Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity Instructors

Abstract

To live a long and healthy life is now considered the main challenge of geriatric medicine worldwide. Exercise, aging, and health are key research topics to maintain functional ability that has been considered one of the strongest predictors of independence in old age. Functional ability comprises the interaction between physical and mental capacities in a particular environment. Increasing physical activity is considered a key recommendation in sustainable policies and action programs for healthy aging. Evidence shows that physical activity impacts functional and cognitive abilities and social activities. The contents of training courses related to Exercise Aging and Health are responsible for ensuring an intervention focused on the needs of older people. Healthcare professionals, physical activity instructors, or other health professionals who work directly with older people may need to understand deeply demography, theories, and current policies on aging, physical, and functional changes associated with aging, physical-psychosocial relationships, contextual determinants of physical activity, and exercise prescription in the older population.

1. Introduction

This chapter aims to present a content course proposal on the topic of “Exercise Aging and Health,” to be taught to healthcare professionals, physical activity instructors, or other health professionals who work directly with older people. In a nutshell, the contents to be addressed include five main topics. The first topic addresses an introduction to the aspects of aging, including issues related to demography, theories, and current policies on aging. The second topic explores the physical and functional changes associated with aging. Morphological changes and physiological systems, i.e. body composition, cardiopulmonary, musculoskeletal, and nervous and sensory systems, are broadly described. Also, in this topic, functional changes are addressed, i.e. functional fitness and mobility. Topic 3 presents research on physical-psychosocial relationships, exploring the relationships between aging, active life, cognitive function, physical activity, well-being, and health-related quality of life. Topic 4 is dedicated to studying the contextual determinants of physical activity in the elderly. Here, the models of adoption and maintenance of physically active lifestyles are explored, as well as the Age-friendly Environments. Finally, the last topic is dedicated to the study of guidelines for exercise prescription in the older population. Here, general guidelines for pre-exercise assessment are outlined, as well as key considerations for maximizing the effective development of exercise programs for older people.

It is expected that students who take this course should be able to properly use theoretical knowledge regarding exercise, aging, and health in different contexts of intervention with older people (i.e. health gyms, rehabilitation centers, elderly centers, city councils, parish councils, among others). They should be able to adopt a scientific attitude and a critical reflective method in the face of research results from the assessment of the physical dimensions (morphological and functional) of the older person. They must show the capacity for initiative, innovation, and acceptable use of information regarding protocols and techniques for assessing functional fitness and know-how to assess the scientificity of the information collected on the relationships and interrelationships of physical activity and chronic diseases, as well as the benefits and risks associated with the regular practice of physical activity and/or exercise. They must systematically carry out a functional assessment of the older person, guaranteeing all safety conditions in the evaluation and intervention, as well as adequately interpreting the objective and subjective data of the physical dimensions assessment process, using this information to prescribe the exercise. Finally, they must be able to conceptualize an exercise plan adapted to a previously outlined functional profile.

2. Topic 1: introductory aspects of aging

2.1 Demography of aging

The demographic transition characterized by an aging population is a global phenomenon that directly impacts different sectors of society. The advancements in medical and pharmaceutical technology, nutrition, and sanitation have resulted in lower healthcare death worldwide. People are living longer, and the population worldwide is growing older. Recent key facts shown by the World Health Organization [1] underlines that between 2015 and 2050, the proportion of the population over 60 years will nearly double from 12 to 22%. Besides the mortality associated with COVID-19, people aged 60 years and older will outnumber children younger than 5 years by 2020. In the same document, it is written that all countries face significant challenges to ensure that their health and social systems are ready to deal with this demographic shift.

Cognitive, physical, and social stimulation can play a crucial role in delaying disability and maintaining the quality of life, allowing people to continue to do what they want, without pain and autonomously, for as long as possible. Additionally, age-related declines in cognitive, physical, and social function are an inevitable human condition that often results in socioeconomic and service overload. These age-associated changes increase the vulnerability of older people to chronic illness and mortality.

2.2 Concepts and theories of aging

Aging refers to a process or group of processes occurring in living organisms that, over time, lead to a loss of adaptability, functional impairments, and eventually death [2]. Taylor and Johnson [3] defined biological aging as slow, progressive, structural, and functional changes at the cellular, tissue, and organ levels, ultimately affecting the function of all body systems.

Numerous theories have been proposed to explain the process of aging but neither appears to be entirely satisfactory [4]. Taylor and Johnson [3] suggested that these can be grouped into five broad categories of aging: (i) wear and tear theories; (ii) genetics theories; (iii) general imbalance theories; (iv) accumulation theories; and (v) the dysdifferentiative hypothesis of aging and cancer.

Jones [5] divided the theories of aging into three main categories: biological, psychological, and sociological. Biological theories of aging—including genetic damage and gradual imbalance theories—focus on the factors that cause senescence of the body and increase the risk of morbidity and mortality with age. Psychological theories focus on the influence of psychological processes and personality characteristics on aging. Sociological theories focus on the impact of the social and physical environments on aging.

The modern biological theories of aging in humans fall into two main categories: programmed theories and damage or error theories [6]. The programmed theories imply that aging follows a biological timetable, perhaps a continuation of the one that regulates childhood growth and development. This regulation would depend on changes in gene expression that affect the systems responsible for maintenance, repair, and defense responses. The programmed theory has three subcategories: programmed longevity, endocrine theory, and immunological theory. The damage or error theories emphasize environmental assaults on living organisms that induce cumulative damage at various levels as the cause of aging. The damage or error theory includes wear and tear theory, rate of living theory, cross-linking free radical theory, and somatic DNA damage theory.

The complexity of aging derives from an aggregate of causes that led to the development and polarization of the theories of aging. In this context, Jones [5] and Jin [6] believe that no single theory thoroughly explains the phenomenon of the aging process, but each offers some clues. Many of the proposed theories interact with each other in a complex way.

2.3 Policies on aging

As previously mentioned, the WHO emphasizes the longevity achieved by the population, reinforcing that most people expect to live beyond 60 years. It is likely that by 2050 one in five people will be 60 years old or more [1]. This means that a longer life brings great opportunities. However, how each individual can benefit from the extra years depends largely on one key factor: Health. On the other hand, evidence suggests that older people do not have a better health status than earlier generations. Additionally, those who have experienced lifelong events have a higher risk of health problems.

In this context, the concept of “healthy aging” emerges, which is the focus of the WHO’s work on aging for 2015–2030. “Healthy aging” is understood as a process of developing and maintaining the functional capacity that enables the well-being of the elderly adult. This central concept emphasizes, on the one hand, the need for action focused on multiple sectors and, on the other hand, the possibility of older people continuing to be a valid resource in their families, communities, and economies. We understand that one of the most important messages that can be drawn from this WHO theory of healthy aging is that one of the main focuses of the work of gerontologists, and all professionals responsible for offering services to the elderly is to find strategies and concerted actions that help the older people to continue doing the things they value most for as long as possible [7]. Within the scope of policies for healthy aging, the WHO assumed five strategic goals: (1) commitment to action, that is, to establish models, strengthen the capacity to formulate evidence-based policies, and combat stigma and stereotype of aging; (2) aligning health systems with the needs of older adults, i.e. orienting health systems around individual needs and potential for involvement, ensuring accessibility to quality care, and ensuring the sustainability of healthcare; (3) develop age-friendly environments, through the promotion of autonomy, the involvement of older people, and the promotion of multisectoral actions; (4) strengthen long-term care, with a view to continuously improving a sustainable and equitable policy in terms of long-term care, also integrating caregivers; and (5) improve evaluation, monitoring, and research, defining the suitable instruments, methodologies, and protocols, strengthening research capacity and encouraging innovation, and sustaining evidence of the benefits of actions focused on healthy aging for the population.

As a continuing of the concept of healthy aging, in 2015 the WHO emphasized the concept of active aging, as a multidimension that involves physical functionality, urban environment, and social inclusion. The WHO defined active aging as “…the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age” [7]. The concept of Active and Healthy Aging (AHA) comprehends the results of the interaction between the physical and mental capacity of an individual and the context of each individual’s life.

3. Topic 2: physical and functional changes associated with aging

3.1 Morphological changes and physiological systems: Body composition and systems: Cardiopulmonary, musculoskeletal, nervous, and sensory

Although it is difficult to distinguish the effects of aging on the physiologic function of the impact of deconditioning or disease, the aging process leads to profound changes in the cardiopulmonary, musculoskeletal, nervous, and immune systems. For example, the American College of Sports Medicine (2018) states that the incidence of stroke decreases about 30% from 25 to 85 years of age; there is a progressive reduction of ventilatory peak flow and lung capacity with advancing age; there is an increased bone loss resulting in reduced bone mineral density; about 25% of muscle function, defined as the highest lifetime force-generating capacity, is lost by around 65 years of age. Also, negative changes of the central nervous system are observed in neurotransmitters, nerve conduction, and fine functional-fitness control.

Regarding the body composition and musculoskeletal changes, one of the major age effects of body composition faced by older people is a gradual loss of skeletal muscle mass and strength that occurs with advancing age, called Sarcopenia. Sarcopenia increases the risk of falls [8], is associated with cardiac disease and respiratory disease [9, 10], and increased risk of death [11, 12]. In addition, it is accompanied by functional decline and disability [13, 14]. With increasing age and from about 40–45 years old, lean soft tissue and skeletal muscle mass progressively decline [15]. Evidence shows that about 25% of muscle function, defined as the highest lifetime force-generating capacity, is lost by around 65 years of age [3].

Finally, it has been reported that cognitive functioning declines with age [2]. Cognitive function is the intellectual process by which a person becomes aware of ideas, perceives, and understands them. It involves all aspects of perception, thinking, remembering, learning, attention, vigilance, reasoning, and problem-solving. This concept includes psychomotor functioning (reaction time, movement time, and performance speed) [16]. There is evidence that regular physical exercise [17, 18, 19] and cognitive training [20, 21] are non-pharmaceutical interventions that attenuate age-related cognitive decline and improve cognitive performance in older people.

According to Fernández-Ballesteros [22], active daily cognitive activity and social and leisure activities have a positive impact on the general functioning of cognitive abilities. Therefore, social contacts and good integration of people in the community are factors that contribute to greater protection of cognitive functioning. In addition, there is some literature to support that interventions based on cognitive stimulation programs associated with group physical activity programs have great potential in older people with identified dementia and healthy older people [2, 3].

3.2 Functional changes: functional fitness and mobility

Among older adults, functional fitness is defined as the ability to perform activities of daily living normally, safely, independently, and without fatigue [23]. Improving functional fitness in older adults (i.e. lower and upper limb muscle strength, aerobic capacity, flexibility, and dynamic balance) is a critical factor in maintaining their independence in daily living activities. In this sense, a reduction in functional fitness levels is generally associated with a decline in general functional capacity and basic activities of daily living such as climbing stairs, walking, carrying groceries, and many other common tasks [3, 23]. Normative functional fitness scores have been published for older adults in different countries: United States of America [24]; Portugal [25]; Brazil [26]; Poland [27]; and China [28]. Results revealed a pattern of decline across most age groups on all variables. The total decrease in muscular strength, cardiorespiratory endurance, and agility/balance was about 30–45% between 60 and 94 years of age. The pattern of decrease over age was similar in men and women. However, men scored better on muscular strength, aerobic endurance, and agility/balance, and women scored better on flexibility [24, 25, 26, 27, 28].

4. Topic 3: physical-psychosocial relationships

4.1 Aging, active life, and cognitive function

Owing to the inevitable well-documented age-related losses in cognitive and physical function [29, 30], one of the biggest challenges is to identify strategies to develop and maintain functional ability at later ages. Functional ability is determined by the individual’s intrinsic capacity, which encompasses cognitive function and mobility, relevant contextual factors, and the interaction between the two [7]. There is evidence that a physically active lifestyle and, consequently, a high level of functional fitness are effective modifiable risk factors that may slow the increase of cognitive impairments in older age [31, 32, 33].

Therefore, from a healthy aging perspective, an early intervention strategy based on supportive environments and opportunities to increase physical activities are determinants of living a long and healthy life [7]. This is supported by physical activity being a modifiable risk factor for cognitive impairment in older age [32, 33]. For this reason, in the last decade, there has been a rapid increase in interest in the potential of physical activity to prevent cognitive decline and maintain good cognitive abilities.

Although it has been demonstrated that maintenance of higher levels of physical activity helps to protect against cognitive deterioration, even at an advanced age [34, 35], it is still an open question which frequency, intensity, time, type, volume, and progression of physical activity is more effective to improve cognition. Finally, the physiological mechanisms underlying the relationship between cognitive function, functional fitness, and physical activity at older ages are still poorly understood.

4.2 Physical activity, well-being, and health-related quality of life

Observational studies have shown an average 20 to 30% reduction in mortality risk when individuals spend at least 1000 kcal per week on physical activity [36]. The American College of Sports Medicine emphasizes the health benefits associated with higher levels of physical activity and aerobic exercise across physiological, metabolic, and psychological parameters. Additionally, there is a decreased risk of many chronic diseases and premature mortality. The variables studied show a lower risk for any cause of mortality in people who maintain higher levels of physical activity or physical fitness over time when compared to those who reduce or maintain low levels of physical activity or physical fitness over time [37, 38].

Some recognized benefits of participating in regular physical activity are slowing physiologic changes of aging that impair exercise capacity [37], optimizing age-related changes in body composition [13], promoting psychological and cognitive well-being [20, 39], managing chronic diseases [40], reducing the risks of physical disability [25], and increasing longevity [41].

Despite the benefits of PA, older adults are the least physically active of all age groups, with only 11% of individuals aged ≥65 yrs engaging in aerobic and muscle-strengthening activities that meet guidelines, and less than 5% of individuals aged 85 yrs and older meet the same guidelines [37, 38].

5. Topic 4: contextual determinants of physical activity in the elderly population adopting and maintaining physically active lifestyle

5.1 Adoption and maintenance of physically active lifestyles

Some physical activity is better than none, and an increase in the physical activity level, up to a point, is better than less. This supports the dose-response relationship between physical activity and health reported by the American College of Sports Medicine in conjunction with other important health organizations such as the Centers for Disease Control and Prevention (CDC), the US Surgeon General, and the National Institutes of Health [42]. The main purpose of healthcare professionals and physical activity instructors is to assist individuals in adopting and adhering to the exercise prescription recommendations made throughout the guidelines. And the main challenge is to overcome the barriers to the exercise.

There are well-known correlates that affect engagement in regular physical activity. Numerous demographic factors (e.g. age, gender, socioeconomic status, education, and ethnicity) are consistently related to the likelihood that an individual will keep their activity regularly [43, 44].

In the context of adopting and maintaining a physically active lifestyle in older people, it is important to focus on the role that modifiable factors have on exercise prescription recommendations, the behavioral theories and models that have been applied to enhance exercise adoption and maintenance, and behavioral strategies and approaches that can be used to increase physical activity behaviors.

Physical activity tends to decline with age, especially when people have age-related disabilities. Still, age does not necessarily predispose an individual to lower activity [45]. Several international studies provide insights on impediments to physical activity in older people. The most common barriers reported were enough other hobbies, too exhausting, risk of injury too high, no knowledge of opportunities, an attitude that sports are only for younger people, no time, and financial reasons, having too few friends to exercise with [46]. Pain is another common barrier to exercise [47]. Another critical point concerns the differences between men and women, reinforcing the importance of specific efforts to increase older adults’ physical activity levels [46]. We recognized that it is crucial, in each context, to identify earlier relevant barriers to physical activity in older adults to better tailor measures to the specific needs and be successful in the promotion and intervention strategies.

People’s physical activity during their leisure time is determined by genetic traits (20 to 70&), beliefs and motivation shaped by learning (25 to 75%), and physical and social environments (10 to 50%) [45]. Creating a friendly-environment that makes physical activity easy/affordable does not ensure that a person living in that environment will be motivated to use it. It is not easy to alter personal preferences or long-standing habits. Changing physical activity is not like changing most other behaviors.

Sustained participation in regular physical activity requires active behavior modification. Following [45] in the “physical activity epidemiology,” most behavior modification techniques for changing physical activity center on (i) goal-setting based on personal characteristics; (ii) identification of personal costs and expected barriers to adoption and maintenance of an activity routine; (iii) strategies for preventing or minimizing the impact of barriers to participation and for increasing support and reinforcement from friends and family; (iv) planning a gradual progression of difficulty to optimize success so that the participant has growing confidence in both physical abilities and the ability to maintain the new pattern of activity; (v) feedback from fitness testing and self-monitoring of activity and progress by the participant; and (vi) personal strategies for returning to activity after relapse to inactivity due to flagging motivation, injury, vacation, and others.

5.2 Age-friendly environments

Promoting age-friendly physical and social environments where people live plays a vital role in whether people can remain healthy, independent, and autonomous long into their old age [7].

Healthcare professionals and physical activity instructors have the responsibility to think correctly about the promotion of age-friendly environments. Promote age-friendly environments means offering free physical and social barriers and support policies, services, products, or technologies that help promote health and build and maintain physical and mental capacities across the life course. Also, age-friendly environments should enable people, even when experiencing capacity loss, to continue to do the things they value. When planning age-friendly practices, healthcare professionals and physical activity instructors must ensure that they are promoting/offering opportunities for older people to meet their basic needs, learn, grow, and make decisions, be mobile, build and maintain relationships, and contribute to the community.

Good practices of Age-Friendly Communities are well documented. For example, the 2022–2027 Master Aging Plan marks the fifth strategic planning cycle for the Orange County Department on Aging [48]. This Master Aging Plan framework contains eight domains of livability that influence the quality of life for older adults: (1) outdoor spaces and buildings (include actions to optimize usability of outdoor spaces and buildings); (ii) transportation (include actions to increase access to and awareness of affordable, safe, and equitable mobility options); (iii) housing (include actions to improve choice, quality, affordability, and stability of housing); (iv) social participation (include actions to promote diverse and accessible opportunities for participation and engagement); (V) respect and social inclusion (include actions to uphold all older adults ages 55+ years as valuable members and provide equitable resources for the community); (vi) civic participation and employment (include actions to connect older adults with resources that help them achieve their diverse employment and career transition goals); (vii) communication and information (include actions to awareness of and access to available services and supports for older adults and their families will increase for everyone), and (viii) community and health services (include actions to ensure the community has accessible and affordable resources to support individual health and well-being goals throughout the aging process). This plan builds off of the 20-year history of formal age-friendly planning in Orange County. This is a model for comprehensive and successful aging and represents a comprehensive vision for the future of several communities that intend to be age-friendly communities.

6. Topic 5: exercise prescription in the elderly population

6.1 Pre-exercise assessment

When people are encouraged to engage in physical activity because of its multiple health benefits, attempts to reduce the risks inherent in more vigorous activities should be considered. Screening for risk factors and/or symptoms of cardiovascular, pulmonary, and metabolic diseases, as well as other conditions (e.g. musculoskeletal conditions), may be aggravated by exercise [38]. The primary goals of pre-participation health screening and risk stratification are to help develop an effective and safe exercise prescription and optimize safety during exercise assessment and performance.

A health screening before starting an exercise or physical activity program is a tiered process: (i) self-guided method via the Physical Activity Readiness Questionnaire (PAR-Q) or the modified AHA/ACSM Health/Fitness Facility Questionnaire Preparticipation; (ii) assessment of risk factors for CVD and classification; and (iii) medical evaluation, including physical examinations and stress tests.

All older people who wish to start a physical activity program should be assessed at least through a medical history or self-reported health risk questionnaire; the responses to these self-guided methods determine the need and level of follow-up. Older adults at moderate risk with two or more cardiovascular risk factors should be encouraged to consult a physician before starting a program of vigorous-intensity physical activity. Although medical evaluation is ongoing, most individuals can begin light to moderate-intensity exercise programs without consulting their physician. Older people at high risk with symptoms or diagnosed illnesses should consult their physician before starting a physical activity and/or exercise program.

Routine stress tests are recommended for individuals at high risk, including those with a diagnosis of cardiovascular disease, symptoms suggestive of new or unstable cardiovascular disease, diabetes mellitus, cardiovascular risk factors, advanced kidney disease, and specific lung diseases.

These recommendations reduce the barriers to adopting more active lifestyles because most of the risks associated with exercise can be lessened by adopting a progressive exercise training regimen. Generally, there is a low risk of participating in physical activity programs.

The assessment of the functional fitness of older adults is of particular importance. First of all, it can be used to identify at-risk participants. Many independent older adults, often due to their sedentary lifestyles, function dangerously close to their maximum ability level during normal activities. Climbing stairs or getting out of a chair requires near maximum effort for many older individuals [30]. More than one-third of community-dwelling older adults are at risk for mobility problems and falls [49]. Early identification of physical decline and appropriate interventions could help to prevent functional impairments, such as in walking and stair climbing, that often result in falls and physical frailty [30].

Second, assessing functional fitness for better program planning and evaluation is essential. A comprehensive functional fitness test provides specific information regarding a client’s physical strength and weaknesses associated with functional tasks and activity goals important to everyday living. This information is necessary to design individualized, targeted exercise, or physical activity programs for clients. Baseline measures repeated during the program provide critical data to track clients’ progress, make program adjustments, provide personalized feedback, and evaluate program effectiveness.

6.2 Exercise programs for the older population

There are important considerations for exercise programming in older people that must be considered at the beginning to maximize the effective development of an exercise program [38].

First, the intensity and duration of physical activity should be light at the beginning, particularly for older adults who are highly deconditioned, functionally limited or have chronic conditions that affect their ability to perform physical tasks. The intensity must be controlled not only by the use of a subjective effort scale but also by a pain scale. Respecting the pain limit is fundamental to ensure continuity in the practice of physical exercise. Second, the progression of physical activity should be individualized and tailored to tolerance and preference. A conservative approach may be necessary for older adults who are highly deconditioned or physically limited to prevent injury events.

A significant and well-documented age-related associated decline is muscular strength, especially after 50 yrs. [50]. This decline is directly connected with loss of strength due to the atrophy of muscle fibers, with a preferential incidence in type II fibers [51]. Practically, this supports the importance of including resistance training across the lifespan since it becomes more critical with increasing age. Strength training involves using selected machines or free weights. Initial training sessions should be supervised and monitored by personnel sensitive to the special needs of older adults.

Once power training is the muscle fitness component that rapidly declines with aging and has been associated with a greater risk of accidental falls, older people benefit from this training. Some recommendations are underlined by ACSM, including single- and multiple-joint exercises (one to three sets) using light-to-moderate loading (30–60% of 1-RM) for 6–10 repetitions with high velocity.

Individuals with sarcopenia, defined as a progressive and widespread skeletal muscle disorder involving loss of muscle mass and function, are associated with several adverse outcomes including falls, functional decline, frailty, and mortality [52]. Sarcopenia has been considered a public health problem, affecting most older people and making them more vulnerable to falls [53]. For this reason, it is essential to increase muscular strength before older people are physiologically capable of engaging in aerobic training.

Another important recommendation for all older people, even if chronic conditions preclude activity at the recommended minimum amount, is that older adults should perform physical activity as tolerated to avoid being sedentary. Older people should gradually exceed the recommended minimum amounts of physical activity and attempt continued progression if they desire to improve and/or maintain their functional fitness. It is an important message for older people to inform them to exceed the recommended minimum amounts of physical activity to improve the management of chronic diseases and health conditions for which a higher level of physical activity is already known to confer a therapeutic benefit, for example, diabetes, blood pressure, obesity, depression, and other.

Regarding older people with identified cognitive declines, moderate-intensity physical activity should be encouraged. In the case of significant cognitive impairment, individualized assistance may require during the physical activity program.

Generically, ACSM recommends a structured physical activity session, with an appropriate cool-down, particularly among individuals with cardiovascular disease. The cool-down should include a gradual reduction of effort and intensity and, optimally, flexibility exercises.

It is high recommendable that the incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance participation in a regular exercise program. In addition, older people should be provided with regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence. These final recommendations will better contribute to a more consistent healthy aging program.