Exercise in care home settings

How much physical activity should people do?

The Department of Health (DH) has issued guidelines that recommend older adults — those over 65 who are generally fit and have no health conditions that limit their mobility — should do one of the following:

• at least 150 minutes of moderate-intensity aerobic activity such as cycling or fast walking every week, and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms)

• 75 minutes of vigorous-intensity aerobic activity such as running or a game of singles tennis every week, and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms)

• an equivalent mix of moderate and vigorous-intensity aerobic activity every week (for example two 30-minute runs plus 30 minutes of fast walking), and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms).

Muscle strength and aerobic fitness are important for service users to maintain their independence and activity levels, especially as they age. Aerobic fitness is related to the health of the heart and lungs and keeping muscles as strong as possible makes it easier to carry out daily activities and reduce risks of falls.

Older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.

Generally, adults of any age who participate in any amount of physical activity will gain some health benefits, including maintenance of good physical and cognitive function. Some physical activity, the DH states, is better than none, and more physical activity provides greater health benefits.

Individual physical and mental capabilities should always be considered for all ages when interpreting guidelines and developing exercise regimes. There is no bar to participation in exercise, and flexible programmes can be developed for people with a whole range of needs, including those with severe disabilities and conditions such as dementia.

Physical activity that meets the guidelines

The DH states that moderate intensity physical activities will cause people to get warmer and breathe harder and their hearts to beat faster, but they should still be able to carry on a conversation. Examples include brisk walking, swimming and ballroom dancing.

According to the guidelines, vigorous-intensity physical activities will cause people to get warmer and breathe much harder and their hearts to beat rapidly, making it more difficult to carry on a conversation. Here examples include climbing stairs, jogging, aerobics and running.

Examples of physical activities that strengthen muscles and use all the major muscle groups include activities that involve stepping and jumping, such as dancing, lifting weights and working with resistance bands.

Examples of activities to improve balance and co-ordination include Tai chi and Yoga.

The problem of inactivity

Not only do the DH guidelines recommend that people do more exercise, they also state that people should minimise the amount of time spent being sedentary. The DH suggests minimising sedentary behaviour by reducing time spent watching TV and taking regular walk breaks.

A whole range of research exists looking into the amount of exercise that the general population actually engages in. This suggests that only 39% of men and 29% of women in the UK meet minimum physical activity recommendations when measured subjectively, and only about 5% when measured objectively. Similar trends are seen in children and in older people, despite a number of initiatives to try to reverse this drift.

The cost of providing medical care for the consequences of this growing lack of physical activity is considerable.

Obesity is one area where lack of exercise is seen to have an obvious effect. The Foresight report, Tackling Obesities: Future Choices, highlighted the growing obesity epidemic and recognised the burden that this was putting on the UK economy and its health and social care systems. The report sets out key recommendations and actions for local governments to positively change obesity levels including health, sports councils, the voluntary and private sectors working together to increase access to exercise.

Increasing exercise options in care homes

Residential care providers have become increasingly aware of the benefits of a healthy diet and exercise for physical and mental wellbeing over recent years and many in the care home sector have worked hard to introduce and develop exercise options for their service users.

A typical care home can do a great deal to encourage and support exercise and activity for its residents.

Structured exercise programmes and classes are probably the most commonly developed option. Such classes can generally be run in-house by staff or volunteers or be contracted from specialist outside providers or physiotherapists and run in the home itself. This has the advantage of making it easier for residents to attend and some will find the basing of the activity in familiar surroundings reassuring. Some care homes have even developed their own gym facilities.

Classes are also usually available locally outside of the home, perhaps from sports centres or in day centres or community centres. Encouraging and supporting service users to access such classes not only satisfies their need for exercise but will also maintain and build their social links with the wider community. Specialist fitness groups for older people are usually available and swimming is a popular option for many, especially if accompanied by a carer.

Group classes and activities can include:

• general mobilisation exercises to improve fitness and mobility

• stretching exercises to reduce stiffness and improve range of movement

• musical exercise including dance and aerobics

• chair exercises, which can be done by people while seated.

One-to-one programmes can include:

• use of exercise bands to gently improve strength and target different muscle groups

• individual physiotherapy programmes for those who have a limited range of movement — can be done in bed or in a chair

• personal training sessions.

Care providers should ensure that those running such classes are suitably qualified and experienced and have the appropriate safeguarding credentials. Most exercise providers will be able to tailor programmes to the individual needs of service users and develop personalised exercise plans for individuals as well as group activities.

Personalised exercise plans can be developed as therapeutic and recovery aids where required, especially as part of rehabilitation programmes for service users who have had falls or who require active physiotherapy and mobilisation. Where a service user has specific nursing or mobility restrictions a specialist assessment from a physiotherapist can usually be arranged via a GP. Those who are infirm can be prescribed specialist bed or armchair exercises, for example.

The existing level of fitness of service users will vary between individuals and should be assessed at the start of any programme. Some may need to see their GP prior to a programme starting. Those who have not exercised for some time or who have health complaints may need a gentle introduction and can find the idea of exercise daunting. Focusing on something the service user enjoys is often a good way to build engagement.

If a service user experiences any pain, dizziness, shortness of breath or palpitations, or if he or she has prolonged discomfort while exercising, he or she should stop straight away and medical advice should be sought.

Exercise prescriptions

For some service users, it may be possible for them to get a prescription from a GP that includes exercise or be referred to an exercise specialist for certain conditions such as obesity, heart disease, back pain, osteoporosis and diabetes.

The exercise on prescription programme usually includes referral to a local active health team for a fixed number of sessions. Depending on what is available locally, the exercise programme may be offered free or at a reduced cost.

Referral may also include an assessment by a sports and exercise doctor.

Preventing disease with sports exercise

GPs are increasingly able to prescribe exercise to their patients, and may also be able to refer their patients to specialist NHS sport and exercise medicine (SEM) services.

Sport and Exercise Medicine: A Fresh Approach was written by the DH as a London 2012 Olympic Games bid commitment. It emphasises the importance of sports and exercise medicine in a number of areas of healthcare, particularly chronic disease management and the diagnosis and management of musculoskeletal injury.

The report states that the health benefits of physical activity are irrespective of age and socioeconomic group or cultural origin. It cites research suggesting that regular physical activity and increased cardiorespiratory fitness is an effective treatment adjunct for most chronic diseases and prevents the development of co-morbidity.

Musculoskeletal disorders, which are reported as accounting for up to 30% of all consultations with a GP, are a key area where physical exercise has a proven record of effectiveness. This is particularly true in areas such as chronic back pain, which has been seen to respond well to management options that include exercise and psychological rehabilitation.

The report recommends that exercise needs to be promoted by all health and social care providers. In addition, exercise rehabilitation and referral schemes need restructuring and modernising in order to provide better access and cultural barriers to long-term behavioural change need to be addressed.

The limitations of physical activity prescriptions

However, the report also points out that current provision within the NHS for physical activity prescription in chronic disease has been inconsistent. While there has already been much important work done in this area the report concludes that physical activity rehabilitation schemes for those with chronic disease are fragmented and adherence on programmes for those with chronic disease remains low.

A contributory factor to this is undoubtedly the fact that those with chronic disease often have additional barriers to exercise. Examples are pain, frailty, fear of exercise, confidence issues and physical difficulties in achieving therapeutic physical activity levels. In order to gain maximum benefit, people have to want to change and comply with long-term programmes and research shows that the most successful approach is achieved by a multidisciplinary approach with a focus on long-term behavioural change.

In a care home context, this means that any prescription for fitness and exercise should be supported by all staff at the home, and by relatives and carers.

The report does refer to vascular health checks, which are currently being piloted in primary care through the use of general practice physical activity questionnaire (GPPAQ). The intention of such screening — formerly known as the vascular check programme and now called NHS Health Check — is to identify high-risk patients who can then be prescribed exercise programmes.

Links with the fitness industry, principally with sports centres and gyms, have been developed and in some areas are effective. However, there is a long way to go to achieve consistent approaches and in many instances people who are prescribed exercise feel excluded for a number of reasons, including co-morbidity, geography, and expense.

SEM specialists

SEM was accredited as a specialty of medicine in 2005. The specialty is led by the Faculty of Sport and Exercise Medicine and the British Association of Sport and Exercise Medicine.

SEM specialists are trained in education, physical activity and chronic disease, exercise physiology, public health, general practice and musculoskeletal medicine.

A Fresh Approach urges all areas to appropriately commission SEM services. It acknowledges that individual localities will have differing needs and will therefore commission varying services based on these needs.

A number of commissioning guides exist. These include Let’s Get Moving — A New Physical Activity Care Pathway for the NHS: Commissioning Guidance published by the DH in 2009. The guidance discusses the importance of physical activity and the potential health gains from active lifestyles. It reiterates the importance of creating a shift in societal attitudes and behaviour towards physical activity.

Let’s Get Moving suggests that care providers provide encouragement for health and social care service users in setting physical activity goals, utilising community based physical activities and inspiring people to gradually become more physically active.