This discussion paper was developed following a review and analysis of the contemporary international and Australian literature, with a primary focus on review of systematic reviews, and randomised controlled trials published since the more recent systematic reviews. A number of concurrent processes assisted the development of the discussion paper and the recommendations. Firstly, we explored the existing evidence base to enable tailoring of recommendations to what is currently known about the capacity of older people to exercise safely. Stakeholders nationally were informed about the project activity and asked for feedback through consultation procedures including a project newsletter, and in latter stages of the project, a project website and consultation meeting and focus groups. The purpose of these consultations was to garner confirmation of the contextual factors that facilitate the adoption and maintenance of physical activity behaviour amongst older people. Stakeholders represented the key appropriate domains, from consumers through to policy makers.
The project team (comprising the project staff and the Expert Advisory Group) participated in two one-day workshops. We used an external Expert Advisory Group to guide the process of recommendation development and refinement. The first workshop was held in the early stages of the project and reviewed the conceptual framework for the project. The second workshop was held mid-way through the project to review the discussion paper and critique the draft recommendations. The principles for guideline development, as outlined by the National Health and Medical Research Council (National Health and Medical Research Council 1998) were used to prepare national recommendations. One of the key principles of guideline development specified by the NHMRC concerns stakeholder involvement, including representatives of all relevant disciplines and consumers. Details of the four stages of the methodological process are described below and outlined in Figure 1.
Phase 1: Framework development
Aim:The aim of this phase of the project was to reach agreement on the scope of the work and to develop, consolidate and produce a conceptual framework. The framework guided the subsequent phases of the project and the production of the project deliverables.
Process:The first project team workshop was held in December 2005. Its objectives were to:
- Agree on a definition of the proposed target group, i.e. ‘older Australians’, and an accompanying rationale for including or excluding particular age-defined or ability-defined populations;
- Affirm a draft framework for the paper and recommendations;
- Provide feedback on existing Australian and international physical activity guidelines in the context of the developed framework;
- Identify key additional areas that the recommendations would need to ensure are covered;
- Ensure the draft guidelines framework would address key sub-groups including older people from culturally and linguistically diverse backgrounds (CLDB) backgrounds, those who have been sedentary long-term, those with physical and psychological co-morbidities, and issues around the built environment.
- Using the World Health Organisation (WHO) guidelines (1997), Bauman (2004) provides a useful conceptual model for the benefits of physical activity. The model’s domains range from disease prevention and the amelioration of risk through physical, functional and psychological to social health benefits. These domains can be used as a classification system for the health benefits.
- Weighting of risk associated with activity versus inactivity.
Figure 1.1 Project activity flowchart
To ensure that the recommendations are contextually relevant across Australia and that particular sub-groups, such as rural and remote communities are properly accounted for, the project team established a National Consultative Network. Key stakeholders were informed about the project, and provided with opportunity to have input to the project through a variety of avenues. The key stakeholders represented a broad cross section of health professionals and organisations (Appendix 1). The following strategies were used:
- An information sheet was forwarded to all peak and state bodies representing aged care, chronic disease, sports and recreation, such as Aged and Community Services Australia, the Royal College of Nursing, the Royal Australian College of General Practitioners, the Australian Divisions of General Practice, NARI volunteers list, Age Concern, National Seniors Foundation, the Council on the Ageing and the Alzheimer's Association.
- Establishment of a web page to provide information about the project and provide a mechanism to receive feedback from interested individuals. This was hyperlinked with relevant sites, including Ageing Research Online and the Australian Association of Gerontology.
The National Consultative Network facilitated rapid and ongoing communication with stakeholders and other interested parties. By promoting awareness of the project, relevant stakeholders were able to consult with others and consider their input and inform the development of this document and draft recommendations.
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Phase 2: Reviewing the evidence and existing guidelines
Aim:The aim of the literature review was to firstly identify the evidence related to the benefits of physical activity in older people. A second aim was to evaluate the level, quality, strength and relevance of this evidence, to identify any gaps in the literature. Additionally, any similar Guidelines that have been produced internationally were obtained and reviewed in the context of the objectives of this project. This information was used to construct recommendations.
Searches:A review of literature identified the evidence regarding physical activity in older people. All available evidence pertaining to prevalence, strategies and safe models of adoption were reviewed, graded and summarised. In addition to literature specifically about healthy older people, we included literature relevant to the following population sub-groups: Aboriginal and Torres Strait Islander populations, culturally and linguistically diverse (CLDB) populations, rural and remote communities, people with multiple co-morbidities, those with dementia, and those in residential aged care. Documentation related to physical, psychological and social outcomes were included. The scope of the literature review was limited to:
- Systematic reviews published in all key areas related to physical activity outcomes for older people;
- Randomised controlled trials published in areas where there are systematic reviews, that were published after publication of the systematic review;
- Areas deemed relevant where there are no systematic reviews or randomised controlled trials.
Inclusion criteria:Published studies in English in peer-review journals and systematic reviews from the Cochrane Collaboration were included. Studies from countries with comparable health and older people’s support systems to Australia, with similar social or cultural values, were sought.
Exclusion criteria:Articles published in languages other than English were excluded, plus articles based on personal, expert opinion and literature reviews.
Search terms:We used search strategies previously successfully used by others and ourselves (Appendix 3). For example, older person related terms used in the Getting Australia Active II report (Bull, Bauman et al. 2004) were complemented by strategies focusing upon RCTs and systematic reviews . We updated the search conducted by Cyarto and colleagues (2004) on the effectiveness of physical activity intervention studies in older adults to incorporate evidence about a range of activity types for older people with varying health status.
Evaluation strategies:The evidence was rated according to the NHMRC (1998) criteria and scored using established scales produced for assessing the scientific quality of trials and reviews respectively (Oxman and Guyatt 1991; Verhagen, deVet et al. 1998; Hoving, Gross et al. 2001):
- Level of evidence. This rating system refers to the design of reviewed studies.
- Level I A systematic review of all relevant Randomised Controlled Trials (RCT)
- Level II At least one properly designed RCT
- Level III-1 Well-designed pseudo-RCTs
- Level III-2 Comparative studies with concurrent controls and allocation not randomised, case-control studies or interrupted time series with a control group
- Level III-3 Comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group
- Level IV Case series, either post-test or pre-test and post-test.
- Quality of evidence. This rating refers to the quality of the methods used in a study to minimise bias. This factor is calculated by items in the scoring indices (Verhagen, deVet et al. 1998; Hoving, Gross et al. 2001)
- Strength of evidence. This classification refers mainly to the magnitude of the intervention effect. This is based on effect sizes or upon the level of evidence.
- Relevance of evidence. The relevance of outcome measures and the applicability of the study results to the clinical question are considered by this criterion. This factor is calculated by items in the scoring indices (Verhagen, deVet et al. 1998; Hoving, Gross et al. 2001).
In limited circumstances (primarily where in areas where there was a lack of systematic review / randomised controlled trial evidence, or where the issue of relevance was not amenable to quantitative evaluation), qualitative studies were reviewed and examined using the criteria for systematic reviews outlined in the Campbell Collaboration guidelines (2001). Decisions on material for inclusion in the recommendations were made based upon the rating of the evidence. A formal consensus process was used to decide upon the inclusion of Level III or IV evidence. Studies with relevance scores of either 3 or 4 were used in developing this document. Qualitative studies with a quality and strength rating greater than 9 were referred to.
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Assessment of existing physical activity guidelines:Recommendations often differ across guidelines on the same topic. These differences can be due to a range of factors: insufficient evidence, differing interpretations of the evidence, unsystematic guideline development methods, the influence of professional bodies and cultural factors (e.g. differing expectations of risks and benefits, socio-economic factors or characteristics of health care systems). The Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration has sought to address this situation. The AGREE instrument aims to systematically evaluate guidelines (The AGREE Collaboration 2001). Although this instrument has been designed with clinical practice guidelines in mind, relevant components were used as a template for the assessment of the available physical activity guidelines.
Many of the existing regional, national and international guidelines have been published in a format for consumers. Where possible, we liaised with the funders and authors of such guidelines in order to evaluate how the guidelines were produced, to fully understand the context for their development and the extent to which they are based upon the prevailing evidence base.
A summary of the strengths and weaknesses of identified existing international guidelines / recommendations for physical activity for older people was developed by the project team, and circulated to the expert advisory group to inform the development of the Recommendations.