Prevention and Health and Wellness in Older Adults

**Topic:** Prevention and Health and Wellness in the Older Adult

**Purpose:**

The purpose of this page is to identify the health and wellness issues impacting older adults. This page also describes the role of the physical therapist in addressing and preventing the health and wellness issues affecting the geriatric population.

1.    Define health and wellness.

2.    Describe the role of physical therapists in providing preventative services and health and wellness recommendations for older adults.

3.    Describe health screening and wellness assessments that can be utilized by physical therapists with older adults.

4.    Identify the health and wellness issues impacting older adults.

5.    Provide recommendations for prevention and improving health and wellness in older adults.

6.    Learn about the evidence regarding effective interventions to improve health and wellness in older adults.

**Information about Prevention and Health and Wellness in the Older Adult:**

**What is health and wellness?**

Health is the “state of complete physical, mental and social well-being and not merely the absence of disease”. Wellness is “the sense that one is living in a manner that permits the experience of consistent, balanced growth in the physical, spiritual, emotional, intellectual, social and psychological dimensions of human existence”.1

**The Role of the Physical Therapist in Prevention and Promoting Health and Wellness**

The American Physical Therapy Association recognizes that physical therapists are qualified to provide leadership in efforts to prevent injury and disability in older adults. Physical therapists are trained and capable of playing an essential role in the promotion of healthy lifestyles, wellness and injury prevention.2Studies have found that physical therapists are well positioned to encourage wellness within older adults.3It is the responsibility of physical therapists to promote health and wellness in the community, demonstrate healthy behaviors, identify available resources in the community, and identify health risks during the systems review. Physical therapists can promote health and wellness in older adults by prescribing exercises for disease management, to increase bone mass and bone density and decrease fall risk. Additionally, exercise and ADL instruction can reduce health care utilization and enhance function for older adults with cardiovascular and pulmonary disorders. Physical therapists are in an ideal position to promote health and wellness in the older adult and can reduce risk factors to prevent and treat chronic conditions by providing patient and client education, prescribing physical activity and exercise and performing therapeutic interventions.2

**Health and Wellness Screening Measures for the Older Adult**

Health and wellness screening and assessments can provide information regarding the older adult’s present status and can be utilized to evaluate progress and monitor change over time. There are several questionnaires available to assess health and wellness in the older adult. The SF-36 is a global health-related quality of life measure that includes assessments of physical health and mental health and has been found to be valid and reliable in older adults.4The perceived wellness scale provides information regarding the patient’s wellness perceptions and provides information about the patient’s mental, physical and spiritual status and social health. The perceived wellness scale has been found to be valid and reliable in older adults.5

Preventative measures such as taking vitals should be performed at each visit. Physical therapists also play a role in determining disease risk stratification for older adults. The ACSM defines cardiovascular disease risk factors as older age, family history, cigarette smoking, sedentary lifestyle, body mass index greater than 30 kg/m2or waist girth greater than 102 cm for men and greater than 88 cm for women, hypertension, dyslipidemia and pre-diabetic.6Physical therapists should assess these risk factors during the evaluation of older adults.

**Health and Wellness Issues Impacting Older Adults**

The leading cause of morbidity and mortality in older adults is chronic diseases including heart disease, cancer, stroke, chronic respiratory diseases and diabetes. These conditions can be significantly altered by positive health and behavior choices or modifications.7Behaviors related to physical activity, nutrition, sleep, stress and tobacco use can significantly impact the health and wellness of older adults.

**Physical Activity**

Prolonged sitting in the older adult is associated with poor health outcomes. Sedentary behaviors are associated with increased risk of diabetes, obesity, cardiovascular disease and cancer in the older adult.8Decreased grip strength has also been found to be an independent predictor of all-cause mortality and cardiovascular diseases in community-dwelling populations.9

Physical therapists are in an optimal position to provide recommendations and education regarding appropriate intensity, frequency and duration of physical activity to improve health and wellness in the older adult. For health and wellness benefits, it is recommended that older adults get at least 2 hours and 30 minutes a week of moderate aerobic physical activity or 1 hour and 15 minutes a week of vigorous physical activity. All aerobic activities should be performed in at least 10-minute bouts. Muscle strengthening should be performed 2 or more days a week for all major muscle groups. Older adults should also incorporate flexibility exercises and add balance activities for individuals at risk for falling. Physical therapists should provide education about the health benefits of physical activity, explore perceived barriers to physical activity, promote self-efficacy for exercise, encourage goal setting, and assist with strategies for helping patients to prevent relapses and build social support.1

**Nutrition**

More than 5 million older adults aged 60 and older struggle with hunger. Older adults who do not have proper nutrition are at increased risk for chronic health conditions.10Changes in the oral cavity, changes in taste and smell, esophageal changes, gastric changes, changes in renal function, changes in the liver and decreased protein synthesis impact nutrient absorption in the older adult. Risk factors for malnutrition in older adults include excessive polypharmacy, constipation, poor self-reported health status, cognitive decline, loss of interest in life and poor appetite.11Mid-upper arm circumference is a recommended measure to assess for poor nutritional status as it has been found to be more strongly associated with an increased mortality risk due to malnutrition in older individuals than BMI loss.12A decrease in lean body mass is associated with a decline in basal metabolism that results in an increased risk of obesity in older adults.13

The nutritional needs of the patient should be addressed by providing education on reducing sodium intake, limiting added sugars and saturated fats, and shifting to healthier food and beverage choices. The patient should also be advised to drink plenty of water, ensure half the plate is fruits and vegetables, choose whole grains, avoid refined grains, and move to low-fat and fat-free dairy. Carbohydrates should make up 45-65% of daily intake, protein should be 15% of daily intake and fat should be 20% of daily intake for older adults. Physical therapists should be aware that medications can impact patient nutrition including decreased appetite, malabsorption of nutrients and may increase the need for nutrient supplementation.14

**Sleep**

Older adults experience changes in sleep habits including increased wakefulness and less REM sleep. Chronic diseases are associated with poor sleep habits, poor sleep quality and sleep interruption. Sleep deprivation is associated with obesity, heart attack, stroke, diabetes and negatively impacts wellness and longevity and daily functioning. In order to promote better sleep for older adults, physical therapists should recommend that patients avoid caffeine and snacks in the evening, participate in relaxation techniques and develop a consistent sleep schedule. If the individual is unable to sleep after 15 minutes, the patient should get out of bed and do something relaxing and avoid stimulating activities.15

**Psychological Wellness and Social Engagement**

Psychological wellness is improved by a sense of continued growth and development as a person, the belief that life is purposeful and meaningful, the possession of good relationships with other people, the capacity to manage one’s life and a sense of self-determination. Social wellness and support greatly influence the ability to cope with life’s stressors. Loneliness and social isolation have been found to be as great a threat to longevity as obesity. Lack of social connections presents an added risk to longevity and the existence of relationships provides a positive health effect.16It may be particularly difficult for older adults to maintain social connections due to deaths of spouses, friends and family that may leave an older adult feeling lonely. Physical therapists can provide resources for community social engagements that older adults can participate in to improve the older adults feeling of purpose and social engagement. Stress management is also an important factor as stress can have a negative impact on the health and wellness of older adults. Physical therapists can provide education for stress management strategies such as teaching an older adult to identify the stressor, relieve stress by incorporating relaxation, deep breathing or coping strategies, and improve overall fitness and health.1

**Tobacco Use**

Tobacco significantly causes disease and premature death in America and is responsible for 435,000 deaths annually. Physical therapists can employ strategies such as the 5 A’s and 5 R’s to assist older adults with tobacco cessation.

5 A’s:

Ask about tobacco use to identify the current status of use.

Advise to quit in a personalized manner.

Assess for willingness to quit and challenges.

Assist by providing a referral for counseling, behavioral treatment and medication and motivational interventions.

Arrange for follow-up.

5 R’s:

Relevant: Encourage patient to indicate why quitting is personally relevant.

Risks: Assist patient in identifying potential negative consequences of tobacco use.

Rewards: Assist patient in identifying potential benefits of stopping tobacco use.

Roadblocks: Assist patient in identifying barriers.

Repetition: Repeat this strategy every time the patient visits the clinic.17

**Multidisciplinary Approach**

It is also important for a physical therapist to employ a multidisciplinary approach for the management of health and wellness in the older adult. Patients should be referred for appropriate screening measures for cancer, depression, diabetes, cholesterol, blood pressure, obesity and osteoporosis as deemed necessary.18

**Additional resources for more information:**

1.    APTA Prevention and Wellness Information: http://www.apta.org/PreventionWellness/

2.    Physical Activity for Older Adults:[http:// http://www.who.int/dietphysicalactivity/factsheet\_olderadults/en/ http://www.who.int/dietphysicalactivity/factsheet\_olderadults/en/]

3.    Enhance Fitness Program for Older Adults: http://www.projectenhance.org/enhancefitness.aspx

4.    Healthy People 2020 Older Adults: https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults

5.    Nutritional Information for Older Adults: https://www.choosemyplate.gov/older-adults

6.    Nutritional Programs for Elderly: https://www.mealsonwheelsamerica.org/

7.    Fall Prevention Program:[http://  https://www.ncoa.org/resources/program-summary-a-matter-of-balance/]

8.    Chronic Disease Self-Management: https://www.selfmanagementresource.com/programs/small-group/chronic-disease-self-management/

**References:**

1Bezner JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. *Physical Therapy*. 2015;95(10):1433-1444.

2Bellamy J. Prevention, Wellness, and Disease Management. APTA. http://www.apta.org/PreventionWellness/. Accessed July 8, 2018.

3Dean E, Al-Obaidi S, de Andrade AD, et al. The First Physical Therapy Summit on Global Health: Implications and Recommendations for the 21st century. *Physiother Theory Pract*. 2011;27:531–547.

4Walters SJ. Using the SF-36 with older adults: a cross-sectional community-based survey. *Age and Ageing*. 2001;30(4):337-343.

5Harari MJ, Waehler CA, Rogers JR. An empirical investigation of a theoretically based measure of perceived wellness. Journal of Counseling Psychology. 2005;52(1):93.

6ACSM’s Guidelines for Exercise Testing and Prescription, 9thed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014.

7Gorina Y, Hoyert D, Lentzner H, Goulding M. Trends in Causes of Death Among Older Persons in the United States. *PsycEXTRA Dataset*. 2005.

8Dunston DW, Howard B, Healy GN, Owen N. Too much sitting: a health hazard. *Diabetes Res Clin Pract*. 2012;97:368–376.

9Wu Y, Wang W, Liu T, Zhang D. Association of Grip Strength With Risk of All-Cause Mortality, Cardiovascular Diseases, and Cancer in Community-Dwelling Populations: A Meta-analysis of Prospective Cohort Studies. *Journal of the American Medical Directors Association*. 2017;18(6).

10Senior Hunger Facts. Feeding America. http://www.feedingamerica.org/hunger-in-america/senior-hunger-facts.html. Accessed July 8, 2018.

11Fávaro-Moreira NC, Krausch-Hofmann S, Matthys C, et al. Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data. *Advances in Nutrition*. 2016;7(3):507-522.

12Schaap LA, Quirke T, Wijnhoven HA, Visser M. Changes in body mass index and mid-upper arm circumference in relation to all-cause mortality in older adults. *Clinical Nutrition*. 2017.

13St-Onge M-P, Gallagher D. Body composition changes with aging: The cause or the result of alterations in metabolic rate and macronutrient oxidation? *Nutrition*. 2010;26(2):152-155.

14Older Adults. Choose MyPlate. https://www.choosemyplate.gov/older-adults. Published August 9, 2017. Accessed July 8, 2018.

15Institute of Medicine of the National Academies. Sleep disorders and sleep deprivation. http://www.iom.edu/∼/media/Files/Report%20Files/2006/Sleep-Disorders-and-Sleep-Deprivation-An-Unmet-Public-Health-Problem/Sleepforweb.pdf. Published April 2006. Accessed July 8, 2018.

16J. Holt-Lunstad, T. B. Smith, M. Baker, T. Harris, D. Stephenson. Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. *Perspectives on Psychological Science*. 2015;10(2):227.

17US Department of Health and Human Services, Public Health Service. *Quick Reference Guide for Clinicians: 2008 Update: Treating Tobacco Use and Dependence.*http://www.healthquality.va.gov/tuc/phs\_2008\_quickguide.pdf. Published 2008. Accessed July 8, 2018.

18Home - US Preventive Services Task Force. Final Update Summary: Colorectal Cancer: Screening - US Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Name/home. Accessed July 8, 2018.