7. What do we mean by ‘older people’? National Service Framework for Older People • Entering old age • Transitional phase • Frail older people (Department of Health, 2001a)

8. What do we mean by ‘older people’? Older people and physical activity • Entering old age Making Activity Choices To promote and extend healthy active life and compress morbidity • Transitional phase Increasing the Circle of Life To maintain independence and reduce long-term dependency • Frail older people Moving in the Later Years To maintain independence and improve quality of life

9. The benefits of physical activity for older people

10. The benefits of physical activity for older people Increasing evidence in relation to: • Disease prevention and management, psychosocial benefits and complications of immobility • Maintaining independence, improving the quality of life, and ‘successful ageing’ • Opportunities for significant savings to health and social care services Benefits can be achieved by healthy older people as well as the frail and very old.

11. The benefits of physical activity for older people Prevention and management of disease • Coronary heart disease • Stroke • Increased blood pressure • Late onset (Type 2) diabetes • Osteoporosis • Colon cancer • Weight control • Reduction in accidental falls Effects apparent even among those taking up activity at a later age.

12. The benefits of physical activity for older people Psychological benefits • Reduction in stress and anxiety • Reduction in depression • Improvement in overall psychological well-being • Improvements in cognitive function • Improvements in self-esteem and self-worth • Reduction in isolation and loneliness Effects apparent even among those taking up activity at a later age.

13. The benefits of physical activity for older people Reducing the complications of immobility • Deep vein thrombosis • Gravitational oedema • Intermittent claudication • Contractures • Pressure sores • Faecal impaction Effects apparent even among those taking up activity at a later age. Movement can be passive and aided.

14. The benefits of physical activity for older people Improvements in independence, quality of life and successful ageing • Maintenance of social networks • Continued independent living • Improved quality of sleep • Sustained performance of ‘activities of daily living’ Effects apparent even among those taking up activity at a later age.

15. The benefits of physical activity for older people Potential social benefits • Enhanced social integration • Formation of new friendships • Widening of social networks • Role maintenance and new role acquisition • Empowerment • Enhanced inter-generational activity • Positive images of older people • Maintenance of caring skills • Reduced health and social care costs

16. The benefits of physical activity for older people Reduction in health and social care costs • Accidental fractures among women (£1.8 billion) • CHD and stroke (£1.6 billion for health care alone) • Diabetes (5% of NHS resources) • Obesity (£2.5 billion) • Poor mental health (£32 billion)

17. Disease prevention Maintenance of independence Age The benefits of physical activity for older people Changing the focus of physical activity promotion

18. How active are older people? Levels of physical activity, fitness and functional capacity

19. 5 kcal/min including brisk/fast walks 2 miles 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile How active are older people? Regular physical activity amongMEN aged 50+, England % participating at least five times a week 80% 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ (Skelton, Young et al, 1999) Age

20. 5 kcal/min including brisk/fast walks 2 miles 80% 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ How active are older people? Regular physical activity amongWOMEN aged 50+, England % participating at least five times a week (Skelton, Young et al, 1999) Age

21. How active are older people? Regular physical activity among minority ethnic groups aged 55+, England Those participating in activity 5 x 30 minutes a week Men Women African-Caribbean Indian Pakistani Bangladeshi Chinese 20% 22% 15% 7% 13% 14% 2% 6% 1% 14% (Erens et al, 2001)

22. 5 kcal/min including brisk/fast walks 2 miles 80% 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Levels of sedentary behaviour among MEN aged 50+, England % participating less than once a week (Skelton, Young et al, 1999)

23. 5 kcal/min including brisk/fast walks 2 miles 80% 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Levels of sedentary behaviour among WOMEN aged 50+, England % participating less than once a week (Skelton, Young et al, 1999)

24. How active are older people? Levels of sedentary behaviour among minority ethnic groups aged 55+, England Those participating less than once a week Men Women African-Caribbean Indian Pakistani Bangladeshi Chinese 57% 67% 73% 85% 68% 59% 78% 85% 92% 64% (Erens et al, 2001)

25. 100% 30+ min 15, < 30 min 1/4 mile or more 80% 5, < 15 min < 5 min 60% 40% 20% 0% 70-74 75-79 80+ 70-74 75-79 80+ How active are older people? Participation in walking among MEN aged 70+, England % able to walk for different periods of time and length of walk, without discomfort (Skelton, Young et al, 1999) Age

26. 100% 30+ min 15, < 30 min 1/4 mile or more 80% 5, < 15 min < 5 min 60% 40% 20% 0% 70-74 75-79 80+ 70-74 75-79 80+ How active are older people? Participation in walking among WOMEN aged 70+, England % able to walk for different periods of time and length of walk, without discomfort (Skelton, Young et al, 1999) Age

27. How active are older people? Older people living in care and residential settings • 86% of women and 78% of men in care homes are sedentary. • Sedentary behaviour in care homes is double that in private households (at age 65+). • Half of all men and women in local authority residential homes never or very occasionally take trips outside the home. (Department of Health, 2002b)

28. Physically active Physically inactive How active are older people? Thresholds for quality of life Exercise performance ‘Threshold’ value necessary for performance of an everyday task Age Adapted from Young (1986)

29. 60 Men Women 50 40 30 20 10 VO2 max to walk comfortably at 3mph 0 50-54 55-59 60-64 65-69 70-74 50-54 55-59 60-64 65-69 70-74 Age How active are older people? Aerobic capacity in MEN and WOMEN aged 50-74 (mean ± 2sd) Maximum oxygen uptake (ml/kg/min) (Skelton, Young et al, 1999)

30. 12 Men Women 10 8 6 4 2 Strength to be confident of rising from low chair without using one’s arms 0 50-54 55-59 60-64 65-69 70-74 50-54 55-59 60-64 65-69 70-74 Age How active are older people? Knee extension strength inMEN and WOMEN aged 50-74 (mean ± 2sd) Isometric knee extension strength (N/kg) (Skelton, Young et al, 1999)

31. 200 Men Women 160 120 80 40 Requirement to wash hair without difficulty 0 50-54 55-59 60-64 65-69 70-74 75-79 80+ 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Shoulder flexibility inMEN and WOMEN aged 50+ (mean ± 2sd) Shoulder abduction (degrees) (Skelton, Young et al, 1999)

32. How active are older people? Functional capacity Even healthy older people lose functional capacity. • Muscle strength ‘lost’ at 1%-2% per year • Muscle power ‘lost’ at 3%-4% per year • Aerobic capacity ‘lost’ at 1% per year • Bone density ‘lost’ at 1% in men and 2%-3% in women after menopause • Flexibility and balance • Proprioception and kinesthetic awareness • Co-ordination and reaction • Thermo-regulation Sedentary behaviour increases loss of performance. (Skelton and Dinan, 1999)

33. Time Human frailty Disease Disuse How active are older people? Functional decline and frailty (Spirduso, 1995)

34. How active are older people? Inactivity-related disease? Disuse rather than disease? • One week’s bed rest reduces:– strength by up to 20%– spine bone mineral content by 1%. • Nursing home residents spend 80%-90% of their time seated or lying down – leading to inactivity-related disability. • Those who are less active and weaker will enter nursing homes earlier than those who maintain their fitness.

35. How active are older people? Physical activity is disappearing from everyday life • Labour-saving devices • Transport patterns • Concerns over safety in public spaces • Sport as entertainment • The impact of information technology Leading to an increase in sedentary and physically less demanding lifestyles

36. How active should older people be? Current recommendations

37. How active should older people be? Recommendations for all adults “30 minutes of moderate physical activity, on at least five occasions a week.” (Department of Health, 1999b) Activities like brisk walking, cycling, swimming, dancing and gardening are good options.

38. How active should older people be? Working towards the recommended levels • Those who cannot achieve the recommended 30 minutes should build towards that target, e.g. 2 x 15 minutes and smaller bouts of activity on a regular basis. • Even the smallest amounts will bring some benefit, e.g. walking to the post box on the corner of the street or to the bottom of the garden.

39. How active should older people be? Physical activity for the older person should also include: • muscle strength and endurance (resistance) exercises for all major muscle groups • balance exercises • flexibility (stretching) (American College of Sports Medicine, 1998)

40. How active should older people be? Physical activity opportunities for older people • Continued or renewed sports participation and active recreation as well as fitness, exercise and dance activities and groups • ‘Active Living’ including walking, cycling, swimming and gardening • Playing with grandchildren, posting a letter, walking in shopping centres • Chair-based activities • Assisted corridor and ward walking, or activities in the bath and at bedtime

41. Can we help to change matters? Evidence of effectiveness and successful interventions

42. Can we help to change matters? Evidence of effectiveness From a critical review of 29 physical activity interventions: • Increased activity levels over a longer period of time • Group/class-based and home-based activity were effective • Tailored to individual needs • Cognitive-behavioural strategies and goal-setting • Telephone support and continued contact (King et al, 1998)

43. Can we help to change matters? Evidence of effectiveness • Strength – Fiatarone et al, 1990 • Functional capacity – Skelton et al, 1995 • Bone density – Rutherford, 1999 • Depression – Blumenthal et al, 1999 • Blood pressure – Young et al, 1999 • Mental health – Fox, 1999 • Cardiac rehabilitation – Jolliffeet al, 2001

44. Can we help to change matters? Evidence of effectiveness – falls prevention • FICSIT Trials: Province et al, 1995 • Tinetti et al, 1996 • Wolf et al, 1996 • Campbell et al, 1997 • PROFET: Close et al, 1998 • Gardner et al, 2000 • FaME: Skelton, 2001 • Day et al, 2002

45. Can we help to change matters? Evidence of effectiveness – duration vs outcome • Gait (8 weeks) • Balance (Static 8 weeks + Dynamic 8 weeks) • Muscle strength (8-12 weeks) • Muscle power (12 weeks) • Endurance (26 weeks) • Transfer (6 months) • Postural hypotension (24 weeks) • Bone strength (1 year for femur and lumbar spine) (Skelton and McLaughlin, 1996)

46. Can we help to change matters? Promoting physical activity through primary health care Physical activity advice/counselling can increase physical activity. • King et al, 1995 • Riddoch et al, 1998 • PAL: Goldstein et al, 1999 • Eakin, 2001

47. Can we help to change matters? Home-based programmes • Improve health and function in older people living in the community • Some studies show higher rates of adherence to prescribed exercise compared with group activities. • Telephone-based counselling improves participation and adherence. • Improvements in muscle strength and functional capacity. (Atienza, 2001)

48. Can we help to change matters? Community-based physical activity programmes Reviews • King et al, 1998; Stewart, 2001 Interventions • CHAMPS: Stewart, 2001 • GALM: Stevens et al, 1999 • On the Move: Cassady et al, 1999 • Dunn et al, 1999 There is a need for differentiation.

49. Can we help to change matters? Best practice for promoting physical activity with older people • Use of a health educator and extended consultation time • Agreement of problem areas • Goals agreed by both older person and professional • Identification and recognition of social and environmental barriers • Tailored action plan • Choice and range of accessible local activities • Supplementary educational materials • Systematic follow-up and support over time

50. What helps older people to become active? Barriers, beliefs, attitudes and motivation