# Motivation and emotion/Book/2013/Motivating the elderly to exercise

* Multimedia presentation (5 min)

## Overview

Lisa (63 years) struggled with depression during her life and decided during her 40s to do something active. She joined community physical activity classes and through this met new friends. She also redeveloped her interest in gardening. Lisa felt so much better within herself when she was actively having fun either through her gardening or through her community physical activity classes with her new friends. (Buman, Yasova & Giacobbi, 2010)
"That's when I realized exercise was really important and would make me a lot happier with my life" - Lisa (Buman et al., 2010, pp. 227)
This chapter is aimed at elderly people and their family members, carers and health practioners to understand reasons why elderly do not want to exercise and mechanisms to motivate them to get moving. The flow of this chapter will involve what are:
* Prohibiting factors elderly experience towards exercise?
* Theories suggested to contribute to motivation?
* Ideas of how to get elderly to exercise that incorporates motivational theories?
Anytime you see "STOP! Activity Time" take a break and participate in the activity.

## Background

* Watch the following link to gain a brief image of perceptions elderly can feel towards exercise.
* http://www.youtube.com/watch?v=NLottSf-sW0
Before proceeding here is a brief background on who elderly are and the benefits exercise provides to them.
A person in later stages of life is known as an elderly, senior or older adult which begins typically between 60 to 65 years old (World Health Organisation, 2013). Exercise is vital for this population for those who do not have chronic disease as well as for those who do as it plays a role in maintaining quality of life. Table 1 provides an outline of the role exercise plays for elderly.
Table 1
Summary of Exercise Benefits Adapted from Neid and Franklin (2002)
* Exercise benefits for elderly
* Improves VO2 max, cardiac output and heart rate
* Decreases risk of heart disease
* Improves congestive heart failure
* Promotes healthy cholesterol
* Decreases type II diabetes risk or can improve insulin sensitivity
* Improve bone density
* Decreases falls
* Improve function for those with osteoarthritis and decreases pain
* Improves sleep quality
* Alleviates depression
* Improves cognition
* Prevent some cancers

## What stops elderly from exercising?
### Health

Poor health is a leading exercise barrier within elderly (Belza et al. 2004; Schutzer & Graves, 2004). Common health implications include:
   * Fatigue/lack of energy (Conn, 1998; Belza et al., 2004; Newson & Kemp, 2007)
   * Joint problems (Conn, 1998; Newson & Kemp, 2007; Hartman et al., 2013)
   * Vision impairment (Conn, 1998; Belza et al., 2004)
   * Shortness of breath (Belza et al., 2004; Hartman et al., 2013)
   * Comorbidities (Phillips et al., 2004)

### Education

Schutzer and Graves (2004) reviewed that seniors are less likely to engage in physical activity (PA) if understanding of the importance of exercise is not established. Newson and Kemp (2007) identified elderly who reported low levels of exercise rated lack of knowledge of their physical capabilities as a prohibiting factor. Conversely, Dergance et al. (2003) found thatolder adults with lower education did not significantly impact on their PA participation.
Elderly trust advice provided by their HP (Dickinson et al., 2011). Dickinson et al. (2011) identified barriers to exercise for elderly who were at risk of falling, in that their HP had either not provided enough information on types of exercise to do or they had shown little interest.
Anonymous lady (Dickinson et al., 2011):
    "I had a very good doctor, years ago, and then the next one did not seem very interested… ‘oh see the surgery nurse’ so I though “right I shan’t bother’ so I didn’t." (p. 727)
    This resulted in the woman not using the exercise interventions to improve her balance ability.

### Childhood behaviors

    Inactivity during childhood could affect seniors perceptions and motivations towards exercise. Through case studies, Buman et al. (2010) identified seniors reported during childhood their PA levels were low. Inactivity during childhood can prevent exercise becoming a habit in older life (Phillips, et al., 2004).
Female (67 years) (Buman et al., 2010):
    "I think that exercise is just not part of who I am. I mean, I know I should be exercising and I know that it is good for me. I guess I just wasn’t raised to think that exercise was something you needed to do and other things in my life have always taken a higher priority. I think that affects me now even though I know how important it is." (p. 228)

### Weather

    Weather like snow, cold, humidity, rain and heat can influence elders decisions to exercise (Belza et al., 2004; Newson & Kemp, 2007; Hartman et al., 2013). Weather impacts exercise motivation because it can prohibit breathing or enhance risk of injury such as falls (Belza et al., 2004; Hartman et al., 2013).

### Time

Conn (1998) compared an earlier study she conducted to the present one and established in the earlier study that nearly half of the older women did not exercise because they did not have enough time in their schedules but in the later study less women reported time as an exercise barrier. More recently Buman et al. (2010) interviewed 17 older adults and 13 of those reported time constraint as a major PA inhibitor. They perceived they did not have enough time or had other priorities to attend to (Buman et al., 2010). Hartman et al. (2013) found that time constraint was an exercise barrier for seniors with pulmonary disease but was less of a barrier compared to other inhibiting factors.

### Access

These are other factors Phillips et al. (2004) recognised that elderly people take into consideration towards exercising at facilities.
   * Transportation
   * Parking
   * Changing and toilet facilities
   * Disabled access

## Theories
### Self-Determination

* Behavioral Regulation in Exercise Questionnaire Subscales and Item
* External Regulation
* I exercise because other people say
* I should I take part in exercise because my friends/family/spouse say I should
* I exercise because others will not be pleased with me if I don't
* I feel under pressure from my friends/family to exercise
* Introjected Regulation
* I feel guilty when I don't exercise
* I feel ashamed when I miss an exercise session
* I feel like a failure when I haven't exercise in a while
* Identified Regulation
* I value the benefits of exercise
* It's important to me to exercise regularly
* I think it is important to make the effort to exercise regularly
* I get restless if I don't exercise regularly
* Intrinsic Regulation
* I exercise because it's fun I enjoy my exercise sessions
* I find exercise a pleasurable activity
* I get pleasure and satisfaction from participating in exercise
Self-determination theory (SDT) refers to developing psychological growth through social support (Deci & Ryan, 2012). Requirements for psychological growth include feelings of competence, relatedness and autonomy (Deci & Ryan, 2012). The SDT is positioned on a continuum ranging from low to high self-determined which include :
   * Amotivation (limited value and belief towards an activity; Thogersen-Ntoumani & Ntoumanis, 2006).
   * Extrinsic motivation is subdivided into four categories which are listed below from low to high self-determined.
    External regulation (behaviours being conducted to gain a reward or avoid punishment; Deci & Ryan, 2000).
    Introjected regulation (behaviours occur to gain social approval and avoid guilt; Deci & Ryan, 2000).
    Identified regulation (behaviours are valued but not particularly enjoyed; Deci & Ryan, 2000).
    Integrated regulation (behaviours occurs because the values the behavior represents reflects the beliefs of the individual; Deci & Ryan, 2000).
   * Intrinsic motivation (engaging in activities that provide interest and enjoyment; Deci & Ryan, 2000).
    The SDT refers to motivation that is innate and meets psychological needs thus it does not take into consideration learned motivations or physiological needs (Dec & Ryan, 2000).
* STOP! Activity Time: To the right is a questionnaire that determines seniors' motivations towards exercise (Mulland & Markland, 1997). If you are a senior find out your motivations towards exercise. If you are not, then go ask someone who is and interpret their motivations.

### Self-efficacy

Self-efficacy is beliefs about one's capabilities to produce effects needed for a performance which impacts motivation (Bandura, 1994). Low self-efficacy is more common in elders than any other age group which can prevent elderly people from exercising (Phillips et al., 2004). Hall and McAuley (2010) evaluated why older women could not attain 10,000 steps per day. Through self-report measures women with low/moderate self-efficacy were challenged in achieving 10,000 steps per day (Hall & McAuley, 2010). Low self-efficacy may be felt within the elderly because of physical strength and stamina decline that occurs with age (Bandura, 1994).
    Sources of self-efficacy from highest to lowest include:
* Mastery experience (individual interprets they are capable of performing an activity; Bandura, 1994).
    John (75years) can confidently walk around his neighborhood block thus motivating him to go for a walk.
* Vicarious experience (observing peers doing an activity determines whether individual can do it or not; Bandura, 1994).
    Joan (78years) is afraid a certain exercise will cause her an injury in her exercise class but watching Angela (80 years) perform the task safely without causing herself an injury, Joan is motivated to perform the exercise.
* Verbal Persuasions (positive encouragement and reinforcement influences behaviour; Bandura, 1994).
    The exercise instructor tells Kevin (69years) that he did well in the strength exercise session and should be proud of his effort.
* Physiological states (motivation provided through current feelings or mood; Bandura, 1994).
    Maria (64years) walks everyday to keep active because of sadness and anxiety that she will not be able to play and keep up with her grandchildren.
    High self-efficacy is considered to motivate PA. However, Samuel, Nayak and Kotian (2013) conducted a study on older community dwelling adults with mild balance impairments. They found exercise adherence was lower in those with higher self-efficacy because those elderly believed they did not need to do balance exercises as they felt their balance was fine. Thus in some circumstance self-efficacy may prevent PA.

### Goal setting

Goal setting is a practical tool that directs human action once the individual determines a purpose for that action (Locke, 1996). Referring to exercise within elderly the goal of HP would be to get elderly active or prevent them from giving up on exercise.[grammar?] Within elderly people their goals may be to become educated so they will exercise or to keep exercising to maintain their health (Phillips et al., 2004). Goals can be short-term (e.g., what PA will be completed for that day or during that exercise session) or long-term (e.g., going for a 30 min walk everyday for 3 months or planning to swim 2km/3times a week by next year) (Locke, 1996).
    Locke (1996) identified what contributes towards goal obtainment. These in reference to elderly and exercise include:
* Goals with a certain threshold of difficultly (but are obtainable) promote greater achievement if seniors are committed, acquires the correct knowledge and is convinced of the benefits of exercise.
* Goals must be specific to allow for precise performance. Exercise goals for elderly should direction (e.g., Bill-79 years-wants to prevent muscle atrophy) intensity (e.g., Kelsey - 81 years - will set her arm ergometer at 20 watts) and duration (e.g., Joe - 64years - is going for an hour swim)
* Positive feedback and reinforcement provides a beneficial effect in obtaining goals.
Goal conflict may occur which is when one goal does not fit into aspects of another goal. Goal conflict can occur within or between individuals. An example of a within goal conflict is when George (65 years) wants to meet his goal of going to a certain exercise class three times a week but one of the exercise classes clashes with his goal of babysitting his grandson after school. An example of a goal conflict between individuals is when an exercise physiologist wants her client Barb (73 years) to do specific balance exercises when Barb wants to train specifically her endurance and strength capacity.
* STOP! Activity Time: Seniors write down short/long term health goals you want to achieve and think of ways they can be achieved. Those who are not seniors write down short/long term goals you think they may/should want to achieve in relation to health and ways to achieve them
How these theories can apply to motivating elderly to exercise will be integrated in the next section.

## How can we get elderly to exercise?

[Provide more detail]

### Education

    Elderly significantly trust their HP, therefore if anyone can motivate them to exercise it would be them. Phillips, Schneider and Mercer (2004) reviewed approaches HP could use to motivate elderly to exercise that include:
* Explaining exercise importance towards health and implications of sedentary lifestyles.
* Instructing types of exercises suitable for seniors.
* Recommending facilities, gyms or community-based programs appropriate for seniors.
* Addressing concerns or barriers elderly experience towards exercise and provide knowledge, suggestions and encouragement to overcome them.
An example of education put to practice is when Lee et al. (2010) examined the effectiveness of exercise motivation through providing PA and nutrition booklets for seniors as well as telephone support. Despite reliability issues of the results as they were obtained through self-report measures by participants, 76% of the seniors found this method motivating for them to partake in exercise. Therefore, exercise education booklets or a telephone hotline service could potentially be a HP use.
Unfortunately, visits to general practitioners regarding exercise promotion is not reimbursed by Medicare thus this could be a costly motivator mechanism (Neid & Franklin, 2002).
Educating and discussing concerns about exercise can allow elderly to feel capable of participating in exercise. Capability is related to feelings of competence which is a psychological need that has to be fulfilled for a senior to experience self-determination. Feelings of capability also contributes to a seniors self-efficacy that can been gained through mastery experience via this education mechanism.

### Customise facilities and cost

Seniors need to feel confident in the accessibility to exercise facilities and programs run within a community (Phillips et al., 2004). Consider the Lungs in Action program at the University of Canberra for elderly who have pulmonary conditions. Participants have access to their own car park that is reserved for health clinic patients, there are toilets across the hall from the exercise class and elderly have access to an elevator to avoid having to walk flights of stairs. This accessibility increases chances of elderly obtaining self-determination through feelings of competence as they can participate without feeling overly exacerbated. They can also achieve autonomy as they have more control over their health and energy levels because protocols have been taken to accommodate interfering factors like lack of parking or disability access that may have previously prevented them from exercising.
Customising exercise techniques or equipment allows elderly to be active disregarding age, disability or illness (Phillips et al., 2004). For example, elderly who are physically disabled could partake in seated exercise rather then standing. Another example is bags filled with rice or cans of food at home can act as weight bearing objects that do not require strength gain through using gym equipment. The last example is also a cost-effective method for seniors. These mechanisms demonstrate to seniors they are fully capable of performing exercise thus contributing to their feelings of competency.
Physicians should know of affordable senior classes ran within a community to inform their elderly patients (Phillips et al., 2004). Elderly should also understand through asking their HP, researching the internet or asking friends what can be reimbursed through Medicare. For example physical or occupational therapy are typically reimbursed (Phillips at al., 2004).
* STOP! Activity Time: Can you think of activities or equipment in your own home that you or elderly could adapt to increase PA?

### Provide exercise prescription

Exercise programs should incorporate difficult but obtainable exercises which can be achieved through manipulating duration and intensity of tasks. Exercise should be demonstrated multiple times so elderly can learn how to correctly do movements (Neid & Franklin, 2002). Exercise programing and exercise demonstration will increase motivation towards achieving goals. Verbal persuasion contributes towards recognizing efforts and reinforcing that the technique is correct which will play a role in improving self-efficacy. In addition written instructions should accompany verbal instruction as that can enhance compliance to exercise which is another important factor in goal achievement(Phillips, 2004). Exercise prescription should be reviewed continually and modified to prevent exercise becoming a bore, as this may decrease motivation leading to physical inactivity (Neid & Franklin, 2002). It is important to tailor the program to the individuals needs. For example if the elderly suffers from musculoskeletal pain then decreasing exercise intensity and incorporating a range of exercises can prevent discomfort (Neid & Franklin, 2002).

### Give them a voice

Imagine wanting to improve your health through exercise but being continually provided with exercise advice or programs that you do not have a say in. Would you feel discouraged or like giving up on exercise because you are not enjoying it? The ageing process unfortunately diminishes sense of control particularly in health (Menec & Chipperfield, 1997). When implementing an exercise program for a senior, they should have input in planning, selecting and evaluating their exercises to return them with a sense of control, which will enable feelings of autonomy. Giving elderly a say can improve their life satisfaction and perceptions of their health (Menec & Chipperfield, 1997). This approach plays a role in goal setting as elderly can help set their own goals and document their progress.

### Promote socialisation

For some seniors interaction with others during exercise is essential in motivating them to exercise. Prevc and Topic (2009) conducted questionnaires at 75 nursing homes and found the residents preferred to exercise with each other. Although, would they enjoy exercise if they were exercising with a younger and/or healthier population? Perhaps, if promoting exercise through socialisation then surrounding peers should all experience similar circumstances as this may be more motivating for elderly (Phillips et al., 2004). Exercising with peers of similar condition can contribute to elderly feeling reciprocal connections with others thus promoting relatedness. Relatedness is another psychological need that is essential in increasing self-determination motivation.
Socialisation can create motivation for elderly to exercise, through vicarious experience. Vicarious experience can encourage self-efficacy as elderly can view their peers participating in PA, raising the belief that they can participate as well. "If they can do it, then so can I!"

### Encourage modern technology usage?

Would the best way to encourage elderly to exercise be by sitting them down in front of a robot that instructs, evaluates and encourages exercise participation? A robot known as SAR (socially assisted robot) has revealed to increase seniors motivation towards exercise because of the positive feedback, praise and evaluation of movements SAR provided (Fasola & Mataric, 2012). The SAR system could play a role in motivation through verbal persuasions as it has been developed to provide positive feedback and reinforcement to elderly which can reassure them they are doing well thus contributing to their self-efficacy. Although, the sample size in that study consisted of 19 females and 5 males only. Using this type of technology to motivate seniors to exercise, may be more useful for those who are somewhat disabled, as the exercises are limited to chairs and perhaps not be as beneficial for more mobile seniors.
What about Nitendo Wii? Nitendo Wii has been shown to motivate elderly to exercise because compared to standard exercises it is significantly more enjoyable for them (Hsu, Thibodeau, Wong, Zukiwsky, Cecile, & Walton, 2011). Nitendo Wii can be beneficial for elderly in improving balance (Williams, Soiza, Jenkinson, & Stewart, 2010), gait (Lee, Biggan, Taylor & Ray, 2014), depression and cognitive symptoms (Rosenberg et al., 2010) and decreases loneliness (Kalhbaugh, Sperandio, Carlson & Hauselt, 2011), stiffness and shoulder symptoms (Hsu et al., 2011). Disadvantages of Nitendo Wii is that elderly more cognitively or physically declined are less susceptible to enjoy the Wii and while pain may be relieved in some areas of the body, other areas such as hands are more likely to be affected (Hsu et al., 2011).

## Summary

There are many factors that prevent elderly from exercising, however there are also many methods which involve improving self-determination, self-efficacy and setting goals that can help motivate elderly to exercise. The first step, when in doubt, is to consult the experts. Motivation to initiate and maintain exercise can be achieved through customising facilities to seniors needs, being creative in cost-effective methods, providing exercise prescription that involves the seniors input and encouraging socialisation during exercise.