Evidence-Based Practice Guideline
D
Exercise Promotion:
Walking in Elders
espite growing evidence of
the health benefits of regular exercise, many Americans still remain sedentary. National
data have shown that approximately
30% of American adults report no
leisure-time physical activity. And by
age 75, one in three men and one in
two women do not participate in any
regular physical activity (U.S. Department of Health and Human Services [USDHHS], 2000). Although
60% of older adults report some
activity, the frequency and duration
are insufficient (USDHHS, 1999).
Two objectives of Healthy People
2010 are to reduce the proportion of
adults (18 and older) engaging in no
leisure-time physical activity from
40% in 1997 to 20% by 2010 and to
increase the proportion of adults exercising according to recommendations from 15% in 1997 to 30% by
2010 (USDHHS, 2000).
Guidelines from the American College of Sports Medicine
(ACSM, 1990), the Surgeon General (USDHHS, 1996), and National
Health Service Scotland (Wood &
Bain, 2001) recommend adults accumulate 30 minutes (duration) or
more of moderately intense activity
on all or most days of the week (frequency). The 30 minutes of exercise
can be divided into two or three ses-
sions of at least 10 minutes duration
throughout the day (National Institute on Aging [NIA], 2008). The
percentages of Americans meeting
this recommendation are 34.3% for
men and 29.8% for women (Jones et
al., 1998).
Recommended activities should
burn approximately 150 kilocalories
per day (USDHHS, 1996). Because a
brisk 30-minute walk (4 m.p.h. pace)
consumes approximately 150 kilocalories, it is an appropriate kind of
exercise to meet the recommendation. In addition, walking is suitable
for older adults because it carries a
low risk of orthopedic injury (Robinson, Brooke-Wavell, Jones, Potter, & Hardman, 1995; USDHHS,
1996), requires no equipment (except
support shoes), can be done almost
anywhere at any time, and costs
nothing. For those who have been
inactive for years, walking is an appropriate mode of exercise. Walking or brisk walking is a moderateintensity exercise that can improve
health and reduce risk of premature
death (Ogawa, Oka, Yamakawa, &
Higuchi, 2005; Schwarz, Bailey, &
Ciarlariello, 2003; Singh-Manoux,
Hillsdon, Brunner, & Marmot, 2005)
in the following ways:
l Lowers the risk of developing
hypertension, type 2 diabetes, colon
cancer, and coronary heart disease
(or second heart attack) and reduces
blood pressure.
l Lowers blood cholesterol (R.S.
Taylor et al., 2004) and triglycerides
and may increase high-density lipoproteins (HDL).
l Maintains healthy body
weight by increasing lean muscle
and decreasing body fat.
l Increases muscle and bone
strength.
l Lowers risk of disability (Van
Den Brink et al., 2005).
l Slows bone loss from the spine
in women who are postmenopausal
(Ciliska, 2003; North American
Menopause Society [NAMS], 2006).
l Helps older adults become
stronger and better able to be ac-
Narirat Jitramontree, PhD, RN
Edited by Deborah Perry Schoenfelder, PhD, RN
10
tive without falling or becoming
excessively fatigued, and improves
fall-related outcomes (i.e., balance,
gait, fear of falling) (Schoenfelder &
Rubenstein, 2004; L. Taylor et al.,
2003).
l Enhances psychological wellbeing and reduces depressive symptoms (Mangione, Craik, Tomlinson,
& Palombaro, 2005; USDHHS,
2000).
In summary, walking, which is
often perceived as a pleasant exercise, is an active lifestyle strategy that
provides physical and psychological
benefits and can result in improved
health (L. Taylor et al., 2003). This
article is an overview of the evidencebased practice guideline Exercise
Promotion: Walking in Elders (Jitramontree, 2007) aimed at encouraging
older adults to exercise by walking.
PURPOSE OF THE GUIDELINE
The purpose of the evidencebased practice guideline Exercise
Promotion: Walking in Elders is to
support health personnel in various
settings as they motivate older adults
to walk for exercise or to maintain
their exercise behavior.
DEFINITION OF KEY TERMS
Walking promotion is the facilitation of bipedal locomotion to prevent illness or to preserve or improve
health and fitness. Walking refers to
the transfer of body position by the
alternating movements of the legs
(Berg & Norman, 1996). The aim of
walking regularly at a moderate intensity is to diminish the risk of diseases, such as coronary artery disease,
hypertension, colon cancer, and diabetes (USDHHS, 1996) and to raise
overall quality of life by improving
health, enhancing independent living
(Potter, Evan, & Duncan, 1995), and
decreasing depression (Mobily, Rubenstein, Lemke, & Wallace, 1996).
INDIVIDUALS AT RISK FOR
INADEQUATE EXERCISE
Although people know exercise
is good for their health, they do not
necessarily follow through and exercise. People most at risk for not
exercising include adults older than
45 (Woods et al., 2005), women with
low educational attainment or low
incomes, postmenopausal women
(Ciliska, 2003; NAMS, 2006), African American and Hispanic adults,
and adults in the northeastern and
southern U.S. states (USDHHS,
2000). Adults who lead sedentary
lifestyles are less apt to exercise
(Wells, 1999). They participate in
fewer than three 20-minute sessions
of leisure-time physical activity per
week. People with disabilities also
tend to not engage in physical activity (Motl & McAuley, 2009).
ASSESSMENT TOOLS
To help older adults exercise safely and gain the most health benefits,
use of the following assessment tools
is recommended before encouraging older adults to start an exercise
program: Physical Activity Stage of
Change Questionnaire (Ingledew,
Markland, & Medley, 1998; Nigg &
Courneya, 1998), Physical Activity
Readiness Questionnaire (ACSM,
1991), Balance Scale (Berg, WoodDauphinee, Williams, & Gayton,
1989), and Borg Scale (Borg, 1998;
“Exercise Strength,” 2002). Three
of the four tools are reprinted with
permission in the full guideline (Jitramontree, 2007), available for purchase from The University of Iowa
College of Nursing (http://www.
nursing.uiowa.edu/hartford/nurse/
ebp.htm). The Borg Scale is available on the CDC website (http://
w w w. c d c . g o v / n c c d p h p / d n p a /
physical/measuring/perceived_
exertion.htm).
Physical Activity Stage of Change
Questionnaire
Changes in behavior are different among individuals, depending
on their intention to change. Specifically, the needs and motivations of people in different stages
of change vary considerably. The
Transtheoretical Model (Prochas-
Journal of Gerontological Nursing • Vol. 36, No. 11, 2010
ka & DiClemente, 1985) proposes
that people change their behavior
by moving through the stages of
precontemplation, contemplation,
preparation, action, and maintenance. This model has been successfully applied to exercise behavior.
The Physical Activity Stage of
Change questionnaire, based on the
Transtheoretical Model stages of
change, contains five yes/no items
that are scored to determine the individual’s stage of change. In addition,
three questions related to current
physical activity and exercise are included. Understanding older adults’
stage of change may enhance their
exercise adherence.
Physical Activity Readiness
Questionnaire
Before starting an exercise program, older adults who have not
exercised for a long time should be
assessed for their fitness and ability
to exercise. The Physical Activity
Readiness Questionnaire (PAR-Q),
developed by Shephard, Thomas,
and Weller (1991), is a simple selfadministered tool widely used as an
initial measure to identify people
who can engage in physical activity without physician approval.
The PAR-Q conservatively screens
older adults who may exercise safely at a low- to moderate-intensity
level (Cardinal, 1997). The ACSM
(1991) recommends this tool for assessing healthy adults who intend
to increase their exercise level.
The PAR-Q includes seven critical concern questions, such as chest
pain, fainting, and uncomfortable
feeling (Shephard, 1995). The original PAR-Q was overly conservative, excluding too many healthy
adults, but the revised 1994 PARQ (USDHHS, 1999) improved its
sensitivity and specificity. The sensitivity of the PAR-Q was found to
be adequate, as no false positives
were found after screening approximately 500,000 people (Shephard,
1999).
11
Assessment of Balance: Balance Scale
Independent walking requires
the ability to stride with one foot
forward while standing on the other
one, thus requiring good balance
(Berg et al., 1989). Balance involves
the ability to control the upright
position as well as to compensate
body alignment in response to a
loss of stability (Berg & Norman,
1996). Measuring balance is useful
for identifying individuals at risk of
falling (Maki, Holliday, & Topper,
1994); therefore, it is recommended
that older adults have their balance
tested prior to starting a walking
program. Older adults with good
balance are confident when walking (Steadman, Donaldson, & Kalra,
2003). For those with poor balance,
exercises to improve balance, such
as progressive resistance training or
aquatic exercise, may be needed before beginning a walking program.
The most comprehensive balance
assessment inventory is a performance-based test developed by Berg
and Norman (1996). The Balance
Scale includes 14 activities of daily
living, with scores ranging from 0 to
4 according to the independence or
dependence of movements needed
for each activity. Older adults who
independently perform the task and
meet certain time and distance criteria are given the highest score (4). The
total score for the entire 14-item battery ranges from 0 to 56. The scale is
a reliable instrument with excellent
inter- and intrarater agreements (intraclass correlation coefficient > 0.95)
and a high degree of internal consistency (Cronbach’s alpha coefficient =
0.96). Compared with other balance
tests, the Balance Scale is a sensitive
measure for older adults (Berg &
Norman, 1996). Further, it is an older
adult-friendly test that requires only
10 to 15 minutes to administer.
Assessment of Perception of
Exertion: Borg Scale
Perceived exertion is how hard a
person feels his or her body is work-
12
ing, which offers a reasonably good
estimate of actual heart rate during
exercise. Perceived exertion for the
same activity varies among people
(“Exercise Strength,” 2002). What is
undemanding for one person might
be exhausting for another. Some people might feel like they are walking
on flat ground, while others may feel
like they are jogging uphill.
The Borg Scale (Borg, 1998) is a
subjective measure indicating level
of effort people feel they are putting into an activity. That perception
of exertion is likely to relate well to
actual physical measurements (“Exercise Strength,” 2002). It is recommended that people perform physical activity at the level of 13 on the
Borg Scale, which is a moderate level
of intensity. Level 13 is the feeling
of working at a somewhat hard level
but still feeling all right to continue.
Brisk walking is an example of an activity at level 13.
assessing the item “standing on one
leg” is specifically recommended before beginning an exercise program.
l For perceived exertion level,
it is recommended that, to achieve
benefit from exercising, older adults
walk until reaching the “somewhat
hard” feeling (Borg Scale level 13).
Walking beyond that level should be
done gradually and with caution.
ASSESSMENT CRITERIA
Precontemplation Stage
Those in the precontemplation
stage include those who are not active and currently have no intention of being active within the next
6 months. Examples of actions for
older adults in this stage include:
l Increasing awareness of their
activity level by assessing activities
in daily life. For example, the health
care provider can ask the older
adults to record their activities in a
diary and then discuss their activity
level with them.
l Helping older adults understand how their current behavior
influences them personally and
also others. For example, inactive
parents model unhealthy behaviors
to their children and grandchildren
(USDHHS, 1999).
l Increasing awareness of what
the older adults might miss if they
continue to be sedentary (Burbank,
Padula, & Nigg, 2000), providing information about the benefits
of exercise (Resnick & Spellbring,
2000), and clarifying the misconcep-
After evaluating older adults’
physical activity stage of change,
physical activity readiness, balancing
ability, and perceived exertion levels,
health care providers should encourage older adults to exercise according
to the following criteria:
l Interventions for older adults
should be tailored to each stage of
change in the Transtheoretical Model, described in more detail below
in the Description of the Practice
section.
l Regarding physical activity
readiness, if older adults respond
yes to one or more items on the
PAR-Q, they should consult with
their primary care provider. If they
answer no to all PAR-Q questions,
an exercise program can be initiated
gradually without talking to a health
care provider.
l For ability to balance, older
adults with lower Balance Scale
scores should be more careful while
exercising. It may not be necessary
to administer the entire tool, but
DESCRIPTION OF THE
PRACTICE
To promote exercise behavior,
psychosocial and physiological aspects should be considered (Quinney, Gauvin, & TedWall, 1994). Approaching individuals differently
addresses diverse levels of motivation to change and is an important
strategy to enhance exercise behavior (Ingledew et al., 1998; Nigg &
Courneya, 1998). Interventions developed for individuals in each stage
of change are discussed below.
tions associated with exercise, such
as injury, excessive muscle hypertrophy, and fatigue (USDHHS, 1999).
l Emphasizing the short-term
benefits, such as enjoyment, feeling
better about oneself, and sleeping
better.
l Linking benefits of a physically active lifestyle to valued people
(White & Maloney, 1990). For example, the health care provider can
have older adults identify the most
significant people in their lives and
discuss important upcoming events
they are looking forward to and
want to attend.
l Emphasizing that by staying
healthy, the older adults will be able
to improve their quality of life (e.g.,
living independently longer, avoiding falls).
Contemplation Stage
Contemplators are individuals who do not exercise but intend
to start exercising within the next 6
months. They are not ready to initiate the action because they are in
the process of weighing the pros
and cons of beginning to exercise.
Consequently, they are ambivalent
about engaging in exercise behavior.
Examples of actions for these older
adults are:
l Assessing their barriers to
exercise and then discussing how to
overcome them (Cooper, Bilbrew,
Dubbert, Kerr, & Kirchner, 2001).
l Assessing their exercise efficacy and providing motivating messages such as “good job” or “you’re
doing great” to enhance self-confidence (USDHHS, 1999).
l Providing awareness about
walking options, such as taking
the stairs, walking to church, or
shopping (U.S. Department of
Transportation, Federal Highway
Administration, 1994). Health care
providers can encourage older adults
to choose to walk and to view these
options as personally and socially
desirable. They can also provide
information about pedestrian safety.
Table
Instructions for older adults starting a walking
program for exercise AND TIPS FOR SAFETY
How to start a walking program:
• Start walking at a comfortable natural pace (warm up) and stretch after walking
(cool down).
• Let your arms swing in a relaxed and rhythmic manner (Kubo, Holt, Saltzman, &
Wagenaar, 2006).
• Hold your head erect, with the chin in, shoulders relaxed, back straight, and
abdomen flat.
• Land on your heel and roll forward to drive off the ball of your foot. Walking
only on the ball of the foot or walking flat footed may cause soreness.
• Take long, easy strides, but do not strain. When walking up hills rapidly, lean
forward slightly.
• After a few walking sessions, begin to pick up your pace by striding out and
walking faster until you feel up to level 13 of the Borg Scale (Borg, 1998).
Tips for safety
• Wear comfortable support shoes with flexible soles, good arch support, and
roomy toe boxes.
• Choose a comfortable time of day to walk that is not too soon after eating
(Shephard, 1995) or rising from bed (Willich, 1995) and when the weather is
not too cold or hot. For outdoor walking, dress in layers that can be added or
removed as needed. Older adults can be easily influenced by the heat or cold
(National Institute on Aging [NIA], 2008).
• Drink fluids after walking and sweating. Older adults are less likely to feel thirsty
(Mack et al., 1994; Phillips, Bretherton, Johnston, & Gray, 1991). Check with your
physician if your fluid intake is restricted.
• Start out at a lower level of effort and work up gradually, especially if you have
been inactive for a long time (Pate et al., 1995).
• Cut back if fatigue persists more than an hour after walking or divide the
workout into several sessions that add up to a total of at least 30 minutes but no
less than 10 minutes per session. Walking less than 10 minutes at a time will not
provide cardiovascular and respiratory system benefits (NIA, 2008).
• Stop if you are panting, nauseous, or dizzy, or have chest pains. Consult a physician before starting again.
l Providing choices (Mullan &
Markland, 1997) of home-based exercise programs, such as stretching,
range of motion, and weight-bearing exercises (King, Haskell, Taylor,
Kraemer, & DeBusk, 1991).
l Providing lists of community
resources (Sallis et al., 1990) so older
adults have an option to participate
in exercise with others.
l Helping older adults with the
“beginning basics,” such as selecting appropriate shoes, socks, and
clothing for exercising (USDHHS,
1999).
Journal of Gerontological Nursing • Vol. 36, No. 11, 2010
Preparation Stage
Individuals in the preparation
stage include those who intend to
exercise in the near future, usually
within the next month. They may
begin to exercise but do so less
often and with less intensity than
recommended. They may be uncertain about the outcomes of their
activity. Examples of interventions
include:
l Providing information about
how to walk and safety considerations (Pucher & Dijkstra, 2003)
(Table), including the time and
13
14
Instructions: Make a dot corresponding to the day of exercise and the amount of
time in minutes that you exercise each day. You can make a dot corresponding to a
duration of exercise time that falls between the numbers given on the graph (e.g.,
12 or 27 minutes). Then connect the dots from Day 1 to Day 2, Day 2 to Day 3, and
so forth.
Duration of Exercise (minutes)
distance one should walk (Howze,
Smith, & DiGilio, 1989).
l Strengthening their exercise
efficacy (Chau, Shiu, Ma, & Au,
2005; Gary, 2006; Resnick & Spellbring, 2000) by:
(a) Facilitating a progressive
walking program, reinforcing successes (Long & Haney, 1988), and
providing self-monitoring methods that help older adults visualize
progress. They may record time
spent walking each day in a graph
or chart (Figure) or record steps
walked each day using a pedometer. Older adults may monitor their
weight as a criterion for success.
Experiencing physiological changes, such as decreased fatigue, also
strengthens self-efficacy (Strecher,
DeVellis, Becker, & Rosenstock,
1986).
(b) Emphasizing individual
competence and accomplishment
focusing on recognition of exercise
participation and mastery, rather
than on extrinsically focused traditional awards based on fitness
assessment (Fitness Canada, 1992;
Prudential FITNESSGRAM, 1992).
(c) Promoting
competence
perceptions by reinforcing the personal progress made (Whitehead &
Corbin, 1991).
(d) Providing a video showing older adult role models who
walk (Reeve, 1996).
(e) Establishing a group field
trip to visit an older adult walking
program (Reeve, 1996).
(f) For group exercise, assigning individuals to groups on the
basis of their confidence and ability
levels (Howze et al., 1989).
(g) Improving balance to enhance walking confidence (Jansson
& Söderlund, 2004).
l Helping older adults establish
short-term goals that are small,
specific, and realistic (Resnick &
Spellbring, 2000), such as “I will
walk for 10 minutes every day.” Pedometers, step logs, and e-mail reminders are recommended to help
35
30
25
20
15
10
5
1
2
3
4
5
6
7
Day of Exercise
Figure. Using this graph, older adults can chart the duration of their exercise by day.
in goal setting (Heesch, Dinger,
McClary, & Rice, 2005).
l Encouraging older adults to
make a commitment by sharing
their intention to exercise with
another person. For example,
health care providers can ask older
adults to sign a behavioral contract
following a discussion of potential
barriers, strategies to achieve walking goals including rewards for success, and motivating methods to be
used (Williams, Bezner, Chesbro, &
Leavitt, 2005).
l Promoting exercise as an
enjoyable activity (Corbin & Pangrazi, 1999; USDHHS, 1999).
l Fostering social support from
the older adults’ spouses, family
members, friends, neighbors, and
coworkers (Cousins, 1993). Health
care providers can involve older
adults’ spouses and family members
by assessing their attitudes, discussing progress the older adults have
made, and offering examples of
reinforcing constructive feedback.
Older adults may also be encouraged to walk with spouses, families,
friends, neighbors, coworkers, or
significant others.
l Discussing barriers to regular
activity and eliciting ways to overcome those obstacles. The recom-
mended nursing interventions for
overcoming various barriers are as
follows (Cooper et al., 2001):
(a) Pain: Older adults should
take medications to reduce pain 1 to
2 hours before beginning to walk.
They should warm up by stretching
for at least 5 to 10 minutes before
and after walking. They should begin at a usual walking speed and increase gradually as tolerated. They
can prevent pain by slowing down
or stopping as needed. Older adults
should let their joints and muscles
recover by walking every other day.
(b) Fatigue: Older adults can
improve their sense of well-being
by arranging a schedule to maintain
balance between rest and activities,
get quality sleep by avoiding caffeine and alcoholic beverages, and
increase energy level with proper
exercise.
(c) Mobility: Older adults
can improve range of motion and
blood flow to joints and muscles
by performing exercises slowly,
smoothly, and gently, and avoiding
overstretching of the joints. They
should walk at a comfortable pace
on a smooth, even floor and use
walking aids as needed.
(d) Sensory
impairments:
Health care providers should inspect
older adults’ feet and legs regularly
for skin lesions. Older adults should
walk in a well-lit area with friends
and wear proper-fitting shoes with
good support.
l Informing older adults about
the temporary nature of unpleasant
sensations (Resnick & Spellbring,
2000), such as muscle aches, joint
pain, shortness of breath, fear of
falling, and feeling bored. They can
decrease or eliminate these unpleasant symptoms (Resnick, 1998) by
taking medication prior to exercise,
applying ice to areas of pain, or
wearing better socks and support
shoes to relieve pain. Older adults
apprehensive about falling should
be encouraged to walk with their
usual assistive devices, walk on a
treadmill while holding the handrails, or walk with a partner.
Action Stage
This stage includes older adults
who currently exercise regularly but
have just started doing so within the
past 6 months. Individuals in the action stage are prone to relapse to old
patterns of behavior. Examples of
interventions for those in the action
stage are:
l Continuing to provide
positive, constructive feedback to
enhance self-efficacy (Whitehead &
Corbin, 1991).
l Increasing walking speed,
distance, or time (Ottenbacher et al.,
2005; Purser et al., 2005) with:
(a) Use of a portable, progressive-resistance exercise machine
(Mangione et al., 2005).
(b) Use of virtual obstacle
training (for older adults who have
experienced stroke) (Jaffe, Brown,
Pierson-Carey, Buckley, & Lew,
2004).
l Assisting older adults in developing a long-term goal for exercise
(Resnick & Spellbring, 2000), such
as “I will participate in a 2-mile
walk this spring.”
l Assisting in identifying potential reasons for relapse (Forkan
et al., 2006), such as risk of injury,
boredom, and failure to meet goals
(e.g., due to inclement weather,
occasional illness, out-of-town
visitors). Health care providers can
discuss solutions for anticipated barriers and develop alternative plans
for missing events. For example,
older adults can try a new time,
partner, or place for walking. Older
adults should be informed that a
relapse does not mean failure but is
a normal part of the change process.
l Encouraging older adults to
foster group cohesion by developing a buddy system (Quinney et al.,
1994).
l For older adults exercising
at home, the health care provider
can visit their home to help them
maintain their activity. This can
include problem-solving techniques
and behavior change strategies, such
as biweekly telephone conversations
to discuss progress, and offering
support and guidance for relapse
prevention (Bodie & Inoue, 2005).
l Reminding older adults to
reward themselves for success.
For example, buying a new pair of
walking shoes or taking a short trip
(USDHHS, 1999).
Maintenance Stage
People in this stage have successfully exercised for more than 6
months and are continuing to exercise regularly. As with the other stages of change, interventions should be
tailored for the individuals:
l Reminding older adults to
recognize and appreciate their successes (Resnick & Spellbring, 2000).
Health care providers can continue
to provide positive reinforcement.
l Providing opportunities for
the older adults to serve as a role
model for others. This will motivate them to continue their exercise
program (USDHHS, 1999).
l Continuing to make exercise fun and entertaining, such as
walking with their favorite music or having conversations with
Journal of Gerontological Nursing • Vol. 36, No. 11, 2010
friends before, during, and after
walking (Corbin & Pangrazi, 1999;
USDHHS, 1999).
l Maintaining a supportive
environment by reminding family members to continue providing
encouragement (Cousins, 1993).
l Helping the older adults set
realistic goals to prevent discouragement (Resnick & Spellbring,
2000).
Relapse
Individuals engaging in an active
lifestyle may go back to an earlier
stage of change. Interventions for
people in the relapse stage are not
the same as for those just beginning
to change their behavior. Individuals
in this stage are more likely to start
their activity again. Examples of actions include:
l Assessing their stage of relapse
to ascertain the length of the relapse
(USDHHS, 1999).
l Learning from other older
adults how they overcame barriers
to exercise and sustained their activity (USDHHS, 1999).
l Identifying causes of relapse
and discussing ways to overcome
and prevent future relapses. Factors
that can help or hinder program
maintenance should be identified
(USDHHS, 1999). For example, inclement weather may prevent older
adults from exercising regularly.
Alternatives may include walking
in a mall, in a gym, or on a home
treadmill.
EVALUATION OF PROCESS AND
OUTCOMES
Each health care provider using this guideline should be asked
to complete the Process Evaluation
Monitor included in the full guideline (Jitramontree, 2007). The 9item scale evaluates the perception
of the usefulness of the guideline for
practitioners. The item scores indicate the need to provide support or
further education for practitioners
implementing the guideline.
15
For each individual receiving
the exercise promotion guideline,
it is helpful to monitor and assess
his or her performance of exercise
behavior. The Exercise Promotion
Outcomes Monitor includes three
indicators: intensity, duration, and
frequency of exercise behavior. This
form, available in the full guideline,
should be completed on a weekly
basis throughout the exercise promotion program for each older
adult.
CONCLUSION AND
IMPLICATIONS FOR NURSING
PRACTICE
The Exercise Promotion: Walking in Elders evidence-based
practice guideline provides practitioners with assessment tools,
evidence-based interventions, and
both process and outcome indicators to measure the effectiveness of
walking programs. Basing a walking program for older adults on the
Transtheoretical Model stages of
change is research based, individualized, and has promising potential for improving overall health in
older adults in various settings and
at different levels of health. Professional nurses are key players on
interdisciplinary teams who must
advocate for initiatives such as evidence-based walking programs to
enhance older adults’ quality of
life.
REFERENCES
American College of Sports Medicine.
(1990). American College of Sports
Medicine position stand: The recommended quantity and quality of exercise
for developing and maintaining cardiorespiratory and muscular fitness in healthy
adults. Medicine and Science in Sports
and Exercise, 22, 265-274.
American College of Sports Medicine.
(1991). Guidelines for graded exercise
testing and prescription (4th ed.). Philadelphia: Lea & Febiger.
Berg, K., & Norman, K.E. (1996). Functional assessment of balance and gait. Clinics
in Geriatric Medicine, 12, 705-723.
Berg, K., Wood-Dauphinee, S., Williams,
J.I., & Gayton, D. (1989). Measuring
16
balance in the elderly: Preliminary development of an instrument. Physiotherapy
Canada, 41, 304-311.
Bodie, D.A., & Inoue, A. (2005). Motivational interviewing to promote physical
activity for people with chronic heart
failure. Journal of Advanced Nursing,
50, 518-527.
Borg, G. (1998). Borg’s perceived exertion
and pain scales. Champaign, IL: Human
Kinetics.
Burbank, P.M., Padula, C.A., & Nigg, C.R.
(2000). Changing health behaviors of
older adults. Journal of Gerontological
Nursing, 26(3), 26-33.
Cardinal, B.J. (1997). Assessing the physical activity readiness of inactive older
adults. Adapted Physical Activity Quarterly, 14, 65-73.
Chau, Y.S., Shiu, A.T., Ma, S.F., & Au, T.Y.
(2005). A nurse-led walking exercise
program for Hong Kong Chinese diabetic patients: Implications for facilitating self-efficacy beliefs. Journal of Clinical Nursing, 14, 1257-1259.
Ciliska, D. (2003). Review: Exercise reduces
bone loss from the spine in postmenopausal women. Evidence-Based Nursing,
6, 50-51.
Cooper, K.M., Bilbrew, D., Dubbert, P.M.,
Kerr, K., & Kirchner, K. (2001). Health
barriers to walking for exercise in elderly
primary care. Geriatric Nursing, 22, 258262.
Corbin, C.B., & Pangrazi, R.P. (Eds.).
(1999). Toward a better understanding of
physical fitness and activity. Scottsdale,
AZ: Holcomb Hathaway.
Cousins, S.O. (1993). The determinants of
late life exercise in women over age 70.
Unpublished doctoral dissertation. Retrieved from the University of British
Columbia website: http://circle.ubc.ca/
handle/2429/2082
Exercise strength & endurance levels. (2002).
Retrieved from the MedicineNet.com
website: http://www.medicinenet.com/
script/main/art.asp?articlekey=10259
Fitness Canada. (1992). The Canadian active living challenge. Ottawa, Ontario:
Government of Canada.
Forkan, R., Pumper, B., Smyth, N., Wirkkala, H., Ciol, M.A., & Shumway-Cook,
A. (2006). Exercise adherence following
physical therapy intervention in older
adults with impaired balance. Physical
Therapy, 86, 401-410.
Gary, R. (2006). Exercise self-efficacy in
older women with diastolic heart failure:
Results of a walking program and education intervention. Journal of Gerontological Nursing, 32(7), 31-39.
Heesch, K.C., Dinger, M.K., McClary, K.R.,
& Rice, K.R. (2005). Experiences of
women in a minimal contact pedometer-
based intervention: A qualitative study.
Women & Health, 41, 97-116.
Howze, E.H., Smith, M., & DiGilio, D.A.
(1989). Factors affecting the adoption of
exercise behavior among sedentary older
adults. Health Education Research, 4,
173-180.
Ingledew, D.K., Markland, D., & Medley,
A.R. (1998). Exercise motives and stages
of change. Journal of Health Psychology,
3, 477-89.
Jaffe, D.L., Brown, D.A., Pierson-Carey,
C.D., Buckley, E.L., & Lew, H.L. (2004).
Stepping over obstacles to improve
walking in individuals with poststroke
hemiplegia. Journal of Rehabilitation
Research and Development, 41(3A),
283-292.
Jansson, S., & Söderlund, A. (2004). A new
treatment programme to improve balance in elderly people—An evaluation of
an individually tailored home-based exercise programme in five elderly women
with a feeling of unsteadiness. Disability
and Rehabilitation, 26, 1431-1443.
Jitramontree, N. (2007). Exercise promotion: Walking in elders. In M.G. Titler
(Series Ed.), Series on evidence-based
practice for older adults. Iowa City: Gerontological Nursing Interventions Research Center, Research Translation and
Dissemination Core, The University of
Iowa College of Nursing.
Jones, D.A., Ainsworth, B.E., Croft, J.B.,
Macera, C.A., Lloyd, E.E., & Yusuf,
H.R. (1998). Moderate leisure-time
physical activity: Who is meeting the
public health recommendations? A national cross-sectional study. Archives of
Family Medicine, 7, 285-289.
King, A.C., Haskell, W.L., Taylor, C.B.,
Kraemer, H.C., & DeBusk, R.F. (1991).
Group- vs home-based exercise training in healthy older men and women. A
community-based clinical trial. Journal
of the American Medical Association,
266, 1535-1542.
Kubo, M., Holt, K.G., Saltzman, E., & Wagenaar, R.C. (2006). Changes in axial
stiffness of the trunk as a function of
walking speed. Journal of Biomechanics,
39, 750-757.
Long, B.C., & Haney, C.J. (1988). Coping
strategies for working women: Aerobic
exercise and relaxation interventions.
Behavior Therapy, 19, 75-83.
Mack, G.W., Weseman, C.A., Langhans,
G.W., Sherzer, H., Gillen, C.M., &
Nadel, E.R. (1994). Body fluid balance
in dehydrated healthy older men: Thirst
and renal osmoregulation. Journal of Applied Physiology, 76, 1615-1623.
Maki, B.E., Holliday, P.J., & Topper, A.K.
(1994). A prospective study of postural
balance and risk of falling in an ambula-
tory and independent elderly population.
Journal of Gerontology, 49, M72-M84.
Mangione, K.K., Craik, R.L., Tomlinson,
S.S., & Palombaro, K.M. (2005). Can elderly patients who have had a hip fracture perform moderate- to high-intensity exercise at home? Physical Therapy,
85, 727-739.
Mobily, K.E., Rubenstein, L.M., Lemke,
J.H., & Wallace, R.B. (1996). Walking and depression in a cohort of older
adults: The Iowa 65+ Rural Health
Study. Journal of Aging and Physical Activity, 4, 119-135.
Motl, R.W., & McAuley, E. (2009). Longitudinal analysis of physical activity and
symptoms as predictors of change in
functional limitations and disability in
multiple sclerosis. Rehabilitation Psychology, 54, 204-210.
Mullan, E., & Markland, D. (1997). Variation
in self-determination across the stages of
change for exercise in adults. Motivation
and Emotion, 21, 349-363.
National Institute on Aging. (2008). Exercise: A guide from the National Institute on Aging (Publication No. NIH
99-4258). Retrieved from http://www.
nia.nih.gov/NR/rdonlyres/25C76114D120-4960-946A-3F576B528BBD/0/
ExerciseGuideComplete.pdf
Nigg, C.R., & Courneya, K.S. (1998). Transtheoretical model: Examining adolescent
exercise behavior. Journal of Adolescent
Health, 22, 214-224.
The North American Menopause Society.
(2006). Management of osteoporosis
in postmenopausal women: 2006 position statement of The North American
Menopause Society. Menopause, 13. Retrieved from http://www.menopause.
org/Portals/0/Content/PDF/psosteo06.
pdf
Ogawa, K., Oka, J., Yamakawa, J., & Higuchi, M. (2005). A single bout of exercise
influences natural killer cells in elderly
women, especially those who are habitually active. Journal of Strength and Conditioning Research, 19, 45-50.
Ottenbacher, K.J., Ostir, G.V., Peek, M.K.,
Snih, S.A., Raji, M.A., & Markides, K.S.
(2005). Frailty in older Mexican Americans. Journal of the American Geriatrics
Society, 53, 1524-1531.
Pate, R.R., Pratt, M., Blair, S.N., Haskell,
W.L., Macera, C.A., Bouchard, C., et
al. (1995). Physical activity and public health. A recommendation from the
Centers for Disease Control and Prevention and the American College of Sports
Medicine. Journal of the American Medical Association, 273, 402-407.
Phillips, P.A., Bretherton, M., Johnston,
C.I., & Gray, L. (1991). Reduced osmotic thirst in healthy elderly men. Ameri-
can Journal of Physiology, 261(1 Pt. 2),
R166-R171.
Potter, J.M., Evan, A.L., & Duncan, G.
(1995). Gait speed and activities of daily
living function in geriatric patients. Archives of Physical Medicine and Rehabilitation, 76, 997-999.
Prochaska, J.O., & DiClemente, C.C. (1985).
Common processes of self-change in
smoking, weight control, and psychological distress. In S. Shiffman & T. Wills
(Eds.), Coping and substance use (pp.
345-363). New York: Academic Press.
Prudential FITNESSGRAM. (1992). The
Prudential FITNESSGRAM recognition
system and program materials. Dallas,
TX: Cooper Institute for Aerobics Research.
Pucher, J., & Dijkstra, L. (2003). Public
health matters. Promoting safe walking
and cycling to improve public health:
Lessons from the Netherlands and
Germany. American Journal of Public
Health, 93, 1509-1516.
Purser, J.L., Weinberger, M., Cohen, H.J.,
Pieper, C.F., Morey, M.C., Li, T., et al.
(2005). Walking speed predicts health
status and hospital costs for frail elderly
male veterans. Journal of Rehabilitation
Research and Development, 42, 535-546.
Quinney, H.A., Gauvin, L., & TedWall, A.E.
(Eds.). (1994). Toward active living: Proceedings of the International Conference
on Physical Activity, Fitness, and Health.
Champaign, IL: Human Kinetics.
Reeve, J. (1996). Motivating others: Nurturing inner motivational resources. Boston:
Allyn and Bacon.
Resnick, B. (1998). Efficacy beliefs in geriatric rehabilitation. Journal of Gerontological Nursing, 24(7), 34-43.
Resnick, B., & Spellbring, A.M. (2000). Understanding what motivates older adults
to exercise. Journal of Gerontological
Nursing, 26(3), 34-42.
Robinson, T., Brooke-Wavell, K., Jones, P.,
Potter, J., & Hardman, A. (1995). Can
activity monitors be used to assess compliance with walking programs in the
elderly? International Journal of Rehabilitation Research, 18, 263-265.
Sallis, J.F., Hovell, M.F., Hofstetter, C.R.,
Elder, J.P., Hackley, M., Caspersen, C.J.,
et al. (1990). Distance between homes
and exercise facilities related to the frequency of exercise among San Diego
residents. Public Health Reports, 105,
179-185.
Schoenfelder, D.P., & Rubenstein, L.M.
(2004). An exercise program to improve
fall-related outcomes in elderly nursing
home residents. Applied Nursing Research, 17, 21-31.
Schwarz, K.A., Bailey, L.B., & Ciarlariello,
J. (2003). Measurement of cardiac func-
Journal of Gerontological Nursing • Vol. 36, No. 11, 2010
tioning in older adults with heart failure
after exercise. Journal of Community
Health Nursing, 20, 109-117.
Shephard, R.J. (1995). Exercise and sudden
death: An overview. Sport Science Review, 4(2), 1-13.
Shephard, R.J. (1999). Readiness for physical
activity. In C.B. Corbin & R.P. Pangrazi
(Eds.), Toward a better understanding of
physical fitness and activity (pp. 3-10).
Scottsdale, AZ: Holcomb Hathaway.
Shephard, R.J., Thomas, S., & Weller, I.
(1991). The Canadian Home Fitness
Test: 1991 update. Sports Medicine, 11,
358-366.
Singh-Manoux, A., Hillsdon, M., Brunner, E., & Marmot, M. (2005). Effects of
physical activity on cognitive functioning in middle age: Evidence from the
Whitehall II Prospective Cohort Study.
American Journal of Public Health, 95,
2252-2258.
Steadman, J., Donaldson, N., & Kalra, L.
(2003). A randomized controlled trial of
an enhanced balance training program to
improve mobility and reduce falls in elderly patients. Journal of the American
Geriatrics Society, 51, 847-852.
Strecher, V.J., DeVellis, B.M., Becker, M.H.,
& Rosenstock, I.M. (1986). The role of
self-efficacy in achieving health behavior
change. Health Education Quarterly, 13,
73-92.
Taylor, L., Whittington, F., Hollingsworth,
C., Ball, M., King, S., Patterson, V., et al.
(2003). Assessing the effectiveness of a
walking program on physical function of
residents living in an assisted living facility. Journal of Community Health Nursing, 20, 15-26.
Taylor, R.S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., et al.
(2004). Exercise-based rehabilitation
for patients with coronary heart disease:
Systematic review and meta-analysis of
randomized controlled trials. American
Journal of Medicine, 116, 682-692.
U.S. Department of Health and Human Services. (1996). Physical activity and health:
A report of the Surgeon General. Retrieved
from the Centers for Disease Control and
Prevention website: http://www.cdc.gov/
nccdphp/sgr/contents.htm
U.S. Department of Health and Human
Services. (1999). Promoting physical activity: A guide for community action.
Champaign, IL: Human Kinetics.
U.S. Department of Health and Human Services. (2000). Healthy People
2010: Understanding and improving
health (2nd ed.). Retrieved from http://
www.healthypeople.gov/Document/
tableofcontents.htm#under
U.S. Department of Transportation, Federal
Highway Administration. (1994). The
17
National Bicycling and Walking Study:
Transportation choices for a changing
America: Final report (Publication No.
FHWA-PD-94-023). Washington, DC:
U.S. Government Printing Office.
Van Den Brink, C.L., Picavet, H., Van Den
Bos, G.A., Giampaoli, S., Nissinen, A., &
Kromhout, D. (2005). Duration and intensity of physical activity and disability
among European elderly men. Disability
& Rehabilitation, 27, 341-347.
Wells, C.L. (1999). Physical activity and
women’s health. In C.B. Corbin & R.P.
Pangrazi (Eds.), Toward a better understanding of physical fitness and activity
(pp. 59-68). Scottsdale, AZ: Holcomb
Hathaway.
White, S.L., & Maloney, S.K. (1990). Promoting healthy diets and active lives to hardto reach groups: Market research study.
Public Health Reports, 105, 224-231.
Whitehead, J.R., & Corbin, C.B. (1991).
Youth fitness testing: The effect of percentile-based evaluative feedback on intrinsic motivation. Research Quarterly
for Exercise and Sport, 62, 225-231.
Williams, B.R., Bezner, J., Chesbro, S.B., &
Leavitt, R. (2005). The effect of a behav-
ioral contract on adherence to a walking program of postmenopausal African
American women. Topics in Geriatric
Rehabilitation, 21, 332-342.
Willich, S.N. (1995). Circadian influences
and possible triggers of sudden cardiac
death. Sport Science Review, 4(2), 31-45.
Wood, R., & Bain, M. (2001). The health and
well-being of older people in Scotland.
Insights from national data. Retrieved
from the NHS Scotland website: http://
www.isdscotland.org/isd/files/older.pdf
Woods, N.F., LaCroix, A.Z., Gray, S.L.,
Aragaki, A., Cochrane, B.B, Brunner,
R.L., et al. (2005). Frailty: Emergence
and consequences in women aged 65
and older in the Women’s Health Initiative Observational Study. Journal of the
American Geriatrics Society, 53, 13211330.
ABOUT THE AUTHORs
Dr. Jitramontree is Assistant
Professor, Faculty of Nursing, Mahidol University, Siriraj, Bangkoknoi,
Bangkok, Thailand, and Dr. Schoenfelder is Associate Clinical Professor
and Editor, John A. Hartford Center
for Geriatric Excellence, The University Iowa College of Nursing, Iowa
City, Iowa.
Guidelines in this series were produced with support provided by grant
P30 NR03979 (PI: Toni Tripp-Reimer, The University of Iowa College
of Nursing), National Institute of
Nursing Research, National Institutes
of Health. Copyright © 2007 The
University of Iowa John A. Hartford
Foundation Center of Geriatric Nursing Excellence.
The author is thankful for suggestions and encouragement from Toni
Tripp-Reimer, PhD, RN, FAAN and
Kenneth Mobily, PhD, as well as support from Deborah Perry Schoenfelder,
PhD, RN, and Lee Southwick.
Address correspondence to
Narirat Jitramontree, PhD, RN,
Assistant Professor, Faculty of Nursing,
Mahidol University, 2 Prannok Road,
Siriraj, Bangkoknoi, Bangkok, Thailand
10700; e-mail: [email protected].
doi:10.3928/00989134-20101001-99