The risks associated with physical activity in older people are not too dissimilar from those for other adults. There are contraindications to physical activity, such as uncontrolled angina or blood pressure. Clinically these need to be addressed whether or not a person intends to be physical active and should only be temporary. The American College of Sports Medicine’s 1998 Position Statement on Physical Activity in Older People (Mazzeo, Cavanagh et al. 1998) reviews the evidence for injury in trials and notes that no serious injury nor cardiovascular event has been reported. There have been isolated reports of minor injury e.g. tripping or sprains, but across the wealth of trials, reporting of adverse events has been rare and whilst this may be partly explained by publication bias, it is likely to reflect reality. For example, in an editorial, McMurdo refers to the exercise program run through the University of Dundee, Scotland. This program sees 1000 older participants per week on a self-referral, no screening, no disclaimer basis. Injuries are scarce. Commonly, modifications have been made to programs to ensure their suitability for people with pre-existing health problems, such as osteoarthritis. Overall, the risks of sedentary behaviour appear to outweigh those associated with physical activity.
Given this evidence, there has perhaps been undue cautiousness surrounding encouraging older people to be physically active. The fears possibly stemmed from the reports of adverse events associated with vigorous activity (as encouraged by previous guidelines). There is evidence from the Framingham Study that strenuous activity may be detrimental to older women’s mortality rates (Sherman, D'Agostino et al. 1994). Vigorous physical activity can increase the risk of sudden death, but the individual level risk is outweighed by the benefits (Bauman, Bellew et al. 2002). The current recommendations to begin exercising gradually and with moderate intensity are intended to promote safe physical activity. The evidence reviewed in the current document supports the potential for training even very old people to increase their level of physical activity.
Progression in physical activity intensity is vital. For older people starting or recommencing physical activity, beginning at a low intensity and gradually increasing to a moderate intensity will manage risk. Moderate intensity physical activity has greater potential to produce health benefits. The recent National Heart Foundation guidelines for physical activity discuss indications for specific sub-groups of those with cardiovascular disease requiring medical clearance before commencing physical activity (Briffa, Maiorana et al. 2006). It is encouraging to note that across the published chronic heart failure (CHF) trials, very few adverse events have been reported, no deaths or cardiac arrest and minimal orthopaedic injuries or serious arrhythmic events during training itself and few deaths during the studies (Witham, Struthers et al. 2003). In a systematic review (Smart and Marwick 2004) of 81 studies, representing 2387 people and more than 60,000 person-hours of physical activity there was no significant difference in the likelihood of deaths or adverse events between exercisers and controls with CHF during the trial period and an odds ratio of 0.71 for deaths in exercisers, indicating improved survival. These findings are particularly encouraging since many schemes have been conducted in the home, without telemetric monitoring.
There is consensus that physical activity programs should include a warm-up and a cool down phase. However, a systematic review based on five studies could find no support for the benefit of stretching before or after exercise to protect against muscle soreness, nor significant reduction of injury risk (Herbert and Gabriel 2002). The generalisability of these findings to older people requires testing. For community or residential care based programs, having an emergency procedure plan in place will help to deal with any injuries or adverse events that may arise. Minimisation of risk will also be assisted by the recent introduction of International Curriculum Guidelines to prepare physical activity instructors of older adults. The International Society for Ageing and Physical Activity has produced these in collaboration with the WHO’s Ageing and Life Course section (Ecclestone and Jones 2004).
SummaryPhysical inactivity in older Australians is an independent contributor to many important health problems. The potential benefits of activity for older people are substantial. Most evidence for benefit to mortality and for cardiovascular events is from epidemiological studies. Actual trials of physical activity promotion have been limited in duration and thus more likely to report impact on intermediate health outcomes.
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