The importance of exercise for mental and physical health and wellbeing is well documented. Implementing this in practice, however, can be a struggle for many, especially older adults, who may not be well informed about how to do so safely. There are many reasons why older adults avoid exercise, such as cognitive decline and general frailty; a lack of knowledge as to what exercise is best and how to exercise safely while minimising falls risk; fear of falls among those who live alone; and depression and other mental illness, which may affect the person's motivation to get up and moving.
Nurses and other healthcare staff can play a key role in encouraging and motivating older adults to exercise, if they know what advice to give, what approach to adopt to get the best outcomes and what interventions to encourage.
Role of motivation in older adult exercise intervention
Booth et al (2019) systematically reviewed the literature on the use of motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment and looked at how and why interventions reduced falls. Rather than use the traditional method for evaluating data in a systematic review, which focuses on outcomes, they used the relatively new realist approach. In this method, inclusion criteria are more flexible and information from a range of sources is used to develop a ‘programme theory’.
Motivation emerged as a key element, and the researchers prioritised this for further study (Booth et al, 2019). They found that older individuals used various measures to increase their participation in exercise when they believed that it would be beneficial to them, but a lack of access to support decreased adherence to, and participation, in exercise regimens. Elements that increased motivation included interventions that were made up of multiple components, held in a preferred setting and at the right intensity and level of progression, while being flexibly delivered in a correctly supported way (Booth et al, 2019).
Booth et al (2019) concluded that motivation plays a key role in enabling the participation of those with cognitive impairment, in exercise-based interventions. They found that there many parallels between the motivators identified in the review and motivational theory (Booth et al, 2019).
‘Perceived benefit’ and ‘support’ as two key mechanisms in motivation
Booth et al (2019) identified two key mechanisms involved in motivation: ‘perceived benefit’ and ‘support’. Both influenced the extent to which an older adult with mild to moderate cognitive impairment was likely to be motivated to take part in an exercised-based intervention. They concluded that if the person believed that exercise would benefit them, they were more likely to use supportive mechanisms, such as access to a ‘gatekeeper’—for example a carer or therapist—to complete an exercise programme. The gatekeeper could then promote the perception of exercise as beneficial, thus further enabling the person with dementia to access and participate in exercise programmes.
Exercise is identified as important in falls prevention programmes. Booth et al (2019) explained that older adults with mild to moderate dementia are particularly prone to falls, and that interventions, such as exercise, should be considered a resource that can help prevent them. Their realist review showed that consideration of the circumstances and underlying mechanisms for exercise-based interventions is vital, and could lead to greater success for future research, the individuals involved and their support networks.
Exercises recommended for those with dementia
Booth et al (2019) identified recommendations for types of exercise-based interventions for people with dementia in different circumstances and what aspects of motivation were entailed.
They recommended multi-component exercise-based interventions that combine physical and cognitive exercises that are appropriately intensive and progressive. The physical exercises should involve strength or resistance training, balance, endurance or mobility training and aerobic exercise. Such physical and cognitive exercises should be supported by suitable staff who are able to interact, communicate and connect with the patient, as well as by suitable materials, while taking into consideration the speed of initiation, length of intervention, encouragement of active lifestyle and enjoyment of the activity (Booth et al, 2019). They also recommended that the exercise-based interventions should be delivered in a flexible manner for a duration of at least 15–20 minutes, two to three times a week and for 6–12 months. Further, these exercises should be delivered in a home setting for those wanting or needing one-to-one support from the intervention staff, or in a group for those wanting carer respite, to increase habit formation of physical activity or for socialising aspects.
Booth et al (2019) also stated that support can encourage older people to complete an exercise-based intervention, and that sources of support can include trained intervention staff, carers, spouses and family members, with adequate training and support.
Where support is being given by trained intervention staff, the staff member should have professional competencies. These would include good time management, knowledge, a firm but encouraging manner, a kind, friendly and supportive attitude to the patient, an understanding of the issues experienced by people who are living with dementia and good rapport development (Booth et al, 2019). When supporting an intervention, they should be able to provide clear and repeated instructions, optimally progressing the exercises and providing supervision according to an individual's needs. Importantly, the staff member should be able to recognise and understand the needs of a person living with dementia (Booth et al, 2019).
While a person is being supported with exercise by a carer, the carer should be able to provide enough information to enable to the person to continue. For example, carers could look at a sheet of exercises provided by a physiotherapist and guide the person in following the instructions. They should understand why the exercises are beneficial. Carers should be able to care for the individual's practical needs, for example, transport to the exercise venue (Booth et al, 2019).
Barriers and facilitators of exercise in older adults
Bethancourt et al (2014) carried out a study to understand the barriers and facilitators for a physical activity programme among older adults. The authors commented that few engage in routine physical activity, with even fewer using programmes that are designed to motivate them to exercise. This qualitative US-based study used focus group interviews, with 52 randomly selected group health medicare members who were aged between 66 and 78 years. The discussions were audio-recorded, transcribed and analysed using an inductive thematic approach and a social–ecological framework.
Bethancourt et al (2014) found that the most prominent barriers to physical exercise and exercise programme participation were physical limitations due to health conditions and ageing, or those resulting from lack of professional guidance and inadequate distribution of information on available and appropriate physical activity options and programmes. The study identified that poor physical health is a barrier to exercise. The reported facilitators for motivating older people to exercise included the desire to maintain physical and mental health and access to affordable, convenient and stimulating physical exercise programmes (Table 1).
| Barriers | Facilitators |
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Bethancourt et al (2014) concluded that the availability of free or low-cost fitness facilities and classes significantly motivated individuals, but often, a greater incentive was required in order to get people to enrol and regularly use the programmes. Socialising was important to some, while for others it was important to have instructors who engaged well with older adults and were well trained in working with this age group. Other motivating factors were the ability to attend a preferred and/or conveniently located fitness centre.
Bethancourt et al (2014) found that their participants had a general desire for their health providers and health systems to support physical activity. However, this was a predominantly well-educated sample of people, which may have affected this finding, as knowledge is a key motivator for physical activity. The participants also showed an interest in having health professionals to help them safely start a physical activity routine, set realistic goals, track their progress and provide assistance in facing and working with the health- and age-related barriers they may encounter in being active. Older adults were also found to significantly benefit from regular verbal encouragement and recognition of performance success (Bethancourt et al, 2014).
The researchers concluded that promotion of physical activity among older adults may benefit from collaboration between, for example, fitness centres, walking groups or other interventions designed to increase the range of options available. They acknowledged that some people may dislike exercise or be too unaccustomed to it and it was, therefore, important for health providers to emphasise that physical activity can also be achieved through other means, such as daily household activities (mowing the lawn and gardening) and walking to accomplish daily tasks (walking the dog or to the shops).
Overcoming the barriers
Stewart (2016) identified five main barriers to older adults engaging in exercise. These include: discomfort and pain, fear of injury, fixed income, isolation and cognitive decline.
To overcome discomfort and pain, which can present in various forms due to heart and lung conditions, arthritis and obesity, Stewart (2016) recommended that older adults discuss these symptoms with their health provider, who might be able to manage the symptoms through medication and physical therapy. The author agreed that the key is to engage with a therapist who can provide suggestions for a wide variety of exercises to match the energy or functional level of the individual at any time.
Fear of injury can be overcome by using appropriate equipment, assisted devices and supervision Balance and strength training can also help older people engage in exercise, thus reducing falls risks (Stewart, 2016). Exercise programmes should be commenced slowly, and excessive exercise should be avoided initially, in order to build confidence.
The issue of cost often comes up when exercise for older adults is under consideration. Stewart (2016) and Bethancourt et al (2014) also recognised this and recommended walking and household tasks as a free option to stay active. Walking to the park, around the area or around the home can be recommended, alongside chores such as mowing the lawn and vacuuming. Walking groups may also be an option, as well as reasonably priced exercise classes.
To overcome the issue of cognitive decline limiting engagement in exercise and physical activity, it is recommended that exercise be made a habit by incorporating activity into daily routine and keeping exercises simple (such as walking, climbing stairs or simple stretching), with repetition of activities being key to the possibility of habit formation (Stewart, 2016).
Lastly, the barrier of isolation can be circumvented through local senior citizens' organisations that offer group activity and fitness classes. Further, support can be sought from family and friends, who can help the older person to stay motivated and even exercise with them. For those who can afford it, a personal trainer may be a good option. Setting reachable goals, such as playing with their grandchild on the floor or working in the garden, can also be motivators (Stewart, 2016).
Conclusion
The positive effects of exercise on physical and mental ill health are well documented, and it has been shown that older adults or those living with chronic conditions, muscle strength has a positive association with a good quality of life (Yang et al, 2019). Thus, it is apparent that exercise is beneficial for older adults, improving overall quality of life. Exercise may also play a part in falls prevention, and it is vital that older adult be encouraged and motivated to be active.
Nurses play an important role in any setting, alongside other health workers or informal carers, in motivating people to exercise. There are numerous considerations when implementing motivational strategies to help patients consider exercise-based interventions, including tailoring the support and supervision to meet the needs of the individual, having the right knowledge to help the patient believe in exercise as an effective strategy and having a good knowledge of dementia so as to modify communication according to the patient needs, in order to reach the best outcome.