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Systematic Review

Practical implications for providing physical activity counseling for the older adult

An integrative review

Otmanowski, Jennifer A. RN, MSN, CNE (Doctoral Candidate)1; Chase, Jo-Ana D. PhD, APRN-BC (Assistant Professor)1

Author Information
Journal of the American Association of Nurse Practitioners: July 2020 - Volume 32 - Issue 7 - p 511-519
doi: 10.1097/JXX.0000000000000483

Abstract

Research by the American College of Sports Medicine demonstrated that 60% of patients stated that they would be more likely to begin exercising if advised to exercise by their health care provider (Blair et al., 2012). Although most clinicians recognize the importance of recommending physical activity (PA) to their older adult patients, they struggle with barriers such as time constraints, lack of training, and lack of confidence in the effectiveness of their interventions (Hébert et al., 2012; Walsh et al., 1999). Nurse practitioners (NPs) have the potential to become key providers of PA counseling. Nurse practitioners see a high volume of patients, an estimated 1.02 billion patients a year and so can have a wide impact (Knowles, 2018). Nurses are considered to be members of a trusted profession and so their interventions may be more likely to be accepted by patients (Brenen, 2018). The purpose of this review was to examine PA counseling intervention research among adults age 65 years and older and to identify best practices for clinical practice.

The population of adults age 65 years and older is rapidly growing in the United States and is the least active of any age group (Watson et al., 1999). The next decade will see the generation termed the Baby Boomers reach their late 70s and 80s. Physical activity declines as people age, with the annual decline accelerating with increasing age (Bachman et al., 2014; Thompson et al., 2014). Globally, 5.3 million deaths per year are associated with physical inactivity (Li et al., 2012). Physical inactivity in the older adult leads to loss of muscle mass, declines in strength and endurance, and problems with maintaining balance that can contribute to functional decline, loss of independence, and subsequent nursing home placement (Rist et al., 2016).

Physical activity is associated with a reduced risk of stroke, cardiovascular disease, breast and colon cancers, hypertension, type 2 diabetes, Parkinson's disease and dementia and has positive effects on lipid levels and glycemic control (Guure et al., 2017; Kyu et al., 2016; Mosen et al., 2017; Ou et al., 2017). Additionally, PA can reduce the rate of falls and improve cognition in the older adult (Aoyama et al., 2015; Langlois et al., 2012). Some of the complaints that patients visit their providers for can be moderated by PA. For example, increased PA is associated with almost immediate positive changes in sleep quality (Kredlow et al., 2015). Additionally, PA is associated with lower rates of depression, improved cognition, and higher quality of life (Langlois et al., 2012; Paulo et al., 2016). Consequently, PA is gaining ground as a global priority for the development of public health policies (World Health Organization, 2013).

To reap the benefits of PA, individuals can participate in any movement generated by skeletal muscles that uses energy (World Health Organization, 2018). The 2018 PA recommendations for older adults from the United States Department of Health and Human Services (USDHHS, 2018a) are 150–300 minutes of moderate aerobic activity a week or 75–100 minutes of vigorous aerobic activity with at least 2 days that include a muscle strengthening activity. Aerobic activities consist of activities where participants move their large muscles in rhythmic method for an extended amount of time (World Health Organization, 2010). Examples of aerobic activities include walking, running, biking, swimming, dancing, or aerobic exercise classes. Additional recommendations for the older adults include balance training as well as aerobic and muscle training activities. The level of effort should be determined by the older adult's fitness level and participants can improve physical fitness by gradually increasing PA intensity and duration (Dasso, 2018). Older adults who cannot attain the 150 minutes per week guidelines due to chronic conditions should strive to be as active as possible (USDHHS, 2018a). Unfortunately, despite the health benefits of PA, the proportion of adults over age 75 years sufficiently active per the guidelines is only 35% to 44% (USDHHS, 2018b).

Many studies have attempted to increase PA in older adults with PA counseling interventions. Physical activity counseling is defined as offering advice or guidance in a verbal or written form to encourage someone to increase PA. PA counseling can be in-person or by phone, which may help overcome the issue of time constraints, the primary barrier for physicians in initiating a PA prescription program (Patel et al., 2011). Physical activity counseling can be based on a variety of theories such as Bandura's social cognitive theory (SCT) (Bandura, 1997) and the transtheoretical model (Prochaska et al., 2015).

Exercise prescriptions are sometimes incorporated in PA counseling interventions. These prescriptions are dispensed after evaluating the patient's goals along with their physical condition and comorbidities. A prescription represents a familiar method of communication between a provider and a patient and has been successful in improving PA levels over verbal advice alone (Swinburn et al., 1998). The American Medical Association and the American College of Sports Medicine (ACSM) are leading advocates of the exercise prescription. Their Exercise is Medicine (EIM) program promotes exercise referrals as a way to increase PA levels and promote health. ACSM has published the Health Care Providers' Action Guide (2019), which includes an exercise prescription sample.

Behavior change theories often provide a framework for counseling interventions and have been demonstrated to improve the success of interventions (Chase, 2015). Social cognitive theory is one that is used widely to guide PA interventions. One of the major constructs of SCT is self-efficacy. Self-efficacy with regards to PA refers to a person's belief in their ability to perform exercises or walk outdoors. Self-efficacy can be increased through vicarious reinforcement or modeling, verbal persuasion, managing physiological arousal, and enactive mastery (experiencing success; Bandura, 1997). Another behavior change theory is self-regulation theory that involves the process of regulating behavior by moving toward, or occasionally away from goals. Individuals use feedback and self-evaluation to self-correct as they move toward their goal (Kanfer & Kanfer, 1991). Like SCT, the transtheoretical model of change has also been used extensively in PA research. In this model, the health care provider identifies the patient's stage of change before initiating appropriate interventions (Prochaska et al., 2015).

Recent reviews and meta-analyses have found that interventions to increase PA in older adult are effective. These studies did not focus on PA counseling interventions specific to the oldest old population (Chase, 2015; Olanrewaju et al., 2016). A recent systematic review on health coaching captured studies with participants ≥60 years old resulting in a mean age of 60–79 years (Oliveira et al., 2017). Additionally, the last 10 years have seen an explosion in research related to PA interventions with the number of articles written about PA in primary care doubling between 2012 and 2004, necessitating this synthesis of the PA counseling research generated in the past 10 years (Lion et al., 2018). This present review aims to summarize the recent body of PA counseling and exercise prescription literature among adults ≥65 years old (Center for Medicare and Medicaid Services, 2019). This review proposes to answer the following questions: 1) which types and combinations of PA counseling interventions are efficacious in increasing time spent in PA in the older adult? and 2) which behavioral theories support counseling interventions that result in increased time spent in PA?

Method

This review used the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) guidelines and the search procedure as outlined in the PRISMA diagram (Moher et al., 2009) in Figure 1. Databases used for this search include CINAHL, PsycINFO, PubMed, Scopus, and SPORTDiscus along with a review of bibliographies of retrieved articles. The search was completed in January of 2020. The following is an example of the search used in PubMed: exercise OR physical activity AND counselling OR counseling OR counsel AND older adult. To capture an older population, the search was restricted to adults ≥65 years old (Center for Medicare and Medicaid Services, 2019). Counseling was defined as a process where a patient learns how to increase their PA and is assisted in addressing barriers to PA by a professional competent in relevant psychological skills. This process may also include goal setting and assessments of readiness to change. Counseling interventions can be delivered in many different modalities and by different interventionists. Eligible studies described PA counseling interventions, which may include exercise prescriptions, in-person counseling, counseling by trained peer leaders, and counseling conducted by phone calls in the generally healthy population. To focus on the average older adult, articles that included participants diagnosed with a specific disease process were excluded. Only peer-reviewed, full-text articles were included, and dates were restricted to the past 10 years to capture the recent growth in PA literature. Articles that were written in languages other than English were excluded because this author does not read any other languages.

Figure 1
Figure 1:
Prisma chart.

A total of 465 articles were screened for eligibility by reviewing the title and abstract (Figure 1). Twelve articles were included with an outcome measure of PA participation. Two articles meeting the inclusion criteria were obtained from CINAHL, three articles from PsycINFO, one article from Scopus, three articles from PubMed, and tnone from SportDiscus. An ancestry search resulted in three additional studies. Information extracted from eligible studies included study design, sample size, age of participants, outcome measures, type of interventions, frequency of interventions, provider of intervention, length of follow-up, outcome measures, and theoretical frameworks. Study details can be found in Supplemental Digital Content 1 (available at http://links.lww.com/JAANP/A63).

Study quality was assessed using the Physiotherapy Evidence Database (PEDro) scale (refer to Supplemental Digital Content 2, available at http://links.lww.com/JAANP/A73;Verhagen et al., 1998). The PEDro scale evaluates methodological quality of trials. Criteria related to external and internal validity and the presence of sufficient statistical reporting for inferences are used to assess the methodological quality. The PEDro scale has been found to be a valid instrument for determining the quality of clinical trials (de Morton, 2009; Maher et al., 2003).

Findings

Study characteristics

In keeping with the global nature of the problem of physical inactivity, the 12 studies reviewed for this article were representative of several different countries. The Netherlands, France, New Zealand, Sweden, Romania, Scotland, United Kingdom, and Finland, each contributed one study, and four studies were from the United States. All the studies reviewed for this article are randomized controlled trials with two of the studies using cluster or stratified randomization (Bickmore et al., 2013; Kerr et al., 2018). All studies reported an outcome measure of time spent in PA, although PA was not the primary outcome in some of the studies. The primary outcome was reducing frailty in two of the studies (Barreto et al., 2018; de Vries, 2013), the primary outcome was fall prevention in one study (Arkkukangas et al., 2019), and one of the studies had multiple health outcomes (Robare et al., 2011). The participants represented in our synthesis are significantly older than previous syntheses, with mean ages range from 71.6 to 85.3 years.

The PEDro scores ranged from six to eight (Supplemental Digital Content 2, available at http://links.lww.com/JAANP/A73). Intention to treat was carried out in eight of the 12 studies. Random allocation was included in each of the 12 studies. In all but two of the studies, the treatment and control group had similar characteristics at baseline such as PA levels, age, and education. For all groups of participants represented, at least one between-group statistic was reported. Six of the studies used objective measures of PA outcomes such as accelerometer and pedometer (Barreto et al., 2018; Kerr et al., 2018; Kolt et al., 2012; McMurdo et al., 2010; Mutrie et al., 2012; Thompson et al., 2014).

Theories

Four different behavioral theories were used, including transtheoretical model of change, SCT, social learning theory, and self-regulation theory. Social cognitive theory with a specific focus on self-efficacy was used most commonly and has historically been a prevalent framework for PA research. Four studies in this review used SCT to inform their counseling interventions (Kerr et al., 2018; Mutrie et al., 2012; Rasinaho et al., 2012). The studies differ in their adherence to theory constructs. In their use of peer counselors, Kerr et al., (2018) were able to provide vicarious experience or self-modeling, important constructs in SCT. Additionally, they used verbal persuasion and performance outcomes or feedback. Although Rasinaho et al. (2012) focused their counseling strategies on reducing and overcoming barriers to increasing time spent in PA, techniques that are not specific to SCT.

In addition to SCT, Rasinaho et al. (2012) used the transtheoretical model of change. Rasinaho et al. (2012) and Arkkukangas et al. (2019) identified their participant's state of change through a brief questionnaire and used the information to guide their counseling approach. Conversely, Herghelegui et al. (2017) assessed for readiness to change but did not describe how those delivering the counseling incorporated the identified stage of change.

In McMurdo et al. (2010), researchers used self-regulation theory along with pedometers to increase PA in sedentary older women. A walking target was set for the first month that was 20% above the participant's baseline. Action plans were created along with plans to address barriers to PA. A brief education session focused on motivation for walking along with goal setting, self-monitoring, and feedback. Four other studies in this review did not identify a theoretical framework (Barreto et al., 2018; Bickmore, et al., 2013; Kolt et al., 2012; Thompson et al., 2014).

Interventions

In all the studies, an intervention was considered successful if time spent in PA increased from baseline or if time spent in PA differed from the control group. In all but one study, the counseling was provided verbally, and the initial counseling was in person. The one study that did not rely on verbal in person advice, used an automated health coach accessed via a tablet (Bickmore et al., 2013). A variety of other interventions were used to supplement the counseling, including pedometers, phone calls, and motivational interviewing, a counseling style focused on resolving the ambivalence that keeps individuals from achieving their goals. Pedometers provide feedback to the participant as well as an objective measure of PA. Phone calls were used after the initial in-person counseling to provide continued support.

Short-term vs long-term results

Short-term PA increases were observed in several studies (Baretto et al., 2018; Bickmore et al., 2013; de Vries et al., 2012; Herhelegiu et al., 2017; McMurdo, 2010; Mutrie et al., 2012). Successful long-term interventions were more elusive. Although some studies showed positive results at the end of the intervention, participants' activity levels reverted to baseline at follow-up (Barreto et al., 2018; Bickmore et al., 2013; McMurdo et al., 2010). Two studies demonstrated continued positive results at postintervention follow-up at 12 or more months (Kerr et al., 2018; Rashinaho et al., 2011). Both studies used SCT and multiple contacts with the interventionist during the maintenance phase. The Kerr et al. (2018) study involved interventions on an individual level (goal setting, pedometers, and phone counseling) and interventions at a community level (group education and peer leaders). The study by Rashinaho et al. (2011) involved follow-up phone calls every 4 months for 2 years. The most successful interventions for attaining long-term results had a structured maintenance phase and relied on behavioral change strategies and theories.

Step counting

A step counting device was used in four of the studies to provide motivation as a supplement to counseling strategies, as well as to record outcomes (Bickmore et al., 2013; Kolt et al., 2012; McMurdo et al., 2010; Thompson et al., 2014). However, in two of the studies, participants did not sustain or maintain step increases with a pedometer without the accompanying counseling support (Bickmore et al., 2013; McMurdo et al., 2010). These results imply that pedometer alone cannot enact long-term behavior change.

Phone calls

Phone calls are a popular method for continuing counseling interventions after initial in-person counseling (Kerr et al., 2018; Kolt et al., 2012; McMurdo et al., 2010; Rasinaho et al., 2012). Phone calls can provide motivation and encouragement or help participants overcome barriers. Follow-up phone calls can enhance compliance with the PA interventions (Lilienthal et al., 2014). A recorded call from the nurse in the office, NP, or the physician can also be a money- and time-saving strategy (Mutrie et al., 2012).

Interventionists

Studies were heterogeneous in regard to the interventionist. Only one study examined an exercise prescription provided by a physician (Kolt et al., 2012). Other interventionists included nurses, physiotherapist, geriatricians, peer leaders, physical therapists, PA instructors, health counselors, and an automated exercise coach. Kerr et al. (2018) is unique among the studies as the only one that uses trained peer leaders to provide the primary intervention.

Counseling strategies

Older participants can be strongly motivated by the desire to help manage chronic conditions and maintain an active lifestyle yet at the same time chronic conditions can limit participation (Newson & Kemps, 2007). Because older adults do have many barriers to participating in PA, two studies included strategies for reducing barriers in the counseling sessions (Herghelegiu et al., 2017; Mutie et al., 2012). Herghelegui et al. (2017) used a health risk assessment tool to identify the participant's barriers to PA before initiating interventions. The ability of the counselor to alleviate concerns and provide reassurance and encouragement is a vital role when working with the older adult. Bardach & Schoenberg (2018) were able to demonstrate improvements in PA levels by providing information to the participants about improvements in their health status. The researchers emphasized improvements in laboratory values and progress toward weight loss goals to motivate the participants. Goal setting was a strategy used in several studies (de Vries et al., 2016; Kolt et al., 2012; Robare et al., 2011).

Implications

The research supporting the positive effects of increasing PA in the older adult population is extensive. Although the most intense interventions generally have greater success, NPs should not be discouraged from beginning to incorporate PA interventions into their practices (Conn et al., 2002). Our findings suggest that PA counseling is an important strategy for increasing PA behavior in this vulnerable population. This review expands on previous work by examining studies aimed at maximizing the effect of PA counseling interventions in the oldest old population.

The Health Provider's Action Guide (2019), from The American College of Sports Medicine, provides practical advice for the NP wishing to incorporate PA counseling into office visits. The guide provides educational brochures for the office, a tool for assessing and recording PA levels, and sample exercise prescriptions. The guide also makes recommendations for patients with special needs and chronic conditions as well as how to refer to exercise professionals (Table 1). Health care providers should prescribe a low-intensity level and short duration of PA at the onset for older adults that are highly deconditioned (Lee et al., 2017). Before progressing to aerobic training, older adults with frailty indicators, such as low energy, poor grip strength, slow walking speed, or unintentional weight loss (Xue, 2011), should participate in exercises that build muscle strength and balance. The first step for the NP is to assess the patient's current health and activity level. The American College of Sports Professionals offers a preparticipation screening tool (Table 1). The National Institute on Aging (2018) and the American College of Sports Medicine (2019) recommend the use of exercise prescriptions as a practical and economical intervention to providers to use in combination with counseling to promote PA. Although older adults are responsive to verbal encouragement to increase PA, they prefer the addition of written instructions or a prescription (Pfeiffer et al., 2001). Writing an exercise prescription is an economic and effective way to incorporate PA interventions into practice. Exercise prescriptions should specify exercise frequency, intensity, duration, modality, and progression (Lee et al., 2017). Helping the patient to set a goal and including it on the prescription can promote success. Sample exercise prescriptions can be found in the article by Lee et al. (2017) (Table 1). Using a behavior change theory or technique is a good strategy for tailoring counseling interventions. For example, counseling based on SCT has been shown to be an effective strategy, at least in the short term (Herghelegiu et al., 2017; Kerr et al., 2018, Mutrie et al., 2012). To tailor PA interventions, NPs may consider assessing patients' self-efficacy or perceived confidence to engage in PA behaviors. Physical activity counseling strategies could target various contributors to self-efficacy, such as identifying ways to improve performance mastery and providing verbal encouragement (Bandura, 1997). Additionally, using the transtheoretical theory of change to assess a patient's readiness for change can help the NP deliver the support the patient needs at each stage of behavior transformation (Herhelegiu et al., 2017). A patient in the precontemplation stage may benefit from discussion of the health benefits of exercise. Although a patient in the contemplation stage may benefit from a discussion of the pros and cons of exercise (American College of Sports Medicine, 2019). A brochure about PA for older adult can be downloaded from National Institute on Aging (Table 1). Older adults may have low self-efficacy for exercise, so starting with something familiar such as walking may help increase their success. Additionally, verbal encouragement from the provider can help build the patient's self-efficacy. Follow-up phone calls can be made by the NP or the office staff to provide support and encouragement. Successful interventions contain multiple opportunities for reinforcement of the older adult's efforts at increasing PA (Herhelegui et al., 2017).

Table 1
Table 1:
Resources

Incorporating other disciplines such as PA counselors reduces the burden on physicians, NPs, and physician assistants who may have time constraints during office visits. For example, physical therapists or kinesiologists are specially trained in PA counseling (Shirley et al., 2010). Barreto et al., (2018) and Kerr et al., (2018) demonstrated that it is possible to train other personnel or peer leaders to provide PA counseling. A multidisciplinary approach could be used where the primary provider leverages their credibility with the patient to make referrals to other providers of PA counseling. If the patient is very deconditioned, functionally limited, or has chronic conditions, they may need more guidance. The American College of Sports Medicine suggests enlisting the help of office staff to generate a list of qualified exercise professionals and offers tips on how to identify qualified individuals (Table 1). Community senior centers may have supervised exercise classes to which older adults may be referred.

Although the risk of injury from participation in PA by the older adult may be a concern for the provider, the benefits of participation in PA outweighs the small risk of injury to the older adult (Stathokostas et al., 2013). The older adult can experience fears related to falling, over exerting, or sustaining injury. In addition to emphasizing the health benefits of PA, counseling should also address patient's fears surrounding increasing their activity level (Baert et al., 2011). NPs may allay patient concerns about the risk of injury from participation in PA by discussing safety strategies. An older adult who is experiencing falls may need a referral to physical therapy for balance training before starting a new exercise regimen (Lee et al., 2017). Nurse practitioners may also share CDC brochures on fall prevention strategies and educate the older client that PA may reduce fall risk (CDC, 2019; Cowper et al., 2017).

Several methodological limitations were noted among studies included in this review. For example, racial/ethnic diversity and certain age groups were not well-represented. Individuals from racial/ethnic minority groups are less likely to participate in healthy exercise and dietary behaviors than Caucasians (August & Sorkin, 2011). Yet increasing PA in these individuals is essential. Obesity rates in African American women, for example, are increasing. Obesity combined with low levels of PA contributes to high rates of heart disease and diabetes (Bland & Sharma, 2017). Additionally, the old-old (85–94 years) and the oldest old (95+) are not well represented in PA research. Yet, frailty, a condition modifiable by PA has been shown to be a predictor for nursing home placement (Kojima, 2018). The need for further research regarding how to encourage older adults from diverse backgrounds and of advanced age cannot be underestimated. Additionally, research is needed to demonstrate long-term compliance with PA, thus further supporting the benefits of providing PA interventions.

Consistent use of objective measures to determine levels of PA as well as larger sample sizes are needed to better establish counseling effectiveness. The collection of accurate PA outcomes is vital for reporting and analyzing data across studies. Social desirability bias can cause participants to choose responses that they believe are more socially acceptable and can influence results (Sallis & Saelens, 2000). Poor recall due to memory impairments in some older adult can further affect the use of self-report in PA research (Sallis & Saelens, 2000).

Further research regarding the health care cost savings related to chronic disease prevention due to greater PA could support incentives for providing PA interventions in primary care. Physical activity counseling interventions have been associated with not only an increase in PA behavior but also a decrease in falls with a cost that is only a small fraction of an individual's health care costs, about 6% (Cowper et al., 2017). Participants who received the Coach2Move intervention reached their outcomes for physical therapy and were discharged after significantly fewer visits than the control group, a significant savings in health care dollars (de Vries et al., 2016).

Limitations

Limitations of this review include a lack of adequate studies using a variety of disciplines, including physicians, nurses, physical therapists, and health counselors as well as studies to determine the minimal amount of counseling encounters needed to improve and maintain PA levels. This current review was limited to only five data bases: CINAHL, PsycINFO, PubMed, SPORTDiscus, and Scopus. Inclusion of more studies involving racially/ethnically diverse participants and the older old adult would be beneficial for identifying interventions for these special populations. The use of objective measures in PA research is important because the majority of adults overestimate their activity levels (Sallis & Saelens, 2000). The concern that participants may overestimate their activity on questionnaires at baseline may affect the ability to demonstrate significant increases in PA. Subsequent reviews should include a more extensive data search along with meta-analysis to determine the most effective interventions in primary care to promote PA in adults ≥65 years.

Conclusion

Physical activity counseling can be an effective way to improve PA levels in older adults. Nurse practitioners can use diverse PA counseling strategies in varied clinical settings to improve the PA levels of older patients. The theoretical frameworks that proved efficacious in the reviewed studies were the SCT and transtheoretical theory of change. Nurse practitioners can incorporate these theories by promoting exercise self-efficacy in their patients and by assessing for stages of change. Resources are available for writing exercise prescriptions. Although following up with the patient by phone or in person is recommended. During counseling sessions, it is important to address the patient's fears related to increasing PA, emphasize the benefits of PA, and help the patient set PA goals. Using an interdisciplinary approach, and using alternative techniques to in-person counseling, may improve efficiency. Further research is needed to determine the ideal amount and duration of counseling and any differences in the older adults' response to counseling based on diverse demographic characteristics.

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Keywords:

Counseling; green prescription; older adult; PA

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