The perspectives of pre-frail and frail older people on being advised about exercise: a qualitative study

The perspectives of pre-frail and frail older people on being advised about exercise: a... Abstract Background Exercise is considered to be the most effective strategy to treat, prevent and delay frailty, a prevalent geriatric syndrome observed in clinical practice. Encouraging frail older people to take up exercise is crucial in the management of this condition. The study aimed to explore pre-frail and frail older peoples’ perspectives in relation to being advised about exercise and their perceptions of the general practitioners’ (GPs) role in promoting exercise for older people. Methods Semi-structured interviews were conducted with 12 community-dwelling older (median age 83 years) participants screened pre-frail or frail using the FRAIL Screen. Their attitudes towards exercise, the advice received, their access to relevant information and their perceptions of the GP’s role in promoting exercise were explored. Thematic analysis was conducted to analyse data. Results The majority of participants had a positive attitude towards exercise, and many participants indicated a preference for being advised firstly by their GPs and then other healthcare professionals. Participants living in the community reported difficulties in accessing information on exercise and indicated that local governments and GP practices should promote exercise for older people more actively. Participants living in retirement villages, however, reported having access to relevant information and being encouraged to participate in exercise. Conclusion This research identified a gap in current practice, demonstrating that GPs, healthcare providers and local governments should promote exercise for older people more actively. Convincing health professionals to encourage regular exercise among their older patients would provide an opportunity to avoid and manage frailty in this population. Exercise, frail elderly, general practitioners, health promotion, perceptions, qualitative research Introduction Exercise is considered to be the most effective strategy for the prevention, treatment and postponement of frailty, a prevalent geriatric syndrome observed in clinical practice (1). Frailty is defined as a ‘clinically recognisable state of increased vulnerability resulting from age-associated decline in reserve and function’ (2). It includes clinical indicators, such as deficit accumulation, fatigue, sedentary behaviour, weight loss and physical function impairment (2,3), and is associated with increased hospitalization, disability, loss of independence and reduced quality of life (4,5). One of the most commonly used frameworks of frailty is the frailty phenotype by Fried et al. (6), which uses a physiological approach to categorize adults into robust (0 indicators), pre-frail (1–2 indicators) and frail (≥3 indicators) based on the accumulation of the following five physical conditions: unintentional weight loss, exhaustion, slow walking speed, weakness and low physical activity. The prevalence of frailty is reported to be 10.7% in community-dwelling older people, and it is estimated that by 2050, 4 million Australians will be either pre-frail or frail (7). Frailty is a dynamic syndrome that is treatable and reversible (8), and a critical component in its treatment is exercise (1). Exercise helps to increase and restore muscle strength and improve the overall physical function. Greater strength and mobility allow for greater independence and an enhanced quality of life (1,8,9). Promoting physical activity programmes for community-dwelling pre-frail and frail older adults and generally encouraging older people to take up exercise are critical in managing frailty (10,11). Although the benefits of exercise are well known, the uptake of exercise in older people is poor (12,13). Barriers to exercise among older people include health issues (e.g. pain), environmental factors (e.g. lack of transportation), lack of knowledge and the lack of physician advice (14). Costello et al. (15) conducted focus groups with 31 independent living, non-frail older adults and confirmed that general practitioners (GPs) play an important role in promoting exercise for older people. However, older adults perceived their exercise conversations with their GPs as inadequate, and it was suggested that healthcare providers, including GPs, should take collective responsibility for encouraging older people to take up exercise. With regard to the frail population, Broderick et al. (2015) investigated the perceptions of 29 frail older adults in order to determine their exercise motivation and behaviour. The study results indicate that family members and social support networks involving friends and peers are critical motivators of exercise activity among frail older people. However, social support networks decline as frailty increases, and family members may not only motivate but also limit frail older people in their physical activities in an effort to protect them (16). Research specifically investigating frail older people’s experiences of being advised about exercise and their opinions regarding who should advise them, and where, is sparse. By better understanding frail older people’s preferred source of exercise advice, researchers can ensure that community-based education and awareness programmes are not only appropriately composed but also that the information is made available through the most appropriate sources. The aims of this study were to (i) understand the perspectives of community-dwelling older people who are pre-frail or frail in relation to being advised about exercise and to (ii) explore their experiences with regard to any advice provided by their GPs. Methods Participants and procedures Participants were recruited from The Queen Elizabeth Hospital (TQEH), the Queen Elizabeth Specialist Centre (QE Specialist Centre) and the Geriatrics Training and Research with Aged Care Centre (G-TRAC Centre) in Adelaide, South Australia, Australia. Potential participants were asked by their TQEH geriatricians (affiliated with the researchers’ department) during a scheduled consult whether they were interested in participating in this study. Interested individuals were then referred to a researcher (ADJ) who provided more information about the study, confirmed interest and performed initial eligibility screening on-site following the consult or over the phone before enrolling them into the study and scheduling an interview. Participants aged 75 years and older, living in the community and screened pre-frail or frail using the FRAIL screen (17), were included in this study. The FRAIL screen represents the Fried frailty phenotype (6) and includes five questions about fatigue, resistance, ambulation, illness and weight loss. It categorizes individuals into pre-frail (1–2 deficits), frail (≥3 deficits) or robust (0 deficit). Participants with a medical history of dementia or who were unable to communicate in English were excluded from the study. Interviews and study questionnaires Semi-structured interviews were held at the Basil Hetzel Institute, an adjacent research centre of TQEH, at the G-TRAC Centre or at the participant’s home, depending on the participant’s preference. ADJ conducted face-to-face interviews with all participants, each lasting approximately 1 h. The interviews included 16 semi-structured questions asking about participants’ previous exercise experiences, their perspectives on receiving advice on exercise, their access to relevant information and their experiences with their GPs. The interviews were audio recorded and transcribed. The transcript of the first interview was reviewed by a member of the research team (JD) to assess ADJ’s interview technique for gathering quality data. Participants’ 5-year mortality risk was determined using the Charlson Comorbidity Index (18), and current physical activity levels were assessed using the Physical Activity Scale for the Elderly (PASE) questionnaire (19). Demographic information, recorded in a separate questionnaire, included age, gender, nationality, education, income level and participation in regular exercise. Data analysis Participants’ characteristics and demographic information were analysed using descriptive statistical methods. The interviews were analysed using thematic analysis (20). ADJ transcribed the audio-recorded interviews, reread the transcripts to ensure familiarity and coded the transcripts line by line using an inductive approach (21). Codes were then collated and categorized into potential themes, gathering all data relevant to each theme before refining the themes and generating clear definitions for each specific theme. The coding framework, the codes and the themes were then discussed with a member of the research team (JD), and a scholarly report of the analysis was prepared (20). NVivo version 10 software was used to manage data analysis. Quotations are provided in this article to support the themes. Data saturation was reached when there was enough information to replicate the study, and new information was not obtained by interviewing additional participants (22). Results Participants’ characteristics Seventeen potential participants were referred to ADJ and screened for eligibility. Three decided not to participate, another felt too unwell and another was neither pre-frail nor frail according to the FRAIL Screen (17). The selected participants provided written informed consent and were advised that participation was voluntary. Twelve participants (eight females and four males) were interviewed. By the ninth interview, data saturation was reached as it was noted that participants’ responses to the interview questions were repetitive. Recruitment was, therefore, ceased after the 12th interview. The median age of the participants was 83 years with a range of 76 to 91 years. Ten participants were pre-frail and two participants were frail. The most common deficits on the FRAIL screen included feeling fatigued (n = 6) and currently having more than five illnesses simultaneously (n = 5). Eleven participants had a low 5-year mortality risk according to the Charlson Comorbidity Index. Six participants reached the current physical activity recommendations for older people according to the PASE questionnaire, considering their age and gender. Demographic data revealed a lower income and a prevalence of men in the non-active group. However, there were no differences in age, education, frailty status and 5-year mortality risk between active and non-active participants (Table 1). Table 1. Participants’ health and demographic characteristics collected during the interviews Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no PASE, Physical Activity Scale for the Elderly. Income per year: low (< $25 000), average ($25 000–$45 000) and high (> $45 000). View Large Table 1. Participants’ health and demographic characteristics collected during the interviews Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no PASE, Physical Activity Scale for the Elderly. Income per year: low (< $25 000), average ($25 000–$45 000) and high (> $45 000). View Large Themes Four themes emerged from the data (Fig. 1): older peoples’ attitudes towards exercise; their difficulties in accessing information on exercise; the crucial role of GPs and healthcare professionals in promoting exercise; and the missing or limited advice on exercise provided by GPs. Figure 1. View largeDownload slide Data analysis and development of themes. Figure 1. View largeDownload slide Data analysis and development of themes. Attitudes, barriers and enablers of exercise The majority of participants (10 of 12) reported a positive attitude towards exercise and physical activity programmes, commenting on the importance of exercise and its benefits in older age, irrespective of their physical activity status (PASE). Being physically active in the past did not correlate with participants’ attitudes towards exercise reported during the interviews. Participants perceived multiple barriers to participation in exercise. These included family commitments (especially for women whose role as carer may override self-care, hobbies or other activities), physical limitations (pain and illness), transportation and seasonal climate (cold weather and darkness common during winter months in South Australia). We just couldn’t cope with the cold and both of us stopped exercising and got stuck inside. (#10) Enablers for exercise included exercising with their partner, social aspects and rehabilitation or healthcare services, such as physiotherapy after hip replacement, where participants recognized the benefits of exercise in the form of improvements in physical function and mobility. I was in hospital (hip operation) and then I went to rehabilitation. I had physiotherapy there every day. I really should have started those exercises straight away. (#4) With regard to enjoyable and preferred aspects of physical activity programmes, participants reported a preference for smaller classes with a variety of gentle, but challenging and beneficial, exercises tailored for their individual health, including strength and balance tasks. Half of the participants (6 out of 12) were engaged in regular exercise, participating in a structured exercise programme. Access to information on exercise and physical activity programmes Both active and non-active participants living in the community felt that information relating to opportunities for exercise in the community was insufficient. They suggested that the local government should be more engaged in promoting physical activity programmes for older people. The government should send out brochures to older people. They should get something in every suburb, like through the council. (#8) I don’t see any advertisement (for exercise or physical activity programs) […] and I have been to the local library and places like that […], but I’ve never seen something […]. I just don’t know where to get information. (#6) All participants living in retirement villages (3 out of 12) revealed that they had greater access to exercise information and physical activity programmes due to the services provided in their villages. Before I came here (retirement village) I had no idea where to go, I had no idea that people even went to exercise classes; you’ve never heard of it. (#12) The majority of participants (9 out of 12) preferred brochures with information, including the health benefits of exercise in older age and available physical activity programmes in the community. They also commented on their preference for personal advice from someone with a positive attitude. Role of GPs and healthcare professionals in promoting exercise Healthcare professionals appear to play a key role in the promotion of exercise for older people, especially when patients receive healthcare services like physiotherapy or rehabilitation. Five participants reported that they received information on exercise opportunities during these services, and four of these participants continued with exercise after completing their treatment. I had physiotherapy [. . . ] and he gave me some exercises [. . . ] which I still do. And they (rehabilitation centre) said there are also other exercise classes you can get involved if you like. (#8) However, half of the participants (6 out of 12) indicated a preference for being advised on exercise initially by their GPs as they see them regularly, and the GP is aware of their medical conditions and is the primary referrer to healthcare services. Initially the doctor as he knows in what condition you are and what you are able to do. (#5) At first point I would have thought [. . .], it is our GP. Older people go to see their physicians naturally. So it is first the GP. (#10) Family members were also reported to have significant influence. My daughter, she was the one that encouraged me to go to Pilates. (#4) Three participants did not nominate a particular individual as the most important adviser, instead, stating that ‘someone who knows about it’ should advise them about exercise, two participants stated that healthcare professionals should advise initially and one participant did not answer the question. Active participants did not differ from non-active participants in their opinions as to who should advise them on exercise. Advice on exercise provided by GPs Even though participants perceived that GPs play a key role in promoting exercise for older people, the majority of participants (11 out of 12; both active and non-active) reported no (n = 6) or only limited (n = 5) recollection of exercise advice being provided during consults. Advice was defined as limited if the GP suggested walking without giving detailed information on the frequency, duration or intensity, or did not refer the individual to healthcare professionals or available physical activity programmes. However, participants consistently expressed faith in their GPs and said that they would appreciate and follow their advice on exercise. I would do it (exercise) if my GP would say it. (#1) When the GP would say do this or this (exercises), yes, I would dare it. (#5) Participants also suggested that GPs should promote exercise and physical activity programmes more actively. If the doctor would have something to hand to you. A notice of who to see and what you could do (#5). One participant received information from his/her GP after taking the initiative and asking about available physical activity programmes. I want to go to an exercise class, do you know any where? And he said, yes I do, you are going to need my referral […]. They are very good, they have classes for falls and balance and all that kind of stuff, and strength. So I went down there for quite a few years. (#12) Discussion Three key findings emerged from this study. Firstly, data analysis indicated that pre-frail and frail older people had mostly positive attitudes towards exercise, irrespective of their current physical activity status. Secondly, half of the participants indicated a preference for being advised on exercise initially by their GPs, but only one participant could recollect getting advice. Thirdly, participants received information on exercise and available physical activity programmes mainly through allied healthcare services (i.e. physiotherapy and rehabilitation) and their retirement villages, while participants living outside of retirement villages or those not receiving any allied health services reported a lack of exposure to exercise and available physical activity programmes. The important role of retirement villages in successfully encouraging physical activity among older adults emerged as an unexpected finding. The mostly positive attitudes towards exercise among the pre-frail and frail older adults reported in this study are consistent with findings in other studies showing that older adults hold positive attitudes towards exercise (23–25). However, findings that report negative attitudes towards exercise among inactive older adults were not supported by this study as most of the inactive participants also reported positive attitudes (24–26). These findings might be due to participants who have a more positive attitude being more likely to consent to an interview about exercise. This bias has been reported previously, for example by Rich and Rogers (25), who used a survey to examine older adults’ attitudes towards exercise and mainly received responses from adults who were likely to exercise. However, the positive attitudes of non-exercisers provide an opportunity to coax more pre-frail and frail older people into physical activity. Attitudes towards GPs confirmed the results of other studies that have noted that older adults are more likely to accept health advice from GPs compared with any other age group (27). Older adults tend to be in regular contact with their GPs, who are not only aware of their medical conditions and limitations but also the primary referrers to healthcare services (13–15). The fact that half of the participants indicated a preference for being advised about exercise firstly by their GPs underlines the important role that GPs play. GPs should capitalize on older people’s positive attitudes towards exercise and their readiness to follow their advice by promoting exercise and available physical activity programmes more actively, especially among those who do not receive any therapy services. A shared decision-making mode where GPs collaborate with patients on treatment options and exercise strategies should be the ultimate goal rather than being paternalistic by merely telling patients what to do (28). However, exercise advice provided by physicians is reported to be rare (29) and not specific (9), which aligns with the findings of this study where only one participant recollected receiving adequate information on exercise and being referred to an exercise programme. It is suggested that specific advice, including the type, frequency, intensity and duration of exercise, can lead to a greater increase in physical activity among older people than general advice with no specifics on where to go and what to do (30). Education and awareness programmes tailored to GPs could be introduced to inform and encourage them to advise their older patients about available physical activity programmes or to refer patients to allied healthcare experts more frequently, as a lack of knowledge is reported to be the main reason why GPs do not advise their patients about exercise (31). The Enhanced Primary Care Program (currently active in Australia), for example, allows supported referrals to exercise physiologists and represents a unique opportunity to tackle frailty. Difficulty in accessing information on exercise for older people has been reported previously, as well as the need for healthcare providers and local communities to promote exercise for older people more actively (32). This study underlines this need and has identified clearly the difficulty in accessing information related to exercise and available physical activity programmes for community-dwelling pre-frail and frail older people living outside of retirement villages. Data from this study revealed that retirement villages and their associated services appear more successful in promoting exercise, as all of the participants in this study who were living in a retirement village received information on exercise and available physical activity programmes. There might be a health promotion strategy to be learnt from the retirement villages which local governments could use to integrate pre-frail and frail older people into community-based physical activity programmes. Furthermore, since brochures related to exercise and physical activity programmes were recorded as being the most popular source of information by participants in this study, local communities could strategically send out brochures to their older residents to promote available physical activity programmes and encourage participation. Healthcare services also play a crucial role in encouraging older people to take up exercise as evidenced by the comments from participants in this study. These tertiary services provided information about available physical activity programmes, and the majority (four out of five participants) continued with exercise after treatment. Healthcare services, like physiotherapy, could therefore be seen as an opportunity to introduce pre-frail and frail older people to physical activity programmes, as it has been reported before that rehabilitation or exercise programmes in a recovery setting impact positively on older people’s exercise beliefs (16). Limitations and future studies Recruiting community-dwelling frail older people to the study at the time of a geriatric consultation proved difficult due to the presence of severe medical conditions resulting in participants feeling too fatigued to be interviewed and declined to participate. This resulted in the recruitment of mostly pre-frail older adults, with the majority (9 out of 12) scoring only one deficit on the FRAIL Screen. The fact that participants were recruited from geriatric clinics only, were mostly pre-frail, were English speaking and had an average level of education limits the generalizability of the study results. Including more frail older adults with different cultural and educational backgrounds may have led to more diverse opinions in relation to exercise and being advised about exercise. Regarding sample size and data saturation, the sample size of qualitative studies depends more on the data in terms of richness and thickness rather than on the sample size (22). Twelve participants were sufficient as data saturation was reached after interviewing the ninth participant. Furthermore, half of the participants were active (PASE), despite being pre-frail or frail, suggesting that additional tools are required to identify pre-frail and frail older adults. The fact that our recruitment method was successful in recruiting pre-frail but not frail participants requires reflection, and future studies should allow more time and resources for recruitment, target more frail individuals (with scores of ≥2 on the FRAIL Screen) and explore why GPs are reluctant to give advice or refer patients to exercise programmes. Conclusion The results of this study suggest that GPs should capitalize on older people’s positive attitudes towards exercise and their readiness to follow the GP’s advice by promoting exercise and available physical activity programmes more actively. Additionally, tertiary healthcare services, like rehabilitation and therapy services, should also be seen as an opportunity where pre-frail and frail older people could be linked long term into exercise programmes. Retirement villages with health promotion strategies are a resource from which the wider community can learn. Further research into health promotion strategies used in retirement villages would be of interest, as well as to explore why GPs are reluctant to give advice or refer patients to exercise programmes. The findings suggest that to facilitate exercise in pre-frail and frail older people further effort to inform and promote exercise is vital. Declaration Funding: ADJ is a recipient of the Beacon PhD Scholarship from the University of Adelaide Ethics: This study received ethics approval from the University of Adelaide Human Research Ethics Committee (HREC reference number H-2015–161). Conflict of interest: The authors report no conflict of interests. References 1. Clegg A , Young J , Iliffe S et al. Frailty in elderly people . Lancet 2013 ; 381 : 752 – 62 . Google Scholar CrossRef Search ADS PubMed 2. Xue QL . The frailty syndrome: definition and natural history . Clin Geriatr Med 2011 ; 27 : 1 – 15 . Google Scholar CrossRef Search ADS PubMed 3. Cesari M , Landi F , Vellas B et al. Sarcopenia and physical frailty: two sides of the same coin . Front Aging Neurosci 2014 ; 6 : 192 . Google Scholar PubMed 4. Clark BC , Manini TM . Functional consequences of sarcopenia and dynapenia in the elderly . Curr Opin Clin Nutr Metab Care 2010 ; 13 : 271 – 6 . Google Scholar CrossRef Search ADS PubMed 5. Weiss CO . 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The perspectives of pre-frail and frail older people on being advised about exercise: a qualitative study

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Abstract

Abstract Background Exercise is considered to be the most effective strategy to treat, prevent and delay frailty, a prevalent geriatric syndrome observed in clinical practice. Encouraging frail older people to take up exercise is crucial in the management of this condition. The study aimed to explore pre-frail and frail older peoples’ perspectives in relation to being advised about exercise and their perceptions of the general practitioners’ (GPs) role in promoting exercise for older people. Methods Semi-structured interviews were conducted with 12 community-dwelling older (median age 83 years) participants screened pre-frail or frail using the FRAIL Screen. Their attitudes towards exercise, the advice received, their access to relevant information and their perceptions of the GP’s role in promoting exercise were explored. Thematic analysis was conducted to analyse data. Results The majority of participants had a positive attitude towards exercise, and many participants indicated a preference for being advised firstly by their GPs and then other healthcare professionals. Participants living in the community reported difficulties in accessing information on exercise and indicated that local governments and GP practices should promote exercise for older people more actively. Participants living in retirement villages, however, reported having access to relevant information and being encouraged to participate in exercise. Conclusion This research identified a gap in current practice, demonstrating that GPs, healthcare providers and local governments should promote exercise for older people more actively. Convincing health professionals to encourage regular exercise among their older patients would provide an opportunity to avoid and manage frailty in this population. Exercise, frail elderly, general practitioners, health promotion, perceptions, qualitative research Introduction Exercise is considered to be the most effective strategy for the prevention, treatment and postponement of frailty, a prevalent geriatric syndrome observed in clinical practice (1). Frailty is defined as a ‘clinically recognisable state of increased vulnerability resulting from age-associated decline in reserve and function’ (2). It includes clinical indicators, such as deficit accumulation, fatigue, sedentary behaviour, weight loss and physical function impairment (2,3), and is associated with increased hospitalization, disability, loss of independence and reduced quality of life (4,5). One of the most commonly used frameworks of frailty is the frailty phenotype by Fried et al. (6), which uses a physiological approach to categorize adults into robust (0 indicators), pre-frail (1–2 indicators) and frail (≥3 indicators) based on the accumulation of the following five physical conditions: unintentional weight loss, exhaustion, slow walking speed, weakness and low physical activity. The prevalence of frailty is reported to be 10.7% in community-dwelling older people, and it is estimated that by 2050, 4 million Australians will be either pre-frail or frail (7). Frailty is a dynamic syndrome that is treatable and reversible (8), and a critical component in its treatment is exercise (1). Exercise helps to increase and restore muscle strength and improve the overall physical function. Greater strength and mobility allow for greater independence and an enhanced quality of life (1,8,9). Promoting physical activity programmes for community-dwelling pre-frail and frail older adults and generally encouraging older people to take up exercise are critical in managing frailty (10,11). Although the benefits of exercise are well known, the uptake of exercise in older people is poor (12,13). Barriers to exercise among older people include health issues (e.g. pain), environmental factors (e.g. lack of transportation), lack of knowledge and the lack of physician advice (14). Costello et al. (15) conducted focus groups with 31 independent living, non-frail older adults and confirmed that general practitioners (GPs) play an important role in promoting exercise for older people. However, older adults perceived their exercise conversations with their GPs as inadequate, and it was suggested that healthcare providers, including GPs, should take collective responsibility for encouraging older people to take up exercise. With regard to the frail population, Broderick et al. (2015) investigated the perceptions of 29 frail older adults in order to determine their exercise motivation and behaviour. The study results indicate that family members and social support networks involving friends and peers are critical motivators of exercise activity among frail older people. However, social support networks decline as frailty increases, and family members may not only motivate but also limit frail older people in their physical activities in an effort to protect them (16). Research specifically investigating frail older people’s experiences of being advised about exercise and their opinions regarding who should advise them, and where, is sparse. By better understanding frail older people’s preferred source of exercise advice, researchers can ensure that community-based education and awareness programmes are not only appropriately composed but also that the information is made available through the most appropriate sources. The aims of this study were to (i) understand the perspectives of community-dwelling older people who are pre-frail or frail in relation to being advised about exercise and to (ii) explore their experiences with regard to any advice provided by their GPs. Methods Participants and procedures Participants were recruited from The Queen Elizabeth Hospital (TQEH), the Queen Elizabeth Specialist Centre (QE Specialist Centre) and the Geriatrics Training and Research with Aged Care Centre (G-TRAC Centre) in Adelaide, South Australia, Australia. Potential participants were asked by their TQEH geriatricians (affiliated with the researchers’ department) during a scheduled consult whether they were interested in participating in this study. Interested individuals were then referred to a researcher (ADJ) who provided more information about the study, confirmed interest and performed initial eligibility screening on-site following the consult or over the phone before enrolling them into the study and scheduling an interview. Participants aged 75 years and older, living in the community and screened pre-frail or frail using the FRAIL screen (17), were included in this study. The FRAIL screen represents the Fried frailty phenotype (6) and includes five questions about fatigue, resistance, ambulation, illness and weight loss. It categorizes individuals into pre-frail (1–2 deficits), frail (≥3 deficits) or robust (0 deficit). Participants with a medical history of dementia or who were unable to communicate in English were excluded from the study. Interviews and study questionnaires Semi-structured interviews were held at the Basil Hetzel Institute, an adjacent research centre of TQEH, at the G-TRAC Centre or at the participant’s home, depending on the participant’s preference. ADJ conducted face-to-face interviews with all participants, each lasting approximately 1 h. The interviews included 16 semi-structured questions asking about participants’ previous exercise experiences, their perspectives on receiving advice on exercise, their access to relevant information and their experiences with their GPs. The interviews were audio recorded and transcribed. The transcript of the first interview was reviewed by a member of the research team (JD) to assess ADJ’s interview technique for gathering quality data. Participants’ 5-year mortality risk was determined using the Charlson Comorbidity Index (18), and current physical activity levels were assessed using the Physical Activity Scale for the Elderly (PASE) questionnaire (19). Demographic information, recorded in a separate questionnaire, included age, gender, nationality, education, income level and participation in regular exercise. Data analysis Participants’ characteristics and demographic information were analysed using descriptive statistical methods. The interviews were analysed using thematic analysis (20). ADJ transcribed the audio-recorded interviews, reread the transcripts to ensure familiarity and coded the transcripts line by line using an inductive approach (21). Codes were then collated and categorized into potential themes, gathering all data relevant to each theme before refining the themes and generating clear definitions for each specific theme. The coding framework, the codes and the themes were then discussed with a member of the research team (JD), and a scholarly report of the analysis was prepared (20). NVivo version 10 software was used to manage data analysis. Quotations are provided in this article to support the themes. Data saturation was reached when there was enough information to replicate the study, and new information was not obtained by interviewing additional participants (22). Results Participants’ characteristics Seventeen potential participants were referred to ADJ and screened for eligibility. Three decided not to participate, another felt too unwell and another was neither pre-frail nor frail according to the FRAIL Screen (17). The selected participants provided written informed consent and were advised that participation was voluntary. Twelve participants (eight females and four males) were interviewed. By the ninth interview, data saturation was reached as it was noted that participants’ responses to the interview questions were repetitive. Recruitment was, therefore, ceased after the 12th interview. The median age of the participants was 83 years with a range of 76 to 91 years. Ten participants were pre-frail and two participants were frail. The most common deficits on the FRAIL screen included feeling fatigued (n = 6) and currently having more than five illnesses simultaneously (n = 5). Eleven participants had a low 5-year mortality risk according to the Charlson Comorbidity Index. Six participants reached the current physical activity recommendations for older people according to the PASE questionnaire, considering their age and gender. Demographic data revealed a lower income and a prevalence of men in the non-active group. However, there were no differences in age, education, frailty status and 5-year mortality risk between active and non-active participants (Table 1). Table 1. Participants’ health and demographic characteristics collected during the interviews Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no PASE, Physical Activity Scale for the Elderly. Income per year: low (< $25 000), average ($25 000–$45 000) and high (> $45 000). View Large Table 1. Participants’ health and demographic characteristics collected during the interviews Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no Characteristic Total participants (n = 12) Active participants; PASE (n = 6) Non-active participants; PASE (n = 6) Age (median) 83 (range 76–91 years) 83 (range 76–91 years) 83 (range 76–90 years) Gender 8 females; 4 males 5 females; 1 male 3 females; 3 males FRAIL Screen 10 pre-frail; 2 frail 5 pre-frail; 1 frail 5 pre-frail; 1 frail Charlson Comorbidity Index 11 low 5-year mortality risk; 1 high 5-year mortality risk 6 low 5-year mortality risk; 0 high 5-year mortality risk 5 low 5-year mortality risk; 1 high 5-year mortality risk Income 8 low; 3 average; 1 high 3 low; 2 average; 1 high 5 low; 1 average; 0 high Highest education 2 primary school; 5 secondary school; 4 technical college; 1 university 0 primary school; 4 secondary school; 2 technical college; 0 university 2 primary school; 1 secondary school; 2 technical college; 1 university Nationality 8 Australian; 3 European; 1 Asian 5 Australian; 1 European; 0 Asian 3 Australian; 2 European; 1 Asian Participation in exercise programme 6 yes; 6 no 5 yes; 1 no 1 yes; 5 no PASE, Physical Activity Scale for the Elderly. Income per year: low (< $25 000), average ($25 000–$45 000) and high (> $45 000). View Large Themes Four themes emerged from the data (Fig. 1): older peoples’ attitudes towards exercise; their difficulties in accessing information on exercise; the crucial role of GPs and healthcare professionals in promoting exercise; and the missing or limited advice on exercise provided by GPs. Figure 1. View largeDownload slide Data analysis and development of themes. Figure 1. View largeDownload slide Data analysis and development of themes. Attitudes, barriers and enablers of exercise The majority of participants (10 of 12) reported a positive attitude towards exercise and physical activity programmes, commenting on the importance of exercise and its benefits in older age, irrespective of their physical activity status (PASE). Being physically active in the past did not correlate with participants’ attitudes towards exercise reported during the interviews. Participants perceived multiple barriers to participation in exercise. These included family commitments (especially for women whose role as carer may override self-care, hobbies or other activities), physical limitations (pain and illness), transportation and seasonal climate (cold weather and darkness common during winter months in South Australia). We just couldn’t cope with the cold and both of us stopped exercising and got stuck inside. (#10) Enablers for exercise included exercising with their partner, social aspects and rehabilitation or healthcare services, such as physiotherapy after hip replacement, where participants recognized the benefits of exercise in the form of improvements in physical function and mobility. I was in hospital (hip operation) and then I went to rehabilitation. I had physiotherapy there every day. I really should have started those exercises straight away. (#4) With regard to enjoyable and preferred aspects of physical activity programmes, participants reported a preference for smaller classes with a variety of gentle, but challenging and beneficial, exercises tailored for their individual health, including strength and balance tasks. Half of the participants (6 out of 12) were engaged in regular exercise, participating in a structured exercise programme. Access to information on exercise and physical activity programmes Both active and non-active participants living in the community felt that information relating to opportunities for exercise in the community was insufficient. They suggested that the local government should be more engaged in promoting physical activity programmes for older people. The government should send out brochures to older people. They should get something in every suburb, like through the council. (#8) I don’t see any advertisement (for exercise or physical activity programs) […] and I have been to the local library and places like that […], but I’ve never seen something […]. I just don’t know where to get information. (#6) All participants living in retirement villages (3 out of 12) revealed that they had greater access to exercise information and physical activity programmes due to the services provided in their villages. Before I came here (retirement village) I had no idea where to go, I had no idea that people even went to exercise classes; you’ve never heard of it. (#12) The majority of participants (9 out of 12) preferred brochures with information, including the health benefits of exercise in older age and available physical activity programmes in the community. They also commented on their preference for personal advice from someone with a positive attitude. Role of GPs and healthcare professionals in promoting exercise Healthcare professionals appear to play a key role in the promotion of exercise for older people, especially when patients receive healthcare services like physiotherapy or rehabilitation. Five participants reported that they received information on exercise opportunities during these services, and four of these participants continued with exercise after completing their treatment. I had physiotherapy [. . . ] and he gave me some exercises [. . . ] which I still do. And they (rehabilitation centre) said there are also other exercise classes you can get involved if you like. (#8) However, half of the participants (6 out of 12) indicated a preference for being advised on exercise initially by their GPs as they see them regularly, and the GP is aware of their medical conditions and is the primary referrer to healthcare services. Initially the doctor as he knows in what condition you are and what you are able to do. (#5) At first point I would have thought [. . .], it is our GP. Older people go to see their physicians naturally. So it is first the GP. (#10) Family members were also reported to have significant influence. My daughter, she was the one that encouraged me to go to Pilates. (#4) Three participants did not nominate a particular individual as the most important adviser, instead, stating that ‘someone who knows about it’ should advise them about exercise, two participants stated that healthcare professionals should advise initially and one participant did not answer the question. Active participants did not differ from non-active participants in their opinions as to who should advise them on exercise. Advice on exercise provided by GPs Even though participants perceived that GPs play a key role in promoting exercise for older people, the majority of participants (11 out of 12; both active and non-active) reported no (n = 6) or only limited (n = 5) recollection of exercise advice being provided during consults. Advice was defined as limited if the GP suggested walking without giving detailed information on the frequency, duration or intensity, or did not refer the individual to healthcare professionals or available physical activity programmes. However, participants consistently expressed faith in their GPs and said that they would appreciate and follow their advice on exercise. I would do it (exercise) if my GP would say it. (#1) When the GP would say do this or this (exercises), yes, I would dare it. (#5) Participants also suggested that GPs should promote exercise and physical activity programmes more actively. If the doctor would have something to hand to you. A notice of who to see and what you could do (#5). One participant received information from his/her GP after taking the initiative and asking about available physical activity programmes. I want to go to an exercise class, do you know any where? And he said, yes I do, you are going to need my referral […]. They are very good, they have classes for falls and balance and all that kind of stuff, and strength. So I went down there for quite a few years. (#12) Discussion Three key findings emerged from this study. Firstly, data analysis indicated that pre-frail and frail older people had mostly positive attitudes towards exercise, irrespective of their current physical activity status. Secondly, half of the participants indicated a preference for being advised on exercise initially by their GPs, but only one participant could recollect getting advice. Thirdly, participants received information on exercise and available physical activity programmes mainly through allied healthcare services (i.e. physiotherapy and rehabilitation) and their retirement villages, while participants living outside of retirement villages or those not receiving any allied health services reported a lack of exposure to exercise and available physical activity programmes. The important role of retirement villages in successfully encouraging physical activity among older adults emerged as an unexpected finding. The mostly positive attitudes towards exercise among the pre-frail and frail older adults reported in this study are consistent with findings in other studies showing that older adults hold positive attitudes towards exercise (23–25). However, findings that report negative attitudes towards exercise among inactive older adults were not supported by this study as most of the inactive participants also reported positive attitudes (24–26). These findings might be due to participants who have a more positive attitude being more likely to consent to an interview about exercise. This bias has been reported previously, for example by Rich and Rogers (25), who used a survey to examine older adults’ attitudes towards exercise and mainly received responses from adults who were likely to exercise. However, the positive attitudes of non-exercisers provide an opportunity to coax more pre-frail and frail older people into physical activity. Attitudes towards GPs confirmed the results of other studies that have noted that older adults are more likely to accept health advice from GPs compared with any other age group (27). Older adults tend to be in regular contact with their GPs, who are not only aware of their medical conditions and limitations but also the primary referrers to healthcare services (13–15). The fact that half of the participants indicated a preference for being advised about exercise firstly by their GPs underlines the important role that GPs play. GPs should capitalize on older people’s positive attitudes towards exercise and their readiness to follow their advice by promoting exercise and available physical activity programmes more actively, especially among those who do not receive any therapy services. A shared decision-making mode where GPs collaborate with patients on treatment options and exercise strategies should be the ultimate goal rather than being paternalistic by merely telling patients what to do (28). However, exercise advice provided by physicians is reported to be rare (29) and not specific (9), which aligns with the findings of this study where only one participant recollected receiving adequate information on exercise and being referred to an exercise programme. It is suggested that specific advice, including the type, frequency, intensity and duration of exercise, can lead to a greater increase in physical activity among older people than general advice with no specifics on where to go and what to do (30). Education and awareness programmes tailored to GPs could be introduced to inform and encourage them to advise their older patients about available physical activity programmes or to refer patients to allied healthcare experts more frequently, as a lack of knowledge is reported to be the main reason why GPs do not advise their patients about exercise (31). The Enhanced Primary Care Program (currently active in Australia), for example, allows supported referrals to exercise physiologists and represents a unique opportunity to tackle frailty. Difficulty in accessing information on exercise for older people has been reported previously, as well as the need for healthcare providers and local communities to promote exercise for older people more actively (32). This study underlines this need and has identified clearly the difficulty in accessing information related to exercise and available physical activity programmes for community-dwelling pre-frail and frail older people living outside of retirement villages. Data from this study revealed that retirement villages and their associated services appear more successful in promoting exercise, as all of the participants in this study who were living in a retirement village received information on exercise and available physical activity programmes. There might be a health promotion strategy to be learnt from the retirement villages which local governments could use to integrate pre-frail and frail older people into community-based physical activity programmes. Furthermore, since brochures related to exercise and physical activity programmes were recorded as being the most popular source of information by participants in this study, local communities could strategically send out brochures to their older residents to promote available physical activity programmes and encourage participation. Healthcare services also play a crucial role in encouraging older people to take up exercise as evidenced by the comments from participants in this study. These tertiary services provided information about available physical activity programmes, and the majority (four out of five participants) continued with exercise after treatment. Healthcare services, like physiotherapy, could therefore be seen as an opportunity to introduce pre-frail and frail older people to physical activity programmes, as it has been reported before that rehabilitation or exercise programmes in a recovery setting impact positively on older people’s exercise beliefs (16). Limitations and future studies Recruiting community-dwelling frail older people to the study at the time of a geriatric consultation proved difficult due to the presence of severe medical conditions resulting in participants feeling too fatigued to be interviewed and declined to participate. This resulted in the recruitment of mostly pre-frail older adults, with the majority (9 out of 12) scoring only one deficit on the FRAIL Screen. The fact that participants were recruited from geriatric clinics only, were mostly pre-frail, were English speaking and had an average level of education limits the generalizability of the study results. Including more frail older adults with different cultural and educational backgrounds may have led to more diverse opinions in relation to exercise and being advised about exercise. Regarding sample size and data saturation, the sample size of qualitative studies depends more on the data in terms of richness and thickness rather than on the sample size (22). Twelve participants were sufficient as data saturation was reached after interviewing the ninth participant. Furthermore, half of the participants were active (PASE), despite being pre-frail or frail, suggesting that additional tools are required to identify pre-frail and frail older adults. The fact that our recruitment method was successful in recruiting pre-frail but not frail participants requires reflection, and future studies should allow more time and resources for recruitment, target more frail individuals (with scores of ≥2 on the FRAIL Screen) and explore why GPs are reluctant to give advice or refer patients to exercise programmes. Conclusion The results of this study suggest that GPs should capitalize on older people’s positive attitudes towards exercise and their readiness to follow the GP’s advice by promoting exercise and available physical activity programmes more actively. Additionally, tertiary healthcare services, like rehabilitation and therapy services, should also be seen as an opportunity where pre-frail and frail older people could be linked long term into exercise programmes. Retirement villages with health promotion strategies are a resource from which the wider community can learn. Further research into health promotion strategies used in retirement villages would be of interest, as well as to explore why GPs are reluctant to give advice or refer patients to exercise programmes. The findings suggest that to facilitate exercise in pre-frail and frail older people further effort to inform and promote exercise is vital. Declaration Funding: ADJ is a recipient of the Beacon PhD Scholarship from the University of Adelaide Ethics: This study received ethics approval from the University of Adelaide Human Research Ethics Committee (HREC reference number H-2015–161). Conflict of interest: The authors report no conflict of interests. References 1. Clegg A , Young J , Iliffe S et al. Frailty in elderly people . Lancet 2013 ; 381 : 752 – 62 . Google Scholar CrossRef Search ADS PubMed 2. Xue QL . The frailty syndrome: definition and natural history . Clin Geriatr Med 2011 ; 27 : 1 – 15 . Google Scholar CrossRef Search ADS PubMed 3. Cesari M , Landi F , Vellas B et al. Sarcopenia and physical frailty: two sides of the same coin . Front Aging Neurosci 2014 ; 6 : 192 . Google Scholar PubMed 4. Clark BC , Manini TM . Functional consequences of sarcopenia and dynapenia in the elderly . Curr Opin Clin Nutr Metab Care 2010 ; 13 : 271 – 6 . Google Scholar CrossRef Search ADS PubMed 5. Weiss CO . 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Family PracticeOxford University Press

Published: Nov 14, 2017

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