National physical activity recommendations for older Australians: Discussion Document

9.2 The frail older person

The National Ageing Research Institute was commissioned by The Department of Health and Ageing to review the evidence and develop physical activity recommendations for older people.

Page last updated: 01 February 2011

Many frail older people remain in the community with formal and informal care provision, although some are living in the residential aged care setting. Sedentary behaviour in older people increases the risk of the health problems outlined in Chapter 3 and increases the likelihood of someone requiring to be cared for in the residential aged care setting. Physical activity can assist independence amongst frail older people and reduce the burden on their informal carers. The Home Support Exercise Program (Tudor Locke, Myers et al. 2000) was established in Calgary, Canada, to assist those already receiving formal home care. An evaluation of the program, using a before-after quasi-experimental design, highlighted a range of benefits, from improved physical function (timed up and go, sit to stand, 6 minute walk) through to better sleep patterns and sense of wellbeing (Tudor Locke, Myers et al. 2000). Participants ranged from 65 to 98 years in age and had an average involvement of 5.6 days of exercising per week. The estimated cost of providing the program was $92 (Canadian dollars) per person. This was based upon the cost of training health care workers and a modest uptake of the exercises amongst clients (10%). The costs are low, since health care workers cost less than health professionals and they are routinely seeing these clients as part of overall care provision. There was no need for medical clearance, transport or expensive equipment. The evaluation highlighted some time and program management challenges that need to be addressed, but the program appears feasible. This program is far less costly than that reported by Gill et al. (2002) - $2000, where health professionals were used and equipment was needed.

Strategies to optimise adherence are important when introducing programs for frail older people. One study incorporating adherence strategies is the WALC program (Walk; Address pain, fear, fatigue during exercise; Learn about exercise; Cue by self-modelling), which encouraged participants to walk on their own or join a walking group, to walk for 20 minutes three times a week (Resnick 2002). Participants were supported by a nurse practitioner who visited them (weekly during month 1, then monthly) to discuss fatigue, pain and fear of falling. The nurse also reviewed their information booklet with them. Long and short-term goals were developed and recorded to act as a reminder and review aid. The intervention was based on social cognitive theory, incorporating mastery of physical activity, seeing like others doing exercise, receiving encouragement and feedback about the physiological and psychological responses to exercise. The intervention had positive outcomes, with increased self-efficacy related to exercise, outcome expectations, exercise behaviour and overall activity in the intervention group. No differences in health status were reported, but the amount of exercise was small, with 3.5-4 hours per month on average. There may be scope for encouraging more exercise to produce health benefits, but this needs to be weighed against increased attrition.

Older people in residential aged care accommodation

A growing number of studies have focused upon physical activity for older people in residential care. Studies involving those living in nursing homes and aged care facilities are included in Cyarto et al’s recent update of the literature (Cyarto, Moorhead et al. 2004). The American College of Sports Medicine’s 1998 Position Statement on Physical Activity in Older People (Mazzeo, Cavanagh et al. 1998) provided an overview of the evidence for physical activity adoption amongst such frail older people. A range of physical activity programs have been shown to be helpful. A variety of outcomes have been measured including function (McMurdo and Rennie 1993; Mulrow, Gerety et al. 1994; Morris, Fiatarone et al. 1999; Meuleman, Brechue et al. 2000), muscle strength (Sauvage, Myklebust et al. 1992; Lazowski, Ecclestone et al. 1999; Morris, Fiatarone et al. 1999), endurance (Sauvage, Myklebust et al. 1992; Gillies, Aitchison et al. 1999; Lazowski, Ecclestone et al. 1999; Morris, Fiatarone et al. 1999; Meuleman, Brechue et al. 2000), balance (Mulrow, Gerety et al. 1994; Lazowski, Ecclestone et al. 1999; Morris, Fiatarone et al. 1999) flexibility (Lazowski, Ecclestone et al. 1999) and mood (Morris, Fiatarone et al. 1999).
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Many of the studies have had small sample sizes. An exception is Morris et al’s trial, which involved 468 people (Morris, Fiatarone et al. 1999). Morris and colleagues (1999) compared different types of physical activity program for nursing home residents. In their cluster randomised trial, one group received a mobility and strengthening program, another functional rehabilitation provided by nursing staff and the third received usual care. At 10 months follow up, there was a significant reduction in functional decline in the two intervention groups compared to the usual care group. In particular, declines in locomotion ability were noted. Sheltered housing residents with lower limb weakness showed improved strength and activities of daily living after 10 weeks of supervised strength training with Therabands™ (Westhoff, Stemmerick et al. 2000). An hourly program once a week in New Zealand women (mean age 83 years) in residential care reduced the time taken to stand up and decreased the need for associated hand assistance (O'Hagan, Smith et al. 1994). McMurdo and Rennie (1993) trialled a seated exercise program with older people in residential aged care accommodation. The 30 minutes, twice a week program preserved function and even restored function in some participants, whilst the control group who had a reminiscence program demonstrated deterioration in function. Physical activity has also been shown to benefit sleep patterns in residential aged care dwellers (Alessi, Martin et al. 2005). The specific impact of physical activity as part of a multifaceted program in isolation is not able to be determined from this study’s methodology.

There have even been a few trials targeting residents with Alzheimer’s disease, albeit with small sample sizes (Tappen 1994; Tappen, Roach et al. 2000; Cott, Dawson et al. 2002). One 16 week walking and talking intervention found no significant group differences (Cott, Dawson et al. 2002), whereas another reported less deterioration in distance walked when participants were compared to those who only walked or talked (Tappen, Roach et al. 2000). A 20 week program targeting functional skills showed ADL improvements post intervention (Tappen 1994). Attrition was common across studies. In one study less than half completed a mobility, strength and exercise program (Schnelle, Alessi et al. 2002), although improvements in injury risk and upper body strength were seen amongst completers.

Not all trials with residential care participants have reported significant differences between intervention and control groups. Karl (1982) reported no significant effect, but suffered from several methodological weaknesses. Other studies have found only small between group differences (Sauvage, Myklebust et al. 1992; Kinion, Christie et al. 1993; Mulrow, Gerety et al. 1994; Gillies, Aitchison et al. 1999; Meuleman, Brechue et al. 2000). The greatest improvement in function was seen more in those most impaired at baseline in Meuleman et al’s study (2000). The authors also noted that few people could effectively perform the endurance training component of the program. This has implications for the targeting and design of interventions. The cost effectiveness of programs also needs consideration. In a four month physical therapy program involving range of motion, balance, transfer and mobility exercises improvements in mobility and a reduced likelihood of using assistive devices for locomotion were reported (Mulrow, Gerety et al. 1994). The average cost of this intervention was $1220 per subject, compared to $189 for the social visit control and other healthcare charges of $11,398. A full cost benefit analysis was not conducted. The costs can be reduced by using para-professional staff, or even care staff or volunteers at the facilities, so long as suitable training is provided (Kinion, Christie et al. 1993; Lazowski, Ecclestone et al. 1999).
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