You are here

Article Text

Article menu

Download PDFPDF

XML
Review
Physical activity is medicine for older adults
  1. Denise Taylor
  1. Faculty of Health & Environmental Sciences, Health & Rehabilitation Research Institute, North Shore Campus, AUT University, Auckland, New Zealand
  1. Correspondence to Dr Denise Taylor, Faculty of Health & Environmental Sciences, Health & Rehabilitation Research Institute, North Shore Campus, AUT University, Northcote, Auckland 0627, New Zealand; Denise.taylor{at}aut.ac.nz

Abstract

There is evidence from high quality studies to strongly support the positive association between increased levels of physical activity, exercise participation and improved health in older adults. Worldwide, around 3.2 million deaths per year are being attributed to inactivity. In industrialised countries where people are living longer lives, the levels of chronic health conditions are increasing and the levels of physical activity are declining. Key factors in improving health are exercising at a moderate-to-vigorous level for at least 5 days per week and including both aerobic and strengthening exercises. Few older adults achieve the level of physical activity or exercise that accompanies health improvements. A challenge for health professionals is to increase physical activity and exercise participation in older adults. Some success in this has been reported when physicians have given specific, detailed and localised information to their patients, but more high quality research is needed to continue to address this issue of non-participation in physical activity and exercise of a high enough level to ensure health benefits.

  • PREVENTIVE MEDICINE
  • PUBLIC HEALTH
  • GERIATRIC MEDICINE

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

http://dx.doi.org/10.1136/postgradmedj-2012-131366

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    It is very clear that physical inactivity is a major contributor to mortality. The WHO reported that around 3.2 million deaths each year are attributable to physical inactivity.1 Governments around the world are recognising the importance and the large impact of physical inactivity on health and health-related expenditure. This has led to the production of global and national guidelines for physical activity.2–5 Many non-communicable chronic health conditions prevalent in both developed and developing countries are associated with physical inactivity.6––8 With increasing age, there is an increased risk of developing non-communicable chronic health conditions.9 In a recently published review, Blair et al emphasised the direct link between physical inactivity, low cardiovascular fitness and the presence of chronic health conditions.6

    Five leading risk factors for death are high blood pressure, smoking, high blood glucose, physical inactivity and obesity.10 A glance at these risk factors reveals that high blood pressure and glucose levels as well as obesity are connected with physical inactivity.6 Alongside the increasing incidence of these risk factors with ageing, there is a decline in many physiological systems; a loss of muscle mass, a decline in balance ability, a reduction in muscle strength and endurance11 and a decline in cognitive performance,12 all of which impact on functional independence. Paterson et al8 suggested that increasing physical activity levels is the most important intervention to improve health in populations. For older adults, extending life is an important factor, but the maintenance of functional independence is also of high importance, both to maintain quality of life and to manage health resources.13

    In the literature, the term ‘exercise’ is frequently used to distinguish structured programmes from incidental day-to-day physical activity, such as housework.14 Whether physical activity is defined as incidental or as exercise is of less importance than the amount, the frequency and the intensity of the activity. In this review, physical activity refers to any activity that has an energy cost, such as housework, shopping, gardening and structured exercise programmes (such as Tai Chi or aquarobics). The objectives of the review are to (a) present clear guidance around the amount, type and frequency of physical activity for achieving health gain in older adults (>65 years of age), (b) discuss the measurement of physical activity, (c) present the evidence for health benefit of increased physical activity for older adults and (d) discuss the extent to which older adults achieve the suggested physical activity guidelines with suggestions on how to improve uptake and maintenance of high levels of physical activity.

    Recommended levels of physical activity for older adults

    The WHO guidelines ‘Global Recommendations on Physical Activity for Health’, included recommendations for physical activity in older adults.10 A position stand published by the American College of Sports Medicine (ACSM) has similar recommendations.7 The recommendations from the WHO publication are summarised in box 1. A key message is that at least 150 min per week of moderate intensity physical activity is required for health benefit in older adults.

    Box 1

    A summary of the WHO recommendations for exercise for people aged 65 years and older

    1. At least 150 min of moderate-intensity aerobic activity, or at least 75 min of vigorous-intensity aerobic activity, or an equivalent combination.

    2. Aerobic activity should be performed in bouts of at least 10 min duration.

    3. For additional health benefits, undertake up to 300 min of moderate-intensity or 150 min of vigorous-intensity aerobic activity, or an equivalent combination.

    4. People with poor mobility should do balance exercise to prevent falls on 3 or more days.

    5. Muscle-strengthening activities should be done on two or more days.

    6. If older adults are unable to do the recommended amounts of physical activity due to health conditions, they should be as physically active as they are able.

    Modified from WHO's publication Global Recommendations on Physical Activity for Health10

    Measurement of physical activity

    Metabolic equivalent

    When accessing the research-based literature on physical activity and exercise, it is important to understand how physical activity levels and intensity are measured. One frequently used method of calculating intensity of physical activity or exercise is the metabolic equivalent (MET) value, which is an indicator of energy expenditure. One MET is roughly equivalent to the energy expended during quiet sitting. Physical activities have been categorised to produce a compendium of MET values,15 for example, bicycling at a leisurely pace of 5.5 mph has a MET value of 3.5 and washing dishes has a MET value of 1.8. The contents of the compendium can be accessed freely at https://sites.google.com/site/compendiumofphysicalactivities/. See table 1 for a selection of common daily activities and their corresponding MET values for adults.

    View this table:
    Table 1

    Examples of activities at a MET level of 3.5 and above

    Physical activity that is below 3.5 METS (light activities) or a total amount of activity that is below around 4200 kJ/week (equivalent to more than 3 h of brisk walking per week) is unlikely to produce health-related changes in adults. However, in older adults who have mobility limitations, the metabolic cost of activities that involve walking are higher than the average adult16 and should be considered when advising people with mobility limitation about physical activity levels. For people without a mobility limitation, time spent in sedentary activities (such as watching TV) and light activities (including light housework) does not reach activity levels high enough to improve health outcomes.3

    Perceived rate of exertion

    In most publically available guidelines, the MET unit is replaced by a more readily understandable metric. In the guidelines published by the ACSM, a simple scale of intensity based on a self-perceived rate of exertion is used. It is scaled from 0–10 with 5–6 being moderate-intensity exercise and 7–8 being vigorous-intensity exercise.7 The ACSM guidelines clarify physical activity intensity by describing sitting as 0 and the greatest effort possible is 10, with moderate-intensity activity being 5 or 6 and producing noticeable increases in breathing and heart rates, and vigorous-intensity activity (7–8) producing large changes in breathing and heart rates.3

    Pedometers and accelerometers

    Pedometers and accelerometers have gained considerable popularity as reliable methods of objectively measuring physical activity.17 Pedometers are low-cost mechanical counters that determine the number of steps a person takes throughout the day by detecting vertical motion during walking. Accelerometers measure accelerations in one or more planes of motion and can give an indication of the frequency, intensity and duration of different types of movement. Pedometers, in particular, are cheap, easily accessible and unobtrusive, allowing data to be collected during normal daily activities. In older adults, data collected from 2–3 days is considered a reliable indicator of usual daily physical activity.17 ,18 There is no complete agreement on how many steps a day are optimal. As a useful guide, an older adult achieving 10 000 or more daily steps is categorised as highly active, over 5000 but less than 10 000 as moderately active, and 5000 steps or below as inactive.19 ,20 Accelerometers can provide a profile of activity throughout the day, determining time of the day with higher activity or lower activity, duration of inactivity and duration of intensity of activity. Current research is exploring the pattern of activity over the day in relation to health.19

    Different types of physical activity and exercise

    Strength and aerobic fitness

    There is strong evidence for the effectiveness of aerobic exercises and muscle-strengthening exercises, with the result that details are clear around the type and intensity of these forms of exercise. Aerobic exercise is defined as any type of activity that uses large muscle groups and can be maintained over a period of time including activities such as brisk walking, swimming or dancing.7 Guidelines state that aerobic exercise should be at a moderate level, in which the individual notices increases in heart rate and breathing rate.3 ,5 Resistance-based strengthening requires muscles to work against a load, which may be an external load or bodyweight that is progressively increased over the time of the programme.21 Most of the trials of progressive resisted strength training in older adults have high-intensity strength training protocols,22 most frequently involving 8–12 repetitions of the exercise to the point of muscle fatigue. These programmes usually involve the support of exercise professionals and are usually based in gymnasiums, as specialist equipment is often used.

    Balance exercises

    The evidence around balance exercises is not as strong as that around strength and aerobic exercises, and therefore, the recommendations are not as clear. In a systematic review of falls prevention interventions, it was apparent that the important components for falls prevention effects are exercises that challenge balance and exercises that strengthen lower limb musculature.23 For community-dwelling older adults, participation in physical activities, such as Tai Chi or individually tailored home exercise programmes, can reduce falls in those at risk of falling.24–26 What is unclear is whether any particular form of falls prevention intervention is better than others.25 There is good evidence that at least some falls prevention programmes reduce falls in community-dwelling older adults but it is unknown whether these programmes raise participants’ physical activity levels adequately to improve health by affecting cardiovascular fitness and strength. In-depth discussion of balance exercises and falls prevention is beyond the scope of this paper. See Sherrington et al23 and Gillespie et al24 for excellent reviews in this area.

    Incidental physical activity

    Incidental physical activity is that which occurs throughout the course of the day during activities of daily living. It is generally of low intensity but often contains some sporadic bouts of moderate intensity activity.27 In a younger cohort (35–65 years old), achieving a moderate intensity of incidental physical activity for 20–30 min per day was positively associated with measures of cardiovascular fitness.28 However, contrary findings in a similar cohort (35–69 years) indicated that incidental physical activity was unlikely to have significant health benefits.29 At present, there is little research of this nature in older adults.

    The evidence for improved health outcomes with increased physical activity

    The good news is that increasing physical activity levels can have a positive effect on both mortality and functional independence in older adults.

    Mortality

    There are many studies that show a reduced all-cause mortality and reduced risk of developing conditions such as cardiovascular disease and type 2 diabetes in people, including older adults, who exercise regularly at a moderate level.30–33 Epidemiological studies show a strong inverse relationship between physical activity, health and all-cause mortality.8 ,34 In a large prospective cohort study of older American women, higher levels of physical activity were associated with around 40–50% lower all-cause, cardiovascular disease and cancer mortality rates compared with women with lower activity levels.34

    There is a strong association between objectively measured cardiovascular fitness and mortality, but not between self-reported measures of physical activity and mortality.35 This may indicate that in addition to emphasising the need for physical activity, it may be important to encourage the use of objective measures of cardiovascular fitness, or objective measures of physical activity, such as pedometers.

    Functional independence

    Both muscle strength and aerobic fitness have been strongly linked to functional independence.36 ,37 In older adults without disabilities, improvements in muscle strength and aerobic fitness resulted in improved functional independence.22 ,38 Findings from a systematic review indicated that when older adults participated in exercise of sufficient intensity and frequency, the reduction in risk of functional limitation and disability was in the range of 30–50%.38

    Aerobic training alone or aerobic training combined with resistance training have been shown to result in improved physical function in older adults without disabilities. In some groups of people with chronic health conditions there are indications of positive effects of increased physical activity and exercise. A review by Vincent et al concluded that for obese older adults, participation in a programme of exercise that included aerobic and resistance exercises combined with dietary restriction did lead to improvements in functional mobility.39 However, in other groups of people, for example, older adults with disabilities from stroke, the translation of improvements in aerobic fitness and muscle strength into functional independence is unclear.40

    Older adults achieving the recommended levels of physical activity

    Many people fall short of achieving the recommended levels of physical activity and exercise. More than 60% of American adults over the age of 50 years failed to achieve the recommended activity levels.3 In England, 20% of men and 17% of women aged between 65 and 74 years achieved the recommended activity levels of 5 or more days of moderate-to-vigorous activity. From the age of 75 years onwards, 9% of men and 6% of women met the recommended guidelines.4 Very few older adults are currently meeting the recommended levels of physical activity and exercise.

    There are a large number of barriers to exercise participation identified. Interestingly, O'Neill and Reid reported that 87% of their older adult participants described at least one barrier to participation in exercise.41 The most common reasons given by older adults for not participating in physical activity was ill-health, pain and injury.42 ,43 One limitation of the research in physical activity and health is that many of the studies have used self-report measures of physical activity. There is some indication that self-report measures do not reliably reflect cardiovascular fitness35 ,44 and may not predict health outcomes as clearly as objectively measured cardiovascular fitness.

    The physical environment in which people live has been shown to influence physical activities, at least for children and younger adults.45 ,46 Access to parks and other recreational facilities, safe footpaths and areas relatively free from crime have been identified as important factors.42 An evaluation of free public transport for older adults in the UK revealed that those with free passes not only travelled more often but they were also more likely to walk further than those who did not receive free passes,47 although it is unknown as to whether sufficient walking was achieved for health benefit. There are promising indicators but it is not yet clear if the environment changes and transport policy changes will sufficiently influence physical activity in older adults.48

    Who should exercise?

    Health-related beneficial effects are observed in older people with no apparent health condition and in those with common non-communicable chronic health conditions such as hypertension, type 2 diabetes, cardiovascular disease and some cancers.6 ,49–51 In a sample of older adults with a mean age of 78 years, those who exercised more than 2 h per week had reduced mortality compared with less active individuals, even after adjusting the analysis for comorbidities and physical and cognitive impairment.52 It is clear that these groups of older adults should be encouraged to exercise at levels that meet most of the WHO guidelines.

    Less is known about frail older adults and those with disabilities. In America, around 38% of people over the age of 65 have a disability, and this figure rises with increasing age to around 74% for people over the age of 80 years.53 Yet the recommendations for physical activity and exercise for health benefit are limited for older adults with disabilities. A recent meta-analysis showed that increased physical activity not only delays the onset of functional limitation but it also slows down the progression of functional decline in older adults with and without disabilities.54

    These groups of the population have an increased challenge to regularly exercise at a level to promote improved health outcomes. Recent reviews and meta-analyses54–56 concluded that exercise had a small-to-moderate positive effect on mobility and physical functioning in frail and mobility-limited older adults, with higher intensity exercise being more effective than low intensity on the outcome of physical function. Although no clear guidance could be drawn from the meta-analysis about the best type of exercise,56–58 there was an indication that strength training interventions were important for functional improvement.57 The evidence for aerobic or strength training programmes leading to a reduction in mortality after a stroke is unclear.40 What is still unclear is the type of exercise and clarification about the intensity of exercise needed to maintain or improve functional levels in adults with disabilities and frail older adults.

    Can we increase exercise participation?

    The importance of the physician

    Older adults, particularly those with chronic health conditions, have relatively high rates of attendance at physician's offices; this puts the family physician in a strong position to give exercise-related advice. Older adults who received physical activity advice from their physician performed more moderate-to-vigorous intensity activity than those who did not receive advice.59 ,60 However, there is evidence to suggest that general practitioners (GPs) do not discuss physical activity with all relevant patients.60––62 In an American study of older adults, about 95% of participants had visited their GP in the last year, yet only about 62% reported receiving advice about physical activity.61

    There is some criticism of the advice given by healthcare providers regarding increasing physical activity levels; one important criticism was that general advice is given with no specifics on how the older adult should go about increasing their activity levels or what they should specifically do.42 Interestingly, in a study in which older adults were given specific advice about the type and frequency of exercise by the GP, with follow-up by exercise professionals, the proportion of intervention group participants achieving adequate levels of exercise increased from 0.14 to 0.31. Perhaps of more interest was the significantly lower rate of hospitalisation in the year following the intervention in the experimental group compared with the controls.59 Giving specific physical activity advice, a plan of action and some form of follow-up are important factors in facilitating the uptake and maintenance of exercise programmes in older adults; this has been demonstrated in physical activity programmes and in falls prevention programmes.26 ,63 ,64

    Behaviour change

    Self-efficacy, a person's belief in their ability to successfully perform a specific behaviour,65 is a concept that has been linked to exercise behaviour in older adults. Self-efficacy may be particularly important in the initial adoption of exercise programmes.42 There are an increasing number of behavioural approaches to maintaining participation in exercise and ongoing physical activity, yet to date there is no strong evidence supporting their use. A review considering adults with no identified cardiovascular disease risk factors concluded that the evidence supporting behavioural interventions is weak and should not be generally adopted without further supporting evidence.66

    Recent research has considered the use of financial incentives to improve adherence to health-related behaviours in an attempt to impact health outcomes.67 Finkelstein et al offered monetary rewards to older adults if they achieved certain levels of aerobic activity on an unsupervised and unstructured walking programme. The group that received financial incentives had significantly higher walking activity levels than their non-financially rewarded counterparts. Time spent walking at a level that would impact on aerobic fitness was 79% greater in those receiving the incentive. Those in the financial incentive group also walked more frequently and for longer durations. Around 7% of the control group in this study achieved activity levels that met public health recommendations, while 38% of the financial incentive group met the recommended physical activity levels. While the research in this area is new with many questions remaining unanswered as yet, further research may help to clarify the role of incentives in promoting physical activity and exercise participation.

    Cognitive benefits of physical activity

    In addition to positive physical effects of increasing physical activity there is a growing body of evidence indicating cognitive benefits. A Cochrane systematic review of the effect of aerobic exercise on cognition in people over the age of 55 years showed a positive effect, improving auditory attention and cognitive processing speed.68 Research findings about the association of exercise with cognitive impairment are suggestive of benefit, but not unequivocal. Paterson et al's38 review of the effects of exercise on cognition concluded that although the data look promising, information about the specific dose and type of exercise is as yet unknown and further research needs to be undertaken. There are some promising indications that moderate level exercise reduces the risk of developing cognitive impairment in older adults,69 ,70 and that for people with mild cognitive deficits, there may be a protective effect of exercise.70

    So, for many older adults, the benefits of exercise are substantial and are likely to improve health-related outcomes. One of the challenges for healthcare practitioners today is to help people to attain and maintain levels of physical activity that will be beneficial.

    Summary

    With the average population age increasing in industrialised countries, there is an increase in the proportion of older adults, many of whom are at risk for developing non-communicable chronic health conditions. Older adults are generally less physically active than younger adults. In the presence of strong evidence linking physical inactivity to chronic health conditions and increased physical activity to lower mortality and morbidity in older adults, it is imperative to develop a strong commitment to improving physical activity levels in older adults. Governments around the world have begun to produce national guidelines for physical activity and health for older adults. The main challenge is to find effective ways to support older adults to increase their physical activity and then to develop habitual physical activity behaviours. Individual health practitioners have an important role in discussing and making recommendations around physical activity. GPs should have sufficient understanding of physical activity prescription to make recommendations to patients about type, amount, intensity and frequency of physical activity for health gain. Inclusion of physiotherapists or exercise professionals for exercise prescription may prove to be a valuable addition to the General Practice team. The health problems relating to physical inactivity are unlikely to be completely solved by individual health practitioners, and significant steps by governments and policy makers have to be taken to create environments that encourage participation in lifelong physical activity.

    Resources for further information on physical activity in older adults

    http://www.exerciseismedicine.org this website provides further background information on the value of exercises and has freely available resources physicians can use in their practice.

    http://www.acsm.org this is the website of the ACSM and provides access to multiple resources on physical activity.

    http://www.cdc.gov/physicalactivity/growingstronger/index.html the Centers for Disease Control and Prevention provide an exercise programme online for patients to access. It contains information for patients about why to exercise and how to exercise, giving specific examples of muscle strengthening exercises.

    Main messages

    • Low levels of physical activity are associated with an increased risk of mortality in people over the age of 65 years.

    • Low levels of physical activity are associated with an increased risk of developing chronic health conditions in people over the age of 65 years.

    • International recommendations for physical activity and exercise in older adults consistently recommend moderate level aerobic exercise for 30 min per day for 5 days of the week, combined with 2 days of strength training.

    • There is some support for improvements in health for people with cognitive deficits who regularly achieve moderate levels of exercise.

    • There is some support for improvements in health for frail older people who regularly achieve moderate levels of exercise.

    • There is limited and conflicting evidence about the association of physical activity with mortality in people with stroke.

    • Physicians have a key role in encouraging people to take up exercise at levels that will promote health and longevity.

    • Physician-delivered physical activity recommendations are more effective when they provide specific recommendations and information about locally available exercise options.

    • There is promising preliminary research looking at behavioural approaches to encouraging the uptake and maintenance of exercise participation.

    Current research questions

    • What are the most effective methods to increase and then maintain physical activity and exercise participation in older adults?

    • What is the most effective approach to improving the health of older adults with mobility limitations?

    • How can societies prevent the decline in physical activity that occurs through middle and into older age and thus reduce the future health burden?

    Self assessment questions

    1. Undertaking 30 min more of light activity, such as light gardening or housework will result in significant health benefit in sedentary older adults. (True or False)

    2. Increasing cardiovascular fitness appears to be a key factor in improving health and reducing the risk of developing non-communicable chronic health conditions. (True or False)

    3. Statistics from the UK indicate that around 6% of women over the age of 75 years achieve recommended levels of exercise to meet national guidelines on physical activity. (True or False)

    4. Sedentary older adults who do not have any risk factors for non-communicable chronic diseases do not need to increase their physical activity levels. (True or False)

    5. Patients who receive local information about specific types of exercise and physical activities from their doctor are more likely to adhere to the advice than those who receive general advice to increase their activity levels. (True or False)

    Answers

    1. False—Evidence strongly suggests that the intensity of exercise has to be at least at a moderate level for around a total of 30 min per day. The person should notice slightly altered breathing, still able to hold a conversation, but panting slightly.

    2. True—There is a strong relationship between high levels of cardiovascular fitness and good health. Any activity or exercise that improves cardiovascular fitness may be beneficial. Older adults can improve their health by improving cardiovascular fitness; this imparts benefit even if starting from a low level of cardiovascular fitness.

    3. True—The challenge to health professionals is to find ways of motivating older adults to take up more physical activity and to maintain it over their lifetime.

    4. False—There is strong evidence indicating that older adults who are apparently healthy should engage in recommended levels of physical activity with positive benefits on mortality and morbidity.

    5. True—Evidence from a number of trials indicates that people who receive specific advice about exercise and/or increasing physical activity from their GP are more likely to increase their physical activity in comparison to those who receive either general physical activity advice, or no physical activity advice.

    Key references

    • U.S. Department of Health and Human Services. Physical activity guidelines for Americans. In: U.S. Department of Health and Human Services, Division of Nutrition, Physical Activity and Obesity. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, 2008.

    • World Health Organization. Global recommendations on physical activity for health. Geneva: World Health Organisation, 2010.

    • Paterson D, Warburton D. Physical activity and functional limitations in older adults: a systematic review related to Canada's physical activity guidelines. Int J Behav Nutr Phys Act 2010;7:38.

    • Kerse N, Elley CR, Robinson E, et al. Is physical activity counseling effective for older people? A cluster randomized, controlled trial in primary care. J Am Geriatr Soc 2005;53:1951–6.

    • Hinrichs T, Moschny A, Klaassen-Mielke R, et al. General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI). BMC Fam Pract 2011;12:26.

    References

    1. ↵
      World Health Organization. Diet and Physical Activity Factsheet. Secondary Diet and Physical Activity Factsheet. 2013. http://www.who.int/dietphysicalactivity/factsheet_inactivity/en/index.html
    2. ↵
      1. Bauman A,
      2. Craig C
      . The place of physical activity in the WHO Global Strategy on Diet and physical activity. Int J Behav Nutr Phys Act 2005;2:10.
      OpenUrlCrossRefPubMed
    3. ↵
      U.S. Department of Health and Human Services. Physical activity guidelines for Americans. In: U.S. Department of Health and Human Services, Division of Nutrition, Physical Activity and Obesity. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, 2008.
    4. ↵
      1. Townsend N,
      2. Bhatnagar P,
      3. Wickramasinghe K,
      4. et al
      . Physical activity statistics 2012. London: British Heart Foundation, 2012.
    5. ↵
      Ministry of Health. Guidelines on physical activity for older people (aged 65 years and over). Wellington: Ministry of Health, 2013.
    6. ↵
      1. Blair S,
      2. Sallis R,
      3. Hutber A,
      4. et al
      . Exercise therapy—the public health message. Scand J Med Sci Sports 2012;22:e24–8.
      OpenUrlCrossRefPubMed
    7. ↵
      1. Chodzko-Zajko WJ,
      2. Proctor D,
      3. Fiatarone Singh M,
      4. et al
      . American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc 2009;41:1510–30.
      OpenUrlCrossRefPubMedWeb of Science
    8. ↵
      1. Paterson D,
      2. Jones G,
      3. Rice C
      . Ageing and physical activity: evidence to develop exercise recommendations for older adults. Appl Physiol Nutr Metab 2007;32(Suppl 2E):S69–108.
      OpenUrlCrossRef
    9. ↵
      World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO, 2009.
    10. ↵
      World Health Organization. Global recommendations on physical activity for health. Geneva: World Health Organisation, 2010.
    11. ↵
      1. Sakuma K,
      2. Yamaguchi A
      . Sarcopenia and age-related endocrine function. Int J Endocrinol 2012;2012(Article ID 127362):10.
      OpenUrl
    12. ↵
      1. Salthouse TA
      . Memory aging from 18 to 80. Alzheimer Dis Assoc Disord 2003;17:162–7.
      OpenUrlCrossRefPubMedWeb of Science
    13. ↵
      1. Lau RS,
      2. Ohinmaa A,
      3. Johnson JA
      . Predicting the future burden of diabetes in Alberta from 2008 to 2035. Can J Diabetes 2011;35:274–81.
      OpenUrlCrossRefWeb of Science
    14. ↵
      1. Caspersen C,
      2. Powell K,
      3. Christenson G
      . Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100:126–31.
      OpenUrlPubMedWeb of Science
    15. ↵
      1. Ainsworth BE,
      2. Haskell WL,
      3. Herrmann SD,
      4. et al
      . 2011 Compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exerc 2011;43:1575–81.
      OpenUrlCrossRefPubMedWeb of Science
    16. ↵
      1. Knaggs JD,
      2. Larkin KA,
      3. Manini TM
      . Metabolic cost of daily activities and effect of mobility impairment in older adults. J Am Geriatr Soc 2011;59:2118–23.
      OpenUrlCrossRefPubMed
    17. ↵
      1. Mudge S,
      2. Taylor D,
      3. Chang O,
      4. et al
      . Test-retest reliability of the StepWatch activity monitor outputs in healthy adults. J Phys Act Health 2010;7:671–6.
      OpenUrlPubMed
    18. ↵
      1. Tudor-Locke C,
      2. Hart TL,
      3. Washington TL
      . Expected values for pedometer-determined physical activity in older populations. Int J Behav Nutr Phys Act 2009;6:59.
      OpenUrlCrossRefPubMed
    19. ↵
      1. Cavanaugh JT,
      2. Kochi N,
      3. Stergiou N
      . Nonlinear analysis of ambulatory activity patterns in community-dwelling older adults. J Gerontol A Biol Sci Med Sci 2010;65:197–203.
      OpenUrlPubMedWeb of Science
    20. ↵
      1. Cavanaugh JT,
      2. Coleman KL,
      3. Gaines JM,
      4. et al
      . Using step activity monitoring to characterize ambulatory activity in community-dwelling older adults. J Am Geriatr Soc 2007;55:120–4.
      OpenUrlCrossRefPubMedWeb of Science
    21. ↵
      1. Latham N,
      2. Liu CJ
      . Strength training in older adults: the benefits for osteoarthritis. Clin Geriatr Med 2010;26:445–59.
      OpenUrlCrossRefPubMed
    22. ↵
      1. Liu C,
      2. Latham N
      . Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009;(3):CD002759.
    23. ↵
      1. Sherrington C,
      2. Whitney JC,
      3. Lord SR,
      4. et al
      . Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 2008;56:2234–43.
      OpenUrlCrossRefPubMedWeb of Science
    24. ↵
      1. Gillespie LD,
      2. Robertson MC,
      3. Gillespie WJ,
      4. et al
      . Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146.
    25. ↵
      1. Taylor D,
      2. Hale L,
      3. Schluter P,
      4. et al
      . Effectiveness of Tai Chi as a community-based falls prevention intervention: a randomized controlled trial. J Am Geriatr Soc 2012;60:841–8.
      OpenUrlCrossRefPubMed
    26. ↵
      1. Campbell AJ,
      2. Robertson MC,
      3. Gardner MM,
      4. et al
      . Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065–9.
      OpenUrlAbstract/FREE Full Text
    27. ↵
      1. Tremblay M,
      2. Esliger D,
      3. Tremblay A,
      4. et al
      . Incidental movement, lifestyle-embedded activity and sleep: new frontiers in physical activity assessment. Can J Public Health 2007;98(Suppl 2):S208–17.
      OpenUrlPubMed
    28. ↵
      1. Ross R,
      2. McGuire KA
      . Incidental physical activity is positively associated with cardiorespiratory fitness. Med Sci Sports Exerc 2011;43:2189–94.
      OpenUrlCrossRefPubMedWeb of Science
    29. ↵
      1. McGuire KA,
      2. Ross R
      . Incidental physical activity and sedentary behavior are not associated with abdominal adipose tissue in inactive adults. Obesity 2012;20:576–82.
      OpenUrlCrossRefPubMedWeb of Science
    30. ↵
      1. Ueshima K,
      2. Ishikawa-Takata K,
      3. Yorifuji T,
      4. et al
      . Physical activity and mortality risk in the Japanese elderly. A cohort study. Am J Prev Med 2010;38:410–18.
      OpenUrlCrossRefPubMedWeb of Science
    31. ↵
      1. Pinto A,
      2. Di Raimondo D,
      3. Tuttolomondo A,
      4. et al
      . Effects of physical exercise on inflammatory markers of atherosclerosis. Curr Pharm Des 2012;18:4326–49.
      OpenUrlCrossRefPubMed
    32. ↵
      1. Iijima K,
      2. Iimuro S,
      3. Shinozaki T,
      4. et al
      . Lower physical activity is a strong predictor of cardiovascular events in elderly patients with type2 diabetes mellitus beyond traditional risk factors: the Japanese elderly diabetes intervention trial. Geriatr Gerontol Int 2012;12(Suppl 1):77–87.
      OpenUrlCrossRefPubMed
    33. ↵
      1. Oguma Y,
      2. Shinoda-Tagawa T
      . Physical activity decreases cardiovascular disease risk in women: review and meta-analysis. Am J Prev Med 2004;26:407–18.
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      1. Gregg EW,
      2. Cauley J,
      3. Stone K,
      4. et al
      . Relationship of changes in physical activity and mortality among older women. JAMA 2003;289:2379–86.
      OpenUrlCrossRefPubMedWeb of Science
    35. ↵
      1. Lee DC,
      2. Sui X,
      3. Ortega FB,
      4. et al
      . Comparisons of leisure-time physical activity and cardiorespiratory fitness as predictors of all-cause mortality in men and women. Br J Sports Med 2011;45:504–10.
      OpenUrlAbstract/FREE Full Text
    36. ↵
      1. Schultz A
      . Muscle function and mobility biomechanics in the elderly: an overview of some recent research. J Gerontol Biol Sci Med Sci A 1995;50:60–3.
      OpenUrl
    37. ↵
      1. Jackson AS,
      2. Sui X,
      3. Hebert JR,
      4. et al
      . Role of lifestyle and aging on the longitudinal change in cardiorespiratory fitness. Arch Intern Med 2009;169:1781–7.
      OpenUrlCrossRefPubMedWeb of Science
    38. ↵
      1. Paterson D,
      2. Warburton D
      . Physical activity and functional limitations in older adults: a systematic review related to Canada's physical activity guidelines. Int J Behav Nutr Phys Act 2010;7:38.
      OpenUrlCrossRefPubMed
    39. ↵
      1. Vincent HK,
      2. Raiser SN,
      3. Vincent KR
      . The aging musculoskeletal system and obesity-related considerations with exercise. Ageing Res Rev 2012;11:361–73.
      OpenUrlCrossRefPubMedWeb of Science
    40. ↵
      1. Brazzelli M,
      2. Saunders DH,
      3. Greig CA,
      4. et al
      . Physical fitness training for stroke patients. Cochrane Database Syst Rev 2011;(11):CD003316.
    41. ↵
      1. O'Neill K,
      2. Reid G
      . Perceived barriers to physical activity by older adults. Can J Public Health 1991;82:392–6.
      OpenUrlPubMedWeb of Science
    42. ↵
      1. Schutzer KA,
      2. Graves BS
      . Barriers and motivations to exercise in older adults. Prev Med 2004;39:1056–61.
      OpenUrlCrossRefPubMedWeb of Science
    43. ↵
      1. Booth ML,
      2. Owen N,
      3. Bauman A,
      4. et al
      . Social-cognitive and perceived environment influences associated with physical activity in older Australians. Prev Med 2000;31:15–22.
      OpenUrlCrossRefPubMedWeb of Science
    44. ↵
      1. Hein H,
      2. Suadicani P,
      3. Gyntelberg F
      . Physical fitness or physical activity as a predictor of ischaemic heart disease? A 17-year follow-up in the Copenhagen Male Study. J Intern Med 1992;232:471–9.
      OpenUrlCrossRefPubMedWeb of Science
    45. ↵
      1. Petrella RJ,
      2. Kennedy E,
      3. Overend TJ
      . Geographic determinants of healthy lifestyle change in a community-based exercise prescription delivered in family practice. Environ Health Insights 2008;1:51–62.
      OpenUrlPubMed
    46. ↵
      1. Pearce JR,
      2. Maddison R
      . Do enhancements to the urban built environment improve physical activity levels among socially disadvantaged populations? Int J Equity Health 2011;10:28.
      OpenUrlCrossRefPubMed
    47. ↵
      1. Coronini-Cronberg S,
      2. Millett C,
      3. Laverty A,
      4. et al
      . The impact of a free older persons’ bus pass on active travel and regular walking in England. Am J Public Health 2012;102:2141–8.
      OpenUrlCrossRefPubMedWeb of Science
    48. ↵
      1. Van Cauwenberg J,
      2. De Bourdeaudhuij I,
      3. De Meester F,
      4. et al
      . Relationship between the physical environment and physical activity in older adults: a systematic review. Health Place 2011;17:458–69.
      OpenUrlCrossRefPubMedWeb of Science
    49. ↵
      1. Kokkinos P
      . Physical activity, health benefits, and mortality risk. ISRN Cardiol 2012;2012:718789.
      OpenUrlPubMed
    50. ↵
      1. Blair S,
      2. Wei M
      . Sedentary habits, health, and function in older women and men. Am J Health Promot 2000;15:1–8.
      OpenUrlCrossRefPubMedWeb of Science
    51. ↵
      1. Myers J,
      2. Prakash M,
      3. Froelicher V,
      4. et al
      . Exercise capacity and mortality among men referred for exercise testing. NEJM 2002;346:793–801.
      OpenUrlCrossRefPubMedWeb of Science
    52. ↵
      1. Landi F,
      2. Cesari M,
      3. Onder G,
      4. et al
      . Physical activity and mortality in frail, community-living elderly patients. J Gerontol A Biol Sci Med Sci 2004;59A:833–7.
      OpenUrlCrossRefPubMedWeb of Science
    53. ↵
      Centres for Disease Control and Prevention. Disability and Health Data. Secondary Disability and Health Data. 2013. http://www.cdc.gov/ncbddd/disabilityandhealth/data.html
    54. ↵
      1. Tak E,
      2. Kuiper R,
      3. Chorus A,
      4. et al
      . Prevention of onset and progression of basic ADL disability by physical activity in community dwelling older adults: a meta-analysis. Ageing Res Rev 2013;12:329–38.
      OpenUrlCrossRefPubMedWeb of Science
    55. ↵
      1. Knight JA
      . Physical inactivity: associated diseases and disorders. Ann Clin Lab Sci 2012;42:320–37.
      OpenUrlAbstract/FREE Full Text
    56. ↵
      1. Chou CH,
      2. Hwang CL,
      3. Wu YT
      . Effect of exercise on physical function, daily living activities, and quality of life in the frail older adults: a meta-analysis. Arch Phys Med Rehabil 2012;93:237–44.
      OpenUrlCrossRefPubMed
    57. ↵
      1. de Vries NM,
      2. van Ravensberg CD,
      3. Hobbelen JS,
      4. et al
      . Effects of physical exercise therapy on mobility, physical functioning, physical activity and quality of life in community-dwelling older adults with impaired mobility, physical disability and/or multi-morbidity: a meta-analysis. Ageing Res Rev 2012;11:136–49.
      OpenUrlCrossRefPubMedWeb of Science
    58. ↵
      1. Theou O,
      2. Stathokostas L,
      3. Roland KP,
      4. et al
      . The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res 2011;2011:569194.
      OpenUrlPubMed
    59. ↵
      1. Kerse N,
      2. Elley CR,
      3. Robinson E,
      4. et al
      . Is physical activity counseling effective for older people? A cluster randomized, controlled trial in primary care. J Am Geriatr Soc 2005;53:1951–6.
      OpenUrlCrossRefPubMedWeb of Science
    60. ↵
      1. Noordman J,
      2. Verhaak P,
      3. van Dulmen S
      . Discussing patient's lifestyle choices in the consulting room: analysis of GP-patient consultations between 1975 and 2008. BMC Fam Pract 2010;11:87.
      OpenUrlCrossRefPubMed
    61. ↵
      1. Balde A,
      2. Figueras J,
      3. Hawking D,
      4. et al
      . Physician advice to the elderly about physical activity. J Aging Phys Act 2003;11:90–7.
      OpenUrl
    62. ↵
      1. Hinrichs T,
      2. Moschny A,
      3. Klaassen-Mielke R,
      4. et al
      . General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI). BMC Fam Pract 2011;12:26.
      OpenUrlCrossRefPubMed
    63. ↵
      1. Hinrichs T,
      2. Brach M
      . The general practitioner's role in promoting physical activity to older adults: a review based on program theory. Current Aging Science 2012;5:41–50.
      OpenUrlPubMed
    64. ↵
      1. Armit CM,
      2. Brown WJ,
      3. Marshall AL,
      4. et al
      . Randomized trial of three strategies to promote physical activity in general practice. Prev Med 2009;48:156–63.
      OpenUrlCrossRefPubMedWeb of Science
    65. ↵
      1. Bandura A
      . Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191–215.
      OpenUrlCrossRefPubMedWeb of Science
    66. ↵
      1. Moyer VA
      . Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157:367–72.
      OpenUrlPubMedWeb of Science
    67. ↵
      1. Finkelstein EA,
      2. Brown DS,
      3. Brown DR,
      4. et al
      . A randomized study of financial incentives to increase physical activity among sedentary older adults. Prev Med 2008;47:182–7.
      OpenUrlCrossRefPubMed
    68. ↵
      1. Angevaren M,
      2. Aufdemkampe G,
      3. Verhaar H,
      4. et al
      . Physical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment. Cochrane Database of Sys Rev 2008;(3):CD005381.
    69. ↵
      1. Geda YE,
      2. Roberts RO,
      3. Knopman DS,
      4. et al
      . Physical exercise, aging, and mild cognitive impairment a population-based study. Arch Neurol 2010;67:80–6.
      OpenUrlCrossRefPubMedWeb of Science
    70. ↵
      1. Smith PJ,
      2. Blumenthal JA,
      3. Hoffman BM,
      4. et al
      . Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med 2010;72:239–52.
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • Competing interests None.

    • Provenance and peer review Commissioned; externally peer reviewed.