The major benefits of exercise for older adults

An article in CMAJ, "Move more, age well: prescribing physical activity for older adults," found that regular physical activity can reduce all-cause mortality by 31%. As Canada’s population ages, maintaining physical activity is becoming an increasingly critical factor in healthy aging. 

On this episode, Dr. Samir Sinha, a geriatrician at Sinai Health and the University Health Network and co-author of the CMAJ article, explains the evidence supporting exercise as a tool for preventing frailty, cognitive decline, and chronic disease in older adults. He addresses common misconceptions about aging and physical activity, emphasizing that even small, progressive increases in movement can help people stay independent longer.

Physiotherapist Steve Di Ciacca, program manager at the Canadian Centre for Activity and Aging at Western University, outlines practical ways clinicians can help older patients build movement into their daily routines. He discusses the role of social engagement, personalized goal-setting, and structured exercise programs in improving adherence. He also highlights evidence showing that a simple written prescription for physical activity can increase adherence by up to 10%.

This episode provides evidence-based insights to help clinicians encourage physical activity in older patients, promoting better long-term health outcomes.

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Transcript

Blair Bigham: I'm Blair Bigham.

Mojola Omole: I'm Mojola Omole. This is the CMAJ podcast.

Blair Bigham: Jola, today we're going to be talking about something we've talked about before, the effects of exercise and all the benefits that come with it. But we're going to be zeroing in on a different population than last time.

Mojola Omole: Yeah, we're going to be talking about exercise in older populations. 

Blair Bigham: So this was actually a review article, entitled “Move more, age well: prescribing physical activity for older adults”, in which the authors described that Canada is really a super-aged country, which.

Mojola Omole: I think we all know that by our patient populations 

Blair Bigham: And it's going to be more super-aged. And of course, Jola, you and I and everybody else in healthcare sees the effects of that aging on people. As they get physical weakness, they get traumatic falls, they get cognitive decline, they need more health care, they need more money to support them, they need more people to support them. And physical activity, lo and behold, might be a way out of that.

Mojola Omole: Yeah, just the impressive stats that it shows when we look at frailty, cognition, and overall mortality in older populations. 

Blair Bigham: And even reducing regular diseases like diabetes, coronary artery disease, stroke, it really does have a massive benefit. And so we're going to talk to a couple of people today about that and about the different types of physical activity that can lead to those benefits and how to motivate people to do so without, you know, falling and breaking a hip.

Mojola Omole: We'll also be speaking to Steve Di Ciacca. He's a program manager at the Canadian Centre for Activity and Aging, just to help us to understand how older patients can safely build exercise into their lifestyle, regardless of where they're starting from.

Blair Bigham: But first, we'll talk to renowned geriatric well-being expert, Dr. Samir Sinha. Dr. Samir Sinha is one of the authors of the review article in CMAJ titled, “Move more, age well: prescribing physical activity for older adults”. Dr. Sinha is a geriatrician and clinical scientist at Sinai Health System and University Health Network in Toronto. We reached him in the UK, where he is currently on sabbatical at the University of Oxford. Samir, thank you so much for joining us today.

Samir Sinha: Thanks for having me, Blair.

Blair Bigham: So I gotta ask, Samir, because we've done a number of episodes on the benefits of exercise, whether it's for your physical health or for your mental health, it feels like that connection is solidly established. So when I see another article about prescribing physical activity, I kind of go like, okay, well, obviously. Tell us why physical activity is so important for older adults and why you felt compelled to write this review.

Samir Sinha: I think there are a number of misconceptions around this because while we all know that exercise and not smoking, and these are motherhood and apple pie statements that we all know and that we all trust, I think the challenge is that it becomes so much more important for my older patients. Because as you think about as you age and you encounter various chronic conditions, it's always helpful to know that exercise or regular physical activity could help actually modify or prevent up to 30 different chronic conditions. It can actually help prevent the onset and development of dementia, for example. It can actually help you stay healthy and independent. And given the aging of our population and the real compelling evidence around this, I think what's sad to see is when so many people aren't encouraged to do this, especially when they might say, well, I guess I missed the boat. It's probably too late for me to derive any benefits. And as clinicians, I think sometimes we also say, well, is it worth telling my patient to do exercise? And I don't want to cause any harm, so maybe it's better if they do nothing. So I think there's a lot of misconceptions, and that's why we wanted to write this article.

Mojola Omole: What do we consider older adults? What's the age range here?

Samir Sinha: Yeah, Jola, this is one of those things where when people say, what do we mean by older adult, for example, I think generally most studies start defining people as older adults in that 65 and older cohort. But in different populations, we know that aging can occur more rapidly. So in our Indigenous populations, our incarcerated populations, our homeless populations, you'll actually see more rapid aging occurring. And so that's why we use the 65 and older cohort. We use that as kind of an idea. But you could actually see some people are aging faster than others, if that makes sense.

Blair Bigham: So it's more about the body's, I guess, physiologic age than chronologic age.

Samir Sinha: Absolutely. Yeah.

Blair Bigham: Okay, so what is the bottom line on how increasing physical activity could impact someone's mortality?

Samir Sinha: 31%. I mean, this is the number that we were able to demonstrate that you could actually reduce all-cause mortality if people are doing a moderate level of physical exercise as adults. And so we talk—when we define moderate levels of exercise, you know, the WHO says that if we get about 150 minutes a week of moderate exercise, so say 30 minutes a day for five days a week, that's what we're talking about. And even less exercise if you're doing more vigorous physical activities.

Blair Bigham: What's considered vigorous?

Samir Sinha: Yeah, so it's a great question because we talk about a moderate level of activity, say that if you get your heart rate up to about 60% of its maximum, so two-thirds of its maximum heart rate would be considered a moderate level of activity. So I always say you're going for a run or you're doing a walk, for example, and you're sweating, you're a bit breathless. Whereas we talk about vigorous exercise where you're getting your heart rate up to near maximum, to 90% of its maximum rate, if you will.

Blair Bigham: So talk to me about that perception that people are maybe frail or that physical activity could be a risk for somebody maybe who has mobility issues, maybe they've got arthritis. What are some of the misperceptions around that to get people to that 30 minutes a day or 150 minutes a week mark?

Samir Sinha: Well, I think when we start thinking about exercise, people say, do you mean I should be running a marathon or I should be pumping iron? And I think people forget that even basic things like walking is a really good exercise. And some people who are not very steady on their feet, this is where we might recommend chair-based exercises, or we might look at other exercises that you could do in the water, like Aqua Fit, for example. You know, people often put their own psychological barriers or just even informational barriers as to what can I do, can I do anything? I think a lot of us as practitioners might actually make our own assumptions, which are sometimes not correct. And then the other challenge is that people—everyone's motivated, but then there might be an actual practical barrier like, how do I get to those Aqua Fit classes? Because I retired from driving 10 years ago, and I'm not sure how I can get from here to there. And sometimes working with a community-based social worker, for example, who can connect you with a transportation service or getting you reoriented to public transit could be a great way to get that person from where they live to where they can do their exercise as well.

Blair Bigham: I guess doing any activity would be better than no activity. But are there particular activities that physicians should recommend to certain elderly patients? Like, is it better to do cardio training or strength training or core training? Like, is there a target area, either of the body or a type of exercise that people might want to focus on to get the most bang for their buck?

Samir Sinha: When my patients ask me what's the best type of exercise for me to do, I'm like, the one that you're most likely going to do. So I try and ask people, what do they enjoy? What did they like playing when they were younger, or is there something that they used to do, and then what's getting in the way of them being able to do that? But if you look at the types of exercise that we talk about, we talk in the paper specifically about aerobic forms of exercise, so ones that really support your cardiovascular health. And then we also talk about resistance exercises, ones that—where you're doing kind of muscle and strength training. And we also talk about balance-based exercises as well, ones that actually help reduce the risks of falling. But I think the one that gets the most bang for your buck, if you had to choose one, would be aerobic forms of exercise, which you can get by simply just walking around. And then if we also talk about the ways you could prescribe resistance training, which is like going to a gym, doing some weights and certain levels of repetition, or even doing that in the form of an exercise class.

Blair Bigham: Talk to me more about how exercise and cognition are linked.

Samir Sinha: Yeah, so the real link here is around vascular health. So, you know, people are well aware that if you maintain a healthy heart, for example, you're less likely to have heart disease. You're less likely to experience strokes, for example, and in that same way, you're likely to have a healthier brain. So the real benefits that we see from exercise or the types of exercise that are aerobic forms of exercise that really improve your cardiovascular or just in general your vascular health.

Because what we've actually seen—the good news is by better treating vascular health, by better preventing or treating hypertension, hyperlipidemia, and having people being more physically active, if you will—we're actually seeing low rates or incidence of things like vascular dementias. And that's why we have less people living with dementia today than we predicted would be living with dementia in Canada 20 years ago.

And really, when you look at the studies that we reviewed, and this gets reflected in The Lancet Commission, which talks about a number of different things that can actually help prevent or reduce the risk of dementia, there are good studies that show that people who have more severe forms of cognitive impairment can actually improve to a milder form of cognitive impairment. And even that progression from what we call mild cognitive impairment to dementia can actually be slowed if people are participating.

So when I have patients whose brain health I'm worried about because I've now diagnosed them with mild cognitive impairment, I tell them, you have a 10% annual risk of converting over to dementia. And they say, well, what can I do to prevent from converting over to dementia? I say, the only two things that you can do are—number one is manage your blood pressure, make sure that you're not hypertensive. And that's part one. Part two, regular exercise. Those are the two things. It's not crossword puzzles, it's not eating a certain food, it's not taking a certain pill. It's actually doing those two things in particular that will really help.

And so I think the nice part is that these studies have really shown that if you really want to value your independence and reduce that risk of dementia, exercise is a very powerful weapon to protect yourself with.

Mojola Omole: Is there anybody that exercise in older adults might not be appropriate? I'm just thinking of someone like, with balance issues. Are those not appropriate in terms of—because we're saying that, you know, cardiovascular aerobic gets you the most bang for your buck, but if there's balance issues, how do we balance that?

Samir Sinha: Exactly. No, I mean, and this is the thing, because I think what we don't want people to do is say, you had a fall the other week, right? So therefore, no exercise for you. What we want to do is when we're worried that a patient might have a risk factor that might potentially say, will this exercise cause harm, for example. Will it actually worsen things? I think this is where we look for alternative ways for them to participate. So sometimes if someone has balance issues, for example, we might prescribe to them chair-based exercises, and there are chair-based exercise classes, for example. Sometimes what I'll do is I'll have a patient who might have balance and strength issues actually work with a physiotherapist and occupational therapist because they can actually do balance and strength training, which might improve that, or give them a specific exercise regime that allows them to deal with that challenge, so that they can still participate meaningfully in some form of exercise.

Blair Bigham: So give us a couple of tips. If you're talking to one of our colleagues in family medicine or gerontology or internal medicine, maybe you're discharging somebody from the hospital back home, or you're just seeing somebody in your clinic or your practice. What are some sort of bullet point, really high-yield tips for how you can actually get that person moving?

Samir Sinha: Yeah, so I think first of all, you know, a lot of what we're doing in healthcare is we're firefighting. We're always just trying to deal with kind of what brought that person here today. I like to focus a lot of my work around this idea of healthy aging, wellness, and prevention. So it's remembering that movement is medicine, that exercise is actually a great thing that you can do to treat chronic health issues, but it's also a great way to prevent them from getting worse.

And so I think the key is that if we raise the issue as clinicians, our patients are more likely to take it seriously. I think this paper helps us, arm us with the facts to say, my patients, when I ask them what matters most to them, they say, I want to stay healthy and independent in my home for as long as possible. I'm like, great, this is why we need to focus on exercise.

But one thing that we focus on in the paper is the WHO has a five-step framework or the five A’s that really help give clinicians kind of some guidance here. And it's first of all figuring out what is their current level of physical activity, like what do they actually do? And then it's doing an assessment—are there any contra—contra, you know, indications, for example, are there any risks? And then we can start thinking about what is the right type of exercise for them to do and then create goals with them, saying, you know what, maybe if you can just do five minutes a day and just start there, that's a great starting point.

And then it's that opportunity to make sure that we follow up—how did it go? Reinforce what were the barriers? And by doing that and just incorporating that as part of the care plan—that you're going to check in on this, you're going to encourage that, you're going to help them problem solve—I think it really helps your patients realize why you value this as well and helps them value this. And knowing that you're not prescribing a medicine, you're not telling them to pop pills, you're actually empowering them to maintain their own health and well-being so that they can stay healthy and independent.

And just remember that I think for everybody, there's usually an opportunity to help them become more physically active. And it's something that can support them, it can support us as clinicians, you know, not seeing them decline faster than they need to. And it really helps the whole healthcare system. So we've known this is motherhood and apple pie. We now have more definitive evidence. So let's get out there and get more of us moving.

Blair Bigham: Awesome. Thank you so much.

Samir Sinha: Thanks for having me.

Blair Bigham: Dr. Samir Sinha is the director of geriatrics at the Sinai Health System and University Health Network. We reached him in Oxford, England.

Mojola Omole: Steve Di Ciacca is a physiotherapist and program manager of the Canadian Centre for Activity and Aging at Western University. He's a longtime colleague of the lead author of the article in CMAJ, Dr. Jane Thornton. They've worked together in clinical settings at the Fowler Kennedy Sports Medicine and through research at Western University. Steve, thanks so much for joining us today.

Steve Di Ciacca: Not a problem. Pleasure to be here.

Mojola Omole: So let's just start with some of the activities that Samir recommended. What sort of patient could benefit from, like, let's say, Aquafit?

Steve Di Ciacca: I think really it's very limited as far as who couldn't benefit from Aquafit. Aquafit certainly has a component of unloading some of the joints. So if you're having some issues around ability to do some traditional land-based exercises, Aquafit could be a very good, good alternative. Also considering what do people want to do and what do they enjoy? And I think when Dr. Sinha was on, he hit it right on the head. It's finding things people like.

So if they love water, if they love Aquafit, great. If they hate water, it's probably the worst thing for them to do. Research really shows, and through our work at the Canadian Centre for Activity and Aging, we look at adherence, motivation. And what we do know from older adults is we're not as apt to go to a commercial gym, jump on a spin bike, and have somebody yell at us for an hour and just be mindless and drones doing it.

We really want to, A, understand—so we want to know what we're doing, why we're doing it, how it affects us in our life. We want to know that it's geared towards us a little bit so they kind of understand some of the things that might come with an older population. They also really enjoy the social impact of, say, group work and interaction. And really, they have to like it. It has to kind of resonate with them. And so those factors are really the big keys in finding what people will do, want to do. And so it can be a huge variety of different things.

Mojola Omole: And so Samir mentioned this, but like chair exercises—what does that look like? Is it just more like the yoga, or is there, is there actually like cardio as they're watching CNN?

Steve Di Ciacca: There could be, there could be. But what kind of frustrates us a little bit now is that we're still watching people doing chair exercises or using one-pound weights for years. So really what we're trying to get through is age isn't your prescription or your limiting factor. It shouldn't be age. Things come with age, especially if you don't use that time well in the early stages.

So just doing chair exercises because I'm 65 is maybe a misnomer. I don't want you to do that. I would rather say, what can you do? And then let's try and create some challenges around that. So for the person who potentially needs—who's maybe partially ambulatory or struggling in a long-term care facility that maybe is falling more into a fragile state—chair exercises can be extremely beneficial.

We at the CCAA have a program where we go into the long-term care facilities and teach some of their personal support workers or rec therapists how to use and set up a chair program where we're targeting strength and mobility and flexibility. It is a little bit more difficult to try to do cardiac or cardiovascular, but it can be done.

What we've actually found lately is where we're going into facilities and with partners where they're doing traditional chair programs, and we're trying to get them a little bit more comfortable—the leaders doing a little bit more standing and a little bit more walking around—and they're finding, hey, this is fine, this is great. And so trying to just unshackle some of the fears and the norms of what people should be doing. What can they do? As long as it's in a safe environment and a monitored environment. 

Mojola Omole: How challenging should the exercise be?

Steve Di Ciacca: Honestly, as long as you consider the relativity of it—it shouldn't really be different depending on your age. And so when you look at those intensities, when you look at how hard you want to push, it has to be a challenge. That is going to be relative to you. A challenge may be lifting a one-pound weight. That may be a challenge to you. And that's okay. The key is it needs to be a challenge, but then it needs to be a progressive challenge over time.

So what the trend now is looking at is something called relative perceived exertion. It is something that's been used in research for a long time. It's a scale that goes from 6 to 20 in research, but it's been simplified to just a 0 to 10 rating scale. And so 0 being I'm sitting stationary, I'm lying in bed, I'm really not exerting any energy. Whereas 10 becomes I'm—I'm running from that saber-tooth tiger. I've got a burst of speed that I'm maxed out, maybe 10, 15 seconds max type of thing.

And so then trying to help them relate to—where is that kind of half, that five, that six? Five would probably be in that area of—I could do this continuously for about an hour or so. I got a bit of a heart rate elevation, maybe a bit of a sweat going on. I can still maintain a conversation with someone if I'm walking with them, but it's a bit laboured. And then stepwise from there, those increments.

And so there's lots of references, and we utilize it with our programs at the Canadian Centre for Activity and Aging. And the research is showing it's extremely valid when compared with people that are using heart rate that doesn't have that. So it's a great tool.

Mojola Omole: And so is there a limit to the type of exercises older people should consider? For example, running long distance or actual power, like not lifting five-pound weights but actually doing, like, powerlifting?

Steve Di Ciacca: I'm gonna harp back to—it’s all relative to what you've done and where you currently are. And so really, the social norm of "we need to slow down, that's too much because you're older"—common sense has to weigh in as well.

But I also happen to be a coach of a master's rowing program. And we have athletes that are 65, got a couple athletes in their mid-70s who are doing Olympic-style lifting, who are training at their maximum levels and really having good performance. We went to the world championships last year. Even at the world championships, they had an octogenarian celebration. And so they had, I think it was 16 boats—so 16 eights, eight per boat, times 16 individuals—that were still rowing at a world championship level in their 80s.

Mojola Omole: That's amazing.

Steve Di Ciacca: So it just goes to show that the time we invest now in this can pay dividends down the road. But it is back to safety and relative—what have you done? You don't want to start Olympic lifting at 80. You don't want to start—and I think really the biggest message, and from this paper, some of the message is how do we get that information into our patients’ hands? How do we get them to start early doing the things, investing in the time, so that as time goes on, we're not waiting till something happens, we're not waiting till we have health issues to then start using exercise as an intervention, but more as a preventative measure. And how we can enjoy those later years and not be worried about comorbidities and poor health.

Mojola Omole: How do we motivate older people to adhere to the 150 minutes a week?

Steve Di Ciacca: I think that's where it falls into our primary healthcare providers, whether it's the first-line physician, physio, kinesiologist, chiropractor, what have you, is helping the people to not get startled and say, ooh, there's no way I can get that, so I'm not gonna bother. But to more help understand that's the goal. That's where we wanna eventually get to. How do we start with some small steps? And what do those small steps look like?

Not everybody loves exercise. And so exercise doesn't have to be in the gym, doesn't have to be in an exercise setting. It could be physical activity, it could be a dance class, it could be other types of hubs, could be joining a master's rowing club. So again, depending on where you are currently, there's so many different options. And as I go back to, people have to enjoy it when we're older. We want to enjoy it, we want to know why it's important. And so knowing those different resources can be very beneficial at that primary care level of what did they enjoy and what's around to help steer them towards.

And really just that building of self-efficacy that, okay, 150 minutes is the goal, maybe that's going to take you a year, maybe that's—maybe you never get there, but you certainly can move the dial from where you currently are. And that in itself is going to be helpful. And so I think it's that behaviour.

Blair Bigham: Steve I’ve heard a lot about social prescriptions and prescribing non-medical, like non-medications. What's your experience with actually prescribing fitness as opposed to just saying, oh, you know, you should move more, or suggesting it?

Steve Di Ciacca: Yeah. And I think over the years, we all know we should move more. We all know that exercise is important, but we still struggle to see that. And recent literature shows that only about a quarter of us in Canada are actually achieving those base goals.

And so some literature, and I believe that Dr. Thornton was involved as a student in this, is looking at even just prescribing and writing down exercise on a piece of paper and handing it to a patient has a bit of an effect. Up to 10% of people would adhere to that. So that doesn't sound like a lot, but 10% of the population is still quite a significant number of people.

And as the authors are certainly ingraining, it's just trying to bring up that exercise in a physician's mind as just as powerful a tool to be prescribing as any other tool in their toolbox. And so I think that's really the important part of helping people get over their barriers to take up some more physical activity.

And then the second one would be just help them find what it is that they love and connect it. Could be dog walking, could be swimming with friends, could be a Tai Chi class, could be square dancing. Doesn't really matter as long as they're clued into, hey, that's part of what you want me to do. Perfect. And then you're going to be much, much better buy-in.

Blair Bigham: Thank you so much.

Mojola Omole: Steve Di Ciacca is a physiotherapist and program manager at the Canadian Centre for Activity and Aging at Western University. Thank you so much for this conversation today.

Steve Di Ciacca: You're very welcome. Enjoyed myself.

Blair Bigham: Okay, Jola, I'm feeling like this episode was maybe produced not to help elderly patients, but to remind you and I that we don't exercise enough.

Mojola Omole: Yeah. Or, you know what? I actually exercise quite a bit, but maybe me taking meetings when I go for walks is not exercise.

Blair Bigham: It doesn't count.

Mojola Omole: It's just—maybe it's just me not sitting. And so this was—I thought this was really insightful, especially in terms of giving patients more guidance when—because I do tell patients all the time, you know, you need to, you know, movement is medicine. And maybe giving them a bit more guidance of how to judge if they're moving enough.

Blair Bigham: I think—I mean, I think Samir said, like, exercise is one of two things that we know keeps you sharp, we know keeps you strong. And like, the physical fitness aside, like, if I—if I'm physically fit, I definitely want to be mentally fit. And so this idea that we can maybe motivate people by tying fitness not only to physical exercise, which—and physical strength, which seems obvious—but also to, like, staying sharp and being cognitively able to take care of yourself and your affairs and enjoy the people around you, I feel like that's probably very motivating to people.

Mojola Omole: Yeah. And, you know, I—funny enough, I'm thinking back to, like, you know, every time I go to a European country, I'm always like, oh, I could see myself living here. And one thing that always stands out, though, is the fact that older people are outside.

Blair Bigham: They're all out, walking around. Totally.

Mojola Omole: And they're—and they're in constant motion and trying to create—I mean, it's colder here, so it's a little bit harder. But, you know, sometimes you see seniors at the mall in the morning going for their walks, is trying to encourage more activity like that,

Blair Bigham: an activity that they want to do, be it walk around the mall, Aquafit, you know. But when we start talking about Aquafit and some of these activities, it does start to be an issue of either transportation or cost or local availability. There is a, there is a component there to sort of overcome. But I think it goes with saying, like, if you can afford to exercise either with a coach or a trainer or if you have physiotherapy coverage, it pays dividends to your future health.

Mojola Omole: But I think just as important is maybe—it's just, you know, that, of course, you know, I heard what Steve was saying about it becoming too much of a social hour. But, you know, because I do know that when I'm working with especially older women from racialized communities, the thought of exercise is just like, ooh, like, you know, that's what men do.

I remember once I was—I'm weightlifting and my mom is training next to me, and she's like, do you have to lift so heavy and grunt? And I'm like, yeah, kind of the point.

Blair Bigham: Interesting.

Mojola Omole: But, you know, and so you—for them, it's just not something that maybe, perhaps, women do. But what they do love to do is socialize. What they do love to do is, you know, window shop. And maybe trying to incorporate more of things that are naturally in their—in, like, in their daily lives and in their cultural upbringing, and investigating that a little bit more when we tell people to move more.

Blair Bigham: That's it for this episode of the CMAJ podcast. If you like what you heard, do us a favor. Spread the word. Like or share—wherever it is you download your audio or anywhere else on social media, or just at work, tell a colleague. Hey, check out the CMAJ podcast.

This podcast is produced by PodCraft Productions. I'm Blair Bigham.

Mojola Omole: And I'm Mojola Omole. Until next time, be well.