Why is physical activity important for older people? The United Kingdom (UK) Chief Medical Officers recently published a report on physical activity (PA) for health, which has drawn upon recent international large scale reviews of the evidence of the impact of physical activity on health and included a specific chapter on older adults [1]. The following benefits for older adults are described: reduced mortality; a reduced risk of over 20 diseases and conditions (including cardiovascular disease, diabetes, obesity, osteoporosis, several cancers, depression, dementia); reduced falls risk; and improved function, quality of life and emotional well-being [1]. These effects are of major importance to both older people and society, with the annual direct cost of physical inactivity to the National Health Service (NHS) across the UK recently estimated at £ 1.06 billion [1].
What are the physical activity guidelines for older people and how much do older people actually do? Older adults are advised to be active daily and over a week their activity should add up to at least 150 minutes (2 ½ hours) of moderate intensity activity in bouts of 10 minutes or more, for optimum health benefits. One effective way to achieve this is to do 30 minutes moderate intensity activity on at least 5 days a week [1–3]. Moderate intensity PA makes you warm and increases breathing and heart rate, but should allow talking. Regular walking is the commonest PA of older adults, walking at a moderate pace of 3 miles (5 km) /hour expends sufficient energy to qualify as moderate intensity PA [4]. Faster walking speeds are associated with reduced mortality in older adults [5]. Both adults and older adults are also advised to minimise the amount of time spent being sedentary (sitting) for extended periods [1]. UK public health policy now has an emphasis on helping older adults to increase their physical activity, particularly walking [1, 6, 7]. These policies are reflected in local initiatives such as Health Walks and GO Active (Get Oxfordshire Active). However, less than 20% of 65–74 yr olds in England report achieving these recommended physical activity levels [8]. The majority of older adults not walking can do so [9]. Since walking is unreliably recalled [10], surveys may overestimate physical activity. Objective accelerometer measurement found only 2.5% of those aged 65 and over [11] achieved recommended physical activity levels.
How can older adults increase their physical activity? A critical review and a best practices statement on older adults’ physical activity interventions advised home rather than gym-based programmes and behaviour change techniques (e.g. goal-setting, self-monitoring, building self-efficacy and social support and relapse prevention) rather than health education alone [12, 13]. These and other effective behaviour change techniques are emphasized in the NHS Health Trainer Handbook, based on several theories of health behaviour change and intended for NHS behaviour change programmes, with local adaptation [14]. National Institute for Health and Clinical Excellence (NICE) public health guidance on behaviour change also concluded that the evidence did not support any particular model of health behaviour change and that training should focus instead on generic competencies and skills rather than specific models [15]. Starting low, but gradually increasing to moderate intensity is promoted as best practice, with advice to incorporate interventions into the daily routine (e.g. walking) and to monitor intensity for progression [13]. A recent systematic review of interventions to promote walking concluded that interventions tailored to people’s needs, targeted at the most sedentary or at those most motivated to change and delivered at the individual or household level, can encourage people to walk more [16].
What are the risks from increasing physical activity for older people? Whilst there are risks for older people associated with regular physical activity, the risks of a sedentary lifestyle far exceed them [13]. Moderate intensity physical activity carries a low risk of injury [17], the commonest adverse events are musculoskeletal injury or falls [18]. Walking appears to be very low risk and has been described as a near perfect exercise [4]. Screening all participants before taking part in physical activity programmes is no longer advocated, as there is a very low degree of risk for light to moderate intensity physical activity [19], but the best practice statement advises that older should have risk management strategies for prevention of activity-related injuries; the most important being to start with low intensity physical activity and increase intensity gradually, the “start-low-and-go-slow” approach [13, 20].
Can activity monitors help to increase physical activity? Pedometers provide direct feedback on physical activity frequency (step-counts); accelerometers require computer analysis but also provide a time-stamped record of step-counts and physical activity intensity (activity counts) for feedback about specific activities. A systematic review found pedometer users increased steps/day by 2491(1098–3885) and physical activity levels by 27%, but information on older adults was limited [21]. A recent, larger American randomised controlled trial (RCT) (n = 147) in older adults showed an increase of 1320 steps/day at 12 weeks [22]. A Scottish pedometer study of 210 older women found that physical activity was increased at 3 months by a pedometer plus behaviour change intervention (BCI), but the provision of pedometers yielded no additional benefit to the BCI apart from reducing drop-outs, and increased physical activity was not sustained at 6 months [23]. A further Scottish study recruited 41 older adults into a primary care pedometer programme and found that step-counts were significantly increased from baseline to week 12 and maintained at week 24, with associated improvements in quality of life and reduced sedentary time [24, 25]. Two other recent trials in older high risk patients (cardiac patients n = 65, and impaired glucose tolerance n = 87) have shown sustained increases in step-counts at 12 months [26, 27]. Our study is larger than any other pedometer intervention with older adults and has longer follow-up than other community based studies. The Scottish studies have measured outcomes with accelerometers, but have not fed back accelerometer information to participants. Two small studies showed promising results from feedback, but neither included older adults [28, 29]. Accelerometers are acceptable to older adults [11, 30] and can monitor physical activity intensity, as advised [13]. Our previous work with older people using these monitors demonstrated that 99% (238/240) of those recruited provided data on at least 5 full days of wear (>10 hours) after 7 days of monitoring [11].
What is primary care’s role? Primary care is accessible and offers continuity of care for older people, with many chronic diseases being an indication for increasing physical activity. New NHS Health Checks being rolled out in primary care by 2013, include adults up to age 74 and incorporate advice on increasing physical activity, particularly regular walking, often by primary care nurses [31]. Health professional physical activity advice is individually tailored [32] and has greater impact than other advice [33]. Primary care nurses have been shown to be effective at increasing physical activity, particularly walking, in this age group [34]. Physical activity promotion by other routes for this age group is unlikely to be as effective [35]. Recent guidance on prescribing exercise in primary care reinforces the importance of follow-up to chart progress, set goals, solve problems and identify and use social support [36] this will be an important feature of the nurse physical activity consultations in this trial. A large primary care trial is comparing home based with community group exercise [37], but is not examining a primary care pedometer-based intervention. Others have adopted this approach in a small sample with success, but called for a larger trial to confirm findings [25]. Evaluation of the UK Step-O-Meter Programme, delivering pedometers through primary care, showed self-reported physical activity increases, but advised investigation with a RCT design [38].
Rationale: A pedometer-based walking intervention, delivered through primary care nurse physical activity consultations, based on established behaviour change techniques and with 12 month follow-up, needs testing in older adults. Accelerometer use, to assess physical activity outcomes and to provide feedback on physical activity intensity as an intervention, in addition to pedometer feedback, also requires testing.
Study aims: The main hypothesis to be addressed is whether or not an intervention based on pedometer and accelerometer feedback combined with practice nurse physical activity consultations in primary care is effective in helping people aged 60–74 years to increase their physical activity levels over a three month period and to maintain any increase over a year. The study will also assess whether any effect is modified by age, gender or taking part as a couple and will estimate the effect of the intervention on patient reported outcomes and anthropometric measures.
