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Promoting Successful Aging
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Healthy, or successful aging has been the focus of attention lately. People are looking to improve their diets, start regular exercise regimens, and decrease the level of stress in their lives. They are doing this not only to increase their longevity, but also to increase the number of healthy and active years of life. People are living longer and living healthier due to changes in lifestyle that are being recommended by physicians, promoted at community and senior centers, and considered trendy by the media. Considerable attention is focused on the negative problems that face older people such as malnutrition, poverty, and elder abuse. While many older people are in situations where these issues are realities and programs and policies should be created to alleviate these problems, the percentage of older adults with these circumstances is low. However, because these problems appear frequently in the media, people assume that they characterize the aging experience. Many of the issues faced by older people are due to social, psychological, and biological problems that have accumulated over the course of their entire lives. Factors such as economic status, health status, social support, and level of education all play major roles in determining whether or not an individual ages successfully. Aging is a universal experience that results in significant changes that impact all aspects of a person's life. How someone adapts to the changes of aging has a strong impact on their physical and emotional well being and their risk factors for health and mental problems in later life. Healthy and successful aging can be characterized by adapting to the changes that come with age. The emphasis in "successful or active aging" is on maximizing independence and function as the person grows older. The individual's physical abilities, psychological issues, and behaviors can have a significant impact, either positive or negative, on how a person ages. |
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| The Bio-Psycho-Social Model
Individuals have the ability to promote successful aging in many ways. One can adapt physiologically through health promotion efforts, exercise, and an adequate diet. Psychological or mental health can be maintained through positive attitudes toward adjustments to limitations and changes that may come with aging, continuing to seek intellectual stimulation by taking classes, attending lectures, and staying involved, and through religious or spiritual beliefs or activities. Social factors that can affect whether or not someone ages successfully include staying active in the community, volunteering, making new friends, and maintaining good relationships with family members and life-long friends.
Because people of the same age cohort are usually at similar stages of life (retirement, "empty nest", birth of grandchildren, etc.) they are typically dealing with many of the same problems. Becoming involved in the activities at the local senior or community center, or in other groups sponsored by religious institutions are good ways for older people to meet others their age. It is important to understand that not all "old people" are the same. There is great diversity in the elderly population, as you can imagine. Diversity in socioeconomic status, age, level of education, level of physical and cognitive functioning, living arrangements, ethnicity, and life experience have great impact on the types of services, programs, and activities for older adults. Gender, ethnicity, and living arrangements have also been shown to impact significantly on physical, psychological and social habits and capabilities. There are many programs sponsored by local hospitals, community centers, churches and synagogues, and senior centers designed to promote health awareness and screening in older adults. The goal of health promotion is to decrease the incidence of chronic diseases and enhance a person's quality of life. Much of the chronic illness experienced by older persons is related to social, environmental, and behavioral factors, especially poor health habits. Health promotion involves changing individual health behaviors through regular exercise, good nutrition, elimination of poor health habits (excessive use of alcohol, smoking, high fat diets, etc.). Other important factors are the proper use of prescription and nonprescription medication, periodic medical check ups, and the ability to handle psychological stress and changes to one's life impact healthy aging. Health promotion seeks to stop problems before they start by increasing awareness, prevention, and through teaching people how to talk to the various health professionals they will come in contact with. Unfortunately, lack of exercise, poor nutrition, drug abuse and misuse, and non supportive social situations and health care professionals can be common in later life. Many older adults have difficulty maintaining adequate nutrition due to low income, functional impairments that make grocery shopping and/or cooking difficult or impossible, and loneliness.
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From one source or another, you've probably learned the basic premise that "exercise is important" or "use it or lose it!" Changing the behaviors of your family members, friends, or clients can be very difficult. Physical health status is an important predictor of overall well being throughout the life course, but especially in later life. Participation in physical activity has been shown to enhance life quality into advanced old age. Physical fitness can help slow the aging process and curtail some of the degenerative diseases and common chronic illnesses associated with aging. A good part of the loss of strength and stamina often attributed to aging is in fact partially caused by reduced physical activity. Some of the benefits of physical activities to older people include:
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| Why Don't Older People Exercise?
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| What Happens
If People Don't Exercise in Their Later Years? Without sufficient exercise people begin to gain weight, putting additional stress on the heart and lungs and on the weight bearing joints of the knees, hips, ankles, and feet. The joints become stiff creating a greater risk of losing balance, falling and breaking bones. Inactivity also causes a loss of muscle mass and strength which causes yet another situation in which the individual is at risk of losing balance and falling. Cardiovascular performance becomes impaired without adequate exercise, and, therefore, the risk of heart disease increases. Inactive persons will also feel less energetic, less motivated to seek social and intellectual stimulation, and may experience symptoms of depression.
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There are four components to physical fitness. Often, one or more of these important parts of the fitness package are ignored. All four are necessary for optimizing successful aging.
One study found that after one year of regular physical activity, men aged 55-65 were found to have significant increases in several lung functions including forced expiratory volume, ventilation, and oxygen uptake. There were also improvements in flexibility, and a greater level of high-intensity leisure time activity. Aerobic exercise can build up the high-density lipoproteins(HDL) levels [the good cholesterol] and lower the low-density (LDL) levels [the bad cholesterol]. By altering the ratio between HDLs and LDLs a person alters his/her risk of heart attacks and strokes. |
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A study examined the subjective effects of aerobic exercise training on psychological, cognitive, and physiological functioning among healthy older adults. They found that those who participated in 4 months of aerobic exercise or yoga perceived significant improvements in sleep patterns, self-confidence, social life, loneliness, family relations and their sex life (Emery and Blumenthal, 1990). It has been found that older people who are physically active are faster at cognitive tasks such as encoding, recognition, rehearsal, and initiating commands than non-active older persons. This suggests that aerobic fitness has positive effects on cognitive aging (Toole et. al., 1993). It used to be accepted that older people could not increase their muscle strength or muscle mass. However, recent research has shown that even very old people who are frail could increase their strength through regular exercise. At the end of a 6-week weight training program, frail older individuals whose average age was 90 had increased their muscle strength by 180 percent. Two participants no longer needed canes and average walking speed increased 48%. Remarkably, they found that weight bearing exercise increased muscle mass at about the same rate as in younger people and non-weight bearing exercise resulted in increased flexibility in these nonagenarian. In the past few years, the term "physical gerontology" has been introduced to describe physical activity programming for older adults that incorporates sport and exercise. A balanced mix of physical activity and stimulating recreation with social aspects is an important part of a preventive health model aimed at promoting successful aging. There are many settings for older persons to exercise. Exercise programs for older people may take place in senior and community centers, adult day health care, and even nursing homes have recreational activities geared toward the needs of their residents. Planned communities for the elderly have even started to add exercise programs that go above and beyond targeted physical therapy. For example, the nation's largest retirement community, Charlestown Retirement Community in Catonsville, Maryland, has its own health club for seniors.
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Besides exercise, good nutrition also plays a key role in successful or active aging by keeping older people healthy and functioning. The United States Department of Agriculture has some general dietary guidelines that are important for all Americans. These include:
Your total energy requirements per day decrease over the life course: from 2700 kilocalories at age 30 to approximately 2100 at age 80. However, recent studies have found that approximately one-fifth of people over 60 years of age take in less than 1000 calories per day.
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| Why Such a Decline in Caloric Intake?
It has been estimated that about one-third of this decrease is from the reduction in the body's metabolic rate caused by a decrease in lean body mass and the other two-thirds is due to decreases in actual energy expenditures. However, caloric requirements relate to activity and lean body mass relates to exercise. Therefore, if increasing numbers of older persons become more active and participate in regular exercise, caloric intake for seniors may change. |
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| Adapting Exercise Programs for Elders with Disabilities While many older people are capable of participating in exercise programs, many avoid them due to specific health conditions that they assume prevents them from participating. However, if the exercise instructor, health professional, or older person themselves incorporates some modifications or precautions, exercise can be enjoyed by almost anyone. Here are some examples of how exercise programs can be modified to meet the needs of older and/or disabled individuals:
These strategies demonstrate how with a little accommodation, people can exercise regardless of some health conditions they might be experiencing. Previously sedentary older persons who start physical activity programs should start with short intervals of moderate physical activity (5-10 minutes) and gradually build up to the desired amount.
It is of the utmost importance that individuals have a thorough physical examination that includes their medical history, an evaluation of current medications, and an exercise stress test to assess cardiac risk before starting an exercise training program. Ideally, the physician/physician's assistant/nurse practitioner will even prescribe a specific exercise program. A balanced fitness training program includes activities to achieve three fitness goals: increased flexibility, increased strength, and increased cardiovascular endurance. An exercise prescription is designed to suit the functional status, health needs, and medical problems of the individual patient. It contains four components:
More than 40% of patients drop out of recommended exercise programs within the first 6 months so it is very important to clearly define the benefits of exercise to the patient. Follow up telephone contact should be made 2 weeks and then 3 months following the evaluation. Exercise programs should be designed to improve the patient's overall well being and reduce isolation and depression. This can include group recreational programs. An example is group movement therapy programs. Group movement therapy programs take place in a variety of settings such as adult day care centers, senior centers, nursing homes, and other group settings. They are designed to accommodate different levels of abilities by incorporating activities that stress involvement of the body, mind and spirit. Examples of activities in a group movement therapy program might include dance, deep breathing and relaxation techniques, theater games, memory reinforcements, sensory training, and intergenerational games. Warm up activities might include using musical instruments, deep breathing, creative dance, or muscle warm-ups. There is a heavy emphasis on relaxation techniques, imagery, and touch. There are basically two types of exercise activities: aerobic exercise and low-intensity exercise. Aerobic exercise strengthens the cardiovascular system while low-intensity exercise helps control weight, improve flexibility and balance, and helps halt age related bone loss. If the purpose of the exercise is to reduce body fat or improve cardiovascular conditions, moderate aerobic exercise is appropriate. A regular aerobic exercise program has physiological benefits for the cardiovascular, pulmonary, musculoskeletal, and nervous systems as well as psychosocial benefits. Aerobic fitness has positive effects on cognitive aging. As we indicated earlier, older people who are involved in aerobic programs are faster at cognitive skills such as encoding, recognition, rehearsal, and initiating commands than non-active older persons. For arthritis and other joint or motion impeding conditions, swimming is an excellent aerobic exercise. It reduces undue stress on joints, which because of arthritis or injury, are unable to repair and rebuild themselves in a normal manner. Swimming, however, does not help in the rebuilding of bone and therefore is not helpful in preventing or slowing osteoporosis, nor does it appear to be helpful in reducing weight. Walking is a good aerobic exercise because it can be done at a pace that individuals can set for themselves, takes no equipment, and can be done at any time. Walking strengthens muscles in the lower body, helps to build new joint bone and tissue, and helps to slow osteoporosis. Walking is also said to help clear the mind, and taking a walk with a friend or loved one is a great way to get exercise and maintain social interaction with one activity! Many senior and community centers have walking clubs where groups of people will meet and walk together for safety and companionship. In addition, many senior and community centers offer aerobic classes specifically designed for older people. In one study, previously sedentary elderly women began a low-impact aerobic dance regimen, and it improved their cardiorespiratory endurance, motor control/coordination, and body agility. Stretching has also been found to be especially beneficial for older people. Static or "held" stretching has been found to be of particular benefit for the prevention and relief of muscle soreness. However, unlike ballistic or bounced stretching, static stretching presents less possibility of tissue damage, requires less energy, and prevents and relieves muscle stress and soreness. |
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Even with all the information we have on nutritional requirements, studies suggest that almost one quarter of people over the age of 65 are malnourished - they are not getting the proper vitamins, minerals and other nutrients that their bodies need. Malnutrition can lead to loss of weight and strength, lessened immunity to disease, confusion and disorientation. Studies have shown that malnourished older individuals make more visits to physicians, hospitals, and emergency rooms. Maintaining adequate nutrition depends on two conditions:
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Who Among the Elderly Is Malnourished?
However, based on the most recent United States Census, 1% of those aged 65 and over represents almost 300,000 persons - an impressive number of older individuals who are not living healthy, active lives and are at risk of disease and frailty. The last place you might expect malnutrition is in a hospital - yet studies have identified large numbers of malnourished older people in hospitals. Older hospital patients encounter health care professionals who frequently have not had the training to recognize and treat malnutrition. Also, the specific food preferences of patients are sometimes ignored, resulting in a lack of interest in food and eating. In addition, hospital routines and policy can negatively impact nutrition. The most common place to find malnourished older people is in nursing homes. Although most nursing homes have a registered dietitian on staff to ensure proper nutritional components, most nursing home residents do not eat their entire meal, causing malnutrition. A number of recent studies have found as many as 85% of nursing home residents are malnourished. |
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What Causes Malnutrition Among the Elderly?
Hospitalized patients over 65 years old eat food containing significantly less calories and nutrients over the course of their hospital stay than younger patients. Younger patients meet 87% of their caloric needs with very little weight loss, while those over 65 met only 56% of their caloric needs with resultant weight loss. An older person's ability to recover from illness and surgery is increased by good preexisting nutritional status and support. A second risk factor is the cost of good nutrition. Many older people cut back on their food budget as they experience increasing medical expenses. Living on fixed incomes can make it difficult to afford decent housing, utilities, health care, medications, and adequate nutritious food. A third risk factor to malnutrition is medications. Older individuals are often treated with multiple medications for their many chronic diseases. Medications can cause loss of appetite, reduced taste and smell, painful swallowing, reduced saliva flow, sedation, and can affect the absorption of nutrients. It has been estimated that older people living at home take three or more medications per day; those in nursing homes and hospitals take from eight to ten. In addition, many older people also take over-the-counter medicines, vitamins, minerals and other supplements. A fourth factor contributing to malnutrition is dental problems. Poor condition of teeth and gums make it difficult to chew. Food intake is greatly affected by the condition of the mouth, teeth and oral cavity. Oral health problems commonly found in older adults include:
Older people dental problems may eliminate foods they can no longer bite, chew, or easily swallow and those that irritate an already irritated and painful mouth. The more foods older adults eliminate from their diet, the greater their chance of developing nutritional deficiencies. Studies have shown that wearing dentures has been significantly related to poor diet in community-dwelling elders. A fifth factor associated with malnutrition in the elderly is the normal physiological changes that occur with aging. Certain normal changes in organ functions take place with aging and often influence the nutritional status of an older person. For example, because the body has decreasing ability to concentrate urine, older people should be particularly careful to maintain adequate fluid intake. Changes in organ functions with aging that may influence nutrient status include:
Written dietary instructions frequently give the older person a long list of foods to avoid without providing adequate instruction on how to prepare foods or shop for foods that they can consume that are both nutritious and appetizing. Without individualized instruction and ongoing follow-up by trained professionals, older persons placed on special diets may indiscriminately eliminate foods and not substitute foods that will give them adequate calories, nutrients and eating pleasure. A seventh factor is that elderly people who are living alone or cooking for themselves tend to rely on ready made and frozen foods that often lack many nutrients or are so unappetizing that they are not eaten fully. It has been estimated that 20% of people over the age of 65 skip at least one meal a day, reducing their calorie, protein, and nutrient intake. In addition, the ability to shop, cook and eat may be reduced preventing proper nutrition. The very oldest and the poorest of the senior population have difficulty with one or more home management activities, including shopping and cooking. So, let's review the seven of the major risk factors or groups associated with poor nutritional status in older people. |
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Risk Factors Associated with Poor Nutrition
Treatment or prevention of poor nutritional status among community-dwelling elders and among older people in nursing homes and hospitals may make a significant contribution in maximizing healthy aging and independence. Older clients receiving home-delivered meals are reported to have fewer hospitalizations and decreased mortality compared to case managed clients without home-delivered meals and older people on waiting lists for home-delivered meals. This may be due in part to the daily or weekly interaction with the volunteers or staff members who deliver the meals.
There are many programs and services available to older adults through government and community resources to insure adequate nutrition, such as congregate meal programs at senior and community centers or the home delivered meals programs. These will be discussed in greater depth in the session on Government and Community Resources.
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In this session we demonstrate the importance of nutrition and exercise in successful aging. It is never to late to alter one's health behaviors in order to reduce the risk of the diseases and disorders of aging. Exercise programs can be tailored to the special needs of the individual. They should include stretching and weight training if possible. Malnutrition is quite common in long term care facilities and can increase the probability of disability and death.
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Researchers
at Tufts University suggest that exercise is the single most important
factor in maintaining healthy functioning as individuals age. The body
repairs itself and performs more efficiently with proper conditioning
that is achieved through a program of regular exercise. 
Protein
should comprise approximately 10-15% of the daily diet. Because lean
body mass decreases with aging, there is also a decrease in the building
blocks of protein, amino acids. This decrease impacts the body's ability
to adapt to demands for increased protein use, especially in times of
stress. Therefore, it is especially important that protein consumption
be increased during infections and diseases. With age, there is a decrease
in thirst sensation and changes in the secretion of hormones that help
regulate water and fluid intake. This places older persons at a greater
risk of dehydration. A general rule for fluid intake is approximately
two quarts per day. This varies by season and region. For example, fluid
requirements in the summer in Arizona would be considerably higher.
One of the most common causes of electrolyte disorders in the elderly
is inadequate fluid intake. This can occur when the body experiences
any kind of infection - which increases fluid requirements and causes
dehydration or in cases of extreme heat. 
Consumption
of adequate calories and protein to give the body fuel and materials
for tissue building, maintenance and repair 
There
are varying degrees of malnutrition in the three different settings
in which older persons live: their own communities, hospitals, and long-term
care facilities. In national surveys of presumably healthy, community-dwelling
older people, the prevalence of protein-calorie malnutrition is less
than one percent, and therefore malnutrition is generally not considered
a problem. 
Throughout
the life course, individuals move along a continuum of wellness and
illness. The aging process itself is not a cause of malnutrition in
old age. As with all factors that effect a person's ability to promote
successful, healthy aging, every malnourished older person has a unique
set of circumstances and events that comes together on the continuum
of wellness and illness to cause malnutrition. Nutrition is often overlooked
as an important factor that effects physiological, psychological, and
social health status. Studies have shown that the risk for malnutrition
is high among specific groups of older people. The two risk factors
most consistently found to be associated with poor dietary intake in
the elderly are: low socioeconomic status (income, education, or occupation)
and, for men only, living alone. Many different risk factors and groups
must be kept in mind when encountering older people and the possibility
of malnutrition. The biggest risk factors for malnutrition are illness
and disease. Certain diseases and conditions are more prevalent in older
than in younger adults and often negatively impact nutritional intake
which, in turn, can negatively impact nutritional status. There is a
rapid onset of protein-energy malnutrition in older people during the
trauma of surgery and illness. Unlike younger adults, older persons
have reduced muscle mass and therefore reduced protein stores. These
protein stores can be depleted in as little as three days when older
persons experience trauma and cannot eat. Unlike the body's ability
to store unlimited amounts of fat, protein storage depends solely on
muscle mass. Starvation often occurs in surgical patients when they
are in the hospital for extended periods of time without solid food.
In
addition to the effects of good nutrition on healthy aging, more and
more information about nutrition interventions on conditions such as
the treatment of pressure sores and hip fractures are proving to be
cost effective. Almost 300,000 hip fractures occur each year due to
osteoporosis, costing our nation between $8 and $10 billion a year.
One-third of these patients require in-home services and many never
recover to their former level of functioning. A significant reduction
in this high cost could be made through a combination of good nutrition,
exercise and, for women, estrogen replacement therapy.
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