A planned program of physical activity is like a magic pill because it can prevent heart disease and reduce blood pressure, promote weight loss, reduce the risk of osteoporosis, enhance ability to perform activities of daily living, and promote more restful sleep. The only problem is that it is not available in an easy-toswallow capsule and will require personal effort and a dose of self-discipline.
The purpose of this article is to: 1) describe the benefits of physical activity in older adults, 2) report data from the Health Evaluation Risk Survey (HERS) on exercise in older women and, more importantly, 3) supply health care providers with tips for integrating physical activity promotion in their practice.
It is a known fact that as people age, there is a decline in physical activity. In the wake of the latest data published in Healthy People 2000, Review and 1995 Revisions (U.S. Department of Health and Human Services, 1995), 250,000 deaths per year in the United States have been attributed to a lack of physical activity. Regular physical activity, musculoskeletal strength and cardiorespiratory fitness are critical to the maintenance of healthy, independent living as people grow older.
FOCUS ON THE F.I.T.T. RECOMMENDATIONS
Conflicting reports in popular media regarding how much physical activity is healthy is confusing to patients and health care providers alike. The question becomes "how much pain for optimal gain?" (Manson, 1996). Another question is, what type, intensity and quantity of physical activity are important to prevent cardiovascular disease? This was the central question debated at the National Institutes of Health (NIH) Consensus Development Conference (1995), "Physical Activity and Cardiovascular Health." Research findings clearly indicate that the majority of benefits of physical activity can be gained by performing moderate-intensity activities outside of exercise. The NIH (1995) defines exercise and physical activity as follows (p. 1):
* Physical Activity -bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive health benefits.
*Exercise - a type of physical activity defined as a planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness.
The central recommendation of the consensus conference is that, "all children and adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, or preferably, all, days of the week" (p. 5). This is a significant departure from the previous recommendations. Table 1 contrasts the old and new guidelines. When applying these recommendations to elderly persons with one or more physicalmedical limitations, the intensity of the activity should be lowered slightly while the frequency and timing could be increased (Pollock, Graves, Swart, & Lowenthal, 1994).
In pioneer days, manual labor /physical activity was a requirement for survival. People worked hard but died young from infectious diseases. In fact, in 1900, average life expectancy was approximately 50 years of age (U.S. Bureau of Census, 1975). Scrolling forward to our present time, life expectancy has been extended by great strides in technology, immunizations, sanitation, refrigeration and miracle drugs. Census data indicate that in 1995 there were 34 million individuals ages 65 years or older, representing 13% of the U.S. population. Furthermore, projections for 2030 indicate that there will be 79 million people ages 65 and over, representing 20% of the population (U.S. Bureau of the Census, 1997). While Americans' quantity of life is expected to be 80 years of age, their quality of life could be greatly improved by a return to the earlier era of daily physical activity.
Several well-designed studies report the prevalence of physical inactivity among Americans. Siegel and colleagues (1991) found that 60% of American adults perform little or no recreational physical activity. Less than one in four adults (more women than men) currently have sedentary lifestyles with no significant physical activity (Crespo, Keteyian, Heath, & Sempos, 1996; Morbidity & Mortality Weekly Report, 1990). A recent estimation reveals that nearly 80% of the U.S. population are not adequately physically active (Pate et al., 1995).
Comparing the Recommendations
There are also age, gender, economic and ethnic variations noted in physical activity surveys. Most studies on physical activity and coronary artery disease (CAD) have been done on middle-aged, white males of middle socioeconomic status. Evidence is now beginning to surface indicating that physically inactive Americans are more likely to be disproportionately less educated, female, elderly, economically disadvantaged and live under unfavorable social circumstances (Crespo, Keteyian, Heath, & Sempos, 1996). In regard to physical activity in the elderly Stephens & Craig (1990) stated the major ference between individuals under and over 65 years of age is that about 50% of older persons who are not physically active have no intention of starting a program of activity.
Shape up America (1995), the health promotion group headed by former Surgeon General C. Everett Koop, recently polled 1,599 urban residents (47% with family incomes under $25,000) and found that lowincome people are just as likely as those with higher incomes to realize the importance of exercise. Persons of lower socioeconomic status report much more serious inhibitory factors than just staying motivated. For example, they report feeling unsafe exercising outdoors in their neighborhoods, but don't have public exercise facilities nearby and can't afford private facilities. This may somewhat account for the two groups that have the highest rates of physical inactivity: non-Hispanic black women - 40% and Mexican American women - 46% (Crespo, Keteyian, Heath, & Sempos, 1996).
Mistretta and Jones (1996) conducted a study which examined older women's perceptions of their risk for cardiovascular disease and stroke. A convenience sample of 491 women 55 years and older completed the Health Evaluation Risk Survey (HERS), an instrument developed and refined by the authors. The women (76% Caucasian and 24% Black) resided in the southeastern United States with 59% living in rural and 41% in urban areas. Data from the exercise/ physical activity portion of the HERS questionnaire yielded the following findings.
* 97% of these older women perceived exercise to be important in disease prevention;
* 88% of the sample reported that regular exercise contributed to their sense of well-being;
* 73% of the participants reported exercising regularly (at least 2 or more times per week);
* Yet 45% of the women reported never having been advised to exercise by their health care provider.
The findings highlight the importance of the health care provider's role in acknowledging and promoting exercise and physical activity in older patients. Older adults currently may be more informed than health care providers concerning the important relationship between physical activity and health and well-being. As baby boomers approach retirement, health care providers should be aware that athletic shoes may replace rocking chairs as a symbol of aging in America.
AT THE HEART OF THE MATTER
According to the National Institutes of Health Consensus Conference on Physical Activity and Cardiovascular Health (1995), "more than 10 million Americans are afflicted with clinically significant CVD [cardiovascular disease] resulting in an annual rate of 300,000 or more coronary artery bypass procedures and a similar number of percutaneous transluminal coronary angioplasty procedures" (p. 7). Coronary artery disease is the major cause of death in the United States population older than 65 years. Further, 60% of patients currently hospitalized for acute myocardial infarction are older than age 65. Clinical evidence of CAD is present in 20% of the population by age 80, with an equal prevalence encountered in men and women, in contrast to the male predominance at younger ages.
Despite progressive declines in age adjusted death rates from CAD over the past 25 years, CAD remains the leading cause of death in the United States. Lifestyle improvements by the American public have been major factors in this decline (NIH Consensus Conference, 1995). Primary care clinicians are working closely with individuals and families to better control modifiable risk factors for CVD including smoking, high blood pressure, blood lipids, obesity and diabetes.
It is now time for health care providers to provide clinical counseling and accept personal accountability in combating the remaining modifiable risk factor for CAD - physical inactivity. A sedentary lifestyle has been shown to be a risk factor for the development of CAD independent of other health habits (Ekelund et al., 1988). As a health care provider devoted to health promotion and disease prevention, how are you addressing exercise and physical activity in your professional and personal life?
Research studies examining relationships between physical activity/exercise and cardiovascular disease provide compelling evidence of the benefits of a program of regular activity. The landmark study that first examined the relationship between physical activity and death was conducted by Morris and colleagues in 1953. Epidemiologic data were employed to compare the relationship of sedentary and active individuals to CVD events. The researchers retrospectively compared the rates of CVD among 31,000 London transportation workers. The conductors who walked and climbed stairs frequently during their work day had significantly lower rates and milder manifestations of CVD than did their less active colleagues driving double-decker buses (Morris, 1953 as cited in Norstrom & Conroy, 1995). Hundreds of studies since have reported the benefits of an active lifestyle in reducing morbidity in several disease states and reducing mortality across the life span.
Primary care providers may be wary of promoting physical activity in their patients for fear of sudden death during exercise. The overall risk of a cardiac event is lower in persons who exercise than in those who are sedentary when both active and non-active hours are taken into account. Siscovick and colleagues (1984) found that the net risk of sudden death was 60% lower in very active men than in sedentary men. The American Heart Association's Medical / Scientific Statement (Fletcher, Froelicher, Harley, Haskell, & Pollock, 1990) reported that one death occurs per 565,000 hours of activity. The vast majority of patients will benefit from "moderate" physical activity which carries a much lower risk than "strenuous/vigorous" activity (NIH Consensus Conference, 1995). Health care providers should remember that patients die from coronary heart disease, not exercise. The authors propose that health care providers should instead be concerned about the possible liability for not promoting physical activity.
EXPLORING THE EXCUSES
Among the common reasons stated by patients when asked why they are not physically active is that they do not have enough time, are fatigued or experience chronic pain. Some patients complain that they are too busy to exercise. This statement presents an opportunity for the health care provider to suggest that the patient keep an activity log for a week and review it together at the next visit. Upon careful self-reflection the patient may be surprised to learn that they are one of the average Americans who spends 27-30 hours each week watching television (Norstrom & Conroy, 1995).
Another excuse or impediment to participating in physical activity is fatigue. Poor sleep habits may leave patients physically and mentally sluggish. If difficulty initiating or maintaining sleep is an issue then the first line of counseling by the health care provider should include common sense sleep "hygiene" advice such as: reduce or eliminate daytime napping, go to bed at the same time every night, gradually eliminate caffeine from the diet, use the bed for sleeping only (not reading, eating and lounging for example), have a light dinner several hours before retiring. Good choices for a light dinner would include pasta with marinara sauce or a turkey sandwich.
Older adults are disproportionately affected by chronic painful conditions such as osteoporosis and osteoarthritis (OA). In regard to osteoporosis the National Osteoporosis Foundation (1996) reported that 25 million Americans are affected by osteoporosis resulting in an estimated 1.5 million fractures annually. Arthritis statistics are equally grim. According to Schumacher (1993), the majority of people over 65 years of age show radiologic evidence of OA at some joint site and the prevalence of OA increases with age. Osteoporosis and OA are only two of the common painful syndromes that can decrease the quality of life in the elderly and discourage them from being physically active. However, a program of physical activity appropriate to a patient's joint or bone condition can contribute to improved function and mobility, an improved energy level and a sense of well-being (U.S. Department of Health and Human Services, 1996).
DETERMINING PHYSICAL AQIVITY
The concept of perceived exertion is replacing target heart rate as a measure of exercise intensity. The old Karvonen formula for determining target heart rate (Start with 220, subtract your age, subtract your resting heart rate, multiply by 60%-85%, then add back your resting heart rate) has been found inapplicable to approximately 30%-40% of adults (Bailey, 1994). These 30% to 40% of persons were found to have hearts that beat faster or slower than the age-predicted maximum.
Two newer and easier tests for exercise intensity are now gaining acceptance by the health care community. One is the test. As the name indicates, one should be able to carry on a conversation while walking with some labored breathing, but never huff and puff to the extent that one can not talk. The converse is true also; if someone can carry on unlimited unlabored discussions, the exercise intensity should be increased. Although the talk test is not as scientifically rigorous as other methods, it is easy for patients to implement and keeps most people at least 60% of maximum heart rate.
Another measure of intensity gaining acceptance in the scientific community is the Borg Scale Perceived Exertion (Borg, 1980). The Borg Scale relies on how hard exercise feels to the patient in terms of heart and lung exertion. "Very Light" corresponds closely to 40% of maximum heart rate whereas "Very, Very Hard" is close to 100%. Neither of these extremes provide optimal health benefits for the average American. Most patients should strive for the "Somewhat Hard" level which correlates with about 75% maximum heart rate. The Borg Scale of Perceived Exertion is found in Table 2.
GERONTOLOGICAL NURSING IMPLICATIONS
Motivating Seniors: Exercise Incentives
People engage in physical activity and exercise for a variety of reasons. Persons who are already actively exercising report that the major reasons why they exercise are to feel better, to have fun, to control weight, to improve flexibility and to relax and reduce stress (Shephard, as cited in Dishman, 1994). Even low-level range of motion or calisthenic exercise, slow walking, or lowintensity swimming can have a beneficial effect on physiologic function and other fitness factors that help maintain one's ability to perform activities of daily living and enhance the quality of life (Pollock, Graves, Swart, & Lowenthai, 1994).
Borg Seuroale of Perceived Exertion
Sociodemographic characteristics (age, gender, educational level and weight) are associated with physical activity patterns and preferences PiPietro, 1995). Duda and Tappe (1988) studied men and women aged 50-81 years to determine factors which predicted personal investment in physical activity and found that exercise is an important means of receiving positive feedback from others and improves one's individual fitness. Gill and Overdorf (1994) studied women over 50 years of age to determine their exercise incentives and found that the most common reasons included social interaction, improved mental health, weight control and appearance. The more health care providers understand what motivates their patients to exercise, the better they can provide counseling aimed at increasing physical activity in their practices. This information should also be considered when developing community-based intervention strategies.
Figure. The Activity Pyramid.
Prescribing Physical Activity
One of the major recommendations from Healthy People 2000 is that 50% or more of primary health care providers will inquire about the frequency, duration, type, and intensity of exercise habits in most new patients. One mechanism to assure that exercise counseling occurs is to provide a written prescription. A "prescription" underscores the importance of exercise for patients. A formal exercise prescription should include specific advice about the frequency, intensity, timing /duration, type and progression of physical activity. Injury prevention and program maintenance should also be addressed (Jones & Eaton, 1995).
In addition to joint /area specific advice about activity and pain relief, patients should be counseled about becoming more active overall. The range of motion that occurs naturally in daily activities is not sufficient to prevent reduction in joint mobility. Immobility leads to joint stiffness, pain, lessening range of motion and thus decreased ability to complete daily activities. Physical activity in the elderly is known to increase muscle tone, strength and agility thereby preventing falls. Physical activity offerings for older adults also create opportunities for socialization, promotes confidence, mastery, independence and a personal sense of well-being. Determining and building on physical activities which patients enjoy(ed) can serve as a baseline for physical activity prescriptions. The authors share a successful model for increasing everyday physical activity.
Pyramid Power: A Physical Activity Model
Exertion has been engineered out of many occupations and automation has taken over recreational activities (elevators, automatic garage door openers, fast food "drive thru," TV remote controls...). The average adult American watches 4 to 5 hours of TV or plays computer games each day. Is it any wonder that one-third of American adults (58 million) have become obese (U.S. Department of Health and Human Services, 1995)? Norstrom and Conroy at the Institute for Research and Education Health System Minnesota recently developed "The Activity Pyramid" (1995, Figure). It is an easy-to-follow graphic based on the recommendation that all adults get 30 minutes or more of moderate-intensity physical activity every day. For the majority of the population, exercise does not have to be vigorous to be a health benefit. "It is unrealistic to expect that this nation will cheerfully embrace an exercise regimen that involves long periods of intense physical activity, whatever benefits in terms of health" (Manson, 1996, p. 1327).
The Activity Pyramid is modeled after the U.S. Department of Agriculture's Food Guide Pyramid which is designed to help consumers visualize that most of their food choices should come from the base of the pyramid with fewer choices occurring toward the apex. Starting from the base of The Activity Pyramid individuals are encouraged to participate in more physical activity on a daily basis. This may include activities such as parking farther away and taking the stairs instead of the elevator. (Health care providers may also want to post a sign by the office elevator giving directions to the nearest stairs.) The next level going up the pyramid is recreational and aerobic exercise such as basketball and brisk walking to be done 3-5 times a week. Leisure activities such as bowling and flexibility/ strength activities such as yoga, Tai Chi and weightlifting are encouraged at least 2-3 times each week. Finally, the top of the pyramid encourages patients to cut down on sedentary activities that require prolonged sitting. Patients who are completely inactive may want to concentrate on the base of the pyramid while those who are somewhat active should be encouraged to find an activity they enjoy and set realistic goals. Persons who are active at least 4 days a week should use the entire pyramid to explore new activities and create diversity in their activity patterns.
Most health-deterring behaviors, including physical inactivity, involve repetitive and habitual actions which are quite resistant to modification. Health care professionals should continue to search for meaningful ways to encourage patients to adopt and /or continue health-promoting activities. In addition to providing the patient a prescription for physical activity, primary care providers should participate with patients in communitybased opportunities for exercise. Health care providers should join and support organized fitness/race walks such as healthy heart walks, joint local walking or track clubs, participate in Senior Olympics, Boys and Girls Club activities and YMCA sponsored exercise activities. Church-sponsored senior groups are also a cornerstone of community-based fitness interventions. Sowing the seeds of physical activity across the life span will yield a more healthy and vibrant nation. So lef s get moving and walk our talk!
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Comparing the Recommendations
Borg Seuroale of Perceived Exertion