Intended for healthcare professionals

Education And Debate Care of older people

Promoting health and function in an ageing population

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7288.728 (Published 24 March 2001) Cite this as: BMJ 2001;322:728
  1. Gary R Andrews (g.andrews{at}flinders.edu.au), director
  1. Centre for Ageing Studies, Flinders University, Science Park, Bedford Park, SA 5042, Australia

    This is the second in a series of four articles

    To ensure the health and wellbeing of the growing numbers and proportion of older people during the opening decades of the new century will require greater effort in health promotion and disease prevention in old age. This article reviews evidence of the effectiveness of strategies for promoting health and function, particularly the benefits of exercise in old age.

    Summary points

    Evidence points to an overall decline in the prevalence of disability in successive cohorts of older people

    For maintaining health and function in ageing, the social, mental, economic, and environmental determinants of health in old age must be taken into account

    The health benefits of exercise may often relate to psychosocial as well as direct health gains

    Most of the health benefits can be gained from regular physical activity of moderate intensity

    Health and wellbeing at older ages is modifiable, and substantial gains could be made by promoting health and fitness throughout life

    Does disability inevitably accompany ageing?

    The extent to which age, chronic disease, and disability are interrelated—and the extent to which population ageing is inevitably accompanied by increased prevalence of chronic disease and disability among older people—remains controversial. In the early 1980s Fries argued that there would be an upper limit to life expectancy but that the onset of morbidity (illness and incapacity) could ultimately be postponed until about the age of 85 and there would thus be a “compression of morbidity.”1 The period of healthy life would thus be extended, he postulated, and the period of morbidity could potentially be “compressed” into the brief interlude between 85 and “natural death.” Other interpretations have offered a more pessimistic scenario: people are living longer because the fatal consequences of certain illnesses have been controlled but the chronic effects of the underlying illness remain, thus ensuring that people spend an increasing proportion of the extra years in poor health. Between these two extremes, a third interpretation has been offered—the concept of “dynamic equilibrium.” This views the prevalence of chronic disease as increasing, whereas the progression of some degenerative diseases has been reduced, with the result that people might suffer chronic illness for a longer period, but with less serious effects.2

    Recent evidence generally points to an overall decline in the prevalence of disability among successive cohorts of older people—at least in US studies—and suggests that scope exists for further positive intervention.3 In the United Kingdom, the Royal Commission on Long Term Care, after weighing up the available evidence, concluded that scientific evidence supported the view that “the factors which are causing us to live longer are also resulting in extra years of life being free from disability.”4 The commission however, called for more research and particularly for population based longitudinal studies to study this phenomenon further.

    Improving the prospects of health and freedom from disabling states at older ages does seem possible. The key questions in this debate, however, are: can the onset of chronic disease associated with old age and accompanying disability be prevented, slowed, ameliorated, or reversed, and can health promotion and prevention of disease in old age be both effective and cost efficient?

    A whole systems approach

    The World Health Organization (WHO) has argued for a proactive and positive approach to dealing with the risk of chronic disease in old age.5 The organisation proposed a “life course” approach for dealing with the health issues associated with ageing and recommended implementing programmes that are oriented towards positive interventions in earlier life. Evidence also exists that some aspects of health and function in later life may be determined in early life, even in utero.6 The ageing and health programme was launched by the WHO in 1995, with the following components: life course, promoting health and wellbeing, culture, gender, intergenerational relationships, and ethics. This programme helped to created a much broader approach to health promotion, with a strong community focus rather than an individual focus, and taking account of the social, mental, economic, and environmental determinants of health in old age.7

    National governments have pursued broad approaches to promoting health in old age. In Canada, for example, policies have addressed income and social status, social support networks, education, employment and working conditions, physical environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, and health services.8 The US surgeon general's 1998 report on health promotion and ageing highlighted preventive health services, drug treatment, dental health, injury prevention, mental health, alcohol, smoking cessation, nutrition, and physical fitness and exercise.9 These topics were selected because in these areas (a) scientific information is sufficient to identify actions that will have positive impacts; (b) constituencies are available to implement recommendations; and (c) substantial interest exists.9

    The report also recommended further research into degenerative processes, the benefits of physical exercise, safe levels of physical activity, and the social and cultural determinants of maintaining an active life.

    Benefits of physical activity in ageing

    The most substantial body of evidence for achieving healthy active ageing relates to the beneficial effects of regular exercise. Increased physical activity is associated with a reduced incidence of coronary heart disease,10 hypertension,11 non-insulin dependent diabetes mellitus,12 colon cancer,13 and depression and anxiety.14 In addition, increased physical activity increases bone mineral content,15 reduces the risk of osteoporotic fractures,16 helps to maintain appropriate body weight,17 and increases longevity.18 Substantial evidence exists that lost fitness can be regained with regular physical activity, even in extreme old age.19 Strength training does not halt the underlying loss of muscle fibres, but the improvements in strength reported in studies of exercise training in older people may be equivalent to 10 to 20 years of “rejuvenation” and may prevent an individual from falling beneath functionally important thresholds. 20 21


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    It is worrying, however, that older people may be confused about the benefits of exercise.22 A Scottish study that investigated older people's perceptions of ageing, health, and exercise concluded that promotion of activity should emphasise its social rewards and should use different strategies for people who are already active and for those who take little or no exercise.23

    An earlier Finnish report showed an association between regular and intensive physical exercise and self rated meaningfulness of life and better subjective health.24 A higher prevalence of depression was significantly associated with no regular physical exercise. The results suggested that involvement in physical exercise may promote positive perceptions of psychological wellbeing among elderly people. On the other hand, psychological wellbeing seemed to be an important predictor for staying physically active at advanced ages. These findings are based on a cross sectional study and therefore leave open the question of direction of causality.

    A growing body of new research has shown that most of the health benefits can be gained from regular physical activity of moderate intensity (the equivalent of brisk walking at 3 to 4 miles an hour (5-6 km/h) for most healthy adults) rather than formal exercise programmes.25-27

    McMurdo has emphasised that it is unfortunate that public health advice has failed to shake off the high tech “lycra clad” image of aerobic exercise and physical fitness; he suggested that advice should embrace the broader concept of health and physical activity—walking, dancing, bowling, or gardening.28 The social benefits of group exercise activities in later life should not be underestimated in a population where social isolation and loneliness may be common.

    Conclusion

    Health and wellbeing at older ages is modifiable, and substantial gains could be made by investment in promoting health and fitness throughout life.29 The determinants of health at older ages are complex. Health promoting activities at any stage in life should be sufficiently broadly based to take into account social and psychological elements in the design, conduct, and possible outcomes of the primary interventions that are chosen.

    Footnotes

    • Series editor Ian Philp i.philp{at}sheffield.ac.uk

    • Funding No special funding.

    • Competing interests None declared.

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