Levels and layers: The keys to older adult fitness
Exercise and ageing specialist Sally Castell looks at the challenges – and the solutions – when it comes to training older adults.
When we’re young we can – and do – challenge our bodies, but over time the body (and mind!) can start challenging us. Ultimately, a fulfilling, quality life is everyone’s goal, whatever their age.
So how can fitness professionals help this be achieved? As we know, effective exercise interventions can reduce, and prevent any unnecessary, health problems.
Your community – which includes older adults and the less able – needs your expertise, energy and vision to support, encourage and equip people to both become and remain physically active and independent throughout life.
The aged population is booming
The fastest growing population is that of the older adult, with the majority living well and independently in their own homes. This population is getting increasingly ‘top heavy’. At the last census, 6 million people were aged between 50 and 89 years. Demographic trends over the next three decades project that the global number of adults aged 65 years and older will double to around two billion by 2050. This will have a huge impact on the health care system. It is imperative, therefore, that we find preventative ways to manage the wellbeing of these older adults in order to slow the escalating costs of managing chronic diseases.
Age need not be a barrier to participation in physical activity. Many older people take part in exercise regimes that are appropriate to their health status and fitness capabilities. Everyone wants to be independent and retain control of their lives – and the ability to remain active is key to this. Older adults need sufficient energy, adequate strength, balance and functional mobility to maintain body control. Physical activity programs combining aerobic, strength and flexibility (and balance) components can protect against the physical and cognitive decline associated with ageing.
As we age, numerous situations can become a challenge and require greater effort, both physically and mentally. Arthritis, for example, can limit movement and make many general activities painful and harder to perform. It affects a large percentage of the population, with over 3 million adults affected. Australia has some of the highest statistics on a global scale for knee and hip replacements.
A 2016 article in the Gerontologist journal1 describing the processes of healthy ageing reported that involvement in physical activities demonstrated reduced rates of chronic disease, and provided more productive older years with greater cognitive and functional capacities to carry out tasks and to participate in and enjoy social and cultural life2.
The negative consequences of ageing and reduced physical activity
Fitness and health declines with age and may eventually fall below the level required to be able to undertake everyday activities easily and safely. Physical and cognitive dysfunction are the major factors contributing to this. Inactivity is associated with a 400% increased risk of disability in activities of daily living; a 300% increased risk of balance disorders and increased risk of fall-related injuries; and a 200% increased risk of gait abnormalities.
Considering these statistics, it is perhaps unsurprising that a person’s capacity to exercise decreases with age, but evidence is growing that appropriate amounts of regular activity throughout life lessens this decline.
Activity limitations in later life
Causes of the activity limitations common in ageing include:
- physiological changes, such as musculo-skeletal (sarcopenia), neuromuscular, neurological and metabolic issues
- multiple chronic conditions, such as osteoarthritis, osteoporosis (osteopenia), Parkinson’s disease, diabetes and heart disease
- decreases in overall fitness and body control, including endurance, strength and flexibility
- changes in balance and gait patterns, which increase the risk of sustaining falls and associated injuries
- changes in fundamental movements due to increased sedentary behavior, often linked with a fear of falling which restricts the desire or will to keep moving
- altered mental states, such as depression and dementia.
Efficient and effective movement is required to perform daily tasks. To achieve purposeful, good and safe results, the body needs to work at an optimal capacity to undertake many tasks together. Changes in movement can occur with advancing age and low activity levels. Inactivity, chronic disease or obesity can be the major reasons for many people to lose abilities and independence, which is often seen as part of ‘normal’ ageing. Activities need to involve a combination of muscular strength (power/endurance), muscle and joint flexibility, good balance, co-ordination and cognitive skills.
The importance of maintaining muscle mass and strength in order to increase functional independence and decrease age-associated chronic diseases has been recognised in numerous research studies.
With advancing age and low activity levels, reduction in strength is a major cause of increased functional disability. Muscle mass and strength gradually declines from the age of 30 years onwards, with greater declines after the age of 40. The long term implication in reduction of strength and mobility is the increased prevalence of disability and increased risk of falls – and therefore fractures. Age is no barrier to the enhancement of muscle mass and function, with progressive strength training leading to improvements comparable to those observed in the young (greater effects due to original deconditioned state).
It is worth noting that, while the ageing and sedentary populations can make significant gains in muscular strength and walking speed through resistance training, the addition of balance and gait training can further enhance these improvements.
Joint mobility matters
Like muscle mass and strength, flexibility also gradually declines from the age of 30. The structures around and within joints change with age, causing them to become tighter and stiffen, making movement less easy. A good level of muscular strength is important for joint stability, and good joint ranges are important for joint mobility.
Energy reserve matters
There is an associated loss of reserve capacity with ageing. Skeletal muscle has an important role in energy metabolism, and with an age-related decline in muscle, it may contribute to other age associated changes, such as insulin sensitivity and aerobic capacity.
Alterations in movement can be a result of changes in the neuromuscular system and/or a specific neurological condition. Unimpaired sensory input and output can change the appropriate timing of muscle activation and movement patterns. The brain and body work well as a team, however if there are changes to either then movement control can diminish, with activities becoming harder and less safe to perform. Evidence is growing that exercise is one way to assist in keeping the brain stimulated and functioning as well as possible.
These are just some basic factors that contribute to a reduction in physical abilities, fitness, health and function. Many chronic conditions also can alter movement and some consideration to specific components may be needed when working with older clients.
Practical application and considerations: levels and layers
People aged 50 years and beyond have a huge diversity of backgrounds, experiences, education, cultural differences and financial circumstances that need to be taken into consideration. Older people (and younger ones!) have different needs, expectations and aspirations concerning prospects of achievement. Some are very active, while others, going down through the scale of abilities, are more dependent on services to retain their version of independence.
Planned programs for groups of participants need to consist of many levels and layers. They need to be implemented at the right level to accommodate the variables in abilities and health states. People at the very low level of ability (and those that have specific conditions) may, and will, need very basic moves. Many more will be able to work and progress through multiple levels to reach an advanced stage of fitness. Good planning, communication, knowledge and practical skills are needed to deliver appropriate programs at the right level.
As previously mentioned, flexibility and strengthening – as well as balance – exercises, are particularly important components in an older adult program. They should account for the physical and mental agility of individuals to negotiate environmental conditions under which they move and any sensory challenges they face. This is particularly pertinent in the case of older adults with conditions such as arthritis osteoporosis, low back pain and issues of reduced balance.
Program and participant considerations
Any program should aim to:
- educate people on the need, ways and means to remain physically active, healthy and safe
- teach and provide appropriate skills
- motivate and support people to become involved in a lifelong commitment to physical activity.
Participants need to develop the necessary skills to move in a safe and effective manner. In order for this to happen, programs should aim to improve not only the physical, but also the sensory systems and mental agility of individuals so that they can cope with the activities. Any program should try to include activities relevant to daily living to provide realistic outcomes for participants. In fact, the ability to perform fundamental functional movements should be a stated fitness goal. As Patricia Brill writes in her book Functional Fitness for Older Adults, ‘Through effective, comprehensive functional fitness programs, older adults may be able to avoid, postpone, reduce or even reverse declines in physical performance’3.
Take some time to remind participants exactly why it is so important for them to be able to move well as they grow older. Explaining the ‘why’ behind their training can help motivate them to adhere to the program. Body control is needed in order to be able to:
- walk safely and easily – to be able to move at different speeds and in different directions
- respond quickly to any disturbance in balance
- move up or down, in different planes of movement with relative ease
- adapt to different environments and respond to different task demands
- do more than one thing at a time
- prevent avoidable slips, trips and falls.
Getting people started and keeping them on track
‘I’m willing to make changes in my lifestyle as long as I don’t have to do anything different!’ When you work with groups of older adults you may well hear similar sentiments expressed! Getting people started and then keeping them motivated to exercise on a long term basis will always be a significant challenge, especially if participants have had a health scare or ‘event’. Many older adults recognise the need to become or remain active for as long as possible, but may be nervous about getting involved because of valid fears concerning exercise, a major one being the fear of injury or exacerbating an existing condition.
To achieve the best results, a knowledgeable, supportive and empathetic approach is required. In addition to conducting suitable screening and assessments, it is important to ascertain individual capabilities and discover the participants’ wants, needs and expectations with regards what they hope to gain from the exercise program. As far as is reasonably possible, your expectations regarding outcomes should match, or at least closely align with, those of the participant.
When working with any older adult you should consider:
- Previous experiences and perceptions (both theirs and yours)
- The many barriers, fears, hurdles and health issues that may be present
- The individual’s perspective, attitude and personality traits
- Background with regards education and literacy, language and culture
- The expectations and perceived outcomes from participation.
A work in progress
Training older adults will be an ongoing learning process for all concerned. Multiple levels and layers are needed in order to plan programs appropriately. Programs need to be graded and progressed where and when possible. Multiple strategies may be needed to suit different individuals.
One program cannot accommodate all at the same time. There are too many variables to consider and adaptations required to ensure that exercises are appropriate, realistic and safe.
Program success depends on innovation, creativity, persistence and recognition of the individual. The ways, means and applications will require a degree of flexibility as you respond to the ability, safety, interest and progression of participants.
I have many inspiring individuals in my classes between 60 and 90+ years of age who, despite having movement limitations due to a health condition or lower fitness level, are very willing and able to participate in regular exercise (some have been doing so for over 20 years!)
Assisting older adults to become and remain active and maintain their quality of life is very rewarding – but you won’t win everyone over, however hard you try. That’s OK, just keep working at it, enjoy and believe in what you’re doing, and find creative ways to achieve the results you and they are aiming for.
Sally Castell has a physiotherapy, recreational therapy and fitness professional background. She has over 40 years’ experience in the health and fitness industries, with vast work experience in rehabilitation centres, hospitals, community settings and retirement centres in the UK and Australia. Her exercise business Movement Matters focuses on exercise for the over 50’s.