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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 82-92

Physical activity as preventive therapy for older adults: A narrative review


1 Department of Physical Activity and Health Promotion, Faculty of Medicine and Surgery, University of Rome Tor Vergata, Roma RM, Italy
2 Department of Urology, National Health Service (NHS), UK
3 Department of Urology, Western General Hospital, Edinburgh, Scotland
4 Department of Urology, National Institute of Urology and Nephrology, Cairo, Egypt

Date of Submission17-Jul-2019
Date of Decision29-Sep-2019
Date of Acceptance07-Oct-2019
Date of Web Publication02-Apr-2020

Correspondence Address:
Chidiebere Emmanuel Okechukwu
Department of Physical Activity and Health Promotion, Faculty of Medicine and Surgery, University of Rome Tor Vergata, Via Montpellier, 1, 00133 Roma RM
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_22_19

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  Abstract 


Sedentary behavior is one of the major risk factors for cardiovascular mortality; hence there is a need to promote physical activity (PA) among adults aged 60–86 years. The aim of this narrative review was to evaluate the role of PA in the prevention and treatment of chronic diseases among older adults. Relevant studies (original articles, systematic reviews, and meta-analyses) that reported on the effects of PA in older adults from 1998 to 2019 were selected. The following electronic databases were searched: PubMed, ScienceDirect, PsycINFO, Embase, Medline, Sports Discus, Web of Science, and Cochrane database. Physical exercise at different intensities was shown to be effective in the prevention and treatment of overweight, functional decline, and mood disorders in older adults. Moderate-to-high intensity endurance exercise can be effective in the prevention of diabetes type 2, hypertension, and cancer in older adults. Resistance training at different intensities was shown to be effective in the prevention and treatment of obesity in the elderly. Mobility and balance training were effective in preventing falls in older individuals. Combined exercise training regimen comprising moderate-to-vigorous intensity aerobic and resistance exercise is beneficial in the prevention of disability, osteoporosis, hypertension, and falls among older adults. Moreover, combined exercise training improves immune function and antioxidant capacity in older adults. Based on the studies reviewed, PA was found to be an effective tool for the prevention and treatment of chronic diseases among older adults.

Keywords: Aerobic, elderly, exercise, physical activity, resistance


How to cite this article:
Okechukwu CE, Deb AA, Emara S, Abbas SA. Physical activity as preventive therapy for older adults: A narrative review. Niger J Exp Clin Biosci 2019;7:82-92

How to cite this URL:
Okechukwu CE, Deb AA, Emara S, Abbas SA. Physical activity as preventive therapy for older adults: A narrative review. Niger J Exp Clin Biosci [serial online] 2019 [cited 2020 Aug 8];7:82-92. Available from: http://www.njecbonline.org/text.asp?2019/7/2/82/281619




  Introduction Top


Sedentary behavior is one of the major risk factors for cardiovascular mortality, hence there is a need to promote physical activity (PA) among adults aged 60–86 years. Moderate-intensity aerobic activity, muscle-strengthening activity and decrease in sedentary behavior should be encouraged among older adults.[1] Older adults are expected to accumulate up to 30–60 min/day (≥150 min/week) of moderate-intensity exercise, or 20–60 min/day (≥75 min/week) of vigorous-intensity exercise, or a combination of moderate- and vigorous-intensity exercise daily to attain the recommended targeted volumes of exercise. Absolute intensity of exercise is estimated using any of the following methods: caloric expenditure (kcal/min), absolute oxygen uptake (VO2; mL/min or L/min), and metabolic equivalents (METs). Relative intensity of exercise is estimated using any of the following methods: Percentages of heart rate reserve (%HRR), percentage maximal heart rate (HR), %VO2R, %VO2, %METs, rating of perceived exertion (RPE), affective valence, OMNI scale, talk test, and feeling scale, and these are relevant tools for exercise prescription, dosing, and therapy among aged adults.[2]

Physiological changes such as steady and persistent rise in pro-inflammatory cytokines due to aging are associated with an increase in the level of free radicals, low production of nitric oxide, low bioavailability of antioxidants, increase in plasma lipid profiles, rise in atherogenic index of plasma, and oxidative stress are associated with aging. These physiological changes during the aging process are associated with endothelial dysfunction which leads to cardiovascular disease and increase in mortality among aged adults, and PA can modify these changes. Exercise improves antioxidant activity, thereby minimizing oxidative stress, and increasing longevity among older individuals.[3] Some of the barriers to PA among aged adults are illness, lack of time, fear of falls, functional limitations, low confidence, doubt about the benefits of PA, lack of fitness and energy, history of traumatic experiences with PA, work obligations, environmental barriers, and pain associated with exercise.[4],[5] PA improves mood and prevents depression in older adults,[6] hence regular physical exercise should be encouraged among aging men and women to enhance their quality of life. One of the positive health outcomes associated with regular PA, is that it improves functional capacity among aging adults.[7]

Owing to the high prevalence of chronic diseases worldwide, and based on the fact that, an active lifestyle is essential for longevity, it is necessary to promote PA and to know the volume and intensity of PA that is effective in producing a positive change in chronic disease conditions with regards to individual's or patient's clinical features. The aim of this narrative review was to evaluate the role of PA in the prevention and treatment of chronic diseases among older adults.


  Methods Top


Search strategy

Relevant studies (original articles, systematic reviews, and meta-analyses) that reported on the effects of PA in older adults from 1998 to 2019 were selected for this narrative review. The following electronic databases were searched: PubMed, ScienceDirect, PsycINFO, Embase, Medline, Sports Discus, Web of Science, and Cochrane database. The following search strategies were modified for the various databases: Exercise, PA, older adults, chronic diseases, and health benefits of exercise training among older adults. The MeSH system was used to search for articles on PubMed.

Effectiveness of physical activity in the prevention and treatment of chronic diseases among older adults

Exercise is associated with improvements in cardiovascular, musculoskeletal, and metabolic health through reductions in oxidative stress, inflammation, and modulations of cellular processes within various tissues in physically active older adults.[8] The combination of two or more exercises as a therapeutic regimen may be more effective than a single exercise regimen, combined training program is associated with an improvement in cardiovascular and psychological well-being among aged adults.[9] Resistance training (RT) improved the lean body mass in aged men,[10] thereby preventing sarcopenia, frailty and functional impairment. Eight weeks of RT reduced the lipid levels in obese women, thereby preventing the pathogenesis of atherosclerosis.[11] Six months of supervised exercise training improved the immune function in elderly people that were formerly sedentary, which illustrates the importance of proper exercise supervision in order to achieve a positive outcome.[12] Regular participation in PA was found to induce suppression of tumor necrosis factor (TNF-α), which shows that PA defends the body against TNF-α-induced insulin resistance, thereby preventing type 2 diabetes mellitus.[13] 12 weeks regular Tai Chi Chuan Program-enhanced regulatory T-cell function, thereby improving immune function,[14] apart from that, Tai Chi improves muscle strength, coordination, and balance. It is a mind exercise that is effective in preventing anxiety, improve mood, quality of sleep, and self-confidence among the elderly. It is effective in the management of stroke and Parkinson's disease.

Short-term exercise training increases the rates of wound healing among healthy older adults.[15] Functional capacity is the major predictive factor of survival in individuals with and without cardiovascular disease and in individuals with specific cardiovascular risk factors.[16] There was an improvement in functional capacity in chronic heart failure patients after participating in aerobic training.[17] Aged individuals who are physically active have lower risk of mortality.[18],[19] However, the intensity of an exercise training regimen, determines its effects and impact.[20] The more the PA levels in older adults, the lesser the chances of morbidity and mortality.[21],[22] PA was able to minimize the risk of falling and monthly fall rate among older men and women, and this shows that PA improves physical functioning and mobility.[23],[24],[25],[26],[27] Aerobic endurance activity reduced the risk of falling sick due to the prevention of chronic diseases, thus minimizing hospital admission rates in older adults.[28]

There is a lower risk of stroke among physically active older adults, due to the improvements in endothelial function associated with exercise.[29],[30] Endurance training and strength training (ST) reduces systolic blood pressure in older men and women, because exercise improves autonomic cardiac control by decreasing sympathetic activity, increasing vagal activity, and baroreflex control of HR.[31],[32],[33] PA lowers the risk of cardiovascular disease in older adults by improving peripheral mechanisms and neurovegetative control of the heart.[34] PA lowered the risk of breast cancer up to 50%,[35],[36],[37] and colon cancer up to 30%.[38] Exercise enhances cardiovascular, mental, and physical functioning, thus improving functional capacity,[39] and cognitive performance[40],[41],[42],[43] among older adults. PA improves neuromuscular performance by preventing sarcopenia and decrease in muscle strength in aged adults.[44],[45],[46] Exercise improves renal function and lowers the progression of kidney disease in older adults.[47] ST Improves bone mineral density, thus preventing osteoporosis in older men and postmenopausal women.[48],[49] Exercise reduces central obesity[50] and improves insulin sensitivity,[51] thereby minimizing the risk of diabetes type 2.[52] Sedentary behavior is associated with depression in older people[53] and exercise prevents depression, anxiety, and low self-esteem.[54],[55] Older adults who exercise regularly have lesser chances of becoming disabled when compared to those that are sedentary.[56],[57]

Higher intensity exercises were effective in improving endothelial function in heart failure patients undergoing cardiac rehabilitation.[58] Supervised treadmill PA was more effective when compared to unsupervised treadmill PA; both exercise regimens were helpful in the reduction of intermittent claudication in older patients.[59] Combined exercise training regimen was more effective in improving the global quality of life among older people when compared to single-dose exercise regimen.[60],[61],[62] Aerobic exercise such as cycling is effective in improving aerobic capacity and ventilatory efficiency in older individuals.[63] Exercise reduces the risk of osteoarthritis and fatigue in older people by improving bone strength, bone mineral density, and physical functioning.[64],[65],[66] Exercise when combined, exerts more positive effects toward preventing functional limitations in older adults.[67],[68],[69],[70] Weight training exercise leads to improvements in muscle strength and activities of daily living among the elderly, moreover, exercise improved the muscle strength, power, functional capacity, and quality of life among patients with dementia and Parkinson's disease, which shows that exercise is effective in the secondary and tertiary prevention of chronic diseases.[71],[72],[73],[74] Exercise is an important tool in health promotion, physical, and rehabilitation medicine for primary, secondary, and tertiary prevention of chronic diseases among aged adults.[75],[76],[77],[78] Cardiovascular morbidity and mortality are due to an increase in workload on the cardiovascular system,[79] and PA increases vagal tone and decreases sympathetic tone, thereby improving cardiac function. Low HR variability (HRV) and baroreflex sensitivity (BRS) are associated with poor cardiovascular health. Iellamo et al.[79] observed that individualized aerobic continuous training and aerobic interval training significantly improved HRV and BRS in patients with chronic heart failure, the training was prescribed using a technique for the individualization of exercise training according to patients' clinical and functional capacity known as session rating of perceived exertion (RPE). RPE is an effective tool for exercise prescription and quantifying of internal training load both in normal and disease state using the Borg CR-10 scale (moderate-intensity activity is at the level of 6 or below on a 1–10 scale, while vigorous intensity is at the level of 7–8 on the 1–10 scale) [Figure 1].
Figure 1: Borg CR-10 scale (Moderate-intensity activity is at the level of 6 or below on a 1–10 scale, while vigorous intensity is at the level of 7–8 on the 1–10 scale)

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Aging men experience decrease in testosterone levels which leads to unfavorable physiological changes. A decline in men's sexual function is often associated with loss of libido, potency, and depression. In an animal experimental study, aerobic exercise (swimming >3 times/week and >30 min each session or >90 min/week) improved testicular function in male Wistar rats.[80] Cho et al.[81] found that the combination of exercise and testosterone replacement therapy (TRT) showed significant improvements in serum testosterone levels and decrease in the symptoms of late-onset hypogonadism among physically inactive older patients with erectile dysfunction and low serum total testosterone compared to the application of TRT alone. These improvements were maintained with continuous exercise after the cessation of TRT. Twelve-week lifestyle modification program involving aerobic exercise training and dietary modifications increased serum testosterone levels in overweight and obese men.[82] PA is important in the primary and secondary prevention of obesity, and there was an association between obesity and late-onset hypogonadism, because morbid obesity is a major risk factor for hypogonadism.[83] Prevention of central obesity through regular physical exercise and smoking cessation may decrease the risk of hypogonadism in aging males.[84] Walking pace lowered the progression of prostate cancer among men diagnosed with prostate cancer, independently of walking duration,[85] and this might be due to the fact that PA modulates p53, p21, and caspase activities resulting in prostatic tumor growth inhibition, apoptosis, suppression, suppressed metastasis, and carcinogenesisin vitro and in transgenic model.[86],[87],[88] Moreover, exercise lowered the side effects associated with androgen deprivation treatment among men diagnosed with prostate cancer.[89]

Exercise prescription for older adults

PA slows down the decrease in quality of life among older adults,[90] by improving physical functioning and minimizing disability among older individuals.

According to the American College of Sports Medicine,[91] older adults should engage in moderate-intensity aerobic exercise training (30 min/day on 5 days/week for a total of 150 min/week), or vigorous-intensity aerobic exercise training (20 min/day on 3 days/week for 75 min/week), or a combination of moderate- and vigorous-intensity aerobic exercise training to achieve a total energy expenditure of 500–1000 MET/min/week, on 2–3 days/week aged adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. To maintain range of joint movement, completing a series of flexibility exercises for each of the major muscle–tendon groups for a total of 60 s per exercise on 2 days/week is recommended. Exercise training regimen should be tailored according to individual's PA levels, physical function/functional capacity, health/clinical status, exercise responses, and goals. Older adults can also benefit from engaging in amounts of exercises less than the recommended dose[91] [Table 1]. [Table 2] illustrates the prescription of PA based on intensity using MET level, HRR, and RPE, which are the easiest methods of PA prescription.[92] [Table 3] shows exerciseprescription for high blood pressure control.[93] [Table 4] described exercise prescription for diabetes type 1 and type 2 patients.[94]
Table 1: American College of Sports Medicine exercise recommendation suitable for older adults

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Table 2: Physical activity prescription based on intensity using metabolic equivalent level, heart rate reserve and rating of perceived exertion

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Table 3: Exercise prescription for high blood pressure control

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Table 4: Exercise prescription for diabetes Type 1 and Type 2 patients

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Exercise contraindications, safety, and precautions outside a supervised environment for aging adults

According to Gill et al.,[95] prior to the prescription and commencement of an exercise training program for aging adults, participants should be assessed by their physicians, and their complete medical history should be thoroughly evaluated. However, a thorough physical examination should be carried out to identify any salient and potential cardiac contraindications to exercise outside a supervised environment; the reason is to prevent sudden cardiac arrest. Cardiac contradictions include occurrence of myocardial infarction in the past 6 months, angina, signs and symptoms of congestive heart failure (e.g., shortness of breath with or without pedal edema), and a resting systolic blood pressure of 200 mmHg or higher or diastolic blood pressure of 110 mmHg or higher. Cardiovascular reserve can be tested through simple techniques such as getting up and down from the bed, walking for 15 m, climbing 1 flight of stairs, and cycling in the air for 1 min while sitting or lying on the bed.[95] Aging adults who develop chest pain or substantial shortness of breath climbing 1 flight of stairs, would not be advised to carry out a home-based and unsupervised exercise training. Electrocardiogram (ECG) test should be conducted and a resting ECG should be reviewed for new Q waves, ST-segment depressions, or T-wave inversions. Older individuals with an overt cardiovascular disease should be categorized and managed accordingly.[95]

To Inorder to prevent sudden death during exercise. All formerly sedentary older adults without obvious cardiovascular disease, at first, should start with a low-intensity exercise program, choosing from 1 or more of the following regimens: gait training, balance exercises, Tai Chi, self-paced walking, and lower extremity RT with elastic tubing or ankle weights. The aged should be well informed and instructed in proper exercise techniques, depending on the type of exercise, should be supervised by clinicians at least in one occasion to ensure adherence and safety. The intensity and volume of exercise should be gradually increased as the person's aerobic and functional capacity increases.[95]

Each exercise session should include a warm-up and cool-down period. If chest pain, shortness of breath, or dizziness develops during the unsupervised training, older individuals are instructed to rest and to see their physician if these symptoms continue with further exercise. Older adults that tolerate low-intensity exercise may progress to moderate-intensity exercise which is the benchmark (e.g., ST using weight machines, fast walking, swimming, or bicycling) of exercise recommendation. At the commencement of a moderate-intensity exercise program, it is important to monitor blood pressure and heart rate. Aging adults who have an abnormal cardiac response (decrease in systolic blood pressure of ≥20 mmHg, increase in systolic blood pressure to ≥250 mmHg or in diastolic blood pressure to ≥120 mmHg, or repeated increase in heart rate ≥90% of age-specific maximum) are not advised to continue with the moderate-intensity exercise program, and they should continue with less intensive exercise program.[95] To monitor and regulate the intensity of exercise, older adults should be taught to use the RPE, and it is easy to use and cost-effective. The RPE scale could be used to monitor exercise intensity; it is an easy method to quantify exercise intensities during exercise training.[96]

Barriers to physical activity in the elderly and possible solutions

Time is one of the major barriers to PA among older adults, because most older adults are busy with their daily activities and hardly create time for PA; another factor that hinders PA among older adults is functional limitation such as arthritis, osteoporosis, low back pain, and falls. Moreover, depression and anxiety contribute to sedentariness in older adults.[97] Behavioral addiction such as Gambling and substance abuse disorders could hinder participation in PA among the elderly.[98] Environmental barriers to PA are weather conditions, lack of recreational facilities, sidewalk quality, infrastructure, and insecurity in the neighborhood.[99] There is need to educate older adults on the benefits of regular PA through health promotion strategies, and the risk associated with PA, such as adverse cardiovascular events, can be minimized through routine PA supervision in a gym or exercise laboratory by a physician, physiotherapist, or an exercise physiologist, because recent studies suggests that exercise training supervised by an exercise professional could improve glycemic control among type 2 diabetes Mellitus patients,[100] prevent neurodegenerative diseases in older adults,[101] and minimize the risk of prostate cancer progression,[102] because a physician, or physiotherapist will ensure that a patient adheres to the instructions with regards to the prescribed exercise regimen. There is need to establish more recreational parks and infrastructures with good sports and exercise facilities, most especially in the urban areas, and this can encourage PA among the elderly. A green environment is another factor that encourages people to exercise; there is need to plant flowers and trees in the urban areas, and construct more sidewalks on the roadside, where people can jog, run, or walk.

Limitation

The limitation of this review was lack of information on the exact dose of PA that can be prescribed for the prevention and in support of the clinical treatment of various chronic disease conditions. However, the optimal dose of PA for various chronic disease conditions is yet to be established.

Future perspectives

The optimal dose of exercise required to achieve improvements in functional and prognostic parameters remains an issue of global debate among health-care practitioners. However, further research studies are needed in this specialty in order to determine the optimal dose (volume and intensity) and the exact physical exercise training regimen that can be prescribed by physicians, generally to improve treatment outcomes/goals for various chronic diseases, prior to the individualization of the therapeutic exercise regimen according to patient's functional and clinical status in different disease conditions.


  Conclusion Top


Based on the outcome of the evaluated studies with regards to this narrative review, PA was found as an effective tool for the prevention and treatment of chronic diseases among older adults. For aging adults who are functionally limited, or have chronic diseases that affect their ability to perform PA, physicians should prescribe a light intensity PA such as light walking, or light calisthenics, at an intensity of 1.1–3.0 METs, or 35%–50% HRR or 1–3 RPE, at the beginning of the exercise training routine, at a duration of 30 min, for 5 days/week. Progression to moderate-intensity exercise training regimen depends on the tolerance and functional capacity of the individual. However, exercise training should be tailored according to the individual's tolerance, functional capacity, health status, and preferences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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