“Adding Life to Years, Not Just More Years to Life" Part I – The Plight

Disease during the 20th century progressed through three separate eras: (a) era of acute or infectious disease; (b) era of chronic disease; and (c) the era of senescence (Guyer, Freedman, Strobino, & Sondik, 2000). The era of acute or infectious disease existed in the early 1900's. During this time infant mortality rates were very high and the leading causes of death for all people were due to infections such as tuberculosis, smallpox, measles, influenza, diphtheria, whooping cough, scarlet fever, and typhoid (Guyer, Freedman, Strobino, & Sondik, 2000). Today most infectious diseases are curable and there has been a drastic reduction in deaths from infectious diseases (Guyer, Freedman, Strobino, & Sondik, 2000). Between the years 1900 and 1998, the percent of childhood deaths caused by infectious diseases decreased from 62% to 2% (Guyer, Freedman, Strobino, & Sondik, 2000).

We are currently in the era of chronic disease . With the near eradication of infectious diseases, chronic diseases such as cardiovascular disease, cancer, and stroke have become the most prevalent health problems (O'Neil, 2003). According to O'Neil (2003), about half of all disabilities among older Americans were caused by chronic disease conditions. The top causes of mortality for all adults in the United States were the following: (a) heart disease; (b) cancer; (c) cerebrovascular disease; (d) chronic lower respiratory disease; (e) accidents; (f) diabetes; (g) influenza/pneumonia; (h) Alzheimer's disease; (i) kidney disease; and (j) septicemia (Arias & Smith, 2003). Most of the diseases listed are chronic in nature. Heart disease is responsible for almost one-third of all deaths in America and has had the infamous title of being the number one cause of death for most of the 20th century (Murphy, 2000). Murphy reported that during 1910 it became the leading cause of death and has remained the top killer (with the exception of the 1918-1920 influenza pandemic). Heart disease is the number one killer of older adults within the United States (Arias & Smith, 2003). The top ten causes of death, in rank order, for people age 65+ is (a) heart disease; (b) cancer; (c) cerebrovascular disease; (d) chronic lower respiratory disease; (e) influenza/pneumonia; (f) diabetes; (g) Alzheimer's disease; (h) kidney disease; (i) accidents; and (j) septicemia (Arias & Smith, 2003). Heart disease, cancer, and stroke are responsible for 60% of all deaths in people age 65 and over (O'Neil, 2003). In all people including older adults, sedentarism is a major risk factor for heart disease (American College of Sports Medicine, 2000). Luckily, there is evidence that moderate levels of physical activity and exercise provides protection from chronic diseases such as heart disease, breast cancer, type 2 diabetes, overweight, and bone loss (DiPietro, 2001; O'Neil, 2003).

People age 85 are the fastest growing group of older adults and generate the greatest demand for health and long term care services (O'Neil, 2003). The percentage of this age group who rated their health as good/excellent has declined between 1982 to 1999 (O'Neil, 2003). When older people are questioned about their fears associated with aging “fear of death” is usually not cited but, instead, fears of chronic disease, pain, decreased mobility, senility, memory loss, and dependence upon other people are cited (Westerhof, Katzko, Dittmann-Kohli, & Hayslip, 2001). Issues pertaining to “quality of life” are becoming increasingly important. According to Rejeski and Mihalko (2001), quality of life is defined as a conscious cognitive judgment of satisfaction with one's life. Older adults prefer quality of life over longevity and that goal can be achieved through participation in exercise and physical activity (Rejeski & Mihalko, 2001). For example, using a survey instrument (Quality of Life after Myocardial Infarction - QLMI), cardiac rehabilitation patients reported better scores than did control subjects after 8 weeks of exercise therapy (Oldridge et al., 1998). According to Wielenga, Erdman, and Huisveld (1998), exercise helped older men with heart disease to perceive themselves as less disabled and increased their general well-being more than controls. People do not necessarily desire to have a “longer” lifespan but, instead, a “healthier” lifespan for as long as possible. This idea is congruent with the official motto of The Gerontological Society of America , “Adding life to years, not just more years to life” (Rejeski & Mihalko, 2001; p. 33). In the medical field, “quality of life” has been used synonymously with the term “health-related quality of life” or simply “health status” (Rejeski & Mihalko, 2001). Older adults desire to maintain their health status and a have a high quality of life up to the time they die. This scenario illustrates an important theoretical concept called “compression of morbidity.”

One very important goal for gerontological public health is to increase the number of years of life lived for people in a healthy non-dependent condition for as long as possible until the time of death (Bryant, Beck, & Fairclough, 2000). The theory of “compression of morbidity” states, if the age at which chronic disease increases more quickly than the increase in average life expectancy, then the time period of disability between disease onset and death is shortened or compressed (Mathers, Sadana, Salomon, Murray, & Lopez, 2001). This critical period of time is of key importance from a public health perspective because as more and more people live to old age, the job of compressing morbidity will become difficult. McMurdo (2000) stated there is evidence to show that compression of morbidity is already occurring but primarily among affluent educated older adults. Engagement in exercise is an effective means to achieve healthy outcomes in the latter years of life. Physical activity is a key factor in avoiding or shortening periods of disability prior to death in old age (DiPietro, 2001; Leveille, Guralnik, Ferrucci, & Langlois, 1999).

There are many ways of addressing health and healthy aging (Bryant, Beck, & Fairclough, 2000; Glanz, Lewis, & Rimer, 1997; U.S. Department of Health & Human Services, 2000). According to Edlin, Golanty, and Brown (2002), health is a multidimensional state of sound physical, mental and social well-being. Health, as defined by the World Health Organization (2003) since 1946, is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health and fitness professionals believe that chronic disabling health conditions are more easily prevented than cured. Implicit within these concepts is the issue of lifestyle modification, which can be obtained through the following efforts: (a) increase behaviors that are conducive to health, (b) enhance awareness of the importance of health, and (c) promote environments that support health (Bryant, Beck, & Fairclough, 2000).

Both terms exercise and physical activity are similar in that they both refer to movement, contraction of skeletal muscle, and result in energy expenditure. Technically, however, there is a difference between exercise and physical activity. According to the American College of Sports Medicine (ACSM, 2000), Exercise is defined as “planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness (ACSM, 2000, p. 4). According to McMurdo (2000), exercise is defined as planned physical activity scheduled into the day for the purpose of achieving health and fitness benefits. Physical activity is defined as “bodily movement that is produced by the contraction of skeletal muscle and that substantially produces energy expenditure” (p. 4). The question arises, how much exercise is needed to achieve health benefits? According to the Center for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) recommendations, “Every U.S. adult should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week” (Pate et al., 1995, p. 402). It has been found that even small increases in lifestyle physical activity in sedentary people leads to a decreased risk in cardiovascular disease and improved quality-of-life (Dunn et al., 1999). The ACSM position stand on exercise and physical activity for older adults specifically recommended that all fitness programs for older adults should incorporate endurance exercises (walking, swimming and cycling) as well as strength and flexibility training of major muscle groups in both the upper and lower extremities (Mazzeo et al., 1998). The ACSM Position Stand specifically stated that even frail and very old individuals should participate in such exercise programs.

Aging, as defined by Spirduso, Francis, and MacRae (2005), is a continuous process within all living things that, with the passage of time, leads ultimately to losses in adaptability and functional ability. Aging rarely causes death but, instead, death is due to the body losing its capacity to withstand internal or external stressors. Disease and age-related physical decline do not have to be inevitable consequences of aging (Blackman, Kamimoto, & Smith, 1999). Exercise provides a coping mechanism and a way to adapt to stressors as humans age. Exercise has an ameliorating effect on cardiovascular health, obesity, blood profiles, osteoporosis, psychological well-being, and functional ability (Robert Wood Johnson Foundation, 2001). Functional ability, health, wellness and disability of older people are modifiable and great gains can be achieved by promoting health and fitness in the older adult population (Allaire, et al., 1999; DiPietro, 2001). Functional independence is defined as the ability to conduct activities of daily living without difficulty and the attributes that lead to functional decline with aging such as decreased strength, muscle mass, aerobic capacity, and balance are reversible or modifiable even within the frail elderly population (Fiatarone, 1996).

Walking ability and participation in exercise or physical activity is integral to the independence of older people. According to Leveille, Guralnik, Ferrucci, and Langlois (1999), physical activity was a key factor that increased the likelihood of avoiding disability prior to death in old age and independence within seniors is closely tied with two factors, manipulation skills and locomotion skills, with walking ability being the most important locomotion skill. “Stay strong and live long” was the message that Davis, Ross, Preston, Nevitt, and Wasnich (1998) took away from their study of older women. They showed that greater levels of physical activity, greater strength, and lower body mass index were all associated with improved performance of activities of daily living. The physically active older adult has an advantage over those who are sedentary.

According to Fiatarone et al. (1990), strength training done over an 8-week period had beneficial results in 10 frail elderly subjects (age 86-96). In their study only the knee extensor muscles were trained. Quadricep strength improved 177%, improvements in independence and mobility occurred, two subjects eliminated the use of their walking canes, and one wheelchair-bound subject was able to rise from a wheelchair without using their arms. Ironically, 90% of frail institutionalized elderly are not provided therapeutic exercise programming (Council on Aging and Adult Development, 2000). Sedentary older adults typically have decreased exercise tolerance and are living below, at, or slightly above their threshold of physical ability (Malbut-Shennan & Young, 1999). A minor illness is all that is needed to render them fully dependent upon others whereas physically active elders have a “cushion” to help them get through their setbacks (Laukkanen, Kauppinen, and Heikkinen, 1998; McMurdo, 2000). Exercise can produce drastic improvements in functions essential during old age and postpone physical deterioration for perhaps 10-20 years (Malbut-Shennan, & Young, 1999). Twin cohort studies have shown physically active twins were 29-43% less likely to die prematurely than their sedentary counterpart (Kujala, Kaprio, Sarna, & Koskenvuo, 1998).

Since the time of Hippocrates (460-370 B.C.) the danger of sedentarism and benefits of exercise have been known. Hippocrates stated, “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health” (Berryman, 2000). If health and independence are integral to achieve a high quality of life and physical activity is a necessary requirement, one might surmise that older adults would be highly committed to engagement in exercise. On the contrary, in the United States it appears that with increasing age comes a decrease in levels of exercise and physical activity (Robert Wood Johnson Foundation, 2001). According to O'Neil (2003), in the year 2000 on average 35% of all older adults reported no physical activity during their leisure time. The state by state report card indicated all states failed to meet the year 2000 leisure time physical activity target goal of 22.0% participation with Utah ranking 1 st and Kentucky ranking 51 st at 22.4% and 50.4%, respectively (O'Neil, 2003). Crespo, Ainsworth, Keteyian, Heath, and Smit (1999) showed the prevalence of physical inactivity does indeed increase with advancing age. They found over one-fourth, one-third, and one-half of the people were completely sedentary in the age groups 60-69, 70-79, and 80+ years, respectively (see Table 1 ). Additionally, females had higher prevalence rates of sedentary behavior than males in all age categories ranging from 20-29 through 80+ years of age.

Table 1

Prevalence Rates of Adult (Age 20 -80+) Sedentary Behavior

Note. Data modified from Crespo, Ainsworth, Keteyian, Heath, and Smit (1999). All data are age-adjusted.

Pratt, Macera, and Blanton (1999) found that sedentarism increased for males with increasing age and at 65 and 75 years of age the percentage of men who were sedentary was 32% and 37%, respectively. These same researchers found that sedentarism generally increased for females as well when they found at 65 and 75 years of age the percentage of women who were sedentary was 36% and 47%, respectively. Pratt, Macera, and Blanton (1999) showed that levels of recommended leisure time physical activity were highest in men during young adulthood, decreased during middle age, and increased again at retirement age but this effect was absent in women. It was concluded by Pratt and colleagues that there was perhaps less social acceptance of physical activity for older women compared to men.

It is important to gain an understanding of what exercise-related behaviors older adults engage in and the reasons or motivations for their behaviors (American College of Sports Medicine, 2000). “Demonstrating that exercise can be beneficial is less difficult than persuading people to be more physically active” (McMurdo, 2000, p. 2). Behaviors associated with health promotion, such as exercise and physical activity, are notoriously resistant to planned recruitment interventions (Susser, 1995). According to the Physical activity and health: A report of the Surgeon General (U.S. Department of Health and Human Services, 1996), one important goal for the nation is to develop ways to recruit participants to exercise programs or to encourage freestanding or unstructured physical activity. Dr. Karl Stoedefalke, founder of the American College of Sports Medicine, stated that exercise professionals must study and learn what factors motivate older adults to engage in regular exercise (Council on Aging and Adult Development, 2000). By understanding the factors related to physical activity status in seniors, it is possible to develop more effective interventions for promoting regular physical activity (King, 2001). Unfortunately, few exercise-based studies have focused solely on older adults and their motivations behind physical fitness or physical activity (King, 2001). McMurdo (2000) stated more research efforts are needed to study factors that would motivate the senior population to adopt a healthy lifestyle. King (2001) made several recommendations about prioritizing and conceptualizing physical activity and exercise promotion in older adults (see Table 2 ).

Table 2

Major Issues Within Physical Activity Promotion in Older Adults

Unfortunately, not enough research has been done on aging and exercise. Lidor, Miller, and Rotstein (1999) concluded that less than 5% of all studies in exercise science journals addressed seniors. Older Americans should be a primary target audience for increasing levels of exercise (Arent, Landers, & Etnier, 2000). According to Physical Activity and Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 1996), physical activity needs to receive the same attention as other important public health issues that impact the nation such as nutrition, alcohol abuse, and tobacco use.

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1. Is physical inactivity among the elderly population a concern in your country?

2. What are some of the barriers or “excuses” which this population seems to offer in your area or region?

3. What interventions have you found to be effective with this population?

4. What might be done to better “market” physical activity for the elderly?

5. What positive “role models”  or innovative programs have you encountered for the elderly?

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