A literature review of evidence on physical activity for older people and a review of existing physical activity guidelines for older people

June 2011 (Draft 3)


June 2011

New Zealand Guidelines Group and University of Western Sydney

Evidence Report: prepared for the Ministry of Health, New Zealand


Contributors

Dr Julie Brown

Senior Researcher

New Zealand Guidelines Group

Dr Richard Rosenkranz

Lecturer/Research Fellow

School of Biomedical and Health Sciences

University of Western Sydney, Australia

Professor Gregory Kolt (Lead researcher)

Head of School

School of Biomedical and Health Sciences

University of Western Sydney, Australia

Dr Jessica Berentson-Shaw

Research Manager

New Zealand Guidelines Group

Emma George (School of Biomedical and Health Sciences, University of Western Sydney), Karen Cheer (Liaison Librarian, University of Western Sydney), Stuart McCaw (Business Development Manager, NZGG) and Margaret Paterson (Information Specialist, NZGG) are also acknowledged for their assistance with various aspects of this report.

Page iii
07/06/2011



Table of Contents

1 Executive summary 1

Key messages 1

2 Introduction 6

Purpose 6

Definitions 6

Epidemiological and demographic context 7

How older people participate in physical activity 8

Conclusions that can be drawn 9

The Australian national policy response 9

New Zealand national policy response 10

References 12

3 Methods 14

Date range of publications 14

Type of publications 14

Participants 15

Physical activity 15

Sedentary behaviour 15

Types of physical activity intervention 15

Outcome measures 15

Search sources 16

Appraisal 18

References 20

4 What are the benefits associated with physical activity participation for older people? 21

Background 21

Definitions 22

Physical activity and the prevention of health-related conditions 22

Physical activity and the management of health conditions 51

Physical activity and the enhancement of functioning 71

Overall conclusions 89

References 90

5 What are the risks associated with physical inactivity for older people? 100

Background 100

Definitions 100

Body of evidence 100

Risks associated with low levels of moderate to vigorous physical activity (mortality) 101

Risks associated with low levels of moderate to vigorous physical activity (morbidity) 105

Risks associated with sitting or sedentary behaviour (mortality) 113

Risks associated with sitting or sedentary behaviour (morbidity) 114

Conclusions 115

References 116

6 What are effective types of physical activity interventions in improving outcomes for older people? 120

Background 120

Definitions 121

Body of evidence 123

Summary of findings 124

Overall conclusions 198

References 207

7 What are the enablers and barriers to physical activity participation in older people? 214

Background 214

Definitions 214

Body of evidence 215

Summary of findings 215

Detailed findings 223

Conclusions 234

References 234

8 What are the safety and risk issues associated with physical activity participation by older people? 237

Introduction 237

Body of evidence 237

Summary of findings 238

Conclusion 249

References 250

9 International guidelines, policies and principles 253

Introduction 253

Definitions 253

Sentinal report from the US Surgeon General 254

Guidelines 254

Policies and scientific statements 263

Horizon scanning 271

Conclusions 272

References 272

10 New Zealand specific issues and cultural considerations 276

Background 276

Body of evidence 276

Summary of findings 277

Conclusion 288

References 288

11 Search strategies 291

Search strategies 291

12 Research questions 298

Glossary 299

Page 124
07/06/2011


1 Executive summary

Consistent with worldwide trends, the population of New Zealand is ageing. Based on the 2006 Census data, the New Zealand population aged over 65 years at the end of 2006 was 519,940 (12% of the total population) (Ministry of Social Development 2007). It has been estimated that the older adult cohort is projected to increase to 25% of the total population by 2051 (Dunstan et al 2006).

Along with the ageing population come challenges in maintaining health and wellbeing. An important key to healthy ageing is the maintenance of a physically active lifestyle. Physical inactivity has both direct and indirect costs to the health of a population, with evidence showing graded health benefits of physical activity for reducing of a range of non-communicable diseases (US Surgeon General 1996).

The phrase ‘older people’, as used in this report, refers to people over the age of 65 years.

This report examines the evidence since 2004 on the benefits and risks of physical activity, as well as the risks of inactivity. It draws conclusions from the evidence as to what the most effective types of physical activity are for older people and does this from the perspective of both preventing the onset of chronic conditions and also the management of those conditions.

The report addresses the enablers and barriers to participation in physical activity for older people; and examines specific issues (especially with regard to safety) and cultural considerations for New Zealand older people. It also examines the existing evidence from international guidelines and policies on physical activity for older people.

Key messages

The key messages identified below are grouped by area of focus and highlight the main findings of the report. Each chapter of the report outlines the details and evidence supporting each of the key messages.

Benefits associated with physical activity participation for older people

The strongest evidence for the benefits of physical activity for older people in preventing negative health and disability relates to all-cause mortality, cardiovascular mortality, cancer mortality, falls, stroke, heart disease, breast cancer, and colon cancer.

The strongest evidence for the benefits of physical activity for older people in the management of health and disability relates to vascular disease, heart disease, stroke, osteoarthritis, obesity, type 2 diabetes, and depression.

Strong evidence exists for the benefits of physical activity for older people in enhancing physical fitness (including strength and aerobic endurance), quality of life and wellbeing, cognitive function, and physical function.

Risks associated with physical inactivity and sedentary behaviour for older people

Having a less active and more sedentary lifestyle increases the risk of premature mortality relative to leading an active lifestyle.

The lack of moderate to vigorous physical activity and large amounts of time spent sitting (sedentary behaviour) are independent risk factors for negative health outcomes.

Incremental increases in physical activity or decreases in sedentary behaviour are both independently associated with reductions in mortality and morbidity risk.

Effectiveness of various types of physical activity in improving health outcomes for older people

Ample evidence exists that physical activity intervention programmes are effective in preventing disease, injury, and other undesirable health conditions:

· moderate to vigorous intensity aerobic endurance interventions can be effective in preventing osteoporosis, hypertension, type 2 diabetes, disability, and hospitalisation

· resistance training, done at a moderate to high intensity, has effectiveness in preventing osteoporosis and disability

· mobility and balance interventions are effective in preventing falls

· interventions combining mixed types of moderate to vigorous intensity physical activity can be effective in preventing falls, physical disability, osteoporosis, hospitalisation, hypertension, and type 2 diabetes.

Evidence exists that physical activity interventions are effective in the management of health-related conditions in older people:

· moderate to vigorous intensity aerobic endurance interventions are effective in vascular disease, heart disease, stroke, cancer, osteoarthritis, neurological disorders, hip injury, and depression

· resistance training interventions, across a range of intensities, have been shown to be effective in managing vascular disease, stroke, osteoarthritis, frailty, obesity and overweight, hip injury, sleep problems, and depression

· mobility and balance interventions are effective in managing stroke, osteoarthritis, frailty, and sleep problems

· interventions combining mixed types of physical activity, across a range of intensities, have shown effectiveness in managing vascular disease, heart disease, stroke, cancer, osteoarthritis, frailty, obesity and overweight, type 2 diabetes, pulmonary disease, neurological disorders, depression, and sleep problems.

There is evidence that demonstrates that physical activity interventions are effective in enhancing a range of functions in older adults:

· moderate to vigorous intensity aerobic endurance interventions have been shown to enhance cognitive function, physical function and mobility, balance, aerobic capacity, and strength

· resistance training, across a range of intensities, is effective in enhancing cognitive function, physical function and mobility, activities of daily living, balance, aerobic capacity, and strength

· moderate intensity mobility and balance interventions are effective in enhancing cognitive function, physical function and mobility, and balance

· interventions combining mixed types of moderate to high intensity physical activity have shown effectiveness in enhancing physical function and mobility, activities of daily living, balance, aerobic capacity, strength, and quality of life.

Enablers and barriers to physical activity participation in older people

Differences were not generally evident between enablers and barriers to physical activity in New Zealand-specific literature and that from international studies. The New Zealand specific literature identified enablers for physical activity to include guidance/encouragement from health professionals, institutional (including religious) encouragement, and access to community-based programmes, For Māori, it was highlighted that programmes be based on the principles underpinning the Treaty of Waitangi, are culturally appropriate, include facilitators trained on marae, and demonstrate an understanding of tikanga. Identified barriers to physical activity in New Zealand specific literature included health problems and concerns, lack of support and encouragement, and cultural and social norms/expectations.

In looking at the broader international literature, the most frequently cited enablers were positive experiences and outcome expectations, promotion of health and feeling healthy, social support for physical activity, easy access to parks/facilities, and low-cost or no-cost programmes. The most frequently cited barriers were problems with health, functional ability, and fear of falling and sustaining injury.

Safety issues and risks for physical activity participation for older people

While most studies of the role of physical activity in older people have focused on benefits as opposed to harm, it appears there is minimal risk in participating in physical activity for the older adult. Evidence suggests that the adverse events associated with physical activity in older people are generally innocuous.

The risk of adverse events occurring from physical activity, however, does appear to be increase as intensity of physical activity increases.

For those with coronary artery disease, there is an increased risk of cardiac event, and as such, medical advice or supervision should probably be recommended for this sub-population prior to engaging in physical activity. Similarly, the risk of sudden cardiac events is associated with periods of vigorous physical activity, and those at high risk of coronary artery disease should probably seek medical advice or supervision.

The risk of falling does not appear to be increased whilst participating in physical activity.

The risk of sustaining an injury through physical activity can be reduced through incremental increases in the amount of physical activity, the provision of appropriate advice, and through the provision of safe physical activity environments.

Evidence exists that suggests that the benefits of regular physical activity participation outweigh the inherent risk of adverse events.

New Zealand specific issues and cultural considerations

Of older people in New Zealand, those over 80 years are the least active, and women are more likely to be less active than men.

New Zealand developed interventions such as the Green Prescription are effective in increasing the amount of physical activity in community-dwelling older people.

Primary care settings appear to be important in terms of promoting physical activity advice in older people in New Zealand.

Māori are no less active than the overall population, and as such, the focus should be on continuing the uptake of physical activity through the provision of culturally acceptable options.

Some ethnic groups such as Asian groups and Pacific people require specific targeting based on risk factors for physical inactivity or culturally-specific targets to promote physical activity.

Key barriers for older New Zealanders include education, financial constraints, physical/built environment, lack of cultural appropriateness, and medical/physical limitations.

International guidelines and policy documents

Evidence suggests that older people should participate in a minimum of 30 minutes of moderate intensity physical activity on most if not all days of the week. This should be supplemented with strength, balance, and co‑ordination activities at least two to three days per week.

Additional moderate and vigorous physical activity is seen to confer additional health benefits.

The duration or physical activity can be accumulated in 10-minute bouts.

Key areas identified as important for the implementation of physical activity recommendations for older people include the development of public health policy, safe community and physical built environments, supportive social environments, public and professional education, inter-agency collaboration and formation of coalitions and partnerships, financial support, evidence based research, evaluation, and monitoring.

Overall conclusion

Given the evidence that forms the basis for the present review of literature on health benefits from physical activity in the prevention and management of disease, and the risks of being physically inactive, it appears that the current burden for health care systems could be eased by developing a more physically active population. Although all people can achieve a variety of benefits from participating in regular physical activity, considerable improvements in population health can occur by focusing health promotion efforts on those sub-populations least likely to achieve sufficient physical activity, such as older people.

References

Dunstan K, Thompson N. 2006. Demographic Aspects of New Zealand’s Ageing Population. Wellington, New Zealand: Statistics New Zealand.

Ministry of Social Development. 2007. Positive Ageing Indicators 2007. Wellington, New Zealand: Ministry of Social Development.


2 Introduction

Purpose

This chapter provides the context for the report in the following areas:

· epidemiological and demographic context

· how older people participate in physical activity

· the Australian national policy response

· the New Zealand national policy response.

The content of each chapter is also described.

Definitions

The operational definitions used in this report are contained in the Glossary. The definitions repeated below for easy reference while reading this chapter.

Older people are people over the age of 65 years. However, not all of the reviewed literature dealt solely with this age group. The average age of people reported on in the reviewed literature is likely to be 65 years or older and the conclusions that are drawn apply to this age group. However, many research articles refer to populations that include younger adults. Where the literature is clear about this, the age range is included in the text. Where it is not clear (especially applies to systematic reviews covering many studies) we note this in the text. Where no age is provided, the population is over the age of 65 years.

A note about frail populations: frailty is related to instability and risk of loss of function, a set of linked deteriorations including, but not limited to, the musculoskeletal, cardiovascular, metabolic, and immunologic systems (Faber et al 2006). Within the summary of findings, a statement is made about whether or not the literature separated out this population, and the specific studies are referenced.

Physical activity is categorised as being of either light, moderate, or vigorous intensity, and most health benefits have been associated with moderate to vigorous intensity physical activity (National Advisory Committee on Health and Disability 1998; US Surgeon General 1996). Light intensity physical activity does not cause noticeable increases to breathing, and results in small increases to energy expenditure, while moderate intensity physical activity (eg, brisk walking), and vigorous physical activity (eg, jogging) both create noticeable increases in breathing and energy expenditure (see glossary for further information).