Cognitive Therapy and Increased Exercise Adherence in Older Adults - Essay Example

Running title: MOTIVATING ELDERLY FOR REGULAR EXERCISE Enhancing adherence to physical exercise by cognitive behavioural changes in elderly Name: Affiliation: Date: Enhancing adherence to physical exercise by cognitive behavioural changes in elderly CONTENTS 1.0 Introduction 2.0 Motivating elderly for regular exercise 2.1 Physical and psychological well being 2.2 Important motivational considerations 2.3 Cognitive behavioural interventions 2.4 Motivating to fight off depression 3.0 Recommendations Enhancing adherence to physical exercise by cognitive behavioural changes in elderly Regular exercise has definite health advantages yet only 31% elderly of 65 to 74 yrs and 23% above 75 indulge in moderate exercise at least three times per week. The vigorous exercise such as cycling and jogging is even lesser among elderly, according to Healthy People 2010. Schneider individual the problem as cognitive hence for motivation of elderly to adhere to exercise would be suitably done using a cognitive behaviour model (Herning et al, 2005, p34). The societal expectations from elderly have been a sedentary life so motivating elderly for regular exercise is a challenge. The ageing conditions such as dementia and depression also reduce interest in exercise. Health care professionals generally motivate elderly by telling them about the benefits of regular exercise but these motivations remain insufficient for continuing long term exercise. A remedy for promoting long term continuous exercise would be paying individualised attention keeping in mind the particular elder’s goals, interests and needs. Activities chosen should have variety and give enjoyment. The discussion here focuses on group activities that serve to provide socialization since a common cause of depression among elderly is separation from peer and family. Increased social interactions are powerful motivation and family and friends may also be involved to do so Mellion et al (2003). While the self- efficacy concept of Bandura (1994) motivates for continuous exercise. 3.0 Motivating elderly for regular exercise: Philips et al (2004, pS52) refer the definition of motivation as the forces acting on or within a person to initiate and continue a behavior. This definition provides a framework that includes both intrinsic and extrinsic factors. Understanding motivation as playing an active part in an individual’s personality may equip care providers’ with tools to motivate their elderly patients and can also make elderly persons to become self-directed about regular exercise participation. 2.1 Physical and psychological well being: Blumenthal and Gullette (in Schaie et al, 2002, p158) found that physical activity enhances cardiovascular performance of older adults. When one begins exercise, heart rate and stoke volume both increase. The latter results when more blood is pumped out of heart due to aerobic exercise. More oxygen is required by the exercising muscles. The maximum oxygen consumption is used to assess the physical fitness of a person. The regular exercise has beneficial effect on elevated blood pressure, diabetes, obesity, gallstones and osteoporosis etc. light to moderate activity reduces the risk of cardiovascular mortality and morbidity. Their study on youth and elderly about cardiac output revealed that the difference was of physical activity which was less by the latter rather than age for decreased cardiac output. Depression is one of the biggest discriminator between active and non active elderly. Strawbridge et al (2002, p330) refer literature to point out that mechanisms explaining reduced depression after physical activity include effect of increased levels of two types of brain neurotransmitters after exercise, monoamines and endorphins The protective aspects of physical activity against development of serious chronic conditions such as diabetes or heart disease could be important as well because of the connection between physical health and depression in old age. Other reasons may be improved fitness and increased self-esteem as a result of greater physical activity. Blumenthal and Gullette (in Schaie et al, 2002, p158) state that along with depression anxiety, fatigue and tension are also decreased in physically active elderly. Role of physical activity in clinical depression is well documented. It was observed that both, elderly who began physical activity much later and those who remained active throughout, had shown reduced risk of depression so being physically active, no matter when one begins, does decreases the risks. In fact, they suggested, exercise may be considered alternative to antidepressants to treat depression. 2.2 Important motivational considerations: The self regulation model encourages group exercise. It incorporates previous and current experiences and the new interpretations of these influence the present and future exercise behaviour. The facilitator/carer steers elderly towards positive meaning of these new interpretations These are the general interpretations and episode specific interpretations. The general interpretations are long term experiences that accumulate while episodic ones are related to current exercise sessions. For example, an elderly lady develops slight muscle soreness soon after beginning a new walking exercise. She may take it seriously and discontinue exercise thinking herself too old for such things (episodic interpretation) or she may take the muscle soreness as healthy outcome of exercise and continue walking (general interpretation) (Hernings et al, 2005). Mackinnon (2003) found that opportunity to enhance physical well being, health, functional capacity and quality of life and also encouragement by physician are important for adhering to exercise regimen.. Elderly stick well to a low to medium intensity exercise focusing on well being rather than performance. Group programs benefit them a lot because of social interaction and support. When exercise is of appropriate intensity, meets their needs and increases health and mobility, elderly are likely to continue it. Enjoyment and feeling of belonging to a group are great incentives to motivate elderly for a regular exercise regime. The deterrents to regular exercise are fear of injury or pain, safety of exercise environment, lack of support from peer or family, cost as most elderly are retired with fixed and often less income. 2.3 Cognitive behavioural interventions: There are a number of strategies considered important for bringing positive cognitive behavioural modifications in elderly for regular exercise. The two strategies, enhancing feeling of self- efficacy and group mediated exercise are discussed in details here. The cognitive behavioural intervention is based on three goals. These are encouraging the group to set realistic exercise goals on the basis of personal information, teach techniques to the group to achieve goals and highlight common struggles of being active. The trainer teaches exercise at the same time encouraging participants to use the intensity of it according to previous knowledge about their experiences (Hernings et al, 2005). The exercise must fulfill goals of physical, functional, and psycho-social benefits of regular exercise. The very well meaning term, ‘self-efficacy’ is used in the Bandura’s Social Cognitive Theory (SCT) (Cousins, 1998). Self-efficacy may be taken as the base to develop cognitive behaviour model to motivate elderly for regular exercise. Albert Bandura, renowned behavioral psychologist and professor from Stanford University, developed the concept of self-efficacy. According to Bandura’s theory the individual’s belief of self- efficacy are central to his/her decision in participating in physical activity. The efficacy expectations are defined as person’ judgment about capability to organize resources and skills to perform an action such that desired outcome happens from it. The four beliefs that guide a human action are: motivation which is an incentive to act, a specific behaviour would lead to achieve goal (outcome expectation), a belief in one’s ability to perform the action (self- efficacy) and a perception that the action would be appreciated ( social-environmental support) (Cousins, 1998, p150). Achieving goals produces the greatest sense of self-efficacy; as one is successful at achieving a target, self-efficacy increases noticeably. Observing others similar to self succeed through vivid experiences is associated with high self-efficacy. Individuals who are socially convinced that they possess the potential to complete certain tasks are more likely to be motivated to work toward their goals than those who self-doubt. Persons with high levels of self-efficacy not only believe in accomplishment but also in healthy competition (Bandura, 1994). Deterrents for participation in regular exercise may include forced competition, unrealistic commitments, low self-efficacy for exercise, and negative opinions of suggested exercise regimen. Cousins (1998) points out motivating factors for continued exercise for individuals that incorporate: High regards for the outcome of physical activity (motive or incentive) Perception that the specific physical activity is beneficial to health without any harmful effects (positive expectation) Believe that they are physically capable to do the exercise (efficacy) Perceive that they will be socially encouraged to do so (social support). They are also taught to monitor negative feelings and unrealistic goals. The training is likely to increase satisfaction and encourage adherence to exercise regimen. After self –efficacy, the next biggest motivation for continued exercise comes from social support and expectation as already detailed somewhat in group motivation. Brown et al (2006) suggest that group mediated cognitive behavioural (GMCB) intervention is likely to enhance the adherence to regular exercise by the older adults. The group setting uses reasonable social pressure and motivation to bring out positive cognitive and behavioural changes for keeping physically fit. The GMCB creates and develops strong group identity by designing a group logo, naming it and having t- shirts, set positive and encouraging environment viz. set goals at little higher achievement but increasing these gradually. Encourages self- monitoring of symptoms, behaviour and efforts. The group discussion may be conducted to facilitate these changes. Creating a social support in cases of failure to achieve goals and encourage to put more efforts for success. The exercise may also be done in pairs as in buddy system to inspire and motivate. Goal setting is done to increase active time and decrease sedentary time at home such as watching television. Discuss relevant topics such as age appropriate exercise regimen, breaking down sedentary time, continuing exercise independently. Members to share their experiences and provide solutions to problems to those who need it. Whether it is self-efficacy building or encouraging a group mediated behavioural change, persons undergone treatments for cardiac complications or joint replacement can not be put on rigorous exercise. Exercise needs to be highly individualised. Individuals should get desired outcome for e. g. person with lower back pain should feel more energetic and less fatigued. 2.4 Motivating to fight off depression: The feeling of self-efficacy and group support is also extremely useful tool to cure depression in elderly. Strawbridge et al (2002) found that being socially active and avoiding chronic health problems are other positive benefits of keeping depression away. Physically active older persons may interact more and form relations with those with whom they come into contact as a result of their physical activity. Persons with high levels of physical activity are also more likely to engage in other beneficial health behaviors such as not smoking, avoiding obesity, and keeping drinking to moderate levels. Thinking that one beneficial health behavior makes way for others seems logical. Thus a few assessments are needed before a depressed person is brought to active exercise regimen. These are (Step to…, 2009): 1. Assess the current physical activity level; it is 30 min moderate exercise preferably all days in a week. In case the elderly is not having sufficient physical activity then assess barriers. These may be depression leading to lack of motivation and confidence in ability. 2. Assess the readiness of person’s to initiate exercise ready to change (contemplator) or already began to change (preparers) 3. Assess physical impediments to exercise such as cardiac complications, fever, infection, frailty. Provide exercise advice such as type of exercise duration and intensity 1. Educate about regular exercise as treatment to depression 2. Let the patient tell about benefits they expect from exercise. The communication should remain two ways. 3. With sedentary elderly with no interest in exercise begin with a small walk every day. Dispel myths such as no pain no gain. Choose realistic goals preferably somewhat smaller than person’s endurance and keep on increasing it. 3.0 Recommendations: Firstly, individualised attention that focuses on particular needs. Consider the case of a 68 year old woman with osteoarthritis. She wishes to live independently in her own home and considers physical fitness essential for that. But her exercise often breaks down due to knee discomfort (Philips et al, 2004, pS53). Putting the case to Mackinnon’s (2003) suggestions: What are individual motivating factors for her to begin exercise? Being physically fit to live on her own What precautions are needed to put elderly to exercise regimen? Intensity of exercise to be endured well by the elderly, preferably a low intensity walking exercise but to be done regularly, being active around home and not too much time spent watching television. What aspect of physical fitness is necessary to be considered for particular elderly? To keep the knee discomfort incidents to very few. How to fulfill a specific request of elderly viz. Beginning a program at home or in a community setting? The lady is already prepared for regular physical activity so such specific request may not arise. Still, a group setting is likely to be encouraging for her. What factors may enhance or impede her continuous exercise? Pain in knee may impede her and if occurs frequently may result in low self esteem. However, social cooperation associated with appropriate exercise regimen enhances her continued exercise. Secondly, Group support is highly encouraging factor, generally, while depression and long sedentary habits put elderly off from exercise. Particularly in the former case, the elderly needs to be brought out of depression first, else he/she would not enjoy the physical activity. Finally, when the group session ends with advice to continue exercise on their own, many elderly gradually return back to sedentary living! The solution to this problem could be breaking the groups sessions, sometimes, and telling elderly to do their exercise as they wish. The elderly would go to malls, climb stairs, come back home walking. The suggestion is to emphasise that alternative exercises should be taught there in the group session itself. This way after end of group sessions the elderly are not at loss as to how to continue exercise since they are so used to the group. Even if the groups are permanent, the elderly would derive enjoyment from variety. References Bandura, A. (1 994). Self-efficacy. In V.S. Ramachaudran (Ed), Encyclopedia of human behavior..4, 71-81. New York: Academic Press. Brown, S. P., Miller, W.C. & Eason, J. M. (2006). Exercise Physiology: Basis of Human Movement in Health and Disease. Lippincott Williams & Wilkins, Cousins, S. O'Brien (1998. Exercise, Aging, and Health: Overcoming Barriers to an Active Old Age. Taylor & Francis. Herning, M. M.., Cook, J. H. & Schneider, J. K. (2005). Cognitive Behavioral Therapy to Promote Exercise Behavior in Older Adults: Implications for Physical Therapists, Journal of Geriatric Physical Therapy, 28(2), 34-38. Retrieved 16 Apr 2009 from: http://www.geriatricspt.org/members/pubs/journal/2005/august/JGPT-herning.pdf Mackinnon, L. T., Ritchie, C. B., Hooper, S. L. & Abernethy, P. J. (2003). Exercise Management: concepts and professional practice, Human Kinetics. Mellion, M.B., Putukian, M. & Madden, C. C. (2003). Sports medicine secrets, 3rd ed, Elsevier Health Sciences. Phillips, E.M., Schneider, J.C. & Mercer G.R. (2004). Motivating elders to initiate exercise. Arch Phys Med Rehabil, 85(Suppl 3):S52-7. Steps to encourage exercise in depressed patients, Retrieved from http://www.blackdoginstitute.org.au/docs/Stepstoencourageexerciseindepressedpatients.pdf [ 15 Apr 2009] Strawbridge, W. J., Deleger, S., Roberts, R. E. & Kaplan, G. A. (2002). Physical Activity Reduces the Risk of Subsequent Depression for Older Adults, Am J Epidemiol 156,328- Read More