How do we encourage our patients to exercise?

Sarah E. Linke, PhD, MPHOctober 25, 2015

Clinical Geriatrics Symposium

Exercise is Medicine

“If exercise could be purchased in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.”

--Robert H. Butler

Current PA Guidelines for Overall Health in Older Adults Aerobic activities (e.g., brisk walking)

≥150 minutes per week of moderate intensity OR

≥75 minutes per week of vigorous intensity Muscle-strengthening activities for

all major muscle groups Flexibility exercises Neuromotor exercises (i.e., balance

and coordination)

≥2 days per week

% of US Adults Meeting PA Guidelines, 2011-2013 (NHIS)

The bad newsCardiac outputLung performanceMuscle mass Insulin sensitivityBone densityMemoryHormone regulation Immune system capacity

Aging

The good newsCardiac outputLung performanceMuscle mass Insulin sensitivityBone densityMemoryHormone regulation Immune system capacity

Aging Activity

Reasons to Exercise Physical health benefits Mental health benefits Stress reduction Quality of life Enjoyment Socializing Self-esteem & self-confidence

Physical Health Benefits Exercise is associated with

improvements/reductions in numerous physical health conditions, including: Premature death Hypertension Cardiovascular diseases Cancer Diabetes Overweight/obesity

Physical Health Benefits Specific to Seniors Prevent falls and fractures Allow greater independence in everyday life Enhance cognitive performance capabilities Improve reaction skills Enhance ability to carry weights Improve flexibility and agility Improve balance Increase life expectancy

Physical Health Benefits Specific to Seniors Decreases the risk of these & other

conditions: Dementia Pain Back pain Congestive heart failure Stroke Constipation Osteoporosis and arthritis

Mental Health Benefits Exercise is associated with

improvements/reductions in numerous mental health conditions, including: Depression Anxiety Substance use disorders Cognitive disorders Severe mental illnesses

Anxiety & Depression Acute effects: immediate and possibly, but

not necessarily, temporary effects arising from a single bout of exercise

Chronic effects: long-term changes over time due to regular exercise

Associations are maintained regardless of the intensity and/or duration of exercise Weight training, yoga, moderate walking

How does it work? Combination of physiological & psychological

mechanisms, including… Physiological explanations

Increases in cerebral blood flow Changes in neurotransmitters Increases in maximal oxygen consumption and

delivery of oxygen to cerebral tissues Reductions in muscle tension Structural changes in the brain

How does it work? Psychological explanations

Enhanced feeling of control Feeling of competency & self-efficacy Positive social interactions Improved self-concept & self-esteem Opportunities for fun & enjoyment

Many other theories/hypotheses, none of which is most widely accepted

Exercise & Quality of Life Increased self-esteem & self-concept Increased feelings of enjoyment Decreased feelings of physiological &

psychological stress Increased feelings of self-confidence Elevated mood states Greater ability to cope with stress and tension

than inactive individuals

Exercise & Sleep in Seniors Randomized controlled trials examining the

effects of exercise on sleep in older adults Total sleep duration, sleep onset latency,

daytime dysfunction, and scores on a scale of global sleep quality showed significant improvements

Reductions in depressive symptoms, daytime sleepiness, and improvements in vitality

Exercise & CognitiveFunctioning Rapidly growing area of research Recent surge in research in the relationship

between exercise & dementia/Alzheimer’s disease risk Perhaps the most critical modifiable risk factor

Chronic exercise shows greater effects than acute exercise But a sufficient amount & intensity of acute activity affects some measures

Exercise as Therapy Adjunct Research support

As effective as SSRIs for major depression in gold standard RCTs

Cost-effective Time-efficient Minimal side effects

So What’s the Problem??

If exercise is so wonderful, why doesn’t everyone “Just Do It”?!

Exercise Attrition/Adherence

Behavior is difficult to change!! Steep drop during the first 6 months Levels off until 18 months

Determinants of Adherence Personal factors

Demographic variables Education, income, age, gender, ethnicity, etc.

Cognitive and personality variables Self-efficacy, self-motivation Exercise beliefs & expectations

Behaviors Early involvement in sport → ↑ adult activity Past behavior is the best predictor of behavior!

Determinants of Adherence Environmental factors

Social environment Spousal support especially critical

Physical environment Convenience, built environment

Physical activity characteristics Exercise intensity and duration

Moderate is best Group vs. individual programs

Groups generally better for adherence, but individual diff. Leader qualities

Reasons for Not Exercising (Perceived) lack of time Lack of energy Lack of motivation Lack of skill Fear of injury Illness/injury Pain Lack of facilities Lack of other resources

It’s not that easy!!! Education is seldom sufficient to promote

behavior change. You also need: Skills to plan and maintain an exercise

program Support from friends, family and society Knowledge about what to do, how much,

how often, etc. The right environment

Guidelines for ImprovingExercise Adherence

Consider individual’s stage of change Help each person discover his/her personal

reason/motivation to exercise Offer choices of activities Make prescribed exercises enjoyable Focus on the immediate benefits of exercise

Improved mood/affect, self-confidence

Exercise Stages of Change

5 A’s for Exercise Counseling

Weighing the Costs vs. Benefits of Exercise Costs of Exercising: _______________________________ _______________________________ _______________________________ Benefits of Exercising: _______________________________ _______________________________ _______________________________

Personal Exercise BenefitsShort-term Benefits

1. _________________________

2. _________________________

Long-term Benefits

3. _________________________

4. _________________________

Importance to Me

1. ________

2. ________

3. ________

4. ________

Guidelines for ImprovingExercise Adherence Tailor intensity, duration, frequency Set goals together

Follow-up with goals & set new ones Include a contract

Provide cues for exercise Leave workout clothes visible

Encourage the individual to schedule time to exercise to make it a routine

Promote & facilitate social exercise

Scheduling Activities

Potential Barriers

1. Barrier: _____________________a. Solution: ______________________b. Solution: ______________________

2. Barrier: _____________________a. Solution: ______________________b. Solution: ______________________

3. Barrier: _____________________a. Solution: ______________________b. Solution: ______________________

Set SMART GoalsSpecificMeasurable AttainableRelevantTimely

Goal Setting Exercise

1) Long-term Goal: _________________a. Short-term Goal: ___________________b. Short-term Goal: ___________________c. Short-term Goal: ___________________

2) Long-term Goal: _________________ a. Short-term Goal: ___________________b. Short-term Goal: ___________________c. Short-term Goal: ___________________

Rewarding Yourself

Plan a specific reward for each goal you meet1) Long-term Goal: _________________

a. Short-term Goal: ___________________b. Short-term Goal: ___________________c. Short-term Goal: ___________________

2) Long-term Goal: _________________ a. Short-term Goal: ___________________b. Short-term Goal: ___________________c. Short-term Goal: ___________________

Exercise Maintenance Think of ways you can make exercise a

consistent part of your weekly routine, and write them below.

Try brainstorming which activities might keep you motivated and who you can turn to for support when you experience setbacks in your exercise program.

__________________________________ __________________________________ __________________________________

Lapse vs. Relapse “Slipping” or “lapsing” from your exercise routine is

different from “relapsing” from your exercise habit. A lapse is a temporary slip to previous behavior – usually a one-

time occurrence. A relapse is a full-blown return to previous patterns.

When a lapse occurs, don’t get discouraged! Get back on track before it becomes a pattern.

A lapse is an opportunity to learn, and it should not be viewed as a failure.

Think about what got in the way of your regular exercise schedule and what you can do to prevent it from happening again in the future.

Socioecological Model of Behavior Change

Env

ironm

ent

The Built Environment Facilities:

Walking paths, exercise courts/equipment Indoor facilities:

Exercise room/equipment, classes/programs, corridors/stairwells

Neighborhood: Walking routes (sidewalks, crossings), exercise

classes, excursions

Indoor Facilities

Walking Paths

Outdoor facilities

Exercise Stations

Summary Exercise is beneficial for everyone! Everyone can do some form of exercise Generally not helpful to force exercise upon

someone Help them find their own personal

motivations for exercise Help them create tools and learn skills that

will keep them on track

THANK YOU!

QUESTIONS?