Healthy Aging: Preventing decreased quality of life in older adults

Preventing Decreased Quality of Life in Older Adults

​October 14, 2017

​Healthy People 2020 is an initiative of the US government that helps providers and consumers find evidence-based answers to health questions to make informed choices to improve their health (Centers for Disease Control [CDC], 2017).  All life stages are considered, including older adults.  The initiative seeks to reduce or eliminate health disparities, so all people have access to resources to maintain or improve their health.  Healthy People 2020 recommendations include how to remain healthy physically and socially.  

Functional limitations in the older adult lead inability to safely remain in their own homes.

The goal of Healthy People 2020’s Older Adult Initiative, objective number five, involves reducing the number of older adults with limitations in activities of daily living (ADLs), commonly known as functional limitations (Department of Health and Human Services [HHS], 2017).  Functional limitations influence the ability of older persons to stay in their homes as they age, leading to placement in alternative housing arrangements they may not be able to afford or enjoy.  

ADL​s include meal preparation, bathing, dressing, toileting, transferring from sit to stand, or rising from an inadvertent fall to the floor.

An older adult’s inability to perform ADLs including self-care and routine home maintenance has the potential to decrease the quality and enjoyment of life.  The inability of older adults to independently manage self-care in their homes is not in alignment with the principal goals of the Healthy People 2020 program. The goal of Healthy People 2020 is for all people to be healthy, have high-quality lives, and be free of disability, regardless of age (HHS, 2012).

Mission of the Program
Some older adults have significant functional limitations due to either physical or cognitive impairment or both. The objective of the Healthy People 2020 initiative for older adults is to improve their strength and endurance so they can care for themselves at home with as much independence as possible.

Exercise is one important way that a person can stay strong enough to live independently as they age. Getting sufficient physical exercise as an older adult may be overlooked for a variety of reasons, including disability from chronic disease. Older adults may feel they have exercised enough in their lives and more is not required.  But just as we are what we eat, and good nutrition is necessary to keep healthy, we must move our bodies enough to maintain cardio-respiratory fitness and strength, whether with others in a class or in solitude in nature if we expect to age well.

150 minutes of moderate intensity exercise per week is recommended by the American Heart Association.

Currently, there are too many older adults who are unable to manage self-care at home without the help of others. As many as one-third of older adults report the inability to manage at home without help (HHS, 2017).  This decreases the quality of their lives by making them dependent on others. Further, it increases the likelihood of injury at home leading to frequent use of emergency medical services and unanticipated hospitalizations.

The evidence demonstrates regular exercise will prevent decline and dependence on assistance for ADLs. 

Advance Practice Registered Nurses (APRNs) promote health practices such as exercise and proper diet, reducing the decline of  physical function and contributing to maintenance of cognitive performance in older adults.  A review of the literature provides evidence of the benefits of exercise for the older adult.  Exercise as an evidence-based intervention promotes health and reduces the development of functional limitations leading to placement in assisted living facilities (ALF) or long-term care (LTC) facilities.

Target Population
The age group this review focuses on adults 65 and older, primarily those living in the community.  According to Healthy People 2020, nearly 30% of older adults have a functional impairment at a moderate to severe level (HHS).  Persons who have significant functional impairment need assistance at home or may be unable to live independently at home.  The Health People 2020 goal is to reduce this number 10% by 2020.

Sedentary lifestyles are shown to decrease quality and quantity of life, whether the older adult resides in their own home or lives in a residential care setting.  If an older adult is currently living in a nursing facility or an assisted living residence, programs of exercise should be promoted to maintain resident function and prevent further decline.  Another application of this research involves motivating persons of all ages to exercise, whether they have current health conditions or hope to prevent them from developing.

The Significance of Functional Limitations in Older Adults
The American Association of Retired Persons (AARP) conducted a survey of older adults in 2012 which outlines some of the limitations many older people face.  Even though there are more older persons still employed than in previous years, and plan to stay at home, about 30% are not able to live at home without assistance (AARP).  In fact, only 43% of persons over 60 years of age report they find it manageable to live independently, without assistance for daily activities of living (AARP).

ADLs include making a meal, eating, bathing, housework such as doing dishes, dressing, and safely moving about in the environment.  Many older persons have chronic diseases such as heart disease, diabetes, and respiratory disorders.  Some of those diseases can be managed by the older person.  Discussion with the older patient by the APRN about preventative strategies such as exercise and a healthy diet, both of which are helpful toward maintaining independence even within the context of chronic disease.

If an older person can manage any chronic disease and stay active, they may be able to continue their level of wellness, prevent further injury, or weakening of their condition.  If they can sustain enough energy to perform self-care and activities of daily living, they may be able to stay at home longer, which will increase the quality of their lives. Exercise is a primary component, as people age, to maintain functional independence.

Effect of Exercise on Individuals and the Community
Despite reports from the government and medical research highlighting the benefits of exercise, many older people are not connecting the relationship between longevity with quality and exercise (McPhee et al., 2016).  When older adults are active in their communities, it is a positive demonstration that aging does not have to consist of physical or cognitive demise. The APRN is in a pivotal position to educate patients of all ages regarding the importance of exercise for overall health.

Physical activity can lower the risk of developing chronic diseases.  The risk of cardiovascular disease, including coronary artery disease and stroke, diabetes, and certain types of cancer all are reduced by participating in regular physical exercise (CDC, 2015; McKinney et al., 2016).  Exercise also improves thinking, mood, and decision-making (CDC; Catalan-Matamoros, Gomez-Conesa, Stubbs, & Vancampfort, 2016).

Chronic disease, infirmity, and dementia are undesired outcomes for the aging population.  Participating in exercises such as Qi Gong and Yoga not only improve balance, strength, and flexibility, they also help elevate depressed mood and improve cognitive ability in the older adult (Barrows, & Fleury, 2016; Chang, Knobf, Oh, & Funk, 2017; Patel, Newstead, & Ferrer, 2012; Wertman, Wister, & Mitchell, 2016). 

Effect of the Health Care System as a Whole
The burden of caring for older persons with decreased functional status has an impact on the person, their family, and caregivers, as well as the resources available in the healthcare system.  For example, a person with frequent falls due to gait instability and weakness may need to use public emergency services for help to get up from the floor.  If there is not a caregiver available to assist an older person who has fallen at home, an emergency call would likely be made, and the fire department must attend to the needs of the fallen person. The person may or may not be injured, requiring ambulance transport if a serious injury has been sustained.  Use of emergency services in this way could potentially compromise the response to other urgent or life-threatening emergencies.   

Unfortunately, due to significant deconditioning, it may not be feasible for the older person to participate in exercise to build strength without assistance.  However, improvement in functional abilities is a worthy outcome of the effort involved to exercise.  A high degree of importance lies in prevention. 

When exercise is a primary component of daily living, as the person ages, they may be more likely to maintain living at home safely and injury free throughout the aging process.  Managing self-care independently and safely will add value to the older adult’s life and decrease the burden on the healthcare system as a whole.

Program Goals and Interventions
The goal set by Healthy People 2020 is an overall reduction by 10% of persons having moderate to severe functional impairment.  One measurement of functional impairment is the number of falls that older adults experience. There were approximately 6,800 falls that generated emergency room visits in 2013, based on data collected by Healthy People 2020 (HHS).  Reducing the number of falls leading to emergency room visits would contribute to improved quality of life for the older person.  

Implementing community exercise programs that include seniors will improve their strength and balance and prevent falls at home, contributing to a reduction of functional impairment.  Even when resources are scarce, exercise programs can be implemented in the older adult’s home to improve functional status.  APRNs should incorporate exercise into every care plan, track patient exercise, and develop a specific follow up plan to encourage the patient to exercise.

How the Goals are Carried Out
Some communities in the US have implemented community physical exercise programs that include seniors.  Communities with resources to provide these services should model those already established.  The National Council on Aging (NCOA) is an organization with resources, including grant money suggestions, that can help communities establish exercise programs for seniors (NCOA, 2017).

Improved compliance with an exercise program is more likely when the health care provider gives specific instructions (Taylor, 2013).  This emphasizes the need for an effective APRN intervention when educating patients about the benefits of exercise.  The teaching should be specific rather making a general statement that the patient should get some exercise. An example of specific instruction may be, “walk 20 minutes at least 5 of 7 days every week and report your progress at your next office visit.”

Organizations Involved in the Program
The Healthy People 2020, NCOA, and the YMCA in local communities offer suggestions for improving fitness or provide exercise classes.  A fitness class called SilverSneakers® may be available free to seniors because the service is billable to many different health insurance plans (SilverSneakers, 2017).

Taylor’s research on activity levels for older adults summarizes the World Health Organization (WHO) recommendations for exercise.  The WHO recommends 150 to 300 minutes of moderate activity for cardiorespiratory fitness, and balance exercises for persons at risk for falls at least three times per week.  Even persons whose disease prevents them from this amount of activity should exercise to the extent of their capabilities (Taylor).

The Office of Health Promotion and Disease Prevention (OHPDP) provides information about the benefits of exercise for older adults (HHS, 2017).  Chronic disease and deconditioning relative to age are two factors that interfere with the fitness level of older adults.  Individuals vary greatly in their abilities.  The message from OHPDP is direct and advises older persons, including those with health challenges, not to be inactive, but instead, seek enjoyable ways to be active.
 
Many benefits come from exercise, even if the person suffers from a chronic disease.  Muscular atrophy, loss of bone strength, inflexibility, joint pain and stiffness, loss of muscle strength, loss of balance, constipation, decreased cognition, decreased memory, poor sleep, and so much more are a direct result of inactivity.  Some studies state that early onset dementia is a result of poor compliance with an exercise program (Kirk-Sanchez & McGough, 2014; Reiner, Niermann, Jekauc, & Woll, 2013).

Healthy People 2020 Recommendations
All adults should continue to participate in enjoyable exercise throughout their lifespan to maintain or improve their functional abilities. Aerobic exercise that challenges the cardiovascular system is recommended for all adults, including older adults. Examples of aerobic exercise include walking, bicycling, jogging, and swimming.  Even dancing can be aerobic when participated in vigorously enough to increase the heart and respiratory rate.  

Aerobic exercise should be part of a weekly routine for older adults. Exercise that raises the heart and respiratory rate should be participated in by the older adult 75 to 150 minutes per week, depending on the intensity level (WHO, 2017). The more intense aerobic exercises with a measured effort of 70% of maximum exertion are recommended at the reduced time commitment.  If the aerobic exercise is at an intensity level of 50-60%, at least 150 minutes of participation per week are necessary to achieve beneficial results.  APRNs should recommend brisk walking for 15 to 20 minutes five to seven times per week, if tolerated, as part of the older person’s exercise plan to improve health and longevity (McKinney et al.).

Participation in strength training is recommended for all adults, including older adults. Examples of strength training could be any exercise that involves resistance such as weight-training, using elastic bands, and even some Yoga or Qi Gong exercises.  Calisthenics such as sit-ups, push-ups, and other exercises that involve effort with or without additional weights help to build and retain muscle mass and are recommended for strength training. 

Strength training should be done twice per week or more, as tolerated.  Each adult will want to participate to the extent of their abilities.   The individual’s capability will vary, depending on the starting fitness level.  The goal is to improve stamina, strength, and endurance and prevent decline.  Just like the recommended daily allowances for nutritional intake, exercise prevents disease and helps manage disease when it exists.

Another type of exercise particularly noted as beneficial for older adults is balance exercise.  Two exercises that can help improve balance are pausing in a semi-squatting position for a few seconds when rising from a sitting position and balancing on one foot.  The older person with balance issues will benefit, and others will build strength and develop equilibrioception, both of which will help prevent falls.  Balance exercises should be done at a minimum of three days per week (WHO).

Literature Review
The literature has long supported the benefits of exercise across the lifespan including older adults point to health maintenance and improvement in functional abilities.  For older adults, exercise leads to a reduction of falls.  Due to advances in health care, people are living longer and should be able to experience health and independence long into their older years.

One of the most interesting studies involves the neuroprotective benefits of exercise. The aging process naturally creates a slowing of cognition, but dementia and degenerative diseases such as Alzheimer’s disease (AD) is not a normal result of aging. According to epidemiologic studies, there is a relationship between exercise and cognitive health (Kirk-Sanchez & McGough, 2014; Taylor, 2013).

Exercise is a contributing factor in the health, longevity, and prevention of disease in all persons. The World Health Organization (WHO) reports 3.2 million deaths worldwide are attributable to inactivity (Taylor).   Two-thirds of adults over age 50 do not participate in the type of exercise needed to have an impact their health (Taylor).  Hypertension, hyperlipidemia, cardiovascular disease, cancer, and diabetes are chronic diseases that can lead to early mortality that may be prevented or alleviated with a consistent exercise routine (Kokkinos, 2012; McKinney et al.; Reiner et al.; Taylor).  Obesity is another detrimental condition leading to disability and disease that may be reversed with regular participation in exercise.  Despite inconsistent evidence relating benefits of exercise in older persons who have congestive heart failure (CHF), there is a small study that shows promise even for those with this debilitating chronic disease (Floegel & Perez, 2016).

Physical exercise is safe for older adults and contributes to a reduction in overall morbidity and mortality (McPhee et al.).  Although the risk of an atherosclerotic plaque rupture is rare, an older adult who has not participated in vigorous physical activity should consult with the APRN prior to beginning a program of intense exercise (Kokkinos).

Loneliness, social isolation, and depression affect older adults to a great degree.  There is emerging evidence that exercise may have a positive effect on these conditions that have a detrimental effect on older persons.  Depression in older adults has an association with increased use of the health care system (Catalan-Matamoros, Gomez-Conesa, Stubbs, & Vancampfort, 2016). Prescribing exercise whenever possible instead of medications that have unwanted or unsafe side effects may be of benefit for the population of older adults suffering from depression (Catalan-Matamoros et al.). 

Overall, the literature overwhelmingly supports the benefits of exercise in older adults in the treatment and prevention of chronic diseases which lead to the use of the health care system and functional disability. A pilot study in South Florida measured the effect of exercise on functional status among an older adult population. Palmer et al., (2016) examined whether the application of a specific set of exercises to enhance functional fitness was effective and provided a satisfactory program to which older adults would adhere.  Studies must continue to evaluate the effectiveness of programs for older adults.  The motivation for participants includes the social aspect of community exercise.

The last consideration from the literature deals with eastern spiritual practices like Yoga that migrated to the US during the 1940s and 1950s.  Yoga is often considered a type of exercise because Yoga involves the execution of physical postures including static holding and systematic movements similar to calisthenics and balance exercises.  Yoga is popular in modern culture and has proven benefits for older adults such as strength, flexibility, and improved balance. 

Qi Gong is another practice derived from eastern traditions that is well-tolerated among the older population.  A study examining the effectiveness of Qi Gong in contributing to overall health and well-being demonstrates positive benefits, while the specific effect on physical health should receive further investigation (Chang et al.).  Even so, the perceived benefits of an exercise program enhance self-efficacy and may help the older adult persist in types of exercises that will improve their overall functional abilities such as Yoga and Qi Gong (Patel et al.; Wertman et al.).

Assessment of Resources
Current availability of resources varies, based on the community in which the older adult lives.  An even surface without significant grade changes is sufficient for walking and is available to nearly everyone.  Filled water bottles or other household items can easily be used as weights for strengthening exercise.  Balance exercise can be accomplished each time the person rises from a chair or by using the back of a chair to stabilize a one-footed balance exercise.

Accessibility may depend on the older person’s present physical ability. If the older person lives in a private residence, access to resources beyond what is described above may involve transportation.  Some communities where older adults live may provide a gym or exercise classes nearby at low or no cost.  For example, SilverSneakers® may be covered by the Medicare benefit, with no additional out-of-pocket costs, except for transportation to and from classes.  There is little to no cost associated with walking, and the in-home exercises described previously, and transportation is not necessary if the person can access an appropriate walking surface directly outside their homes.

The NCOA provides information on developing a community-based program for exercise for older adults.  As mentioned, Palmer et al. (2016) implemented a successful program to increase the exercise level of older residents in Florida.  This program, Enhance Fitness, is supported by the NCOA. There are currently 708 sites in 40 states providing specific exercises for older adults (NCOA, 2017). There are many types of exercise classes offered that are appropriate for older adults in communities throughout the nation.  A class is not required but does provide a social aspect that may improve adherence to a program of exercise.

The APRN must be aware of their community’s resources so a referral can be made for older adult patients who are ready to begin an exercise program or are interested in continuing their current exercise regimen. Searching the NCOA Map of Partners will help identify if local resources already exist.  Partnering with NCOA will help establish services in your area if none exist.  Other resources accessible to seniors include the local YMCA, community college, or senior center.  Checking with the city government web page may reveal other nearby resources.

Barriers to Change/Implementation
Barriers include access to community-led events or classes due to transportation issues.  A way to circumvent transportation issues is to offer expert facilitated exercise at the neighborhood level.  Other barriers such as deconditioning exist on an individual level.  The APRN may make a referral to an appropriate rehabilitation program, covered by Medicare if possible, to improve the older adult’s overall fitness prior to participating in a community-led or at-home exercise.

Some researchers believe that the exercise must contain a social component to encourage participation (Devereux-Fitzgerald, Powell, Dewhurst, & French, 2016; Heiman, & Artiga, 2015).  However, some older adults prefer to be alone while participating in their exercise program.  The APRN should be mindful of personal preferences and allow the older person to choose which type of exercise, classes or solitary, the person prefers.  The benefits of improvement in overall health and functional status that lead to the individual’s ability to maintain independent living are the goal.

Summary
The Healthy People 2020 Older Adult initiative directs both the older adult and health care providers toward the goal of reducing the number of older adults with functional impairment by 10%.  The recommendation is aerobic exercise, 150 minutes per week at a moderate level of intensity or 75 minutes at a vigorous intensity, strength training two times per week, and balance exercises two to three times per week for older adults. 

Community resources should be sought out along with home exercise such as walking in the neighborhood and using household items such as filled water bottles and chairs to exercise.  The APRN should also be aware of programs and classes offered that are covered by Medicare to avoid unnecessary expense on the part of the patient.

Quality of life includes being able to self-manage care and continue to live independently in the community.  Having a measure of quality in one’s life also means not being dependent on others for ADLs such as bathing, dressing, or walking.  Being able to maintain higher cognitive functions such as thinking, and decision-making also contribute to the quality of life in older adults.  Exercise including aerobic exercise, strength training, and balance exercise are ways that have been proven to allow older adults to maintain independence and enhance cognitive function, so they can live safely in their homes.

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