Functioning, disability and exercise in the elderly

The age of the population is increasing worldwide and is becoming an emerging problem in society. Maintaining physical as well as mental health, together with preventing and reducing disability, particularly in the older population, should be one of the most important aspects of successful aging. Thus, the goals of health programs should be the promotion of successful, active, and healthy aging. Elderly patients are usually associated with multiple medical conditions, which should be evaluated in a multidisciplinary fashion, bearing in mind the needs of this group of individuals. Even though it is assumed that aging is associated with a decline in functioning and, therefore, with reduced functional capacity in the elderly, it is important to identify the factors which play specific roles in healthy and active aging. Special consideration should be given to cognitive functioning. Furthermore, the elderly are at risk, due to habits characteristic of a sedentary lifestyle. Despite the positive effects of physical activity, particularly in the prevention and delay of chronic diseases and conditions, as well as in reducing the risk of premature death and in supporting positive mental health and healthy aging, the elderly population may face obstacles in terms of limited space for the safe execution of activities and the lack of proper knowledge on how to be active while taking into account one’s physical limitations. When planning and implementing a physical activity, especially in the older population, the important factors that need to be considered include duration, frequency, intensity and mode. It should be stressed that exercise programs for the elderly should include aerobic, resistance, flexibility, and balance training.

INTRODUCTION

The age of the population is increasing worldwide and is becoming an emerging problem in society. During the 50-year period between 1900 and 1950, the elderly population doubled in number in the United States of America (USA) – people over the age of 65 years comprised 4.1% of the US population in 1900 and more than 8% of the US population in 1950 [1]. This trend continued, and in 2000 the percentage was 12.6%. It is estimated that in 2050, around 80% of the population of low and middle-income countries will be older people [2]. The review by Arai et al. states that developments in medicine together with improvement in hygiene and food supply have influenced life expectancy in Japan, which is the country with the longest life expectancy in the world [3].

Aging and old age can be approached from the micro-level perspective (individual experience) and the macro-level perspective (experience of older individuals within the society as well as societal implications of population aging) [4]. Maintaining physical as well as mental health, together with preventing and reducing disability, particularly in the older population, should be one of the most important aspects of successful aging [4]. Thus, the goals of health programs should be the promotion of successful, active, and healthy aging [5].

FACTORS ASSOCIATED WITH AGING AND HEALTHY AGING

There are numerous factors associated with the increased age of the population. Among them are increased life expectancy and the decreasing fertility rate in the population [6]. Additionally, there are factors that influence healthy aging. Such factors should be given special attention and they need to be promoted in such a way as to reach every level of society. This should be done through appropriate educational programs. Race, income, and education are considered to be social factors that may potentially influence healthy aging. Recently, other social factors have also been studied, including neighborhoods and different systems, such as the healthcare system [7]. In the study by Liu and Su, the authors state that educational and economic status, health behavior, and social participation may also be factors predicting healthy aging [8]. Among health behaviors, physical activity and diet are very important [9],[10]. It has been established that physical activity has numerous favorable effects, including the prevention of falls, sarcopenia, osteoporosis, and cognitive impairment [9]. Diet might be considered as a potential modifiable factor in preventing age-related diseases [10]. This clearly demonstrates that successful aging is multidimensional and is linked to physical, social, psychological and spiritual aspects of the individual, as well as to the cultural and environmental aspects of the society [11].

AGING AND COMORBIDITIES

Elderly patients are usually associated with multiple medical conditions, which should be evaluated in a multidisciplinary fashion, bearing in mind the needs of this group of individuals. The importance of early detection and timely treatment of comorbid conditions, particularly in the elderly, relates to the fact that comorbidity itself is associated with complex medical management, less favorable health outcomes, and increased healthcare costs that could represent a significant burden [12].

Comorbidities can be associated with the aging process itself, due to increased life expectancy and, therefore, prolonged exposure to numerous risk factors [13]. So far, numerous comorbidities have been described, some of them being cardiovascular diseases (including hypertension, heart failure, stable angina, and other cardiovascular conditions), diabetes, chronic obstructive pulmonary disease (COPD), osteoarthritis, delirium, sensory impairment, and other diseases and conditions [13],[14]. In their study, Fan et al. state that the two most frequent conditions present at the same time are hypertension and dyslipidemia, while the three most frequent conditions present simultaneously are hypertension, dyslipidemia, and diabetes [14].

FUNCTIONING IN THE ELDERLY

Even though it is assumed that aging is associated with a decline in functioning and, therefore, with reduced functional capacity in the elderly, it is important to identify the factors which play specific roles in healthy and active aging. It has been noted that functional capacity presents one of the vital indicators of health status in the elderly population and relates closely to the quality of life in this group of individuals [15]. Functional impairment can be on the individual level (inability to perform everyday activities independently and personal autonomy loss) and on the populational level [15].

Special consideration should be given to cognitive functioning. It has been previously noted that cognitive decline can be detected in older individuals and that cognitive performance is associated with numerous variables, which include socioeconomic factors, health status, social capital, and health behavior [16]. Additionally, cognitive decline might be associated with dementia, medication use, mood shifts, and other [17].

Among the most studied health related aspects of physical fitness and function are body composition and cardiovascular fitness [18]. Muscle and bone mass as well as musculoskeletal and neuromotor function changes might be associated with functional decline [18] in the elderly, leading to various degrees of disability.

DISABILITY AND THE ELDERLY

The increase in the proportion of the elderly in the overall population worldwide, the increase in functional disability, as well as in the social, medical, and economic burden, are becoming more and more relevant. An important aspect of disability is that it can be dynamic over time, progressing to a more severe state.

According to the World Health Organization (WHO), old age disability can be defined as difficulty in performing one or more basic self-care tasks or physical activities of daily living (PADL) or difficulty in performing one or more instrumental activities of daily living (IADL) [19]. The Finnish Centre for Interdisciplinary Gerontology of the University of Jyväskylä defines disability as a mismatch between a person’s abilities and environmental requirements [20]. Furthermore, it is estimated that approximately every fifth individual aged 70 years and above and every second individual aged 85 years and above reports a difficulty in performing PADLs, including bathing, dressing, going to the toilet, maintaining personal hygiene, maintaining bowel and bladder control, feeding, and transferring from chair to bed [19],[20]. It should also be mentioned that IADL difficulties are common, including the use of the phone, housekeeping, doing the laundry, using public transportation, taking medication, and finance handling [20]. The importance of the early detection of existing disability in the elderly population, as well as the introduction of preventive programs, has to do with the fact that disability itself increases dependency on others, as well as the risk of premature death, at the same time reducing a person’s quality of life.

Disability can be related to reduced mobility, which includes difficulty walking, climbing stairs, and performing transfers; it can be related to self-care, which includes difficulty in performing activities related to eating, getting dressed, going to the toilet, maintaining personal hygiene, and bathing; it can also be related to household activities, which includes difficulty in preparing meals, shopping for groceries, performing housework, driving, taking medication, using the telephone, and managing money [21].

There are certain risk factors of disability in the elderly population that should be identified. They can be categorized as non-modifiable risk factors (age, gender, and genetic factors) and modifiable risk factors, which can be subdivided into factors related to the individual (age-related diseases, unfavorable health behaviors, functional limitations, etc.) and characteristics of the environment [20].

It has been shown that dementia in the Japanese population, particularly in those above 75 years of life, is the most frequent cause of functional disability, irrespective of gender [22]. Similar findings were obtained in a study on the Swedish population [23]. Vision and/or hearing impairment also contribute to the presence of disability in the older population. Those with impaired vision, aside from potential difficulties in performing everyday tasks, have a higher incidence of falls, social isolation, and dependency on others [24]. Talking and hearing may be affected in those with hearing impairment, which, therefore, has an impact on socialization [24].

PHYSICAL ACTIVITY AND EXERCISE

Physical inactivity is considered to be the fourth leading risk factor for global mortality and an important risk factor for the development of non-communicable diseases and chronic conditions, as well as for increase in body weight [25]. The elderly are at risk of developing habits characteristic of a sedentary lifestyle, with a range of physical inactivity in individuals above the age of 55 years in Europe spanning from 5% in Sweden to 29% in Portugal [26]. Despite the positive effects of physical activity, particularly in the prevention and delay of chronic diseases and conditions, as well as in reducing the risk of premature death and in supporting positive mental health and healthy aging, the elderly population may face obstacles in terms of limited space for the safe execution of activities and the lack of proper knowledge on how to be active while taking into account one’s physical limitations [27],[28].

When planning and implementing a physical activity, especially in the older population, the important factors that need to be considered include duration, frequency, intensity and mode [29]. According to the WHO 2020 guidelines regarding physical activity and sedentary behavior, it is recommended that individuals 65 years of age and above should be involved in 150 – 300 minutes of moderate-intensity exercise or 75 – 150 minutes of vigorous-intensity physical activity or an equivalent combination of these two, each week, and should perform muscle strengthening exercises twice or more times a week [30]. The Copenhagen Consensus statement 2019: physical activity and ageing states that emerging evidence suggests that beneficial effects can be achieved for older adults at a lower volume and lower intensity of physical activity than the recommended 150 minutes of moderate to vigorous intensity physical activity [31]. It should be stressed that exercise programs for the elderly should include aerobic, resistance, flexibility, and balance training [32].

AEROBIC TRAINING

The elderly population is associated with a decline in cardiorespiratory capacity, which is associated primarily with a decline in maximal cardiac output and changes in arteriovenous difference [33]. Aerobic training can modulate such alterations by inducing central and peripheral adaptations [33]. Such modulations are lowering of the heart rate at rest and during submaximal exercise, smaller increases in blood pressure, whole body insulin action improvement, and plasma lipid concentration reduction [32].

During aerobic exercise, large muscles of the body rhythmically move for sustained periods of time and energy is used through the oxidative metabolism [32]. The following aerobic exercises in the elderly can be considered: walking, treadmill walking, climbing stairs, stationary cycling [33], with individually designed modalities that take into consideration the preferences, physical capacities, and comorbidities of the elderly individual. For example, those with lower back pain or poor balance may be advised stationary recumbent cycling [32].

RESISTANCE TRAINING

Resistance training is beneficial for the elderly who are severely frail [33]. This type of training improves muscle mass, strength, and function, and includes static (isometric) and dynamic (concentric and eccentric) types of exercises [32]. Additionally, this type of training promotes neuronal adaptation (intermuscular and intramuscular coordination) [34] and improves bone density and metabolic health [35]. Furthermore, resistance training is used in the treatment of various symptoms and conditions, including but not limited to, osteoporosis and degenerative joint disorders [34]. For elderly adults with existing pain, isometric strengthening exercises are advised, while for those with poor balance and conditions that may limit weight bearing activity, aquatic resistance exercises are advised [32].

FLEXIBILITY TRAINING

It has been hypothesized that flexibility or range of motion (ROM) in a joint or group of joints declines after the age of 70 years, especially in women [32]. Significant decline in the flexibility of hip and shoulder joints in the population of adults aged above 70 years was observed in a study by Stathokostas et al. [36]. In the elderly population, the goal of flexibility training programs is to improve ROM in the muscle-tendon groups, so as to enable the individual to perform functional everyday activities [37]. The flexibility exercises that can improve ROM include dynamic stretching, static stretching, proprioceptive neuromuscular facilitation, and ballistic methods, which are usually not recommended for everyday exercise [32].

BALANCE TRAINING

In the elderly population, there is a decline in balance control, which affects the individual’s ability to move and function independently [38]. Thus, impaired balance might be a major risk for falls in this population group [38]. When performing everyday activities, both static and dynamic balance are susceptible to change [39]. Therefore, balance relies on the proper functioning of the visual, vestibular, proprioceptive and tactile senses along with an adequate functioning of the neuromuscular system [39]. The recommended exercises include progressively difficult postures, dynamic movement, stressing postural muscle groups, and sensory input reduction (standing with eyes closed) [32]. Examples of exercises include tandem walking, standing on one leg, stepping over objects, climbing slowly up and down steps, turning, maintaining balance in a moving vehicle [33].

CONCLUSION

The elderly population presents a fragile group of individuals with an increased likelihood of functional decline in performing everyday activities, which ultimately reduces their independence and increases the need for the care of these individuals, at the family and community levels. Special attention should be focused on multimorbidity and the increased needs of these individuals, in order to prevent premature death, reduce hospitalizations, and favor positive lifestyle habits and healthy aging. Therefore, preventive measures, implemented at healthcare centers and at the level of the community, are of great importance. Educational programs and awareness raising regarding the impact of health habits are vital in the elderly population, while the timely identification of comorbidities and functional deterioration, as well as a multidisciplinary approach are important for achieving a more favorable outcome in the treatment and follow-up of this population. Finally, a healthy and active elderly population poses a lesser burden to the medical system and the community.