In 2020, the number of persons aged 65 years or older was more than 9% of the world’s population at 727 million, with that number projected to more than double by 20501.

This is driven by factors such as increased life expectancy, decreasing fertility and changes to other social patterns. The greatest changes in population ageing are occurring in low- to middle-income countries.

Physiologically, ageing leads to decreased physical capacity and a growing risk of disease, with common conditions of older age including musculoskeletal disorders, cardiovascular impairment and diabetes. In fact, there is evidence to suggest that the proportion of our lives spent in good health has remained generally constant despite our ageing populations, the implication of this being that our additional years are spent in poor health.

There is however good news, with research showing a positive impact of physical activity on healthy ageing2. Researchers at the University of Birmingham are designing studies and programmes to get older people more engaged in exercise to improve or maintain physical independence and delay mobility disabilities.

Mobility Disability

The least mobile segment of the population are those over 65 years who are also the fastest growing group of our society. Afroditi Stathi, Professor of Physical Activity and Community Health at the University of Birmingham, conducts research aimed at arresting the downward spiral of inactivity: more inactivity leading to less mobility and less mobility leading to more inactivity, with subsequent negative consequences for the older person, their families and society.

To this end, Professor Stathi led the REtirement in ACTion (REACT) randomised controlled trial, a 42-month study funded by the UK National Institute for Health Research, which added unique, robust evidence that a relatively low-resource, one-year exercise and behaviour maintenance intervention can improve physical functioning in real-world community settings, with clinically meaningful benefits that are sustained over at least 24 months3. With a study population of 777 older adults exhibiting characteristics representative of the UK population of adults over the age of 65 and a low attrition rate (19.1%), the REACT study provided robust evidence that the trajectory of declining physical functioning with age is modifiable and may even be reversible for many older adults.

How can declining physical capacity be slowed, or even reversed as we age?
Being the largest translational study conducted to date targeting long-term changes in lower-limb physical function in older adults with mobility limitations, REACT has the potential to have a profound impact on subsequent research in other countries and to underscore to health professionals and public health policy makers and practitioners the powerful effect of physical activity on prevention and management of mobility limitations in later life.

Age-friendly environments

The United Nations Decade of Healthy Ageing (2021 – 2030) is a global collaboration aimed at improving the lives of older people. Among its four areas of action is ‘Age-friendly Environments’, acknowledging the need to remove physical and social barriers to improve the experience of ageing.

Professor Afroditi Stathi’s research aims to identify “ways to embed physical activity into people’s lives without too much effort on their behalf”. Her research has highlighted the complexity and range of personal, social and environmental barriers, including perceptions of ill health, lack of social support, poor access to facilities and transport and a lack of understanding on the need for physical activity or how much is enough. Her programmes are designed with these barriers in mind, proposing older people activity options that integrate with their lifestyle without being burdensome.
 
Her growing citizen science research on age and activity friendly urban environments aims to the co-creation with older adults of cities where all residents enjoy higher quality of life, lower health inequalities and mortality and live in greener, sustainable neighbourhoods feeling empowered to take greater responsibility for their environments. Engaging with older adults, who participated as citizen scientists, and a range of community stakeholders across urban planning and ageing well services, together with PhD candidate Grace Wood, they examined how local urban spaces in Birmingham, UK, impact active and healthy ageing. The project has enabled older adults to collect environmental data, discuss the study findings with community stakeholders and co-produce recommendations for improving their local areas.  The co-produced recommendations are now being disseminated across multiple stakeholders and decision-makers, with the vision of enacting change and support Birmingham in become a more age and activity friendly city.

Professor Carolyn Greig, Professor of Musculoskeletal Ageing and Health at the University of Birmingham, also has a major research interest in maintaining physical independence in older age through improving musculoskeletal health. Sarcopenia, loss of muscle mass and function, is a well-known consequence of ageing and contributes to frailty and increased risk of fractures. Using interventions such as increased physical activity and nutritional supplements, Professor Greig looks at how muscle responds to these interventions and measures their effect on functional ability. Functional ability means the ability to perform normal everyday tasks and activities important for a physically independent life.

How can we reduce the years older people spend in poor health?

Another key focus for Greig is tackling the challenge of population ageing in low and middle-income countries. It is projected that by 2050, 80% of older people will reside outside of the high-income countries4. With relatively little funding and research effort targeting healthy ageing, the World Health Organisation states that about 75% of the world’s countries have little or no data on healthy ageing. Without data, monitoring and evaluating progress towards indicators of healthy ageing are exceedingly difficult.

Prof Greig, along with her University of Birmingham colleague Justine Davies, Professor of Global Health, is trying to find out more about ageing on a global scale. She asserts: “We want to try and find out more about healthy ageing, particularly in low- and middle-income countries around the world. What are older adults’ perceptions and experiences of older age and where are their priorities?” Indeed, the pattern and rate of population ageing varies in different countries, and even with similar rates of ageing, the causes may be driven by different factors such as reduction in mortality or the ageing of the Baby Boomers, for example5, shaping the priorities and policies implemented.

The United Nations Decade of Healthy Ageing (2021 – 2030) is a global collaboration aimed at improving the lives of older people. Among its four areas of action is ‘Age-friendly Environments’, acknowledging the need to remove physical and social barriers to improve the experience of ageing 6. Achieving this goal will require not just targeted interventions, but a greater focus on how the broader choice environment can help or hinder more physical activity.

Raising Awareness

Along the themes of the WHO’s decade of healthy ageing, Prof Greig and colleagues Prof Janice Thompson and Dr Victoria Goodyear in the School of Sport, Exercise and Rehabilitation Sciences, recently launched a Massive Online Open Course (MOOC) ‘Healthy Ageing: concepts, interventions and preparing for the future’ covering healthy ageing with a strong global focus on maintaining optimal functional ability in older age, and, in the words of the World Health Organisation, ‘doing the things you value for as long as possible’. What might this global focus look like?

There would be more awareness of the needs of older people and more research into developing strategies to meet those needs in different contexts and cultures she says. Taking physical activity research as an example, a number of countries around the world, including the UK, have produced national guidelines for physical activity. (The UK Physical Activity Guidelines also describe the types of physical activity which could be attempted not only by active older adults, but also by those who are living with frailty or transitioning to frailty). The WHO also produces guidance, however what is interesting is that this guidance, along with the guidance from the UK and other countries, is informed mainly by High Income Country (HIC) data. Informing policy through healthy ageing primary research in LMICs (not just its evaluation), is vitally important if the WHO Decade of Healthy Ageing initiative is to be successful. Prof Greig would like to see more resources put towards this, something that may be more difficult with the recent cuts in overseas aid.
 
Raising awareness, knowledge and understanding of healthy ageing in low- and middle-income countries is however a more complex concept, as an increasingly aged population and its associated non-communicable diseases is now coupled with existing problems caused by infectious diseases, along with maternal, neonatal and child health needs, to which limited public health funding is allocated. Prof Greig thinks this “quite worrying” as limited resources will be further stretched to deal with a rapidly ageing population on the back of issues which have not yet been dealt with. With relatively little research being carried out, there are few data on which to base interventions and policies; “a perfect storm brewing” is Prof Greig’s very apt description of the situation.

Understanding Needs

Guidelines suggest 150 minutes of moderate intensity aerobic activity weekly, but for the older adult living with or without frailty, this target – for any number of reasons, may be too challenging  to be met. Some might have various perceptions of their limitations with perception being even more of a barrier than the actual limitation. Some may believe that the recommendations are the starting point and not the end goal. Some, may simply believe they are either “too old” for doing the recommended types of physical activity.

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Professor Stathi stresses that: “For many years, the research, policy and practice communities focussed maybe too much on the health importance of physical activity when promoting exercise. Well-being in later life is more than simply maintaining health. People want to maintain health and functional ability to be able to do the things they love doing. In our research we see it again and again: The real motivation for older people is having a life worth living, a life with meaning, a life with enjoyment and social interaction. For most people, physical activity is not the goal, physical activity is a means to an end, that being a higher quality of life. It is therefore important to understand the needs of the older adult and support them in their efforts to increase their physical activity”.

Professor Greig agrees with this, suggesting that how we frame recommendations may be received differently: “Telling people what to do, this is what you should be doing, if you do this your muscle strength and balance will improve by this much, kind of thing, might not be what’s most important to an older person. An older person might not be interested whether their step count has increased or that their muscles have grown – that person wants to know whether they will be able to get up from a toilet or climb their stairs or get to their front door when the doorbell rings”.

Watch Professor Greig's Inagural Lecture Four Score Years and Then...?: Improving health span in older adults.

Notes

1. United Nations Department of Economic and Social Affairs, Population Division - 'World Population Ageing 2020 Highlights' (2020)

2. International Journal of Behavioral Nutrition and Physical Activity - The impact of physical activity on healthy ageing trajectories: evidence from eight cohort studies (2020)

3. University of Birmingham Research - Effect of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: the REACT (REtirement in ACTion) randomised controlled trial (2022)

4. World Health Organization - 'Ageing and Health' (04/10/2021)

5. NCBI - 'The Demography of Aging in Low- and Middle-Income Countries: Chronological versus Functional Perspectives' (2018)

6. World Health Organization - 'UN Decade of Healthy Ageing 2021-2030' (14/12/2020) 

Top banner image courtesy of Alex Rotas.

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