Explore concerns

Many people with health problems - and those without - have reasonable concerns about becoming more active

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1
Ask

“What concerns might you have about becoming more active, if you decided to?”

Saying “if you decided to” reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

For example say ‘Yes, that is a common concern’  or a reflection such as ‘you’re concerned that being more active may make you feel worse’ (said as a statement, not a question)

Your role is to help them feel listened to and understood rather than to immediately jump in to dismiss their concern or to offer information, advice and reassurance.  Acknowledging their views will help them to feel supported and may help them to be more receptive to any new information you might want to share with them.

Allow some space for people to talk about and explore new information, asking ‘what do you think about what I’ve just said?’ rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

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Share

If they mention one of these common concerns, click on it to see a useful response.

I am worried about falling over and getting injured

When starting a new exercise routine, gradually pacing physical activity and including flexibility exercises, resistance exercises and balance exercises reduce these risks. If an individual’s falls risk is high then they may need additional support to start exercising. The advice then is to seek support from appropriately trained staff with experience and expertise of working with individuals with cognitive decline and/or frailty and mobility problems.

I am worried about doing something wrong

The local Age UK or Alzheimer’s Society office may be able to sign-post individuals to local support networks. Walking for exercise is a safe activity and starting with friends or care providers may provide additional support.

I am worried that gym staff will not understand what support I need and will not be able to help me to become more active

Many charitable organizations and community groups are working with public and private organizations to help create supportive environments through training and education where individuals experiencing cognitive decline and dementia can participate safely in physical activity.

Contact Age UK or the Alzheimer’s Society for sign posting to local facilitates.

I do not have the facilities or support I need to be active

Many charitable organizations and community groups are working to increase opportunities of individuals experiencing cognitive decline and dementia to participate in physical activity.

Contact Age UK office or the Alzheimer’s Society for sign posting to local facilitates.

I am worried that increasing my activity or exercising in public might make some of my symptoms worse

Studies promoting physical activity as an intervention for individuals experiencing cognitive decline or dementia do not report a decline in symptoms or significant adverse events from taking part. In the short-term, when starting a new exercise routine there may be an increased risk of falls and musculoskeletal injuries. Gradually pacing physical activity and including flexibility exercises, resistance exercises and balance exercises reduce these risks.

I am worried that encouraging physical activity and exercise may increase risk of wandering and getting lost

Studies promoting physical activity for individuals experiencing cognitive decline and living with dementia do not report increased risk of wandering or behavioral symptoms.

Expert advice suggests discussing emergency planning to prevent getting lost, including emergency contact numbers, and mapping out safe walking routes if appropriate. Alternatively, the advice is to seek opportunity to exercise with supervised support.

I am worried that exercising in public or with strangers might increase anxiety and agitation

Encourage family and caregivers to participate in and share the activity to reduce anxiety and agitation

I am worried that I will experience more pain and physical symptoms from exercising more

Review other medical conditions and optimize management including pain control, blood pressure management and depression management to improve mood.

Tips you may wish to share: 

  1. Some mild discomfort post activity does not mean damage. It is normal for anyone who is not used to exercising to experience some muscle soreness after doing a new exercise, but, over time, this will reduce.
  2. Adequate warm up and cool down of 5- 10 minutes help to minimise pain.
  3. Suggest exercise at the time of day when they are most comfortable.

I am not confident to be active around where I live

Identify where individuals would feel most comfortable being active and explore motivators and barriers to exercise.

Identify what would help increase confidence and if needed refer of appropriate support or sign post to the local Age UK office or the Alzheimer’s Society for more information on local facilitates and potential community support.

I don’t have time!

Finding time to be more active, especially at the beginning, can be a challenge. It is important to remember that exercise and activity are not necessarily the same things, and activities like walking to the bus stop, cycling to work and gardening all count towards health benefits and feeling better. Regular activity can be fitted into an individuals daily routine.

Tips you may wish to share:

  • Start slowly and gradually build up
  • Experiment with different activities
  • Build activity into daily routines – try standing on one foot whilst waiting for the kettle to boil, use a stress ball and squeeze it 10 times during a television advert break
  • Exercise with others – dance with your partner/grandchildren/friends
  • Have fun with it

I don’t enjoy it

The most important thing is to try and make moving more a fun thing to do.  Have you thought of these things that count as moving more –  singing, dancing, sex, games with your grandchildren, gardening, household jobs, shopping?

Tips you may wish to share: 

  1. Make moving more something sociable to do.
  2. Ask if friends or family would like to do things with you – like go to the park

I already feel tired and you want me to do more….

Becoming more active is the most important treatment for persistent fatigue as it helps with body reconditioning and boosts energy levels. It can be a way for individuals to take back some control over their health

Tips you may wish to share:

  • Encourage a slow start with a gradual build up to small bouts of activity (this just needs to be a few minutes). This can increase over time
  • Increase the number of activity sessions first, then increase the duration each activity, followed by the intensity of an activity

My gym said I need medical clearance before being active: am I OK to exercise?

For the vast majority of people, medical clearance is not required to safely undertake progressive, moderate intensity activity. Important exceptions to this are people experiencing active symptoms (see below) or previously inactive people who disregard advice to build up gradually. An additional list of contraindications is listed below [1,2].

Significant events are so rare that medical screening has the potential to be an unnecessary barrier to physical activity. Screening is most effective when focussed on active symptoms and co-morbidity [3].

It is fairly common for gyms to request a medical letter for people to use their facilities. Consider the option of providing a signed letter to overcome this barrier for individuals. Encouraging a slow start with gradual build up of activity (over 3 months or so) reduces the chances of poor outcomes.

This flow diagram will help you decide who might need referral for formal assessment before increasing their physical activity levels and may help address queries from gyms:

Notes

Signs and symptoms, at rest or during activity; includes pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia; intermittent claudication; known heart murmur; or unusual fatigue or shortness of breath with usual activities

  1. An easy way to explain the intensity of exercise is the talk test:
  • Moderate intensity: breathing rate is increased but you can still talk
  • Vigorous intensity: breathing rate is further increased and it is not possible to talk in full sentences

 

  1. Patients with active symptoms or high risk necessitating medical screening will require formal investigations such as cardiac stress testing

Contraindications to physical activity include:

  • Unstable angina
  • Severe valvular stenosis or regurgitation
  • Active myocarditis or pericarditis
  • Ventricular tachycardia (uncontrolled)
  • Decompensated heart failure
  • Blood pressure >200/115 mmHg
  • Recent myocardial infarction (< six weeks)
  • Other clinical entities known to worsen during exercise
  • Acute Systemic infection

References

1) Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.

2) Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3:1-72.

3) Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-7.

How do I know when to stop exercising?

It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new activity and this pain will reduce as they become more accustomed to the activity.  Worsening symptoms may be due to increasing activity too quickly – reducing activity levels a little and then gradually increasing them again more slowly can help

Dizziness, sickness or excessive tiredness are signals to stop exercising and wait for symptoms to settle. Warning signs to seek urgent medical attention include blacking out, chest pain, or excessive shortness of breath.

Tips you may wish to share:

  • Encourage a slow, steady increase in activity to allow for adaptation to the new activity.
  • During the first 2-3 months of increasing physical activity it is sensible to be physically active with other people

I am worried about having a heart attack if I become more active

The risk of dying during physical activity is very low [3, 4]. The risk to health from being inactive far outweighs the risk from regular physical activity.

For the majority of people starting moderate intensity activity, medical screening is not indicated. It is often an unnecessary barrier to physical activity.

Who has increased risk?

  • Habitually sedentary individuals may have unknown cardiovascular disease so should increase physical activity very gradually – suddenly doing vigorous intensity activity may increase risk of myocardial infarction in this inactive group by 100-fold [5]
  • Those with active symptoms such as chest pain, acute breathlessness, palpitations signs of heart failure may have serious underlying pathology and should be referred for specialist investigation [5]

Tips you may wish to share:

  • If starting physical activity for the first time build up very gradually over 3 months
  • Avoid sudden unaccustomed vigorous physical activity. Vigorous activity increases breathing to the level that it makes it hard to complete a sentence

References

Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.

Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361

Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-217.

3
Ask

“Has that helped?”

Did you know?

Start gently and build up slowly

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

  1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.
  2. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.

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