National physical activity recommendations for older Australians: Discussion Document

7. A description and critique of existing guidelines and recommendations

The National Ageing Research Institute was commissioned by The Department of Health and Ageing to review the evidence and develop physical activity recommendations for older people.

Page last updated: 01 February 2011

A number of countries have introduced physical activity guidelines as part of their physical activity promotion policies. These include Canada, New Zealand and Switzerland. Australia introduced physical activity national guidelines in 1999. Like those of most countries, these were targeted at the adult population broadly, and as such are considered not to address the specific needs of some sub-groups, including older people. Other countries such as Brazil and Scotland have adopted existing guidelines, e.g. American College of Sports Medicine, Centres for Disease Control and United States Surgeon General’s recommendations (Pate, Pratt et al. 1995; Mazzeo, Cavanagh et al. 1998). Canada has produced guidelines for population sub-groups, such as children and older people. Australia recently developed national recommendations for children and youth.

All Guidelines and recommendation documents deemed relevant by the project team were evaluated, using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument (The AGREE Collaboration 2001). The AGREE instrument is an instrument designed to provide a standard framework for assessing the quality of clinical practice guidelines. It assesses “both the quality of the reporting, and the quality of some aspects of the recommendations. It provides an assessment of the predicted validity of the guideline, that is, the likelihood that it will achieve its desired outcome. …… Most of the criteria contained in the AGREE Instrument are based on theoretical assumptions rather than on a empirical evidence. They have been developed through discussions between researchers from several countries who have extensive experience and knowledge of clinical guidelines. Thus the AGREE Instrument should be perceived as reflecting the current state of knowledge in the field (The AGREE Collaboration 2001)(p 2).”

Guidelines and recommendation documents reviewed for this project varied widely in terms of their scope, method of development, target group, method and style of presentation, and some have not been developed as clinical practice guidelines (which is the target of the AGREE document). As such, not all the guidelines and recommendation documents reviewed were able to be fully rated with the AGREE instrument, however, relevant sections of the AGREE instrument were completed for these guidelines and recommendation documents.

The following tables provide details of the physical activity guidelines and recommendation documents reviewed (Table 7.1) and a summary of the AGREE evaluation of the guidelines and recommendation documents (Table 7.2). A summary of the physical activity recommendations for older people derived from these guidelines and recommendation documents appears in Appendix 6.
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Table 7.1 Physical activity guidelines and recommendations reviewed.

NoCountryOrganisationTitleYearAGREE Review rating and relevance
1Australia Australian Government Dept. of Health and AgeingRecommendations for children’s and youths’ participation in health promoting physical activity http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-active-recommend.htm2005Not directly relevant, though provides useful framework for considering similar issues in older people.
2Australia National Public Health PartnershipGetting Australia active II http://www.nphp.gov.au/publications/documents/GAA_2_Body.pdf2004Good update of recent research literature (to 2004) on physical activity across the lifespan, though little specifically on the needs of older people or people with disabilities. Provides a useful overall framework for coordination of policy, planning, and research. Rating – Recommend
3Australia New South Wales Dept. of Local GovernmentCreating active communities. Physical activity guidelines for local councils http://www.communitybuilders.nsw.gov.au/building_stronger/vibrant/phys_councils.html2001Promotes physical activity across all ages, has separate section for older people, people from CALD backgrounds, and rural and remote areas. Rating-Recommend
4Australia Diabetes AustraliaNational Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus Part 2 Primary Prevention http://www.diabetesaustralia.com.au/_lib/doc_pdf/NEBG/PP/Part2-Prevention-311201.pdf Part 5 Evidence Based Guideline for the Prevention and Detection of Macrovascular Disease in Type 2 Diabetes (2004) http://www.diabetesaustralia.com.au/_lib/doc_pdf/NEBG/MV/Part5-Macrovascular-180304.pdf2001Part 2 – Primary prevention. Not targeting older people specifically, although relevant for older people with diabetes, and some recommendations are relevant for older people generally. Rating – Recommend
5Australia Australian Government Dept. of Health and Family ServicesDeveloping an active Australia: A framework for action for physical activity and health http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-publicat-document-active-cnt.htm/$FILE/active.pdf1998One of the earlier documents establishing a national agenda in physical activity across the lifespan. Key strategies identified in the areas of education, environments, infrastructure, and monitoring. Useful framework, though literature substantially out of date. Rating – Recommend
6Canada Public Health Agency of CanadaCanada’s physical activity guide for healthy active living for older adults http://www.phac-aspc.gc.ca/pau-uap/fitness/pdf/guide_older.pdf1999Information guide / booklet for older people. Rating–Recommend
7South AfricaSouth Africa Dept. of HealthGuideline for the promotion of active ageing in older adults at primary level http://www.doh.gov.za/docs/factsheets/guidelines/ageing/ageing.pdf2000Appears to be aimed at older people and some physical activity providers. Rating – borderline usefulness
8United States of AmericaNational Public Health PartnershipEvidence-based protocol. Exercise promotion: walking in elders. http://ngc.org/summary/summary.aspx?doc_id=30742002Protocol targets older sedentary people. Based around the Stages of Change model, provides suggested strategies to increase physical activity (especially walking) at each stage. Rating-Recommend
9United States of AmericaThe American Geriatrics SocietyExercise prescription for older adults with osteoarthritis pain: consensus practice recommendations http://www.americangeriatrics.org/products/positionpapers/oae_guidelines.pdf2001Provides an evidence based summary of the research evaluating effects of physical activity (exercise prescription) for older people with osteoarthritis. Includes discussion of assessment, how to start, basic principles of exercise prescription, and details of progression, dosages etc for flexibility, strength training, and fitness activities. Rating – Strongly recommend
10United States of AmericaThe National Institute on AgingExercise: A guide from the National Institute on Aging http://www.niapublications.org/exercisebook/ExerciseGuideComplete.pdf1996Targets older people, written as a guide for older people. Rating- Recommend
11United States of AmericaU.S. Dept. of Health and Human ServicesPhysical activity and health. A report of the Surgeon General. Executive Summary & full report http://www.cdc.gov/nccdphp/sgr/pdf/execsumm.pdf1996Has been a landmark document since published 10 years ago. Covers physical activity across the lifespan, though has little emphasis on older people or people with disability specifically. Currently being updated. Rating-Recommend
12United States of AmericaU.S. Dept. of Health and Human ServicesPhysical Activity for Everyone: Recommendations: Are there special recommendations for older adults? http://www.cdc.gov/nccdphp/dnpa/physical/recommendations/older_adults.htm1999Useful website link, with information and resources specifically for older people and health professionals. Does not consider issues related to frailer older people / those with comorbidities undertaking physical activity. Rating – Recommend
13 World Health OrganisationThe Heidelberg guidelines for promoting physical activity among older persons http://www.who.dk/document/e75205.pdf1996Useful, well laid out, though brief framework for supporting improved physical activity through involvement of policy and planning staff and health workers. Rating – Strongly recommend
14Australia National Heart FoundationNational Heart Foundation of Australia physical activity recommendations for people with cardiovascular disease. http://www.heartfoundation.com.au/index.cfm?page=42 A position statement on these guidelines has been published in the Medical Journal of Australia (16 Jan 2006): http://www.mja.com.au/public/issues/184_02_160106/bri10727_fm.pdf2006Targets people with cardiovascular disease, though much is transferable to other groups with co-morbidities. Rating –Strongly recommend
15United States of AmericaAmerican College of Sports MedicinePosition stand on exercise and physical activity for older adults (Mazzeo, Cavanagh et al. 1998)1998Provides a review of the research evidence on physical activity for older people in five key areas – cardiovascular training, strength training, postural stability and flexibility training, psychological responses to physical activity, and physical activity for the very old and frail. Good summary statement of the evidence at the time of publication (1998), needs to be supplemented with more recent research evidence. Rating – Strongly recommend
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Table 7.2 Review of existing physical activity guidelines and recommendations for older people.

GuidelineAGREE – Scope and purposeAGREE – Stakeholder involvementAGREE – Rigour of developmentAGREE – Clarity and presentationAGREE – ApplicabilityAGREE – Overall assessmentAny useful info for recommendation document
1. Australian Government Dept. of Health and Ageing – Recommendations for children’s and youths’ participation in health promoting physical activityNot reviewedStructure used as basis for discussion document on physical activity for older people.
2. National Public Health Partnership – Getting Australia active II Targets policy / planning staff, researchers, health care workers, and others with involvement in supporting physical activity across the lifespan.Stated aims were to update the research literature, identify gaps and recommend on key areas for development and new investment areas in capacity building and health gains, and consultation, in order to develop a national physical activity strategy and action plan.Collaborative research consortium. Steering group of SIGPAH oversaw the work.Used Bauman 2002 as basis, so literature only updated from that review. Lists 17 independent reviewers / researchers reviewed specific components of the literature update. Minimal new information on physical activity and older people / CLDB reported / people with disabilities.Well presented. Includes sections on update of the epidemiological evidence; update of the research on effectiveness of physical activity interventions; review of national strategy related documents; review of international policies on physical activity; and conclusions and recommendations.Generic for supporting physical activity across the lifespan. Small sections on older people, people with disabilities, and people from CLDB. The chronic disease section is quite limited, covering only overweight and obesity, diabetes, and PRT.Useful overall document, with quite a number of recommendations that are relevant for older people, even though they have been developed for all ages.Figure 5.5 – draft schema for structuring the action components of the national physical activity strategy in Australia – has potential to be modified for older people.
3. NSW Health (Australia) – Creating active communities: Physical activity guidelines for local councils. Target group is local councils. Guidelines are across all ages (not older people specific)Objective clearly defined.Included broad range of stakeholders, including state government, divisions of local government, Heart Foundation, and individual councils. Does not appear to have included older people in the process of development. Does not state if there was any pilot testing of the guidelines.Describes some research throughout, but does not appear to have utilised a systematic review of the literature. Method of formulating the recommendations is not clearly stated, other than review by relevant individuals on the Working Group. Recommendations are generally in line with the research evidence, though there is limited reference to the specific supporting research evidence. Discusses benefits to councils and wider community of supporting physical activity opportunities for all people (reduced injuries, increased feelings of safety). Key issues and specific risks relating to physical activity for older people are discussed (p 92), and also for other key population sub-groups.Well structured list of key principles to increase physical activity across all ages (p5): whole of council approach integrated planning safe and supportive environment activities / events / programs special needs groups (including older people) community involvement partnerships ongoing monitoring & evaluation Examples for councils to implement to meet guidelines are described, and case studies provided. In house training package included for council staff.General physical activity recommendations are provided across all ages, many have direct implications for older people and people with disabilities. No criteria for ongoing review provided. Highlights key issues for older people (p92):increased risk of injury living alone / limited social networking and opportunities cost issues transport issues fear of crime. Has a section also on CALD populations (p108), and rural and remote (p 112).Provides useful framework for councils to consider ways to support physical activity in their communities, which should be more widely generalisable.Key principles (p5) provide a useful framework for organisations to consider their role in promoting physical activity. Highlights importance of ensuring terminology used in promoting physical activity for older people needs to be tailored to what older people perceive to be relevant and important.
4. Diabetes Australia. National Evidence Based Guidelines for the Management of Type 2 Diabetes Mellitus Part 2 Primary Prevention Target group is those with diabetes, and health practitioners working with them.Aims to inform and guide health promoting and preventive activities for Type II diabetes with evidence based information on the effectiveness of non-pharmacological interventions. Guidelines are directed to clinicians, health promotion pract-itioners, policy makers and policy planners. Main focus on 1:1 interventions.Expert Group of researchers, practitioners, and professional organisations.Strong methodology, double review of database searches, double review of most identified research articles. Key issues were identified by the Expert Group. Each issue was supported (based on research evidence) with recommendations, evidence statements, background evidence, summary and evidence tables.Well structured guidelines. A possible limitation for practitioners is the large amount of detail of the supportive research evidence for each section – this might be better presented as a brief snapshot / plain language summary of the research. Recommendations are clearly identifiable. No implementation tools are provided.Highly applicable for people with applicability and generalisability to the older population generally, and particularly older people with diabetes.Not targeting older people specifically, but relevant for older people with diabetes, and some recommendations also applicable to the wider population of older people.Highlights the need for further research evaluating the impact of psycho-social stress or major depression as triggers in increasing the risk of type II diabetes. Also raises the question of whether physical activity outcomes vary for diabetics of differing CLDB.
5. Australian Government Dept. of Health and Family Services – Developing an active Australia: A framework for action for physical activity and health. Targets all AustraliansDeveloped as part of the Active Australia initiative, based on the US Surgeon General’s findings and report.Commonwealth and State / Territory health authorities and experts in some areas of physical activity were involved. Initially involved a national symposium, and a subsequent workshop.Experts, policy and planning staff, and researchers involved. Does not appear to have involved a systematic review. Includes a brief research summary. References cited throughout. Key strategies in a separate section, not directly linked to the supporting evidence. Was externally reviewed by two experts.Generally well presented. The majority of the recommendations are quite general, difficult to implement and monitor. However, reported a plan for an evaluation in 2000, and that baseline measures in physical activity for comparison had already been established for future comparisons.Generic for supporting physical activity across the lifespan. Minimal of direct relevance to older people, however a number of the strategies are applicable to older people.Useful brief summary throughout of key actions to support increased physical activity.
6. Public Health Agency of Canada Physical activity guide to healthy active living for older adults. Written for older adults.Identifies rationale for being / becoming active. Puts strong emphasis on link between physical activity and independence, as well as physical and mental health and quality of life.Stakeholder involvement in development not stated, however the information booklet has been endorsed by extensive range of stakeholders (p 22).Development process not stated.Most recommendations are clearly stated, and supported with statements of likely benefit. Four groupings of physical activity described (endurance, strength, balance, flexibility). Note- combines discussion of balance and strength activities, with focus largely on strength activities (p 8). Would benefit from greater discussion of balance activities.Good discussion of barriers to taking up and sustaining a physical activity, and tips provided to overcome these. A range of useful tools included in the booklet, including checklists, posters, a physical activity diary for completion to monitor progress, and case studies.Well written, plain language booklet promoting both incidental and formal physical activity options. Strong focus on effect of physical activity on independence.Posters, activity diary.
7. Dept of Health, South Africa Target group not clearly defined, but appears to be mostly consumers / older peopleObjectives defined, although very general. States main target group is people over 60 years, but also defines a broad range of other groups who could be targeted for education / training / special at risk groups, who could be involved with the active ageing program.Broad listing of stakeholders consulted (p23), including policy and planning staff, researchers, & non-government organisations (though which ones is not stated). Doesn’t list older people on the list of key Does not state if there was any piloting of the guideline.Not statedRecommendations are not clearly separated from other text. Very broad coverage, divided into 3 main types of physical activity (cardio-respiratory, strengthening and balance). Has a general set of exercises included, but are quite a low level of challenge.Some points are made to support facilitation of participation (p 22).Borderline usefulness overallLists range of medical conditions for which physical activity should only be undertaken with medical supervision (p5, 8). Lists range of risk factors which if present should be screened by a medical practitioner before commencing physical activity (p5, 8).
8. Evidence-based protocol. Exercise promotion: walking in elders.Objectives defined. Aims to provide health care providers with information and strategies to support increased walking among older people.Stakeholder involvement not defined in summary document.Based on a systematic review and evidence based grading of the research literature. Criteria for inclusion / exclusion of studies not provided. Reviewed by series editor for the guidelines, and two content experts.Main part of the document is broken down into recommendations to support increased walking, under headings of each level of the stages of change model. Includes a number of tools to assist implementation, including an exercise promotion knowledge assessment for staff (pre and post education program), a process evaluation monitor, an exercise promotion outcomes monitor, physical activity stages of change questionnaire, physical activity readiness questionnaire, and a balance test.Useful framework for health care providers. Useful tools to support implementation. Lists parameters of walking programs to be monitored (intensity, duration and frequency of walking).Strong focus on stages of change model, and provides suggested strategies to support physical activity (especially walking) for older sedentary people. Useful resource.An exercise promotion knowledge assessment for staff (pre and post education program), a process evaluation monitor, an exercise promotion outcomes monitor, physical activity stages of change questionnaire, physical activity readiness questionnaire, and a balance test.
9. The American Geriatrics Society. Exercise prescription for older adults with osteoarthritis pain: consensus practice recommend-ations. Targets health practitioners involved in management of older people with osteo-arthritisTargets older people with osteo-arthritis, though identifies that over half of all people aged over 65 are affected by osteo-arthritis. Highlights the importance of physical activity in this target group in combination with other management modalities including medication and education.Panel of experts from many disciplines including geriatrics, internal medicine, orthopaedics, physical therapy and rehabilitation, exercise physiology, nursing and pharmacy.Developed based on literature review, and consensus from expert multidisciplinary panel. External review of final draft.Well organised. Provides review of literature, then sub- sections on: - benefits of physical activity for OA patients; - assessment and exercise prescription, including details of starting, and progressing flexibility, strengthening and fitness activities.Directly applicable to older people with osteoarthritis, and likely to be generalisable to some other health conditions. Has emphasis on health professionals assessing and guiding physical activity program together with other elements of care (eg education, medication).Good review of research evidence and practical guidelines for practitioners in helping older people with osteoarthritis to commence and progress physical activity options. Focus on more structured physical activity options.Provides an algorithm for Steps in managing osteoarthritis in older people, highlighting the important role of physical activity (p 816).
10. NIH Targets consumers / older peopleObjectives and target group well described.Primarily (very experienced) researchers involved in development. Does not appear to have been reviewed by older people / consultation group or having been piloted. Target users clearly defined.Strong team of researchers developed the guide. Evidence based, but criteria for selecting evidence and method of formulating evidence not described. Good discussion of risks, but tends to be limited to a small number of clinical conditions. No external review or updating procedure reported.Recommendations not clearly identified, mixed throughout text. Detailed, but simple, non technical language. Provides examples of different types of exercise – generally good, although balance exercises are limited to mostly modified strengthening exercises. Includes tools for monitoring progress and facilitating motivation.Considerable discussion of factors facilitating and barriers to uptake and sustained engagement in physical activity.Generally very good. Perhaps is most useful for older people without many co-morbidities. Perhaps needs stronger focus on incidental activity, and group approaches to physical activity (eg tai chi).Sample exercises, useful tip sheets (in the appendix), daily and weekly activity calendars, monthly progress records, and resource list.
11. U.S. Dept. of Health and Human Services: Physical activity and health. A report of the Surgeon General. Targets practitioners, researchers and policy planners, to support increased physical activity across the lifespan.Aims to summarise the existing literature (1996) on the role of physical activity in preventing disease. Has a general focus across the lifespan. States (p4) that “a review of the special concerns regarding physical activity for … people with disabilities is not undertaken here.”Large number of contributors, mainly academics and researchers, small number of representatives involved from other stakeholder organisations (eg American Alliance of Health, Physical Education and Dance).No formal systematic review of the research literature undertaken, relied on researcher knowledge of research base. Had an expert Group, and a range of expert reviewers. Recommendations were included dependent upon Expert Group’s endorsement of “strong evidence base”. Is currently being updated. Adverse events were considered in the document.Well presented document. Moist information is generic, but a small amount of information is generic, provided about specific sub-groups, including older people No additional tools provided to support implementation.Chapter 6 is devoted to understanding and promoting physical activity behaviours. There is a small section in this chapter on older people.Was a landmark document when first published in 1996, still often referred to as a benchmark. Useful framework for considering key issues in physical activity across the lifespan., though little emphasis on older people, and those with disability. There is a considerable volume of research literature that has been published since this document was published, which is likely to impact upon key recommend-ations. Currently being updated.
12. U.S. Dept. of Health and Human Services – Centre for Disease Control and prevention (website). Targets older people.Not stated.Not statedNot stated, but appears evidence based.Well presented, simple messages.Has a section specifically asking “Are there special physical activity recommend-ations for older people?”Useful brief summary, targeting older peopleWebsite also includes other useful information, including commonly used terms, tips forgetting started (not specific to older people), and resources for health professionals.
13. World Health Organisation – The Heidelberg guidelines for promoting physical activity among older persons. Targets policy & planning staff and health workers with a role in promoting physical activity to older people.Aims to provide guidelines for facilitating development of strategies and policies in both population and community based interventions aimed at maintaining / increasing the level of physical activity for older adults.Method of development not stated.Evidence based, though not clear what processes were involved in development.Simple, well designed framework. Minimalist approach with recommendations.Very relevant.Useful though brief framework for promoting physical activity for older people.Health gradient schematic (p 8). List of barriers (though no list of potential solutions).
14. National Heart Foundation of Australia Targets health care providers involved in providing physical activity recommend-ations for people with cardiovascular disease.Purpose and scope well defined.Broad range of health professionals on expert working group. Does not appear to have been focus group tested; nor other strategies used to obtain patient’s perspective. Target users well defined.Based on NHMRC levels of evidence, though details of paper review process not provided, nor is the process for selecting evidence detailed. The literature review was limited to key national and international publications since the US Surgeon General’s report (1996). Recommendations were developed using an evidence based consensus approach, with guidance from an expert working group, and consultation with major stakeholders. Considerable emphasis placed on precautions / contra-indications to physical activity. Notes the low level of risk associated with walking, gardening and cycling. Medico-legal considerations and risk of adverse events during physical activity are discussed (p 17). Provides a summary table of recommend-ations (p8) and level of evidence, and has supportive text and references in latter part of document.Generally good clarity and presentation. Relates frequently to recommendation of 150 minutes physical activity / week. Management options for main clinical groups (of cardiovascular health conditions) are provided. Has a range of support tools including safety advice when undertaking physical activity, a grading for heart failure, key components of successful physical activity strategies, and an algorithm for implementation of physical activity for people with cardiovascular health disease.Discusses issues general practitioners need to consider to facilitate uptake of physical activity in this at risk group. Also discusses adverse events and medico-legal considerations (p12).Generally good structure, moderate evidence base though not an extensive literature review. Useful algorithm to support engagement in physical activity (p 32). Practical application framework using 5A’s approach (Appendix 4). Includes recommended actions for GPs to support increased patient physical activity (p 20). Covers broad range of cardiovascular related co- morbidities, with considerable relevance to other groups with moderate levels of co-morbidities.Algorithm (p 30) very useful.
15. American College of Sports Medicine Position Stand on exercise and physical activity for older adults. Targets practitioners, policy and planners involved in physical activity for older promotion for older people.Purpose not stated overtly, though provides an endorsed position and recommend-ations for physical activity for older people by the American College of Sports Medicine.Written by high profile researchers in the area of physical activity and older people, and reviewed and endorsed by ACSM members, the Pronouncements Committee, and by independent experts not involved in development of the Position Stand.Extensive review of research evidence, although processes for literature searching / retrieval not described.Well structured, with a brief summary of the research literature, and then recommendations, in each of the five key areas: cardiovascular training strength training postural stability and flexibility training psychological responses to physical activity, and physical activity for the very old and frail.Highly applicable, for well older people as well as those with multiple health problems and frailty.Good summary statement of the evidence at the time of publication (1998), needs to be supplemented with more recent research evidence.

Summary

Many guidelines and recommendations exist for physical activity generally (which include at least a section related to physical activity for older people), and in a few instances, are specifically targeting older people. The guidelines and recommendations vary as to their target audience, rigor of development process, and format. A summary of potential recommendations and support information derived from the reviewed guidelines are included in Appendix 6.
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