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Overcoming Exercise Barriers in Older Adults

James Dunlap, MD; Henry C. Barry, MD, MS

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 11 - OCTOBER 15, 1999


In Brief: Barriers to exercise among older adults include personal factors such as discomfort, fear of injury, and social isolation, plus environmental difficulties such as lack of access and unfavorable weather. When selecting tactics to overcome the barriers, it is helpful to consider the patient's position within the six stages of behavior change. Key measures include controlling pain, treating chronic conditions, explaining the benefits of exercise, dispelling misconceptions, identifying personal goals that exercise can help the patient attain, setting realistic exercise goals, and following up.

The benefits of exercise are well documented, but while the number of adults of age 40 or older who participate in regular physical activity has increased, most adults have remained sedentary. Jones et al (1) note that in the 1990 National Health Interview Survey, about 17,000 women and 12,000 men were queried about their leisure activities. Only one third of those surveyed reported participating in moderate activity. In 1995, the US Centers for Disease Control and Prevention (CDC) published a consensus recommendation that all adults should accumulate at least 30 minutes of moderate physical activity most days (2). Despite widespread dissemination in the media, the evidence of exercise's many benefits has not helped a majority of older (or younger) Americans to reach this goal. Accordingly, physicians should examine barriers to exercise and seek ways to overcome them.

Dishman and colleagues (3,4) have classified determinants of exercise participation into three broad categories: personal, environmental, and exercise-specific. The personal and environmental barriers are most relevant for this discussion.

Personal Barriers

The barriers to regular physical activity vary with age among adults. In an Australian survey, the main barriers among adults 60 to 78 years old were injury and poor health, while among adults 18 to 39 years old, they were child care responsibilities, lack of time, and lack of motivation (5). The barriers are essentially the same for those 40 to 59 years old, but these patients begin to have chronic diseases and injuries. Other common barriers include discomfort, fear of injury, and misconceptions about exercise.

Temperament. Attitudes reflect, among other things, people's self-esteem, overall outlook, and health beliefs. The best predictors of intention to exercise are different for men and women. In women, participation is best predicted by attitude toward exercise, perceived control over their lives in general (voluntary vs involuntary action), their assessment of the benefits of exercise, and self-efficacy (the self-confidence to initiate exercise) (6). In men, attitude toward exercise is the only predictor.

The popular media influence attitudes as well; they depict slender young individuals exercising and seldom portray older people doing so. Such depictions reinforce the perception that older people do not belong in aerobics or swim classes.

Time. People are busy. Because couples are having children at later ages, child-rearing may act as a barrier for patients well into their 50s. The daily routine of arising early, preparing children for school or day care, commuting to work, working, and then returning home does not leave much time for traditional exercise. Often, parents fulfill their family's requirements at the expense of their own. Others simply place work goals ahead of regular physical activity. Retirees may have more discretionary time, but they frequently are busy caring for grandchildren and doing volunteer work.

Discomfort. Many surveys have revealed that the most common barriers to exercise are physical ailments, rapid fatigability, and fear of injury. In a Canadian survey of 199 people, at least 50% listed these as barriers (7). Within groups whose physical ailments (such as low-back injuries, knee joint degeneration, or restrictive and obstructive lung or heart disease) limit physical activity, pain is a common reason for remaining inactive. In addition, many sedentary adults tire easily. This is particularly true for overweight individuals.

Fear of injury. Fear of injury is an understandable impediment to exercise for many older people. Patients with diabetes and peripheral neuropathy may be afraid of exacerbating foot pain, inducing fractures, or triggering hypoglycemia. Patients may fear falling and breaking a hip; they may tell of friends who started a new activity, were injured, and incurred a lasting disability.

Inertia. Clinicians often hear sedentary patients say about exercise, "I don't know how/I don't like it/I get bored/I'm too busy." Inertia has many possible causes, but the most likely one is a lifetime of little exertion. For older people, as noted, the perception that exercise is not socially acceptable may restrict the opportunity for group activity. Most adults who have never exercised will never start even if counseled.

Isolation. Many adults do not want to exercise alone, and program compliance without social support is poor. Motivating older patients to exercise can be particularly difficult because they may have lost a spouse or have a spouse whose disability limits exercise options. Divorce or the demands of work can also impede exercise participation. And having a family member does not guarantee access to a partner: When families do not have time to dine together, they tend not to have time to play together.

Misconceptions. Patients may have a limited concept of what exercise is—they may feel that jogging is the only exercise or that all forms of exercise are repetitive and therefore boring. Many blue-collar workers may mistakenly feel that their jobs provide enough exercise. A colleague quotes her mother's admonition, "Animals sweat, men perspire, women do neither." Many women who grew up receiving such advice in the 1930s to 1950s lack the knowledge or skills to engage in regular physical activity.

Environmental Barriers

Environmental (external) barriers are quite common and may be among the most seductive reasons for nonparticipation. Individuals cannot control environmental barriers but can use them to rationalize not exercising.

Physician advice. Physicians may unwittingly impede lifestyle changes. A survey (8) by the CDC revealed that physicians inquired about diet and exercise less than one third of the time; patients may thus get the impression that exercise is unimportant.

In addition, busy practices, in which providers see more patients in a given time, may allow little time for counseling, an activity that is often uncompensated. Finally, lack of follow-up to monitor progress and attainment of goals reinforces the notion that exercise is unimportant.

Access. Access and cost are common barriers. Health clubs are too expensive for many people. Some patients live in dangerous neighborhoods, while others lack community recreational resources or transportation to get to an area where they can exercise. Although most studies that show access, transportation, and cost as significant barriers were conducted among minority groups (9-11), these problems are probably common in all older populations.

Climate. In northern climates, inclement weather and unsafe outdoor conditions due to ice and snow may cause many individuals, especially the elderly, to go without regular physical activity for 6 months. For those living in warmer regions, extremes of heat and humidity are obstacles to activity.

Stages of Exercise Adoption

Many of the barriers are not easily addressed. The act of starting an exercise program (or of changing any high-risk behavior) has been described as a series of stages: precontemplation, contemplation, preparation, action, maintenance, and termination (12). In the precontemplative stage, the patient has no interest in starting to exercise. In the contemplative stage, the patient is thinking about starting, but has made no plans. The preparation stage involves planning to exercise; the action stage, starting a program; and the maintenance stage, continuing it. Unfortunately, many exercisers drop out, entering the undesired termination stage, in which they can either remain mired (precontemplative) or cycle again through the stages.

Success is more often achieved when patients move from one stage to the next rather than jumping right into an exercise program. The healthcare provider's goal should be to move patients through the stages to the maintenance stage. To facilitate this, strategies should match the patient's stage of change (table 1). Prochaska (12) has shown that stage-matched programs for cardiovascular disease prevention can achieve participation rates as great as 85%, compared with 1% to 5% for traditional programs.


TABLE 1. Stages of Exercise Initiation and Matched Strategies

Stage of Change Strategies

Precontemplation Elicit reasons and barriers.

Provide simple educational information.

Open ending (talk about a program when the patient is ready).


Contemplation Motivate (describe benefits, specific goals, use family involvement, etc).

Elicit commitment.


Preparation Identify goals.

Start plans (date, equipment, etc).

Follow up.


Action Review goals.

Suggest coping strategies (eg, for fatigue, discomfort).

Follow up.


Maintenance Review coping strategies.

Reassess goals.

Advise on injury prevention.


Office-based nurses can implement strategies to increase exercise participation using Prochaska's method, but this has not been effective in long-term studies (13). Although preparedness-based strategies may be helpful for motivating sedentary adults (14,15), Bull et al (16) did not find the methods useful. Thus, interventions using this method will require additional study.

In spite of these findings, others have found that simple advice from the physician is effective (17). Simple inquiries about diet and exercise produced patient changes in physical activity and dietary modifications that approached 75% (18). Since these approaches seemingly conflict, try simple advice first. If that is unsuccessful, use a stage-matched approach.

Most interventions to increase physical activity have been delivered by personal contact in small groups, a mode that limits utility as a public health method. Some interventions, however, can be delivered by mail and telephone and may be more generally applicable (19).

Overcoming barriers

Personal. The first step in alleviating fear of discomfort is to provide options for its prevention or relief. Patients with chronic pain can move more freely if it is adequately managed. Thus, once pain control is achieved, cardiopulmonary and musculoskeletal rehabilitation, either in a supervised setting or at home, can begin. Patients with other chronic conditions (eg, diabetes, hypertension, asthma, arthritis) that are poorly controlled may benefit from multidisciplinary approaches, depending on their individual goals. Although the presence of an unstable medical condition is a contraindication to maximal exertion, submaximal exertion and flexibility training may help to improve control of symptoms and facilitate the initiation of low-level activity.

Motivation can be a significant barrier to initiating exercise among the elderly, even after treatment of comorbid conditions like anemia, diabetes, depression, or dementia. While educating patients about the general benefits of exercise is an important starting point for motivating them, it is often insufficient. A more useful beginning may be identifying unmet personal goals that can then aid in developing appropriate recommendations. For instance, the patient who wants to be able to play on the floor with grandchildren will need flexibility and strength as well as some aerobic capacity. This goal is very different from that of a severely impaired patient who merely wishes to be fit enough to use the toilet unassisted.

While group activity is a common strategy to motivate the elderly to begin exercising, group participation does not necessarily increase long-term exercise frequency among sedentary elderly women (20). However, their expectation of health benefits is an important motivating factor, and this underscores the importance of explaining the health benefits when counseling elderly women.

The risk of injury with low-level exertion is small, and explaining the benefits of exercise—improved function and increased mobility—may offset fear of injury. Once those with fears and physical ailments have been given permission to exercise and information on maximizing existing health, specific program suggestions and follow-up plans can be made. For all patients, injury risk can be minimized by beginning with programs that emphasize balance and flexibility, followed by ones that increase endurance and strength. Patients do get injured, but overuse and inadequate warm-ups are the most frequent cause.

As for misconceptions about exercise, Project PACE (Patient-centered Assessment and Counseling for Exercise and Nutrition) (21) was designed to provide physicians with tools to assess and counsel sedentary patients and dispel mistaken notions. Selected Project PACE strategies, summarized in table 2 (not shown) (22, 23), can be used to overcome misconceptions about exercise.

Although walking may be the easiest exercise to prescribe, patients should also know that exercise can also take the form of raking leaves, gardening, shoveling snow, vacuuming, and doing many other household chores. (For more on the "lifestyle activity" approach, see Oct 1, 1999, page 41.) In addition, patients should be taught that exercise benefits can also accrue with short bouts that are not exhausting, fit into any schedule, and pose few risks of injury. For example, three 10-minute walks in a day are about as beneficial as one 30-minute walk.

For additional practical tips on motivating patients to exercise, see the sidebar "Exercise Counseling Guidelines," below.

Environmental. Cole et al (24) evaluated a program to promote regular, moderate physical activity among employees working in a federal agency. The objective was to assess the short-term effects of the intervention by examining the stages people pass attempting to make permanent changes in physical activity. Of the 1,192 participants, 35.4% progressed one (21.1%) or more (14.3%) stages during the 50-day intervention. These findings support the notion that the stages-of-change model can serve as an indicator of the change process and also show that this program holds promise for increasing physical activity in a worksite population (24). Interventions that involve modifying the environment, such as posting signs to encourage use of stairs, also have been effective over the short term (16). For elderly patients, other helpful modifications include improved lighting, wheelchair access, use of indoor malls (they are frequently open early), senior citizen centers, and television programs that have specific exercise routines.

Counseling the Frail Elderly

A multidisciplinary approach is crucial for the frail elderly. Physical therapists can assist in developing specific therapies to accommodate or rehabilitate defined impairments. Pharmacists can identify medications or medication interactions that can hinder exercise participation. Finally, family and friends can serve as an important source of motivation. They often know what tactics to use and can be very effective in using guilt (or other strategies) as a motivator! Recent guidelines for the frail elderly from the American College of Sports Medicine (see reprint, page 115) suggest these patients should improve their strength, balance, and joint stability before starting aerobic exercise.

Long-Term Compliance

Once patients have begun an exercise program, long-term compliance is, of course, the desired goal. Franklin (25) identified key characteristics that have been associated with long-term compliance (table 3). Awareness of these factors may help in your approach to providing exercise advice.


TABLE 3. Exercise-Program Characteristics Associated With Long-Term Compliance


Low probability of injury (low impact, low-to-moderate intensity, shorter duration)

Group participation

Emphasis on variety and fun (games used as a proxy for exercise)

Use of personal goals and contracts

Assessment of training response

Support network (friends, family, spouse)

Monitoring of progress

Use of music

Positive feedback

Enthusiastic leadership and role models


References

  1. Jones DA, Ainsworth BE, Croft JB, et al: Moderate leisure-time physical activity: who is meeting the public health recommendations? A national cross-sectional study. Arch Fam Med 1998;7(3):285-289
  2. Pate RR, Pratt M, Blair SN, et al: Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-407
  3. Dishman RK, Sallis JF, Orenstein DR: The determinants of physical activity and exercise. Public Health Rep 1985;100(2):158-171
  4. Dishman RK, Sallis JF: Determinants for physical activity and exercise, in Bouchard C, Shephard RJ, Stephens T (eds): Physical Activity, Fitness and Health: International Proceedings and Consensus Statement. Champaign, IL, Human Kinetics, 1994, pp 214-238
  5. Booth ML, Bauman A, Owen N, et al: Physical activity preferences, preferred sources of assistance, and perceived barriers to increased activity among physically inactive Australians. Prev Med 1997;26(1):131-137
  6. Biddle S, Goudas M, Page A: Social-psychological predictors of self-reported actual and intended physical activity in a university workforce sample. Br J Sports Med 1994;28(3):160-163
  7. O'Neill K, Reid G: Perceived barriers to physical activity by older adults. Can J Public Health 1991;82(6):392-396
  8. Missed opportunities in preventive counseling for cardiovascular disease: United States: 1995. MMWR 1998;47(5):91-95
  9. Jones M, Nies MA: The relationship of perceived benefits of and barriers to reported exercise in older African American women. Public Health Nurs 1996;13(2):151-158
  10. Clark DO: Racial and educational differences in physical activity among older adults. Gerontologist 1995;35(4):472-480
  11. Macera CA, Croft JB, Brown DR, et al: Predictors of adopting leisure-time physical activity among a biracial community cohort. Am J Epidemiol 1995;142(6):629-635
  12. Prochaska JO: Why do we behave the way we do? Can J Cardiol 1995;11(suppl A):20A-25A.
  13. Sims J, Smith F, Duffy A, et al: Can practice nurses increase physical activity in the over 65s? Methodological considerations from a pilot study. Br J Gen Pract 1998;48(430):1249-1250
  14. Laforge RG, Rossi JS, Prochaska JO, et al: Stage of regular exercise and health-related quality of life. Prev Med 1999;28(4):349-360
  15. Marcus BH, Bock BC, Pinto BM, et al: Efficacy of an individualized, motivationally-tailored physical activity intervention. Ann Behav Med 1998;20(3):174-180
  16. Bull FC, Jamrozik K, Blanksby BA: Tailored advice on exercise: does it make a difference? Am J Prev Med 1999;16(3):230-239
  17. Lewis BS, Lynch WD: The effect of physician advice on exercise behavior. Prev Med 1993;22(1):110-121
  18. Harris SS, Casperson CJ, DeFriese GH, et al: Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting: report for the US Preventive Services Task Force. JAMA 1989;261(24):3588-3598.
  19. Dunn AL, Andersen RE, Jakicic JM: Lifestyle physical activity interventions: history, short- and long-term effects, and recommendations. Am J Prev Med 1998;15(4):398-412
  20. Caserta MS, Gillett PA: Older women's feelings about exercise and their adherence to an aerobic regimen over time. Gerontologist 1998;38(5):602-609
  21. Long BJ, Calfas KJ, Wooten W, et al: A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med 1996;12(2):73-81
  22. Calfas KJ, Long BJ, Sallis JF, et al: A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med 1996;25(3):225-233
  23. Physician-based assessment and counseling for exercise, in Long B, Calfas KJ, Wooten W, et al: Physician Manual, Atlanta, Centers for Disease Control and Prevention, Cardiovascular Branch, 1992, pp 32-46
  24. Cole G, Leonard B, Hammond S, et al: Using "stages of behavioral change" constructs to measure the short-term effects of a worksite-based intervention to increase moderate physical activity. Psychol Rep 1998;82(2):615-618
  25. Franklin B: Program factors that influence exercise adherence: Practical adherence skills for the clinical staff, in Dishman R (ed): Exercise Adherence: Its Impact on Public Health. Champaign, IL, Human Kinetics, 1988, pp 237-258


Exercise Counseling Guidelines

The US Preventive Services Task Force has developed some simple, practical suggestions for counseling that are readily adaptable for sedentary patients (1).

1. Frame the teaching to match the patient's perceptions. Inquire about the patient's beliefs and concerns, including the patient's concept of exercise.

2. Help the patient set goals. Help the patient identify long-term goals, and then develop intermediate, more easily attainable goals. Some patients may want to run in a marathon; the elderly may wish to gain independence (eg, be able to get out of chairs and beds and to go to the toilet unassisted). By identifying goals, healthcare providers can help design a goal-congruent exercise program.

3. Fully inform patients of the expected benefits and the time to achieve them. Telling patients when they may expect observable results may prevent discouragement when immediate results are not seen. Remind them of their intermediate goals, rather than focusing on long-term goals. Patients should be told about common pitfalls in beginning an exercise program, ways to avoid problems, and simple remedies. In addition, patients should be informed of the symptoms of exercise intolerance.

4. Suggest small changes rather than large ones. Ask patients to do progressively more: "It is great that you are walking 10 minutes in the morning; could you add an additional 5 minutes?" This reinforces patients' ability to achieve goals.

5. Provide specific, informative instructions. For example, ask patients how much they are comfortable doing now, then ask them to do this activity more often (eg, three times a week) and for a longer time (by 10% to 25% per week) until the patient is doing 20 to 30 minutes of any aerobic exercise, three to four times a week. Behavioral change is enhanced if the regimen and its rationale are explained, demonstrated to the patient if appropriate, and given in written form.

6. Keep in mind that adding new behaviors is sometimes easier than eliminating established behaviors. For instance, if weight loss is a concern, suggesting that the patient begin moderate physical activity may be more effective than suggesting a change of diet.

7. Link new behaviors to old behaviors. For example, suggest to patients that they exercise before eating lunch or use an exercise bike while watching the news.

8. Use the power of the profession. Patients view clinicians as health experts and regard what they say as important. Don't be afraid to use direct messages such as "I want you to start an exercise program." Simple and specific messages are particularly powerful.

9. Get explicit commitments. Clinicians should ask patients to describe what they plan to achieve this week (ie, what, when, and how often). The more specific the commitment, the more likely it is to be honored. After getting commitments, ask patients how sure they are that they will execute them. Those who express more assurance are more likely to meet the commitment.

10. Use a combination of strategies. Programs can be tailored to individual needs. Written materials strengthen the message and may be personalized by jotting pertinent comments in the margins. Printed materials, however, cannot substitute for oral communication with patients.

REFERENCE

1. US Preventive Services Task Force: Guide to Clinical Preventive Services, ed 2. Baltimore, Williams & Wilkins, 1996


Dr Dunlap is assistant professor of family practice medicine at Michigan State University in East Lansing. Dr Barry is senior associate chair and associate professor of family practice medicine at Michigan State University. Address correspondence to Henry C. Barry, MD, MS, Dept of Family Practice, B-100 Clinical Center, Michigan State University, East Lansing, MI 48824-1315.


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