QJM Advance Access originally published online on July 31, 2008
QJM 2008 101(9):743-744; doi:10.1093/qjmed/hcn095
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Physical activity in the elderly—it is never too late!
From the Diabetes Centre, Northern General Hospital, Sheffield, UK
Address correspondence to Dr Soon H Song, Diabetes Centre, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK. email: soon_song{at}hotmail.com
The number of elderly people is growing rapidly. By 2050, Europe will have twice as many older people (aged above 60 years) as children.1 With more people living longer, the major causes of death have changed from infectious to non-communicable diseases and from younger to older individuals. In industrialized nations, 
75% of deaths in individuals aged above 65 years are attributable to cardiovascular disease and malignancy.2 Unsurprisingly, ageing is the most important contributor to the increase in health care costs. Improvements in preventive medicine and health care have increased the life expectancy in adult and elderly populations. This demographic shift towards the fraction of the population with the greatest health care needs deserves more attention, not only from policy makers but also from researchers and clinicians.
To understand the dynamics of health and disease in the elderly, more data are needed pertaining to functional status, morbidity and mortality. Since the epidemiology of chronic diseases has focused mainly on the adult population, much less is known about the elderly. In particular, studies are needed to understand the interaction between functional status such as physical activity and cardiovascular health. This is important as cardiovascular disease is prevalent among the elderly and can impinge on the disability adjusted life-years.
In this issue of QJM, Bianchi and colleagues assessed the relationship between physical activity, insulin resistance and metabolic syndrome (MetS) in a cohort of 1144 elderly individuals aged between 65 and 91 years in Pianoro, Italy.3 Physical activity was assessed by the validated Physical Activity Scale for Elderly (PASE) questionnaire taking into consideration the type of activity, namely, leisure time and household activity. The authors found that increased leisure time physical activity (LTPA) was associated with lower insulin resistance and MetS even among elderly individuals. Household activity had no impact on these parameters. The authors concluded that encouraging recreational physical activity for cardiovascular health improvement was worthwhile even among the elderly.
This study raised some interesting points. First, it serves as a reminder that elderly individuals should not be forgotten for physical activity intervention. Previous studies have demonstrated the cardiovascular benefits of physical activity in the advanced age. Mortality from cardiovascular and all causes were reduced in physically active individuals.4 Modest increase in life expectancy was possible even in those individuals who did not begin regular exercise until 75 years of age.5 Mortality rates were also lower in those individuals who did not begin regular exercise until late in life compared with individuals who were active only in younger years and then subsequently stopped exercising.5 Even modest exercise such as walking for 45–75 min/week was associated with substantial benefit.6
Second, this study highlights the importance of differentiating the type of physical activity and its impact on cardiovascular health. The salutary effects of exercise appear to vary depending upon the type of physical activity. Population studies have shown that LTPA is associated with a lower risk for cardiovascular disease and better cardiorespiratory fitness.7,8 However, it has not been clearly shown that higher levels of work related physical activity (WRPA) including household activities lead to better health outcomes.9 This is an important distinction for the following reasons. Individuals from lower socio-economic and educational background tend to engage in less LTPA at the expense of more WRPA.10 From the individual perspective, there is prevailing misconception that WRPA is a form of health-benefiting exercise. Based on these points, public health efforts to encourage greater LTPA has to tackle not only the lower socio-economic strata of the population but also to change individual's perception of the type of physical activity that is beneficial to health.
Third, it is debatable whether diagnosing MetS to identify individuals at risk of cardiovascular disease for lifestyle intervention is a clinically useful effort. A recent analysis of longitudinal data from two independent population-based cohort on elderly individuals showed MetS has negligible association with the risk of cardiovascular disease and that the predictive value of MetS for cardiovascular disease is not greater than the sum of its individual components of the syndrome.11 Criticisms and concerns pertaining to the MetS concept as previously raised12 appear to apply to the elderly cohort.
Fourth, multi-factorial intervention, physical activity being one of its components, should be the cornerstone of lifestyle changes. Knoops et al.13 showed that adherence to Mediterranean diet, moderate alcohol consumption, non-smoking status and moderate physical activity (at least 30 min daily) led to lower all-cause mortality in European men and women aged between 70 and 90 years. Combination of these factors was associated with a mortality rate of approximately one-third that of those with none or only one of these protective factors. Each of these factors was associated with lower mortality but combinations were more powerful.
One of the major challenges in medicine is achieving behavioural changes. Elderly individuals can present a bigger challenge due to barriers unique to this age-group. Issues such as musculoskeletal discomfort, physical disability, fear of falls, lack of confidence and sedentary habit have to be overcome. Initiatives to induce lifestyle changes and to sustain this change in the long-term should be innovatively sought such as prescribing a range of exercise intensities compatible with the individual's functional level, incorporating simple exercise regime into a routine, engaging in enjoyable social activities and building self-confidence. Given the continuous dose–response relationship between physical activity and health benefits,14 individuals who go from none to some exercise will receive substantial health benefits.
Although the understanding of the dynamics between lifestyle and health outcomes continues to refine, information available now is sufficient to take action. A monumental amount of money is spent on chronic disease management and risk factors intervention. Channelling some of this investment to promote healthy lifestyle in the community would yield greater benefits. In this era of evidence-based medicine, it is time to put the evidence into practice with this motto in mind—it is never too late to exercise!
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