Have you ever wondered whether it’s worth your while to encourage an older person to start exercising?
In 2014, the top-notch journal JAMA published the results of a fantastic research project: a study in which 1635 sedentary older adults (aged 70-89) were assigned to get either a structured exercise program, or a program of “successful aging” health education. The researchers called it the Lifestyle Interventions and Independence for Elders (LIFE) study. (You can read the full study here.)
During the LIFE study, the two groups were followed for a little over 2.5 years. And by the end of the study, guess which group of volunteers was more likely to still walk a quarter of a mile (without a walker)?
That’s right. When it came to avoiding “major mobility disability” — which the researchers defined as becoming unable to walk 400 meters or more — a structured exercise program was better than a program of healthy aging education.
Specifically, the researchers found that 30% of the exercisers experienced a period of major disability, compared to 35.5% of the seniors enrolled in the healthy aging education program.
This is a very encouraging finding! That said, it’s also a bit sobering to realize that even with exercise, almost 1 in 3 older adults experienced a period of limited mobility, of which half lasted 6 months or more.
In this post, I’ll share some more details on this study, because the results provide a wonderful wealth of information that can be helpful to older adults, family caregivers, and even geriatricians such as myself.
Want to know how often the exercisers experienced “adverse events”? (Hint: often!) Wondering just what the structured exercise program involved? (Hint: more than walking!)
Let’s dig into the details! At the end of this post, I’ll share my list of key take-home points for older adults and family caregivers.
Key features of the exercise in aging study
Who were the study volunteers? Whenever you read about a research study, it’s important to understand how the study volunteers compare to the older adults in *your* life. One of the many things I love about this study is that they purposefully enrolled older adults who were sedentary, and physically vulnerable. To identify vulnerable adults, the researchers looked for volunteers who could walk a quarter of a mile, but showed signs of physical weakness on a test known as the Short Physical Performance Battery (SPPB).
(The SPPB includes tests very similar to the Timed Up and Go, the 30 Second Chair Rise Test, and the 4 Stage Balance Test. These tests are often part of assessing an older person’s risk for falls; you can watch short videos demonstrating these tests here: Videos Illustrating Otago Exercises for Fall Prevention.)
Specific criteria for the study volunteers included:
- Age 70-89 years
- Sedentary at the start of the study, meaning less than 20 min/wk of regular exercise in the past month
- Evidence of high risk for mobility disability, based on a score of 9 or less (out of 12) on the Short Physical Performance Battery. Results on this test have previously been shown to predict future disability.
- Able to walk 400 m in less than 15 minutes, without a walker or the help of another person.
- No major cognitive impairment (i.e. no Alzheimer’s or other dementia)
Ultimately, of the 1635 older adults who completed the study, about two-thirds were women. I found the list of chronic medical conditions interesting: 70% had hypertension, about 25% had diabetes, and 15% had chronic obstructive pulmonary disease.
What was the exercise intervention? The older adults assigned to exercise received a very structured and organized program of physical activity. People were ramped up toward a goal of 150 minutes/wk of walking, along with additional activities to improve strength, balance, and flexibility. Here are some specifics:
- In-person activity sessions at the study center twice a week, plus home-based activity 3-4x/week.
- Daily walking at moderate intensity, goal of 30 minutes/day
- Lower extremity strength training using ankle weights (2 sets of 10 repetitions), goal 10 minutes/day
- Balance training and large muscle flexibility exercises, goal 10 minutes/day of activity
Of note, the study provided personalized assistance, and helped the older participants slowly work up to these goals. The study also included a protocol to safely restart the exercise program after a hospitalization or other interruption. (For more on the exercise protocol, see this journal article which describes it in detail.)
What was the health education intervention? Half of the study volunteers participated in a health education program focused on “successful aging,” rather than the exercise program. For the first 6 months, this involved weekly workshops on various topics related to health and aging, followed by monthly sessions thereafter.
Per the study report, these topics included ” how to effectively negotiate the health care system, how to travel safely, preventive services and screenings recommended at different ages, where to go for reliable health information, nutrition, etc.” The health education sessions also included 5-10 minutes of gentle exercises.
An informational brochure on physical activity was provided at the first successful aging session, but otherwise physical activity topics weren’t included in the workshops. However, the LIFE researchers noticed that many study volunteers in the health education group began exercising during the study.
Overall, the researchers noted that the physical activity group maintained an average of 218 min/week in walking and weight training activities, whereas the health education group maintained an average of 115 min/week.
What were the results? The main outcome of interest was whether study participants developed “major mobility disability,” which the researchers defined as being unable to walk 400 meters (a quarter of a mile) unassisted, within 15 minutes. Here’s what the researchers observed over the 2.5 year follow-up period:
- Major mobility disability happened to 30% of the exercisers, versus 35.5% of the healthy aging education group.
- Persistent major mobility disability — meaning disability lasting at least 6 months — happened to 14.7% of the exercisers and 19.8% of the education group
- “Serious adverse events” — usually a hospitalization — happened to 49.4% of the exercisers, and 45.7% of the health education group (a difference that was not statistically significant). The reasons for hospitalization were quite varied, and often seemed unrelated to the exercise study.
- Among the exercisers, almost 60% had to go on medical leave at least once. Half of the medical leaves lasted longer than 49 days.
- 5.1% of the exercisers died, compared to 5.9% in the health education group. (This difference was not statistically significant.)
Other findings based on the LIFE study
A good randomized trial, such as LIFE, will often result in several different published research papers. That’s because different projects will use the same original data set, but analyze and report on different outcomes of interest.
Since the publication of the main LIFE findings in 2014, several related studies have been published.
Unfortunately, the results were disappointing, in that the exercise intervention didn’t seem to help with many health outcomes of interest to older adults.
In particular, participants assigned to exercise didn’t seem to experience better cognitive outcomes, fewer cardiovascular events, fewer serious fall injuries, or less need for help with key life tasks.
Here are the details related to these studies:
Effect of a 24-Month Physical Activity Intervention vs Health Education on Cognitive Outcomes in Sedentary Older Adults: The LIFE Randomized Trial (2015)
- Participants in the LIFE study completed a series of cognitive tests at the start of the study, and after 24 months.
- Based on their cognitive tests and other factors, participants were also assigned one of three cognitive classifications at the beginning and end of the study: no cognitive impairment, mild cognitive impairment (MCI), or dementia.
- 13.2% of the physical activity group developed MCI or dementia by 24 months compared with 12.1% of the health education group. This difference was not statistically significant.
- The exercise intervention did not seem to result in better cognitive testing results.
- The exercise intervention provided in the LIFE trial did not seem to result in better cognition. Participants in the exercise intervention did not experience lower rates of MCI or dementia.
Cardiovascular Events in a Physical Activity Intervention Compared With a Successful Aging Intervention
The LIFE Study Randomized Trial (2016)
- Participants in the LIFE study were followed for 2.6 years and the occurrence of cardiovascular events was tracked.
- Tracked events included strokes, heart attacks, hospitalizations for heart failure, and death from cardiovascular disease.
- New CVD events occurred in 14.8% of the physical activity participants and in 13.8 % of the health education participants. This difference was not statistically significant.
- Being enrolled in the exercise intervention provided in the LIFE trial did not seem to reduce participants’ risk of cardiovascular disease.
Note: A follow-up study of LIFE participants published in December 2017 found that increased physical activity, as measured by a wearable device, did correspond to a decrease in cardiovascular events. This means the actual steps taken mattered more than whether or not an older person was enrolled in the exercise group.
Effect of structured physical activity on prevention of serious fall injuries in adults aged 70-89: randomized clinical trial (LIFE Study) (2016)
- Researchers counted serious fall injuries among all participants in the LIFE trial.
- Serious fall injuries were defined as a fall that resulted in a clinical, non-vertebral fracture or that led to a hospital admission for another serious injury.
- Over the 2.6 year follow-up period, a serious fall injury was experienced by 9.2% of participants in the physical activity group and 10.3% in the health education group. This difference was not statistically significant.
- The exercise intervention provided in the LIFE trial did not reduce the risk of serious fall injuries.
Effect of Physical Activity on Self-Reported Disability in Older Adults: Results from the LIFE Study (2017)
- Participants in the LIFE study were regularly interviewed as to any difficulties managing Basic Activities of Daily Living (BADLs) and Instrumental Activities of Daily Living (IADLs).
- Over an average follow-up of 2.6 years, the overall occurrence of BADL dependency was essentially the same among the two groups: 15.2% of the physical activity participants and 15.1% of the health education participants.
- The groups also had similar rates of BADL disability and IADL disability.
- Dependency was defined as “receiving assistance” or “unable” to do ≥1 activities. Disability was defined as having “a lot of difficulty” or “unable” doing ≥1 activities.
- Although the LIFE exercise intervention did reduce major mobility disability among participants, it didn’t result in less difficulty managing life tasks.
Take-home points for older adults & family caregivers
The New York Times coverage of this study was titled “To Age Well, Walk.” It’s a good article and I agree with the media’s general conclusion, which is that a walking program is healthy and is doable, even in people who are older and start off with physical weaknesses.
That said, I think this study — and the related findings — highlights many additional issues that family caregivers should keep in mind:
- Getting an older person to exercise requires consistency and a plan. This study didn’t test how a structured program compares to a far more common scenario, which is that either a doctor, or an adult child (or both), tell a sedentary older adult to walk more.
If you want your older loved one to get moving, I recommend you start by asking the doctor about any contraindications or concerns. Assuming the doctor gives an ok, you’ll then want to think hard about how to make it feasible and sustainable. For example, people of all ages tend to find it easier to exercise with another person, or a group, because it helps maintain motivation. And don’t forget that slowly ramping up the activity will be important for most sedentary adults.
You can certainly ask your loved one’s doctor for a recommendation on where to find an exercise program. But in my experience, most docs will not know where to send you, unless their own healthcare system has activity program for seniors. So you might have to sleuth around a bit to find something suitable.
Once you have a plan for exercise, try to find a way to track the daily exercise, via a pedometer or other device. (Those fancy new fitness trackers might come in handy for this purpose.) Most people like being able to see their progress, although they may not bother to track it unless the tracking is easy.
- Physically vulnerable older adults are fairly likely to have a period of reduced mobility. I always tell people to hope for the best, but plan for the likely. Even with exercise, this study found that almost 1 in 3 seniors had a period of reduced walking ability. So I would recommend that all older adults and families consider what they’d do if this happened to them. Can the older person’s home be managed with a walker?
- Hospitalizations are common. Almost half of the older adults in this study experienced at least one hospital stay, over 2.5 years. So if you are caring for someone similar to these study participants, it’s a good idea to have some planning in place, in case you have to help your older loved one through an emergency or a hospital stay. What does this type of planning look like? Well we could do a whole course on that topic, but at a minimum, I would say:
- Make sure you have considered who will be involved in any surrogate decision-making; it’s very common for older adults to lose the ability to make decisions during a hospitalization.
- Be prepared to tell the hospital staff what the older person’s wishes are regarding resuscitation and ICU care. The ideal, of course, is to have completed a good process of advance care planning, but at a minimum, you should be ready to answer the hospital’s questions regarding CPR and resuscitation.
- Plan to have a family member or advocate in the hospital with your older loved one, as much as possible.
- Learn to identify and minimize common hospital problems in older adults, such as delirium, falls, risky sedatives, and restraints.
- Educate yourself about the risks of hospitalization in general. Some good resources (for people of all ages) include the tip sheets on EmpoweredPatientCoalition.org, as well as Elizabeth Bailey’s book on Hospital Checklists.
- Exercise is not guaranteed to solve all your health worries. Getting a sedentary older person to start exercising more is a terrific idea, and I would certainly encourage people to pursue this. But it would be a mistake to assume that this, in of itself, is enough to reduce the risk of cognitive decline, or cardiovascular disease, or eventual declines of independence, or of any of the other things that we don’t want our older loved ones to experience.
- Along with exercise, be sure to look into other proven ways to help older adults prevent or delay any health problems you may be concerned about. For instance, blood pressure treatment has been shown to reduce cardiovascular events in older adults with high blood pressure.
- It’s also probably best to accept that despite the best efforts of seniors and family members, disability and difficulties will eventually happen to many older adults. So don’t just hope for the best and don’t forget to prepare for the possibility of future difficulties. No one likes to think about this, but families who plan ahead often experience a little less stress and difficulties. You can find my tips on planning ahead here: Addressing Medical, Legal, & Financial Advance Care Planning.
Now, if you’ve been interested in helping older adults get more exercise, I’d love to hear from you in the comments below.
What have you found works well, to help aging adults get regular exercise?
I’m female age 70. I needed more than my 30 minute walk once or twice a day. I searched for a good exercise program for years. Finally found a town nearby that sponsors 1-hour vigorous fitness class twice a week, early morning so you don’t lose a day. Seniors 50 to 80 are all feisty and keep up in this challenging class. Some with disabilities adjust exercises as they need to.
This has 5 minutes warm up stretching, light marching, shoulder rolls. Then 20 minutes aerobic with marching and moving all body parts (swinging arms to bicep curls). 20 minutes strengthening with stretch bands and hand weights (with balance challenges), 20 minutes in chair with more strengthening, stretching, crunches and twisting to move every body part.
Health clubs and gyms do a poor job on how to warm up and get into using their machines, personal trainers are not very good, and classes can be too aggressive. After injury from such machine use, I got frozen shoulder – I am sure that low movement set me up for this. The solution was this good fitness class. Our bodies are made to be active and need to MOVE.
Leslie Kernisan, MD MPH says
Thanks for sharing your story. I agree, many health classes and gyms are probably not suitable tailored to the needs and vulnerabilities of people your age. So it’s a good idea to carefully research one’s options, and choose something specifically designed for older adults when possible.
Glad you found something that is working well for you!
e-Patient Dave says
Another encyclopedic article, Dr. K. You amaze – and your generosity in giving it away is just terrific!
I find myself frustrated looking at the 2014 JAMA paper on the LIFE study, for three reasons, and I wonder what you think about them:
First, in figure 3, showing how well an exercise program or healthy aging education will prevent major mobility problems, there’s really not much difference, right? I mean, a few points of difference, but it’s not like one is majorly better than the other, right?
Second, how come they didn’t track a control group that got neither?? As shown here, we have no idea if EITHER made any difference compared to doing nothing at all.
Third, I can’t find any comparison of age-matched groups. As a 67 year old, I know a lot of 70 year olds and a fair number of 80 year olds and some 90+, and I can’t BELIEVE they would lump them all into one category – they’re so different! Am I missing something in the article?
Of course I’m quite interested in what works but I can’t imagine anything useful for my wife and me coming out of a study of 80 and 90 year olds. (She has a huge family reunion every year, and it’s a vivid display of the decades – pre-teen, 20s, 30s, all the way on up. The 60s and 70s bear no resemblance in mobility to the elder-elders, right?
Leslie Kernisan, MD MPH says
Dave, glad you enjoyed this article. Re your comments:
1. The absolute benefit of the LIFE study, for preventing major mobility disability, was about 5 percentage points. This corresponds to a number needed to treat of 20 (so if you exercise, you have a 1-in-20 chance of avoiding disability due to the exercising). This may not sound super impressive, but it’s better than the number needed to treat of many other medical interventions that we consider worthwhile.
2. Re the lack of a third control group: a large randomized study like this is very expensive and complicated to run. Adding a third group would have made the study much more expensive to run. People designing studies are always making a tradeoff between what’s feasible/affordable vs what provides more data.
3. In Figure 4, the authors do present a subgroup analysis comparing the benefit of exercise in people aged 70-79, vs people aged 80+. There was a trend towards exercise being more beneficial in the older group, but not statistically significant.
I don’t know that these study results are particularly useful for you and your wife, because I’m guessing you aren’t as sedentary as the participants in this group. Still, if you have sedentary older relatives, it might be useful to have this understanding of how exercise is likely to help, and also to realize that it’s not a panacea and one should still plan for managing hospitalizations and disabilities.
Francesca Fisher says
As a healthcare professional, and a senior fitness instructor for over 33 years, I’d like to see the 30 Second Chair Rise Test removed from the battery of testing seniors have to go through in order to determine if they are fit. It is outdated and unnecessary. A better test would be if the person can stand up ONE time from a seated position without assistance. I’ve seen the 30 second chair rise test in action many, many times over the years and have seen more damage caused to knees, popping, misalignment, etc. than any other protocol. It is dangerous to the knees when a timed test is required and someone is not used to standing up and sitting down rapidly. In the Geri-Fit program for older adults, we assess pre-client fitness and mobility using the one rep chair rise principle and can determine immediately if the person is at risk for falls or requires progressive resistance training to regain strength in the lower body that’s been lost through the aging process. Great article otherwise.
Leslie Kernisan, MD MPH says
This is an interesting issue to consider, re the chair rise test. I did a quick search in the medical literature and I didn’t see much questioning the test. But it’s possible that no one has bothered to try to quantify harms from this test.
It does seem to me that it’s useful to have a strength test that can be done before and after a strength training program, this way people can see if what they’re doing is improving that lower leg strength.
It certainly might be good for the physical therapy profession to careful evaluate and then offer an opinion on this test.
I just wanted to say how helpful I am finding your articles. I am elderly myself (almost 85) but walk almost every day. I also exercise and go to a Tai Chi class once a week. I walk six days a week to do my shopping; this is about 3.5 kms…
I have a cousin who is 92, vision-impaired and walks very little.
Thank you for your articles, I am finding your column very helpful and informative.
Leslie Kernisan, MD MPH says
Thank you for this comment, I’m so glad you find this site helpful.
How wonderful that you are doing so much walking. Tai Chi is also an excellent activity, as this helps maintain balance and strength. Sounds like you are doing an excellent job maintaining yourself through physical activity.
genie deutsch says
I have read of Alzheimer’s disease reversal when both exercise and nutrition were involved…so I guess it takes more than exercise to prevent it…it is life style
genie deutsch says
I swim at least 6 days a week doing 10 laps of the pool each time.
I do resistance and balance exercises and brief Tai Chi every morning.
I found that I was tired at night and have added the brief Tai Chi in the afternoon and that helps
Boone Sumantri says
Excellent study and advice.
I am 89, and still active doing 5K walks. Exercise about an hour each day. Ride horseback and do epee fencing once a week.
Plan to increase my walking rate. Did 5K walk in one hour and 4 minutes. Would like to reduce it to less than one hour. What would you advise?
Leslie Kernisan, MD MPH says
Congrats on remaining so active, that sounds like an impressive time for a 5K.
Truthfully, you sound exceptionally fit and I’m not sure what will make you a little faster. As a doctor, my focus in is treating health problems and helping average people get to a better level of fitness and function. Whereas you need someone who knows how to help athletic high-performers reach still higher levels of performance. Given the aging of the population, there may be some coaches or physicians who specialize in this. You could perhaps try contacting people your age who compete in athletic events, to see if they can recommend a suitable expert. Good luck!
Stephen Simac says
The Complete Book of Walking has excellent advice on how to improve walking form and speed. I find the benefits of walking outdoors go far beyond the cardiovascular workout, Stress reduction from the physical exercise is enhanced by the pleasure and relaxation of observing nature. That’s why I think speed is less important than enjoying your pace, which can vary from day to day.
Leslie Kernisan, MD MPH says
Agree that walking outdoors is wonderful for the spirit, as well as good exercise.
Hi Dr. Kernisan,
I act as my own “caregiver” for now. I find walking is an exercise I can enjoy … in almost any kind of weather. I give myself the option of not walking two days a week if I want but I usually walk six or seven days each week.
I have found that walking with others becomes a chore after a while, whereas walking solo lets me walk further and enjoy it more. Perhaps because I don’t have to concern myself with making conversation, walking at “their” speed, etc. I know walking with others is supposed to motivate a person to walk more but in my case, it is just the opposite.
Great post! Thanks for making it available.
Leslie Kernisan, MD MPH says
Great that you have found a way to walk regularly!
That’s an interesting point re walking solo versus walking with others. I think the key is to do a little trial-and-error, in order to figure out what makes it work best for your situation. Thanks for this comment.
Gerald Roux says
Thank you for the very informative post. I have read it twice and will keep a paper copy handy.
I am the care giver for my wife who has early stage vascular dementia. We are both 84 and my wife also has pseudoxanthoma elasticum (PXE) and is legally blind due to the PXE.
Please keep up the posts as they are helpful and reassuring.
Leslie Kernisan, MD MPH says
Glad to know you found this post helpful. I hope you and your wife are able to walk regularly, or otherwise stay active.
I have noticed that many people with early dementia seem to do better when they remain physically active…exercise is good for health in so many ways! Good luck and thank you for this comment.