Art & science | research
Effects of a 12-week community exercise programme on older people Nurses should promote exercise to reduce patients’ social isolation and increase their independence, say Ricky Wallace and colleagues Correspondence [email protected] Ricky Wallace is non-medical prescribing lead/research and development support, Liverpool Community Health NHS Trust Carolyn Lees is quality standards manager, Liverpool Community Health NHS Trust Massoumeh Minou is research associate, Swansea University Diane Singleton is lead nurse for older people/Liveability service lead, Liveability service, Liverpool Community Health NHS Trust Gareth Stratton is professor of paediatric exercise sciences, Swansea University Date of submission July 25 2013 Date of acceptance October 11 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Abstract Aim To measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in people aged 60 and older. Method An intervention group took part in a 12-week exercise programme. The intervention and comparison groups undertook the Senior Fitness Test at baseline, 12 weeks, six months and 12 months. Focus groups were conducted with the intervention and comparison groups at 12 weeks, then again with the intervention group after 12 months. Results Fitness increased significantly (P>0.001) after 12 weeks of exercise in the intervention group. Results demonstrated significant difference between PREVENTIVE ACTIONS underpin the public health agenda, for example, national interventions such as Change4Life and local projects like SportsLinx in Liverpool. Such initiatives aim to promote the benefits of exercise, eating well and healthy living to schoolchildren. However, there appears to be a lack of direction on exercise for older people. Despite 2012 being the European Year for Active Ageing, the House of Lords (2013) stated that the UK was ‘woefully underprepared’ for its ageing population. Liverpool has a population of 446,400 of whom 89,800 (20%) are 60 years or older, with figures set to rise to 95,372 (21%) by 2018 (Office for National Statistics 2012). This article presents findings from a community-based, 12-week exercise programme for people aged 60 years and older, which was delivered in Liverpool. It focuses on the programme’s
20 February 2014 | Volume 26 | Number 1
intervention and comparison groups’ fitness at six months (P>0.01) and 12 months (P>0.001) respectively. Focus groups supported the results, suggesting exercise increased independence and quality of life. Conclusion Nurses can promote exercise in patients to reduce social isolation, increase independence and improve quality of life. The findings from this study may be useful during the development of community services for older adults. Keywords Community, exercise, fitness, frailty, health, physical activity, public health effectiveness and discusses how it could be used by interested parties, including nurses, to improve the population’s health and wellbeing, and affect future guidance on exercise with older people.
Background Ageing results in an exponential loss of bone and muscle, along with reduced muscular strength and power (Karakelides and Nair 2005). Consequently, older people become frailer and rely more on NHS services (Karakelides and Nair 2005, Landi et al 2013). There are many reasons why some people lose muscle and bone quicker than others. The lifetime accumulation effect was outside the scope of the study reported in this article, but it does address what can be introduced when people show risk of functional decline. NURSING OLDER PEOPLE
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Dionigi and Cannon (2009) investigated the effects of strength training on people aged between 69 and 72 years and reported improved strength, functional competency, physical condition and body satisfaction. Changes in strength and performance were related to perceived changes in positive psychological outcomes. Manini et al (2005) reported that older people do not appreciate the benefits of strength training. Of 129 participants with a mean age of 77.5 ± 8.6 years, 37% thought that walking resulted in more muscle than strength training. This is important because ageing is associated with a significant reduction in muscle mass accompanied by elevated fat production, a term which has recently been named sarcopenic obesity (Lu et al 2013). Most muscle atrophy occurs in type 2 muscle fibres, in particular the quadriceps muscle group (Drey 2011, Maden-Wilkinson et al 2013). Type 2 muscle (fast twitch) fibres provide fast contractile velocity, essential for acceleration, deceleration and directional change. Type 1 muscle fibres – those used primarily for endurance – have slow contraction velocity and do not experience the same atrophy (Kirkendall and Garrett 1998). The aerobic enzymes in type 1 muscle fibres do, however, deteriorate with age, making them also work more ineffectively (Kirkendall and Garrett 1998). As such, muscle loss leads to reduced functional capacity and reduced calorie use, which in turn lead to slower metabolism and increased fat production (Westcott and Baechle 1999). People aged 65 and older should be moderately active for 150 minutes a week and, if they are already moderately active, they can achieve similar benefits from 75 minutes of vigorous activity. When exercising moderately a person will breathe more heavily, experience an increase in heart rate and feel warmer, whereas during vigorous activity a person will have a rapid heart rate, be short of breath and struggle to maintain a conversation (Department of Health (DH) 2011). The DH (2011) also recommend that older people should complete at least two sessions of exercise to improve muscle strength, and aim to incorporate balance and co-ordination exercises on two or more days a week. These recommendations provide a rationale of how to develop an exercise session, encompassing multiplanar physical movement of varied intensities including strength and balance activities. The National Institute for Health and Care Excellence (NICE) (2013) identifies that older people struggle to find time to exercise despite the associated physical, mental and social benefits. The NICE (2013) scope of guidance on exercise referral schemes aims to highlight barriers to
and facilitators of successful completion of an exercise programme. Nurses have opportunities to promote physical activity for older people (Hindle and Coates 2011). Quite often nurses have detailed knowledge about individuals’ physical needs and limitations and are able to assess their risk of health deterioration (Hindle and Coates 2011).
Aim The aim of this study was to measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in people aged 60 and older. The study objectives were to: ■■ Measure physical fitness at baseline, 12 weeks, six months and 12 months for the intervention and comparison groups. ■■ Explore older people’s beliefs and attitudes about improving health through exercise. ■■ Explore the effectiveness of the intervention on older people’s attitudes, behaviour change and physical activity.
Method A mixed methods approach was adopted, which consisted of an intervention group and a comparison group. The mixed methods approach was chosen to enrich and generalise the results from a sample February 2014 | Volume 26 | Number 1 21
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Art & science | research Figure 1 Intervention group mean percentile scores for Senior Fitness Test at baseline, 12 weeks, six months and 12 months 100 -
Senior Fitness Test (%)
90 80 70 60 50 40 30 20 10 0Baseline
12 weeks
6 months
12 months
Chair stand
35
79
80
83
Arm curl
20
66
83
83
Two-minute step
29
71
68
82
Sit and reach
29
40
56
53
Back scratch
41
44
63
60
Eight foot up and go
54
69
72
77
Percentile ranks: at risk ≤ 25, below average >25≤50, normal average >50≤75 and above average >75
to a population and gain a deeper understanding of the phenomenon under study (Hanson et al 2005). The primary intervention was a 12-week, gym-based exercise programme delivered by a qualified instructor twice each week. The Senior Fitness Test (SFT) (Rikli and Jones 2001), already tested for validity and reliability in a primary care setting (Purath et al 2009), was used to measure fitness. The SFT provided a measure of upper and lower body strength and power, cardiovascular fitness, flexibility and dynamic balance and agility. Quantitative data from the SFT were collected for the comparison and intervention groups at baseline, 12 weeks, six months and finally at 12 months. The SFT was conducted by a group of staff associated with a community trust including older people, volunteers, nurses, healthcare assistants, researchers and university students. Microsoft Excel 2010 was used to derive descriptive statistics and to perform a two-sample t-test of unequal variances on the overall fitness percentage scored on the SFT. Data from the focus groups were audio recorded and transcribed verbatim. Analysis was undertaken using framework analysis with the identification of 22 February 2014 | Volume 26 | Number 1
key words and phrases expanding to include themes. This technique is valued for its effectiveness in generating policy and practice-orientated findings (Ritchie and Spencer 1994). The first of the focus groups with the intervention and comparison groups took place immediately after the 12-week intervention. Only participants from the intervention group took part in a focus group at 12 months due to the difficulties encountered in arranging for those who had initially been interviewed to meet together. Ethical considerations Ethical approval was granted by the NHS research ethics committee. Appropriate local research approval was also obtained and participants provided informed consent, with the option to withdraw from the study at any stage.
Results In total, 42 Liverpool residents aged 60 and older took part. The sample consisted of 12 men (72.4 ± 7.94) and 30 women (71.8 ± 8.05). Twenty five participants (67.72 ± 5.62) were allocated to the intervention group and 17 (78.18 ± 6.68) to the comparison group. Participants in both groups had a variety of physical and mental health conditions NURSING OLDER PEOPLE
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Figure 2 Comparison group mean percentile scores for Senior Fitness Test at baseline, 12 weeks, six months and 12 months 100 -
Senior Fitness Test (%)
90 80 70 60 50 40 30 20 10 0Baseline
12 weeks
6 months
12 months
Chair stand
21
30
44
43
Arm curl
15
25
52
40
Two-minute step
12
28
37
38
Sit and reach
13
30
18
30
Back scratch
32
45
47
46
Eight foot up and go
17
27
37
38
Percentile ranks: at risk ≤ 25, below average >25≤50, normal average >50≤75 and above average >75 including arthritis (n=23), dementia (n=1), chronic obstructive pulmonary disease (COPD) (n=1), high cholesterol (n=9), stroke (n=1) and one was a single leg amputee. Table 1 shows demographic data for all participants. The intervention and comparison groups increased their overall scores in the SFT over the first 12 weeks. A two-sample t-test of unequal variances between percentage scored at baseline Table 1
Demographic data for all participants (n=42) Male (n=12)
Female (n=30)
Mean age (standard deviation)
72.4 (±7.94)
71.8 (±8.05)
Sex, %
29
71
Disabled, n (%)
4 (33)
7 (23)
Caucasian, n (%)
10 (83)
29 (97)
NURSING OLDER PEOPLE
and week 12 was statistically significant (P>0.001) in the intervention and comparison groups (P>0.05). However, a two-sample t-test of unequal variances, comparing overall percentage of fitness scored between the intervention and comparison groups, demonstrated a higher rate of increase in the intervention group at six (P>0.01) and 12 months (P>0.001) respectively. Figures 1 and 2 demonstrate the percentile ranks at baseline, 12 weeks, six months and 12 months in each fitness component of the SFT in the intervention and comparison groups. They provide a further visual indication of the difference in fitness performance measurements between both groups. In the qualitative phase of the study, four main themes emerged: attitudes, physical changes, enjoyment and maintaining health. Attitudes Views on exercise were reported as having a psychological effect on older people. Good health was defined as ‘the ability to cope with daily pressures in life’ (FI). A positive attitude towards exercise was inextricably linked to good health: ‘how you feel inside and having a positive attitude towards life’ (MI). February 2014 | Volume 26 | Number 1 23
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Art & science | research xxx Participants from the comparison group felt that their health had deteriorated as they had aged. They referred to pre-existing conditions that limited their physical activity leading to isolation and dependence, ‘well, the COPD I’ve got, it stops me a lot from doing things’ (FC), about feeling low and depressed at times and being socially isolated, ‘as far as social life is you’re limited to that extent because if I have to go out I have to rely on my children or my grandchildren to take me’ (FC). Participants from the intervention group shared the view that the main indicators of good health were having energy and motivation to carry out daily activities of life independently, such as household chores and socialising, ‘you can tell if you are healthy when you are still able to do things like before’ (MI). Similarly, one female participant described, ‘some days you are more motivated to go out or see friends or clean the house, for me that’s the sign of good health’ (FI). Physical changes Physical changes were attributed to understanding health in older age. There was a comparison with younger ages and tasks getting more difficult to perform; ‘when I was young I could sprint like hell to get the bus but now it leaves me breathless’ (MC). Others reported physical and functional limitations as a result of their age: ‘We are lucky we don’t have any serious problems due to getting old, but you might not be able to do as much as you would like to do simply because you’re limited physically’ (MI). Most participants in the comparison group described good health as being able to stay independent: ‘If you are still able to do things yourself then you are in good health. I feel I’m in good health because I can still do many things’ (FI). Poor health was associated with experiencing pain: ‘If you have pain and you are not able to move around like you used to, it gets you down. It’s poor health’ (FC). Conditions such as arthritis restricted mobility, ‘I have poor health, I have to use a stick now’ (FC). The comparison group tended to be less active, experience troublesome pain or have other debilitating symptoms such as COPD. This group also reported that the ageing process had affected their memory and they tended to forget events, dates and intentions quickly. One participant expressed this as, ‘you know, you sort of go upstairs and you think, “what have I come up here for?” and then I get down to the bottom and remember and have to go back up again’ (FC). Some participants believed that physical activity was essential for achieving good health, whereas 24 February 2014 | Volume 26 | Number 1
others considered it too tiring: ‘I used to be active when I was young, but now I mainly sit and watch TV; it’s too exhausting’ (FC). Some comments made by participants from the intervention group reflected an increase in strength and flexibility after the 12-week exercise programme: ‘I am doing 100 per cent more now than before and feel a lot stronger’ (MI). Some of the physical benefits included muscle gain, improved mobility and confidence in maintaining their balance, ‘my flexibility has improved and so has my balance’ (FI). Enjoyment All participants reported mixed opinions, particularly about the social factors that influenced their physical activity. Some participants from the intervention group thought that having someone to go for a walk with or having a purpose would encourage them to exercise for pleasure. ‘I walk to my daughter’s house every morning to take my granddaughter to school and back, I look forward to it and it’s part of my exercise’ (FC). Views about the environment were evident from some participants, particularly in relation to their safety and enjoying activities: ‘I like to go and stroll around the beach, you know you can’t do it there, you get attacked by young ones, you can’t even defend yourself’ (MI). However others felt protected and had no concerns about safety. Proximity to places and the absence of facilities, including public transport, were also identified as constraining factors for participating in physical activity: ‘One thing that puts me off is public transport is zilch of an evening; you can wait for hours. I like to walk to the bus station but don’t like the wait’ (FI). Participants from the comparison group who did not attend the 12-week exercise sessions considered their social activities were focused on visiting family and friends once or twice a week, as well as taking part in occasional pleasurable social events. ‘I see my daughter and grandchildren every Sunday and I pick them up from school sometimes’ (MC) and ‘It is very quiet here and sometimes you don’t feel like going out’ (FC). Maintaining health Self-sufficiency was considered an important element of maintaining good health for one individual because, ‘if you are dependent on someone because you can’t do it yourself, you are in poor health’ (FC). Some participants from the intervention group suggested that wealth preserved health: ‘It’s about being able to afford a car, sometimes public transport prevents you from getting to places for physical activity’ (MI). A good diet and healthy eating were acknowledged NURSING OLDER PEOPLE
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as factors contributing to health in older age: ‘If you eat healthy and don’t overeat and have a balanced diet you will be fine’ (MI). One participant reflected good health as, ‘what you eat and what you drink and if you smoke, if you exercise or you don’t exercise’ (MI). Another explained, ‘good health is related to a healthy diet’ (FI). Another said, ‘you should keep your weight under control, all problems start when you are overweight’ (FI), and another concluded, ‘you should enjoy life with your family and friends and keep positive’ (FI).
Discussion This study provides valuable information on the effectiveness of group exercise sessions for older people. Nonetheless, the findings should be viewed in the context of their limitations. First, the small sample size should be taken into consideration. Second, participants were self-selected for each group, with the comparison group being slightly older and frailer at baseline than the intervention group. The main aim of the study was to measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in older people. Data suggested that participants in the intervention group maintained their physical activity levels after the intervention ended. They generally reported improved health and wellbeing as a result of attending the 12-week programme and reported maintaining the behaviour change for up to 12 months after the intervention had finished. The intervention group made quick strength and power gains, which should be of particular interest to commissioners and other healthcare providers, as will the maintenance of fitness after six and 12 months. Findings cannot demonstrate what would happen to participants’ fitness levels after a period of detraining. However, a study of 69 pre-frail older adults aged between 64 and 95 randomised participants into a strength training group (STG), a power training group (PTG) and control group. The study found that pre-frail adults who were trained for 12 weeks improved their muscular strength and power (Zech et al 2012). The 12 weeks were then followed by a period of detraining. During this period, fitness was maintained by the PTG but was lost in the STG. Physiologically, the human body adapts quickly after exercise (Taaffe 2006). Gianoudis et al’s (2013) 12-month exercise randomised controlled trial of older adults with risk factors for falls and/ or low bone mineral density (BMD) demonstrated NURSING OLDER PEOPLE
The intervention group made quick strength and power gains, which should be of interest to commissioners and healthcare providers significant improvements in BMD, muscle strength, functional muscle power (P>0.05) and dynamic balance (P>0.01), relative to the control group. These findings were mirrored by the fitness measurements taken in the intervention group in this study. A main theme arising from the focus groups was participants’ attitudes towards physical activity as well as their ability to exercise: ‘My attitude has changed for the better as I used to think you shouldn’t have to exercise after your retirement’ (FI). Similarly, Manini et al (2005) identified that older people are not always aware of the benefits of strength training. Through attending the exercise classes, they reported that their knowledge about how to exercise had increased and they acknowledged that they had learned more about the benefits of regular exercise: ‘I have more knowledge about being healthy and what it entails’ (FI). Findings suggest that older people understand health in terms of physical activity. A point to consider for healthcare providers would be to train staff on how to sell the benefits of exercise to older people in a way that will motivate them to take part. Data also concur with Dionigi and Cannon’s (2009) findings of empowerment and self-belief through exercise. The psychological benefits of the 12-week intervention also included overcoming emotional problems: ‘The programme makes you feel so strong in your mind as well’ (FI) and participants described feeling mentally stronger from exercise: ‘I feel positive and more confident now’ (FI). The study also identified strong social benefits that can be gained by engaging in an exercise programme. It can provide structure and allows older adults to meet new people, gain social support and feel cared for: ‘It’s about the camaraderie. The group is around for each other. It’s not all about sitting in the house on your own. Coming here makes you feel better’ (FI). The same positive attitude did not appear to be present in the comparison group. Participants reported that they often felt emotionally low about their health and the effect that it had on their psychological wellbeing, described by one as: ‘I feel very down. I’m hoping that once I see the doctor in January things will change and my health will improve and I’ll get back to the way I used to be’ (FC). February 2014 | Volume 26 | Number 1 25
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Art & science | research Conclusion Nurses can influence older people’s general health and wellbeing and reduce social isolation by informing and inspiring them to take part in physical activity. Developing a community-based programme of exercise is one means of enabling older adults to take part in physical activity and exercise (Tolson et al 2011). The data from this study indicated that the 12-week community exercise programme motivated and encouraged individuals to continue with regular physical activity after the intervention was
completed. Nurses can motivate individuals to access such programmes by using their skills and knowledge to lead and support them. The intervention in this study appeared to be effective in changing behaviour in a positive way by increasing confidence and by providing a socially acceptable programme of exercise. Nurses can improve older people’s physical activity levels and health by being aware of local resources and services such as transport and by networking outside NHS organisations.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Department of Health (2011) Start Active, Stay Active: A Report on Physical Activity for Health from the Four Home Countries’ Chief Medical Officers. DH, London. Dionigi R, Cannon J (2009) Older adults’ perceived changes in physical self-worth associated with resistance training. Research Quarterly for Exercise and Sport. 80, 2, 269-280. Drey M (2011) Sarcopenia – pathophysiology and clinical relevance. Wiener Medizinische Wochenschrift. 161, 17-18, 402-408. Gianoudis J, Bailey C, Ebeling P et al (2013) Effects of a targeted multi-modal exercise program incorporating high speed power training on falls and fracture risk factors in older adults: a community-based randomised controlled trial. Journal of Bone Mineral Research. doi: 10.1002/jbmr.2014 Hanson W, Creswell J, Plano Clark V et al (2005) Mixed methods research designs in counseling psychology. Journal of Counseling Psychology. 52, 2, 224-235.
Hindle A, Coates A (Eds) (2011) Nursing Care of Older People: A Textbook for Students and Nurses. Oxford University Press, Oxford.
Maden-Wilkinson T, McPhee J, Rittweger J et al (2013) Thigh muscle volume in relation to age, sex and femur volume. Age. 36, 1, 383-393.
House of Lords Select Committee on Public Service and Demographic Change (2013) Ready for Ageing? tinyurl.com/ckcsaps (Last accessed: December 17 2013.)
Manini T, Druger M, Ploutz-Snyder L (2005) Misconceptions about strength exercise among older adults. Journal of Aging and Physical Activity. 13, 4, 422-433.
Karakelides H, Nair K (2005) Sarcopenia of aging and its metabolic impact. Current Topics in Developmental Biology. 68, 123-148.
National Institute for Health and Care Excellence (2013) Public Health Guidance Draft Scope: Physical Activity: Exercise Referral Schemes to Promote Physical Activity (Partial Update of PH2). NICE, London.
Kirkendall D, Garrett W Jr (1998) The effects of aging and training on skeletal muscle. American Journal of Sports Medicine. 26, 4, 598-602. Landi F, Cruz-Jentoft A, Liperoti R et al (2013) Sarcopenia and mortality risk in frail older persons aged 80 years and older: results from ilSIRENTE study. Age and Ageing. 42, 2, 203-209. Lu C, Yang K, Chang H et al (2013) Sarcopenic obesity is closely associated with metabolic syndrome. Obesity Research and Clinical Practice. 7, 4, e235-320.
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Office for National Statistics (2012) 2011 Census: Population and Household Estimates for England and Wales. tinyurl.com/nufb75p (Last accessed: January 7 2014.) Purath J, Buchholz S, Kark D (2009) Physical fitness assessment of older adults in the primary care setting. Journal of the American Academy of Nurse Practitioners. 21, 2, 101-107.
Rikli R, Jones C (2001) Senior Fitness Test. Human Kinetics, Champaign IL. Ritchie J, Spencer L (1994) Qualitative data analysis for applied policy research. In Bryman A, Burgess R (Eds) Analyzing Qualitative Data. Routledge, Abingdon. Taaffe D (2006) Sarcopenia – exercise as a treatment strategy. Australian Family Physician. 35, 3, 130-134. Tolson D, Morley J, Rolland Y et al (2011) Improving nursing home practice: an international concern. Nursing Older People. 23, 9, 20-21. Westcott W, Baechle T (1999) Strength Training for Seniors. Human Kinetics, Champaign IL. Zech A, Drey M, Freiberger E et al (2012) Residual effects of muscle strength and muscle power training and detraining on physical function in community-dwelling prefrail older adults: a randomized controlled trial. BMC Geriatrics. 12, 68.
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Effects of a 12-week community exercise programme on older people Nurses should promote exercise to reduce patients’ social isolation and increase their independence, say Ricky Wallace and colleagues Correspondence [email protected] Ricky Wallace is non-medical prescribing lead/research and development support, Liverpool Community Health NHS Trust Carolyn Lees is quality standards manager, Liverpool Community Health NHS Trust Massoumeh Minou is research associate, Swansea University Diane Singleton is lead nurse for older people/Liveability service lead, Liveability service, Liverpool Community Health NHS Trust Gareth Stratton is professor of paediatric exercise sciences, Swansea University Date of submission July 25 2013 Date of acceptance October 11 2013 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nop.rcnpublishing.com
Abstract Aim To measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in people aged 60 and older. Method An intervention group took part in a 12-week exercise programme. The intervention and comparison groups undertook the Senior Fitness Test at baseline, 12 weeks, six months and 12 months. Focus groups were conducted with the intervention and comparison groups at 12 weeks, then again with the intervention group after 12 months. Results Fitness increased significantly (P>0.001) after 12 weeks of exercise in the intervention group. Results demonstrated significant difference between PREVENTIVE ACTIONS underpin the public health agenda, for example, national interventions such as Change4Life and local projects like SportsLinx in Liverpool. Such initiatives aim to promote the benefits of exercise, eating well and healthy living to schoolchildren. However, there appears to be a lack of direction on exercise for older people. Despite 2012 being the European Year for Active Ageing, the House of Lords (2013) stated that the UK was ‘woefully underprepared’ for its ageing population. Liverpool has a population of 446,400 of whom 89,800 (20%) are 60 years or older, with figures set to rise to 95,372 (21%) by 2018 (Office for National Statistics 2012). This article presents findings from a community-based, 12-week exercise programme for people aged 60 years and older, which was delivered in Liverpool. It focuses on the programme’s
20 February 2014 | Volume 26 | Number 1
intervention and comparison groups’ fitness at six months (P>0.01) and 12 months (P>0.001) respectively. Focus groups supported the results, suggesting exercise increased independence and quality of life. Conclusion Nurses can promote exercise in patients to reduce social isolation, increase independence and improve quality of life. The findings from this study may be useful during the development of community services for older adults. Keywords Community, exercise, fitness, frailty, health, physical activity, public health effectiveness and discusses how it could be used by interested parties, including nurses, to improve the population’s health and wellbeing, and affect future guidance on exercise with older people.
Background Ageing results in an exponential loss of bone and muscle, along with reduced muscular strength and power (Karakelides and Nair 2005). Consequently, older people become frailer and rely more on NHS services (Karakelides and Nair 2005, Landi et al 2013). There are many reasons why some people lose muscle and bone quicker than others. The lifetime accumulation effect was outside the scope of the study reported in this article, but it does address what can be introduced when people show risk of functional decline. NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 27, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
NURSING OLDER PEOPLE
Getty Images (posed by model)
Dionigi and Cannon (2009) investigated the effects of strength training on people aged between 69 and 72 years and reported improved strength, functional competency, physical condition and body satisfaction. Changes in strength and performance were related to perceived changes in positive psychological outcomes. Manini et al (2005) reported that older people do not appreciate the benefits of strength training. Of 129 participants with a mean age of 77.5 ± 8.6 years, 37% thought that walking resulted in more muscle than strength training. This is important because ageing is associated with a significant reduction in muscle mass accompanied by elevated fat production, a term which has recently been named sarcopenic obesity (Lu et al 2013). Most muscle atrophy occurs in type 2 muscle fibres, in particular the quadriceps muscle group (Drey 2011, Maden-Wilkinson et al 2013). Type 2 muscle (fast twitch) fibres provide fast contractile velocity, essential for acceleration, deceleration and directional change. Type 1 muscle fibres – those used primarily for endurance – have slow contraction velocity and do not experience the same atrophy (Kirkendall and Garrett 1998). The aerobic enzymes in type 1 muscle fibres do, however, deteriorate with age, making them also work more ineffectively (Kirkendall and Garrett 1998). As such, muscle loss leads to reduced functional capacity and reduced calorie use, which in turn lead to slower metabolism and increased fat production (Westcott and Baechle 1999). People aged 65 and older should be moderately active for 150 minutes a week and, if they are already moderately active, they can achieve similar benefits from 75 minutes of vigorous activity. When exercising moderately a person will breathe more heavily, experience an increase in heart rate and feel warmer, whereas during vigorous activity a person will have a rapid heart rate, be short of breath and struggle to maintain a conversation (Department of Health (DH) 2011). The DH (2011) also recommend that older people should complete at least two sessions of exercise to improve muscle strength, and aim to incorporate balance and co-ordination exercises on two or more days a week. These recommendations provide a rationale of how to develop an exercise session, encompassing multiplanar physical movement of varied intensities including strength and balance activities. The National Institute for Health and Care Excellence (NICE) (2013) identifies that older people struggle to find time to exercise despite the associated physical, mental and social benefits. The NICE (2013) scope of guidance on exercise referral schemes aims to highlight barriers to
and facilitators of successful completion of an exercise programme. Nurses have opportunities to promote physical activity for older people (Hindle and Coates 2011). Quite often nurses have detailed knowledge about individuals’ physical needs and limitations and are able to assess their risk of health deterioration (Hindle and Coates 2011).
Aim The aim of this study was to measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in people aged 60 and older. The study objectives were to: ■■ Measure physical fitness at baseline, 12 weeks, six months and 12 months for the intervention and comparison groups. ■■ Explore older people’s beliefs and attitudes about improving health through exercise. ■■ Explore the effectiveness of the intervention on older people’s attitudes, behaviour change and physical activity.
Method A mixed methods approach was adopted, which consisted of an intervention group and a comparison group. The mixed methods approach was chosen to enrich and generalise the results from a sample February 2014 | Volume 26 | Number 1 21
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Art & science | research Figure 1 Intervention group mean percentile scores for Senior Fitness Test at baseline, 12 weeks, six months and 12 months 100 -
Senior Fitness Test (%)
90 80 70 60 50 40 30 20 10 0Baseline
12 weeks
6 months
12 months
Chair stand
35
79
80
83
Arm curl
20
66
83
83
Two-minute step
29
71
68
82
Sit and reach
29
40
56
53
Back scratch
41
44
63
60
Eight foot up and go
54
69
72
77
Percentile ranks: at risk ≤ 25, below average >25≤50, normal average >50≤75 and above average >75
to a population and gain a deeper understanding of the phenomenon under study (Hanson et al 2005). The primary intervention was a 12-week, gym-based exercise programme delivered by a qualified instructor twice each week. The Senior Fitness Test (SFT) (Rikli and Jones 2001), already tested for validity and reliability in a primary care setting (Purath et al 2009), was used to measure fitness. The SFT provided a measure of upper and lower body strength and power, cardiovascular fitness, flexibility and dynamic balance and agility. Quantitative data from the SFT were collected for the comparison and intervention groups at baseline, 12 weeks, six months and finally at 12 months. The SFT was conducted by a group of staff associated with a community trust including older people, volunteers, nurses, healthcare assistants, researchers and university students. Microsoft Excel 2010 was used to derive descriptive statistics and to perform a two-sample t-test of unequal variances on the overall fitness percentage scored on the SFT. Data from the focus groups were audio recorded and transcribed verbatim. Analysis was undertaken using framework analysis with the identification of 22 February 2014 | Volume 26 | Number 1
key words and phrases expanding to include themes. This technique is valued for its effectiveness in generating policy and practice-orientated findings (Ritchie and Spencer 1994). The first of the focus groups with the intervention and comparison groups took place immediately after the 12-week intervention. Only participants from the intervention group took part in a focus group at 12 months due to the difficulties encountered in arranging for those who had initially been interviewed to meet together. Ethical considerations Ethical approval was granted by the NHS research ethics committee. Appropriate local research approval was also obtained and participants provided informed consent, with the option to withdraw from the study at any stage.
Results In total, 42 Liverpool residents aged 60 and older took part. The sample consisted of 12 men (72.4 ± 7.94) and 30 women (71.8 ± 8.05). Twenty five participants (67.72 ± 5.62) were allocated to the intervention group and 17 (78.18 ± 6.68) to the comparison group. Participants in both groups had a variety of physical and mental health conditions NURSING OLDER PEOPLE
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Figure 2 Comparison group mean percentile scores for Senior Fitness Test at baseline, 12 weeks, six months and 12 months 100 -
Senior Fitness Test (%)
90 80 70 60 50 40 30 20 10 0Baseline
12 weeks
6 months
12 months
Chair stand
21
30
44
43
Arm curl
15
25
52
40
Two-minute step
12
28
37
38
Sit and reach
13
30
18
30
Back scratch
32
45
47
46
Eight foot up and go
17
27
37
38
Percentile ranks: at risk ≤ 25, below average >25≤50, normal average >50≤75 and above average >75 including arthritis (n=23), dementia (n=1), chronic obstructive pulmonary disease (COPD) (n=1), high cholesterol (n=9), stroke (n=1) and one was a single leg amputee. Table 1 shows demographic data for all participants. The intervention and comparison groups increased their overall scores in the SFT over the first 12 weeks. A two-sample t-test of unequal variances between percentage scored at baseline Table 1
Demographic data for all participants (n=42) Male (n=12)
Female (n=30)
Mean age (standard deviation)
72.4 (±7.94)
71.8 (±8.05)
Sex, %
29
71
Disabled, n (%)
4 (33)
7 (23)
Caucasian, n (%)
10 (83)
29 (97)
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and week 12 was statistically significant (P>0.001) in the intervention and comparison groups (P>0.05). However, a two-sample t-test of unequal variances, comparing overall percentage of fitness scored between the intervention and comparison groups, demonstrated a higher rate of increase in the intervention group at six (P>0.01) and 12 months (P>0.001) respectively. Figures 1 and 2 demonstrate the percentile ranks at baseline, 12 weeks, six months and 12 months in each fitness component of the SFT in the intervention and comparison groups. They provide a further visual indication of the difference in fitness performance measurements between both groups. In the qualitative phase of the study, four main themes emerged: attitudes, physical changes, enjoyment and maintaining health. Attitudes Views on exercise were reported as having a psychological effect on older people. Good health was defined as ‘the ability to cope with daily pressures in life’ (FI). A positive attitude towards exercise was inextricably linked to good health: ‘how you feel inside and having a positive attitude towards life’ (MI). February 2014 | Volume 26 | Number 1 23
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Art & science | research xxx Participants from the comparison group felt that their health had deteriorated as they had aged. They referred to pre-existing conditions that limited their physical activity leading to isolation and dependence, ‘well, the COPD I’ve got, it stops me a lot from doing things’ (FC), about feeling low and depressed at times and being socially isolated, ‘as far as social life is you’re limited to that extent because if I have to go out I have to rely on my children or my grandchildren to take me’ (FC). Participants from the intervention group shared the view that the main indicators of good health were having energy and motivation to carry out daily activities of life independently, such as household chores and socialising, ‘you can tell if you are healthy when you are still able to do things like before’ (MI). Similarly, one female participant described, ‘some days you are more motivated to go out or see friends or clean the house, for me that’s the sign of good health’ (FI). Physical changes Physical changes were attributed to understanding health in older age. There was a comparison with younger ages and tasks getting more difficult to perform; ‘when I was young I could sprint like hell to get the bus but now it leaves me breathless’ (MC). Others reported physical and functional limitations as a result of their age: ‘We are lucky we don’t have any serious problems due to getting old, but you might not be able to do as much as you would like to do simply because you’re limited physically’ (MI). Most participants in the comparison group described good health as being able to stay independent: ‘If you are still able to do things yourself then you are in good health. I feel I’m in good health because I can still do many things’ (FI). Poor health was associated with experiencing pain: ‘If you have pain and you are not able to move around like you used to, it gets you down. It’s poor health’ (FC). Conditions such as arthritis restricted mobility, ‘I have poor health, I have to use a stick now’ (FC). The comparison group tended to be less active, experience troublesome pain or have other debilitating symptoms such as COPD. This group also reported that the ageing process had affected their memory and they tended to forget events, dates and intentions quickly. One participant expressed this as, ‘you know, you sort of go upstairs and you think, “what have I come up here for?” and then I get down to the bottom and remember and have to go back up again’ (FC). Some participants believed that physical activity was essential for achieving good health, whereas 24 February 2014 | Volume 26 | Number 1
others considered it too tiring: ‘I used to be active when I was young, but now I mainly sit and watch TV; it’s too exhausting’ (FC). Some comments made by participants from the intervention group reflected an increase in strength and flexibility after the 12-week exercise programme: ‘I am doing 100 per cent more now than before and feel a lot stronger’ (MI). Some of the physical benefits included muscle gain, improved mobility and confidence in maintaining their balance, ‘my flexibility has improved and so has my balance’ (FI). Enjoyment All participants reported mixed opinions, particularly about the social factors that influenced their physical activity. Some participants from the intervention group thought that having someone to go for a walk with or having a purpose would encourage them to exercise for pleasure. ‘I walk to my daughter’s house every morning to take my granddaughter to school and back, I look forward to it and it’s part of my exercise’ (FC). Views about the environment were evident from some participants, particularly in relation to their safety and enjoying activities: ‘I like to go and stroll around the beach, you know you can’t do it there, you get attacked by young ones, you can’t even defend yourself’ (MI). However others felt protected and had no concerns about safety. Proximity to places and the absence of facilities, including public transport, were also identified as constraining factors for participating in physical activity: ‘One thing that puts me off is public transport is zilch of an evening; you can wait for hours. I like to walk to the bus station but don’t like the wait’ (FI). Participants from the comparison group who did not attend the 12-week exercise sessions considered their social activities were focused on visiting family and friends once or twice a week, as well as taking part in occasional pleasurable social events. ‘I see my daughter and grandchildren every Sunday and I pick them up from school sometimes’ (MC) and ‘It is very quiet here and sometimes you don’t feel like going out’ (FC). Maintaining health Self-sufficiency was considered an important element of maintaining good health for one individual because, ‘if you are dependent on someone because you can’t do it yourself, you are in poor health’ (FC). Some participants from the intervention group suggested that wealth preserved health: ‘It’s about being able to afford a car, sometimes public transport prevents you from getting to places for physical activity’ (MI). A good diet and healthy eating were acknowledged NURSING OLDER PEOPLE
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as factors contributing to health in older age: ‘If you eat healthy and don’t overeat and have a balanced diet you will be fine’ (MI). One participant reflected good health as, ‘what you eat and what you drink and if you smoke, if you exercise or you don’t exercise’ (MI). Another explained, ‘good health is related to a healthy diet’ (FI). Another said, ‘you should keep your weight under control, all problems start when you are overweight’ (FI), and another concluded, ‘you should enjoy life with your family and friends and keep positive’ (FI).
Discussion This study provides valuable information on the effectiveness of group exercise sessions for older people. Nonetheless, the findings should be viewed in the context of their limitations. First, the small sample size should be taken into consideration. Second, participants were self-selected for each group, with the comparison group being slightly older and frailer at baseline than the intervention group. The main aim of the study was to measure the effectiveness of a 12-week exercise intervention in reducing the health risks associated with physical decline in older people. Data suggested that participants in the intervention group maintained their physical activity levels after the intervention ended. They generally reported improved health and wellbeing as a result of attending the 12-week programme and reported maintaining the behaviour change for up to 12 months after the intervention had finished. The intervention group made quick strength and power gains, which should be of particular interest to commissioners and other healthcare providers, as will the maintenance of fitness after six and 12 months. Findings cannot demonstrate what would happen to participants’ fitness levels after a period of detraining. However, a study of 69 pre-frail older adults aged between 64 and 95 randomised participants into a strength training group (STG), a power training group (PTG) and control group. The study found that pre-frail adults who were trained for 12 weeks improved their muscular strength and power (Zech et al 2012). The 12 weeks were then followed by a period of detraining. During this period, fitness was maintained by the PTG but was lost in the STG. Physiologically, the human body adapts quickly after exercise (Taaffe 2006). Gianoudis et al’s (2013) 12-month exercise randomised controlled trial of older adults with risk factors for falls and/ or low bone mineral density (BMD) demonstrated NURSING OLDER PEOPLE
The intervention group made quick strength and power gains, which should be of interest to commissioners and healthcare providers significant improvements in BMD, muscle strength, functional muscle power (P>0.05) and dynamic balance (P>0.01), relative to the control group. These findings were mirrored by the fitness measurements taken in the intervention group in this study. A main theme arising from the focus groups was participants’ attitudes towards physical activity as well as their ability to exercise: ‘My attitude has changed for the better as I used to think you shouldn’t have to exercise after your retirement’ (FI). Similarly, Manini et al (2005) identified that older people are not always aware of the benefits of strength training. Through attending the exercise classes, they reported that their knowledge about how to exercise had increased and they acknowledged that they had learned more about the benefits of regular exercise: ‘I have more knowledge about being healthy and what it entails’ (FI). Findings suggest that older people understand health in terms of physical activity. A point to consider for healthcare providers would be to train staff on how to sell the benefits of exercise to older people in a way that will motivate them to take part. Data also concur with Dionigi and Cannon’s (2009) findings of empowerment and self-belief through exercise. The psychological benefits of the 12-week intervention also included overcoming emotional problems: ‘The programme makes you feel so strong in your mind as well’ (FI) and participants described feeling mentally stronger from exercise: ‘I feel positive and more confident now’ (FI). The study also identified strong social benefits that can be gained by engaging in an exercise programme. It can provide structure and allows older adults to meet new people, gain social support and feel cared for: ‘It’s about the camaraderie. The group is around for each other. It’s not all about sitting in the house on your own. Coming here makes you feel better’ (FI). The same positive attitude did not appear to be present in the comparison group. Participants reported that they often felt emotionally low about their health and the effect that it had on their psychological wellbeing, described by one as: ‘I feel very down. I’m hoping that once I see the doctor in January things will change and my health will improve and I’ll get back to the way I used to be’ (FC). February 2014 | Volume 26 | Number 1 25
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Art & science | research Conclusion Nurses can influence older people’s general health and wellbeing and reduce social isolation by informing and inspiring them to take part in physical activity. Developing a community-based programme of exercise is one means of enabling older adults to take part in physical activity and exercise (Tolson et al 2011). The data from this study indicated that the 12-week community exercise programme motivated and encouraged individuals to continue with regular physical activity after the intervention was
completed. Nurses can motivate individuals to access such programmes by using their skills and knowledge to lead and support them. The intervention in this study appeared to be effective in changing behaviour in a positive way by increasing confidence and by providing a socially acceptable programme of exercise. Nurses can improve older people’s physical activity levels and health by being aware of local resources and services such as transport and by networking outside NHS organisations.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Department of Health (2011) Start Active, Stay Active: A Report on Physical Activity for Health from the Four Home Countries’ Chief Medical Officers. DH, London. Dionigi R, Cannon J (2009) Older adults’ perceived changes in physical self-worth associated with resistance training. Research Quarterly for Exercise and Sport. 80, 2, 269-280. Drey M (2011) Sarcopenia – pathophysiology and clinical relevance. Wiener Medizinische Wochenschrift. 161, 17-18, 402-408. Gianoudis J, Bailey C, Ebeling P et al (2013) Effects of a targeted multi-modal exercise program incorporating high speed power training on falls and fracture risk factors in older adults: a community-based randomised controlled trial. Journal of Bone Mineral Research. doi: 10.1002/jbmr.2014 Hanson W, Creswell J, Plano Clark V et al (2005) Mixed methods research designs in counseling psychology. Journal of Counseling Psychology. 52, 2, 224-235.
Hindle A, Coates A (Eds) (2011) Nursing Care of Older People: A Textbook for Students and Nurses. Oxford University Press, Oxford.
Maden-Wilkinson T, McPhee J, Rittweger J et al (2013) Thigh muscle volume in relation to age, sex and femur volume. Age. 36, 1, 383-393.
House of Lords Select Committee on Public Service and Demographic Change (2013) Ready for Ageing? tinyurl.com/ckcsaps (Last accessed: December 17 2013.)
Manini T, Druger M, Ploutz-Snyder L (2005) Misconceptions about strength exercise among older adults. Journal of Aging and Physical Activity. 13, 4, 422-433.
Karakelides H, Nair K (2005) Sarcopenia of aging and its metabolic impact. Current Topics in Developmental Biology. 68, 123-148.
National Institute for Health and Care Excellence (2013) Public Health Guidance Draft Scope: Physical Activity: Exercise Referral Schemes to Promote Physical Activity (Partial Update of PH2). NICE, London.
Kirkendall D, Garrett W Jr (1998) The effects of aging and training on skeletal muscle. American Journal of Sports Medicine. 26, 4, 598-602. Landi F, Cruz-Jentoft A, Liperoti R et al (2013) Sarcopenia and mortality risk in frail older persons aged 80 years and older: results from ilSIRENTE study. Age and Ageing. 42, 2, 203-209. Lu C, Yang K, Chang H et al (2013) Sarcopenic obesity is closely associated with metabolic syndrome. Obesity Research and Clinical Practice. 7, 4, e235-320.
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Office for National Statistics (2012) 2011 Census: Population and Household Estimates for England and Wales. tinyurl.com/nufb75p (Last accessed: January 7 2014.) Purath J, Buchholz S, Kark D (2009) Physical fitness assessment of older adults in the primary care setting. Journal of the American Academy of Nurse Practitioners. 21, 2, 101-107.
Rikli R, Jones C (2001) Senior Fitness Test. Human Kinetics, Champaign IL. Ritchie J, Spencer L (1994) Qualitative data analysis for applied policy research. In Bryman A, Burgess R (Eds) Analyzing Qualitative Data. Routledge, Abingdon. Taaffe D (2006) Sarcopenia – exercise as a treatment strategy. Australian Family Physician. 35, 3, 130-134. Tolson D, Morley J, Rolland Y et al (2011) Improving nursing home practice: an international concern. Nursing Older People. 23, 9, 20-21. Westcott W, Baechle T (1999) Strength Training for Seniors. Human Kinetics, Champaign IL. Zech A, Drey M, Freiberger E et al (2012) Residual effects of muscle strength and muscle power training and detraining on physical function in community-dwelling prefrail older adults: a randomized controlled trial. BMC Geriatrics. 12, 68.
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