Increasing Physical Activity in the Older Adult Population

One thing I appreciate about my neighborhood gymnasium is its provision of physical activity opportunities for people of all ages and abilities. It offers personalized fitness programs, hosts a wide variety of group classes, and maintains a motivational message board that targets diverse audiences. Several months ago, as I ascended the stairs, I noticed a new message featured on the board: “Strength training through your 60s can help you maintain your strength and independence” (emphasis in original). Although factually correct, this statement is misleading. It implies that the value of strength training expires with one’s 70th birthday, when in fact we never outlast the benefit of muscle-strengthening activity. I was of a mind to strike out “through your 60s” with a sharpie and replace it with “throughout life.” But I am a law-abiding type.

The inadequacy of this message was doubly conspicuous. First, it appeared in a fitness center that caters to all ages, where I not infrequently share equipment with septuagenarians and octogenarians—a phenomenon that encourages intergenerational camaraderie and reinforces my resolve to follow in their physically active footsteps. Second, this message serendipitously appeared shortly after my colleagues and I had published a paper analyzing the association between leisure-time physical activity and all-cause mortality in older U.S. adults. We had found, unsurprisingly, that older adults who reported achieving recommended levels of aerobic and muscle-strengthening activity per the Physical Activity Guidelines for Americans ¹ had a significantly lower risk of death than their colleagues who failed to achieve those levels. (We adjusted for several factors, including underlying health conditions, thus reducing the possibility of a confounded relationship). Perhaps unexpectedly, this association held even when we restricted to those aged 85 years and older at the time of their interview. The mortality reduction in this oldest age group was a staggering 28% (with a 95% confidence interval of 19% to 36%). ² Sign me up for that!

Ours is just one of many studies showcasing the salubrious effect of physical activity among older adults, usually defined as those 65 and above. The overwhelming evidence of benefit, coupled with the stubbornly low uptake of physical activity in this segment of the population, prompted the U.S. Department of Health and Human Services in 2023 to release the Physical Activity Guidelines for Americans Midcourse Report: Implementation Strategies for Older Adults. ³ Typically shorthanded as the “Midcourse Report,” this document does not alter the recommended types or amounts of physical activity adumbrated in the second edition of the Physical Activity Guidelines for Americans (i.e., multicomponent physical activity that includes [1] aerobic activity, ideally exceeding 150 minutes of moderate-intensity activity weekly; [2] muscle-strengthening activity, ideally at least twice weekly and targeting all major muscle groups; and [3] balance activity that helps prevent falls). ¹

Rather than updating the physical activity recommendations for older adults, the Midcourse Report clarifies how to achieve those recommendations. As the press release explains: “The Physical Activity Guidelines emphasizes why people need to engage in physical activity and what dose of physical activity they need to get health benefits. The Midcourse Report focuses on how and where to do physical activity” (emphases in original). ⁴

Despite this pragmatic and straightforward objective, the Midcourse Report is not pithy. Checking in at 63 pages, it is not digestible by a busy health care provider between patient encounters. This is partly by design: The report is not intended solely for health care providers, but also for policymakers, local leaders, and built environment experts. Consequently, in this issue of the journal, Piercy and colleagues ⁵ from the Office of Disease Prevention and Health Promotion provide a great service by distilling the Midcourse Report for lifestyle practitioners. Although their analytic review is designated for internists, it is applicable to all health care providers who work with older adults. For example, nurses and physical therapists might profit from the user-friendly Table 4, which posits practical solutions for nine common barriers to physical activity among older adults. A sample entry: If patients have a fear of falling, “Remind them to start with activities they are most confident with (e.g., chair exercises for support with balance or walking in place to limit trip hazards).” ⁵ Like many recommendations in Table 4, this seems almost painstakingly obvious. But for those of us who have not (or not yet) experienced the fear of falling, would we even consider this barrier in the first place?

Rather than regurgitate Piercy’s excellent points, I hope to expand on them by offering three insights for lifestyle medicine practitioners. First, providers should recognize that older adults do not constitute a homogenous block vis-à-vis physical activity participation. Among this cohort, men are more likely than women to be physically active, White persons more so than Black and Hispanic, and those with a college education more so than those without. Physical activity also declines with age, and fewer older adults report adequate muscle-strengthening activity than aerobic. ⁶ These epidemiologic nuggets may be beneficial when counseling older adults. If nothing else, providers should not forget to address muscle-strengthening activity, which for some older adults might be accomplished best through body weight exercises, such as squats and arm circles, or by using everyday items for weights, such as soup cans and water bottles.

A second point of consideration, which may be more germane when counseling older adults than their younger counterparts, is the patient’s living context. The Midcourse Report outlines opportunities for incorporating physical activity in three key settings where older adults spend much of their time: in the community, within health care facilities, and at home. To promote physical activity in the former setting, providers and clinics might develop a list of community resources that can be distributed to patients, either in a handout or as part of a formal exercise prescription. This list could include obvious resources, such as nearby parks, trails, and fitness centers, but it could also offer more creative ideas, such as places not typically associated with physical activity (e.g., the mall) and physically active community events (e.g., ballroom dancing classes). Better yet, providers could participate in physical activity alongside their older patients, such as through Walk with a Doc, a program that is featured in the Midcourse Report. ³ Given the health risk posed by loneliness, ⁷ group fitness programs like Walk with a Doc are especially beneficial because they offer both physical activity and socialization.

A final tip: When counseling older adults, the medication review may present an opportune time to promote physical activity. Approximately nine of ten older adults take at least one prescription medication, with four of ten concurrently taking at least five (42%, to be exact, compared with just 16% in the early 1990s). ⁸ This explosion of polypharmacy in the past two decades dwarfs the modest increase in physical activity among older adults. ⁸ Assuming it’s relatively legitimate to compare data from distinct nationally representative surveillance systems (the National Health and Nutrition Examination Survey and the National Health Interview Survey), an older American adult is three times as likely to take five prescription medications ⁸ than to meet the aerobic and muscle-strengthening physical activity guidelines ⁹ (42% vs 14%). Fortuitously, increasing the latter figure may also decrease the former. As quipped by Dr. Robert Butler, former director of the National Institute on Aging: “If exercise could be packed in a pill, it would be the single most widely prescribed and beneficial medicine in the nation.” ¹⁰ I would not revise this quote, but, to forestall any misperceptions, I would add that this exercise pill has no expiration date—no, not even at age 70.