Incidence, contributory factors and impact of low levels of physical activity and functional decline

Physical activity — often also called exercise — refers to any task that is associated with some level of energy expenditure. Some tasks, such as standing up from a chair or showering, involve relatively little energy expenditure, while other tasks such as mowing lawns, playing tennis or group exercise programs can involve relatively high levels of energy expenditure.

Low level of physical activity is responsible for about 7% of the burden of preventable health problems and disability, and between 1.5–3% of total direct health care expenditure (Mathers et al 1999; Oldridge 2008). Physical inactivity is a risk factor for a range of health problems and functional limitations, including increased risk of falls (Lord et al 2007) and increased risk of cardiovascular disease, stroke, diabetes and some forms of cancer (Warburton et al 2007). Less than 50% of older people are sufficiently active to achieve health benefits (defined as up to 30 minutes per day of moderate or vigorous activity on most days of the week, or an accumulation of 150 minutes per week), with physical activity rates higher in older men than older women (Armstrong et al 2000; Bauman et al 2003). Therefore strategies to improve older people’s participation in physical activity have the potential to achieve a range of health benefits.

Physical activities can vary in their intensity, and are often classified as light, moderate or vigorous physical activity.

Moderate or vigorous intensity physical activities are required to achieve improved health outcomes (Glasgow et al 2005).

There are many ways for older people to become or remain physically active. These can be grouped broadly as incidental activities or organised activities. Incidental activities are activities that involve some degree of physical exertion, but are undertaken as part of routine activities. They include activities such as gardening, vacuuming, walking to the local shops instead of driving and taking the stairs instead of the elevator. Incidental activities, particularly when performed at moderate intensity level, contribute to the cumulative amount of physical activity a person performs each day.

Organised physical activity refers to more formal approaches to exercise. These are often in a group setting. Research has shown that many types of organised physical activity can achieve positive outcomes for older people, including those with health problems. Health benefits include:

There are many approaches to organised physical activity. These include:

Many recreational activities also have a physical component to them, and are likely to have some health benefits associated with them as well, although these have been less well researched. For example, dancing, lawn bowls and golf have all been shown to have some associated health benefits, as well as having strong benefits for older people from social and connectedness perspectives.

A specific type and intensity of physical activity will be of different challenge to older individuals depending upon their current level of fitness and their concurrent health problems. As such, a regular game of lawn bowls or bocci might have limited effect on health for a well older person (who would probably require a more physically taxing activity to achieve health benefits), however might be suitable and have some health-promoting effects for some less well older people. For a frail older person with multiple comorbidities however, this activity level might not be possible (see Fig 12.1).

Figure 12.1 Physical activity options across the health continuum

Even frailer older people who have a range of acute or chronic health problems can still be involved in physical activity programs and derive positive health outcomes. For example, older people with stroke (van Peppen et al 2004), arthritis (Keysor & Jette 2001), Parkinson’s disease (de Goede et al 2001) and those with increased risk of falls (Sherrington et al 2004) have been shown to safely and effectively participate in physical activity programs. However, people with these health conditions should discuss commencing participation in a new form of physical activity with their general practitioner or other health professional, and it is often preferable for these people to commence an exercise program under supervision of a trained exercise leader such as a physiotherapist, accredited exercise leader or exercise physiologist (Nelson et al 2007).

There are many associated benefits of participating in physical activity in group settings. The social interactions and networking that occur during exercise groups have been highlighted as key factors influencing longer-term participation (Vrantsidis et al in press). However, some older people prefer to undertake physical activity alone. Many of the approaches to exercise described above (e.g., strengthening exercises, balance exercises, walking programs, tai chi) can be performed at home alone, sometimes with intermittent support (e.g., DVD of the tai chi movements), particularly after initial training with an exercise leader. Individualised exercise programs targeting balance and muscle strength problems might also be recommended as a home program. These are often prescribed after a comprehensive musculoskeletal assessment by a health professional, such as a physiotherapist. Home exercise programs incorporating balance and strengthening exercises have been shown to be effective in improving balance and muscle strength and reducing falls (Robertson et al 2002). Both group exercise programs and individualised home exercise programs have been shown to achieve positive health outcomes. Personal preference, safety issues, comorbidities and the desired health outcomes are important considerations in determining the type, location and intensity of an exercise program for an individual.

Age alone is not a barrier to participation in any form of physical activity. The number of concurrent health problems is a much stronger determinant of the type and level of physical activity an older person can undertake safely. Some well older people can continue to participate in quite vigorous physical activity (Nelson et al 2007) such as long-distance running or swimming.

Screening and assessment for low levels of physical activity / functional decline

A widely recommended level of physical activity to maintain health is the accumulation of 150 minutes per week of moderate intensity physical activity, comprising 30 minutes on most days of the week (Armstrong et al 2000). Therefore, ascertaining the amount of physical activity over a 1 week period is a simple screen that indicates if a person is meeting this minimum requirement. Pedometers, accelerometers and actigraphs can also provide quantitative information on standing and walking or running-related activities.

For a detailed profile of physical activity either to assist with identifying specific areas of need, or to use in tailoring a physical activity program, more detailed physical activity assessments are required (Melanson & Freedson 1996). Examples of physical activity questionnaires include the 94 item Human Activity Profile (Fix & Daughton 1988) and the CHAMPS tool (Cyarto et al 2006). A new assessment tool that provides a measure of function, mobility, and balance performance is the de Morton Mobility Index (DEMMI). This tool has recently been shown to be a useful assessment of function in older people in hospital (de Morton et al in press).

Screening and assessment for falls risk

One of the strongest risk factors for having a future fall and for functional decline is having had a previous fall, even if the fall did not cause an injury. However many older people do not report falls to their general practitioner or health professional. One of the most useful single items in a screening tool, even by itself, is to ask whether an older person has had a fall in the preceding 12 months. If they have, then this should be further investigated by the health professional and a treatment plan implemented if risk factors are identified.

An example of a falls risk screening tool (the FROP-Com screen) is shown in Figure 12.2 (Russell et al in press). This is a three-item screen for older people living in the community that was developed from a validated falls risk assessment tool (the Falls Risk for Older People — Community version: FROP-Com), shown in Figure 12.3 (Russell et al 2008). The FROP-Com screen has been used in a range of community-based settings, including older people with low falls risk (Murray et al 2005) and high falls risk (Russell et al 2006). Other assessment tools have been reported for use in residential care settings (Lundin-Olsson et al 2003) and in hospital settings (Haines et al 2007). The presence of fear of falling should also be considered for those at risk of falls, or who have had a recent fall. A screening question may be just to ask: ‘As a result of the fall or near fall, have you lost confidence in walking and other activities?’ For those who report positively, a detailed assessment of fear of falling (also called falls efficacy) should be undertaken. The Short Falls Efficacy Scale International (Short FESI) is a recently developed abbreviated assessment tool to measure fear of falling (Kempen et al 2008).

Figure 12.2 The FROP-Com screening tool

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