Promotion of Exercise Prescriptions in General Practice for Older Populations
Boyd Swinburn, MB, ChB, FRACP, MD, Professor, Centre for Physical Activity and Nutrition, Deakin University, Melbourne, Victoria, Australia.
Richard Sager, BHlthSc (N&D), APD, Public Health Research Fellow, Greater Green Triangle University, Department of Rural Health, Deakin University, Warrnambool, Victoria, Australia.
Regular physical activity in older populations reduces the risks of cardiovascular diseases, diabetes, osteoporosis and falls and also improves mental health. Some programs of written exercise prescriptions by general practitioners have been shown to significantly increase physical activity levels over the medium-term (six to 12 months). Increasing the confidence and skills of general practitioners to prescribe and monitor exercise programs is important. However, the more challenging barriers to the widespread uptake of exercise prescription programs are the structural and economic constraints within general practice, as well as the competing promotion of prescribing pharmaceutical products. Implementation research on overcoming these barriers is urgently needed.
Key words: exercise prescriptions, general practitioner, health gains, training, barriers, health promotion.
The rationale for promoting regular physical activity in older populations is relatively straightforward. What is less clear from the literature is the mix of strategies needed to achieve sustainable increases in physical activity levels in older people and the health impacts (both positive and negative) of such programs. Of particular interest to primary care is the concept of written exercise prescriptions by general practitioners (GPs).
Benefits of Physical Activity
Regular physical activity has consistently been shown to improve physical, social and mental health in people of all ages.1,2 Many of the conditions with high prevalence in older populations, such as coronary heart disease, diabetes, hip fractures and some cancers, have been associated with low levels of physical activity in epidemiological studies.1,2 The intermediate risk factors for many of these diseases, such as blood lipids, blood pressure, insulin resistance, obesity and bone mineral density, have shown improvement with physical activity in clinical trials.1,3 Other common conditions among older people, such as chronic obstructive airway disease and chronic heart failure, have shown improvement with regular exercise within the limits of the disease.4,5 Other potential benefits, including preventing declines in mental health, reducing falls and improving overall functionality in daily living contribute to the rationale for promoting physical activity.2,6-8
A further reason for promoting physical activity in older people is that their absolute risks of morbid or mortal events are higher than in younger people, such that the absolute benefits, in terms of event reduction, of any intervention will also be higher. In other words, the numbers needed to treat to reduce clinical events such as myocardial infarctions and hospitalizations are relatively low among older patients.
Potential Risks of Physical Activity
The potential risks of increased physical activity in older people include sudden cardiac death, injury and exacerbation of osteoarthritis.2 While the relative risks of sudden death are increased two- to six-fold during vigorous exercise, the absolute risks are very low (about one death per 1.5 million episodes of vigorous exercise) and are mainly confined to people who were previously not regular exercisers.2 To minimize these risks, sedentary people should progress gradually from light to moderate exercise and should avoid unaccustomed heavy exertion.1 Such advice is also prudent for minimizing the risk of injury and preventing exacerbations of osteoarthritis.
The Role of GPs as Exercise Prescribers
In most countries, the GP holds a unique position at the hub of health care delivery. In Australia, for example, approximately 83% of the population visit their GP each year,9 and among older people, the proportion is even higher. GPs are seen as a credible source of information and both GPs and their patients expect health promotion to