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Preventive Medicine 39 (2004) 1056 – 1061

www.elsevier.com/locate/ypmed

Review
Barriers and motivations to exercise in older adults
Karen A. Schutzer, R.N., M.S. a,* and B. Sue Graves, Ed. D. b,1
a
Florida Atlantic University, Davie, FL 33314, USA
b
Department of Exercise Science and Health Promotion, Florida Atlantic University, Davie, FL 33314, USA

Available online 11 June 2004

Abstract

Although exercise is an established component in the management of many chronic diseases associated with aging, activity levels tend to
progressively decline with increasing age. Given the growing proportion of older adults, these suboptimal levels of physical activity represent
an increasing public health problem. The predicators of adherence elucidated in younger adults are unreliable in elderly populations. Age-
specific barriers and motivators unique to this cohort are relevant and must be acknowledged. The identification of reliable predictors of
exercise adherence will allow healthcare providers to effectively intervene and change patterns of physical activity in sedentary elderly. In
particular, because older patients respect their physician’s advice and have regular contact with their family doctor, physicians can play a key
and pivotal role in the initiation and maintenance of exercise behavior among the older population.
D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Keywords: Elderly; Aging; Exercise adherence; Physical activity

Introduction Trends in physical activity consistently show that activity


levels progressively decrease with age. The prevalence of
In 1996, the Surgeon General’s Report on Physical inactivity is highest among adults aged 65 or greater [1],
Activity and Health established the importance of a phys- which due to aging baby boomers will shortly become the
ically active lifestyle in the prevention of chronic disease fastest growing segment of the American population. Cur-
and the promotion of health and well being [1]. The report rent estimates indicate that 66% of adults over 75 do not
linked sedentary behavior to osteoporosis, obesity, depres- engage in any regular physical activity [3]. Moreover,
sion, and to the staggering death rates from coronary heart evidence suggests that 50% of sedentary adults have no
disease, type 2 diabetes, and colon cancer. Participation plan of starting an exercise program [4]. Among those
and maintenance of regular physical activity was recog- engaged in physical activity, adherence rates reveal only
nized as one of the most important health behaviors in 30% of older men and 15% of older women actually
preventing the onset or reducing the severity of many participate in regular sustained activity [1].
chronic diseases. Given the growing proportion of older adults, the sub-
Yet, despite documentation of the physical and psycho- optimal levels of physical activity in the United States
logical benefits derived from regular activity, surveys con- represent an increasing public-health problem. This predic-
clude more than 60% of the adult population is not engaged ament will continue to increase as the growth of the over 65
in physical activity on a regular basis and 31% of adults are age group is expected to increase by 29.7– 36.4% between
not exercising at all [1]. In the United States, the annual the years 2010 and 2020 when the large cohort of baby
number of deaths related to physical inactivity is estimated boomers reach retirement age [5]. Although an increased
at more than 250,000 [2]. vulnerability to chronic disease and disability is inherent in
the aging process, evidence suggests being physically active
may alter the course of many frequently occurring diseases
* Corresponding author. Florida Atlantic University, 2912 College among the elderly. Not only has regular exercise been
Ave., Davie, FL 33314. Fax: +1-267-989-4938.
E-mail addresses: karenschutzer@hotmail.com (K.A. Schutzer),
specifically reported to reduce the risk factors associated
sgraves@fau.edu (B.S. Graves). with heart disease and stroke, exercise is also an important
1
Fax: +1-954-236-1259. factor in reducing overall morbidity and mortality [6]. In

0091-7435/$ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2004.04.003
K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061 1057

addition, an active lifestyle helps to increase the quality of populations. There does not appear to be a one-size-fits-all
life of older adults by preserving functional ability and approach to physical activity [10]. Unique challenges are
independence across the life span. associated with initiating and maintaining physical activity
Physical activity has been defined as any bodily move- in the elderly.
ment produced by skeletal muscles which results in energy First, as Chao et al. [10] point out, many elderly deem the
expenditure [7]. Moderate physical activity performed at 3 adoption of moderate physical activity as time consuming.
to 6 METS (equivalent to brisk walking at 3 to 4 miles per Time commitments include the time needed to perform
hour) is recommended for good health and optimal physical activity and the time required for travel to an exercise
function in the elderly [6]. In contrast, the term exercise facility. This time commitment increases substantially for
indicates a regularly structured program of physical activity those who rely on public transportation.
seeking optimal levels of fitness [7]. Furthermore, these investigators maintained older adults
However, persuading the elderly to become physically tended to view exercise as a recreational pursuit instead of
active is a difficult task. While the importance of an active necessary medical therapy. This viewpoint is perpetuated
lifestyle is well known, the elderly often believe themselves because health practitioners frequently give unclear direc-
to be too old or frail for physical activity. Exercise is rarely tions when recommending exercise. Healthcare providers
viewed as a necessary prescription medicine. In addition, were likely to instruct elderly patients to ‘‘be more physically
older adults, due to a preponderance of health problems, active’’ without offering specific guidelines. The ability of
encounter more barriers to physical activity and exercise providers to recommend appropriate exercise guidelines
participation. Varied interventions studied to enhance exer- is also compounded by the fact many elderly suffer from
cise participation have consistently revealed limited evidence poor concentration, memory deficits, and dementia.
for long-term effectiveness in this age group. The largest Additionally, the authors contended that the elderly often
attrition occurs within 6 months of exercise initiation, with perceived the symptoms associated with exercise as nega-
approximately 50% of participants dropping out before tive. Sweating, labored breathing, and muscle soreness
realizing any health benefits [8]. Unfortunately, those with typical during exercise is believed by some to do more
the most to gain from exercise activity are least likely to harm than good. Older women, in particular, were often
participate. raised to believe exercise is not ‘‘ladylike.’’
Because physical activity is a complex and dynamic
process involving an intricate series of behaviors, identifi-
cation of the variables affecting exercise adherence is often Barriers to exercise
difficult. However, awareness of the individual factors
affecting exercise behavior in this cohort is essential to Thus, acknowledging the unique challenges and clarifying
determine the interventions associated with the greatest the relevant issues is an essential step in developing a strategy
participation and maintenance of exercise behaviors. Iden- to facilitate exercise in the elderly population. Yet, regardless
tification of reliable predictors among older adults will of an individual’s beliefs in the benefits of regular exercise,
allow healthcare providers, situated in a unique position to many barriers, real or perceived, exist which represent
influence health habits of their patients, to effectively obstacles to the adoption and maintenance of exercise be-
structure interventions to promote change in patterns of havior. O’Neill and Reid [11] found that 87% of the elderly
physical activity in sedentary individuals. By improving have at least one barrier to prohibit exercise participation.
health status, physical activity participation will ultimately An overview of the exercise science literature indicates
reduce the need for healthcare services among the elderly certain domains as strong influences for sustaining regular
and ease the economic burden sedentariness places on exercise programming, although uncertainty still exists as to
today’s healthcare system. what variables or strategies are most effective in influencing
long-term adherence. These domains can be classified as
either motivators or barriers to exercise. The following is a
Elderly pose unique challenge discussion of the perceived barriers or constraints to exer-
cise that have gained empirical support.
Although the benefits of regular physical activity have
been studied extensively, researchers have only recently Health
examined the determinants of physical activity in special
populations such as the elderly. The focus of earlier exercise Unlike younger adults who typically cite lack of time as
research was centered on healthy young and middle-aged the main constraint to exercise [4,12], the elderly most
white men [9]. As research into the older population has frequently cite poor health as the leading barrier to both
progressed, it is apparent that physical activity behavior in physical activity and exercise. In a relatively recent inves-
older adults is associated with diverse factors from multiple tigation of community-dwelling elderly, health problems
domains. Not surprisingly, the predictors of exercise adher- and pain emerged as the most common barrier to exercise
ence elucidated in younger adults are unreliable in elderly [13]. These findings were also consistent with survey data
1058 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061

obtained from Booth et al. [14] in their investigation of Despite optimum exposure to the general public, re-
inactive elderly Australians. In this particular study, the data search findings have indicated physicians are not regularly
obtained rated both ill health and injury as the major barrier counseling their patients about exercise [19 –21]. Balde et
to exercise participation in respondents aged 60 to 78 years. al. [19] found only 62% of the respondents in their survey
In a 10-year follow-up study of home-based walking in received advice about exercise from physicians. However,
postmenopausual women, illness was again found to best with advancing years, the inactive elderly generally pre-
predict long-term exercise behavior [15]. ferred to receive exercise advice or support from their own
physician or healthcare professional [12]. In a selected
Environment sample of 301 Medicare beneficiaries living in the metro-
politan Baltimore area, 40% of the patients who initiated
The physical environment can also present as a potential an exercise program did so because of their physician’s
barrier to exercise adherence. Environments with available influence [22].
and convenient resources used both for exercise and phys- Common barriers cited for lack of physician intervention
ical activity performance, such as sidewalks, parks, recrea- include: lack of time during the office visit, limited reim-
tion centers, and fitness facilities, make it easier for people bursement for preventive counseling, and the lack of train-
to be exercise. Conversely, environments with high crime ing and perceived effectiveness as a behavioral counselor
decrease the likelihood of people becoming more active. [21]. However, because patients respect their physician’s
The CDC was first to document a relationship between the advice, the elderly are more likely to change their levels of
prevalence of physical activity and neighborhood safety activity as a result of conversations with their physicians.
[16]. In 1996, data from the Behavioral Risk Factor Sur- Elderly adults who receive exercise advice from their
veillance System (BRFSS) were analyzed in selected states. physician perform more moderate to heavy levels of exer-
The results indicated older adults, especially for whom cise per week than those who did not receive advice [19].
walking was the preferred exercise modality, performed
greater levels of physical activity when they perceived Knowledge
higher levels of safety in their neighborhoods.
In contrast, a similar study in Australia looking at perceived In the elderly population, the lack of knowledge and
environmental influences associated with physical activity, understanding of the relationship between moderate exercise
found no significant difference between neighborhood safety activity and health is an especially relevant barrier, as many
and levels of sustained walking [12]. Geography and crime lived through a time period when exercise was not valued or
pattern differences between the two countries may offer a deemed necessary. Many elderly feel they already receive
possible explanation for the inconsistency in the findings. enough exercise in their activities of daily living [11]. Poor
Inevitably, these data suggest to promote exercise behavior awareness of the role of exercise in disease prevention is
among older adults, some level of public health action and seen not only among the elderly in the United States, but
community support is needed to provide alternatives or also in other countries. For example, in Hong Kong, 812
ensure safe physical environments within communities. Chinese adults were surveyed. The results revealed levels of
Booth et al. did, however, confirm structural constraints exercise and activity decreased with age. When asked to rate
in the environment as barriers to exercise. Elderly individ- various behaviors as factors contributing to their health,
uals not living in close geographic proximity to a recrea- older Chinese adults perceived any form of physical activity
tion facility, park, golf course, swimming pool, or foot as the least important influence to good health [23]. This
path were found to be significantly more inactive. The data confirm that sedentary behavior can be related to
association between levels of exercise participation and limited educational opportunities. Interestingly, the authors
access or convenience to exercise facilities was demon- also reported a greater proportion of Chinese adults than
strated as well in studies of exercise determinants among American adults were completely sedentary.
younger populations [17]. Knowledge of and belief in the health benefits derived
from exercise actually seem to be more helpful in motivat-
Physician advice ing initial involvement in an exercise program. Yet as
Dishman [4] points out, the level of one’s knowledge does
Physicians play a key and pivotal role in promoting not necessarily translate into long-term exercise adherence.
exercise behavior among the elderly. In general, Americans Over time, perceived feelings of enjoyment and satisfaction
average 3.1 office visits per year to their doctor [18]. For the appears to better predict higher levels of adherence [24].
older population, beleaguered by chronic health conditions,
this statistic is even higher. In a 2003 survey of 146 elderly Childhood exercise
living in public housing, 94% of the respondents reported
visiting their physicians at least once in the past year [19]. In conjunction with the publication of the Surgeon
Clearly, this establishes the family physician as the most General’s Report on Physical Activity and Health, research-
effective person for giving advice about exercise [20]. ers are working to understanding the potential carryover
K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061 1059

effect of exercise benefits achieved during youth. Although ations mediate all behavioral change and determine whether
limited studies have been performed thus far, some evi- an individual attempts a given task, the degree of persis-
dence exists that exercise patterns in childhood can ad- tence when difficulty is encountered, and ultimate success
versely affect levels of exercise in adulthood. In their or failure of the behavior [26]. The stronger one’s self-
investigation, Taylor et al. [25] used a sample of 105 efficacy expectations and outcomes, the more likely the
middle-aged males ranging in age from 32 to 60 years, to individual will initiate and persist with a specific behavior.
administer a questionnaire on physical activity patterns and Barring health factors, self-efficacy exerts a consistently
psychosocial factors related to exercise during childhood. powerful influence on the exercise behavior of older adults
The researchers found a weak negative relationship be- [27 –29].
tween the experiences and factors from childhood and In one of few studies designed to systematically examine
adolescence and current activity levels. Although participa- long-term predicators of self-efficacy in the elderly, McAu-
tion in team sport was positively associated with greater ley et al. [30] independently assessed several of the social
adult exercise behavior, being forced by parents to exercise cognitive constructs theorized to be important in the forma-
in the preteen years seemed to negatively affect exercise tion of self-efficacy beliefs. McAuley et al. studied the
participation in adulthood. extent to which the effects of perceived social support, the
value of physical health, affective responses to exercise
(pleasure or displeasure associated with an exercise session),
Motivators for exercise and exercise frequency were related to exercise adherence.
The data obtained in an 18-month follow-up after 6 months
Because of the complex interaction between the large of exercise training reaffirmed the role of self-efficacy in
number of potential variables associated with behavioral long-term exercise participation.
change, many of the barriers to exercise for the older adult As the investigators hypothesized, the frequency of
can actually serve as motivators to exercise activity. In their exercise influenced the degree of social support from the
research, Cohen-Mansfield et al. [13] noted barriers to group and the exercise-related affect. These two factors
exercise to be highly related to motivators. For example, acted together as sources of self-efficacy, ultimately deter-
deteriorating health, which can reduce an older adult’s mining levels of activity at the end of the trial and at follow-
ability to exercise, was also frequently cited as a motivator up. Although the findings suggest a significant relationship
for increasing physical activity. Other motivators reported between social support and exercise adherence, this influ-
by Cohen-Mansfield et al. include having more time, ence does appear to be indirect. Furthermore, enhancing
receiving more information on exercise benefits or physi- social support appears to be gender-specific. A higher level
cian recommendation, and living closer to an exercise of exercise efficacy associated with social support is usually
facility. noted among older women [31].
Consequently, if more elderly are to profit from the Another variable in self-efficacy, group cohesiveness,
benefits of exercise, the salient issue for health and exercise also appears to be related to levels of exercise adherence
professionals is ensuring that the behavior becomes habit- in older adults. In an investigation involving two separate
ual. Therefore, awareness of the cognitive processes specific studies focused on group cohesion, perceptions of similarity
to motivation and behavioral change is fundamental to and closeness within the group predicted both short and
understanding exercise adherence. Self-efficacy is the es- long-term adherence [32]. In the first study, exercise partic-
sence of this process. ipation (attendance) was examined and in the second study,
the effects of team building strategies or group goal setting
Self-efficacy to enhance cohesion were explored. Adherence data were
measured at months 1, 6, and 12 of a 12-month program in
The concept of self-efficacy is consistently identified as study one and after a 10-week hiatus of a 6-week program in
an important determinant of exercise behavior in various study 2. Data collected on the participants in the team-
populations and in many types of behavioral learning building condition indicated significantly higher rates of
throughout the scientific literature. Defined as an individ- adherence than in the other study condition.
ual’s belief in their ability to successfully perform a specific The self-efficacy data cited in the above studies among
behavior, self-efficacy plays a central role in Bandura’s older adults were consistent with the observations of many
social cognitive theory [26]. According to the theory of previously published research reviews on exercise adher-
social cognition, self-efficacy is a product of both expect- ence also reporting perceptions of efficacy as important
ations (perceived ability to achieve a certain behavior) and predictors in the acquisition and maintenance of new be-
outcomes (expected success the behavior will provide). havior [9,33 – 39]. In general, the majority of research
Personal efficacy is based on four major sources of infor- affirms self-efficacy beliefs as critical in the initial adoption
mation: performance experience or mastery, vicarious or of an exercise routine. Feelings of pleasure and satisfaction,
observational experiences of others, verbal persuasion, and along with self-regulatory skills, are more important in
emotional and physiological states. Self-efficacy expect- sustaining exercise behavior. Self-regulatory skills include
1060 K.A. Schutzer, B.S. Graves / Preventive Medicine 39 (2004) 1056–1061

goal setting, monitoring of progress, and self-reinforcement who lead an active lifestyle, were more fit at baseline, have
or motivation. lower body mass, have fewer chronic diseases and pain,
were nonsmokers, and have higher levels of self-efficacy
Prompts [19,44,45]. Exercise participation is greater among men than
women [14,19] and black women seem to be less active than
Various behavioral strategies have been analyzed to white women [46].
enhance self-regulatory skills and facilitate exercise com-
pliance in aging adults. However, many of the tested
interventions have typically involved intense education with Discussion
lengthy contact between study participants and researchers.
In an attempt to identify more efficient and less costly Given the large cohort of aging Americans, the number
methods to motivate and promote exercise behavior, the of older adults experiencing chronic disease and disability
use of prompts, such as informational mailings and tele- will continue to increase substantially over the next few
phone contact, have been investigated. decades. Consequently, maintaining health and postponing
Telephone supervision is a common feature in home- the onset of debilitating disease for as long as possible is
based exercise training programs. In a study comparing necessary to avoid morbidity later in life. Compressing
home-based exercise to organized group exercise, the inves- morbidity can be accomplished through exercise and regu-
tigators discovered the telephone-supervised (home-based) lar physical activity. Although the Surgeon General’s mes-
program was as effective as the face-to-face interventions of sage was disseminated in 1996, adherence to regular
the group program in increasing health benefits and exercise physical activity remains problematic among the older
participation [40]. This research suggested telephone population.
counseling serves as a source of social influence and Efforts to optimize health through physical fitness in the
support, which can enhance participant motivation and elderly have incited researchers to investigate both barriers
ultimately improve compliance. and motivators of exercise. Since a one-size-fits-all strategy
In an effort to evaluate the effectiveness of telephone vs. does not address the specific needs of a given population,
mail-mediated interventions on exercise in older adults, identification of reliable exercise predictors is essential to
Castro et al. [41] discovered although both interventions adherence research. However, in the older population, bar-
were effective, once participants successfully adopted a riers and motivators often intertwine, making it difficult to
more active lifestyle, additional telephone contact did not isolate factors specific to this cohort. Additionally, much of
provide added benefit. This implies that the less intensive the data gathered on the elderly uses healthier adult partic-
intervention, mailed information, could be used to maintain ipants and the majority of research studies are based on
exercise. The mail-mediated intervention presents a viable correlational, retrospective, and self-reported surveys [38].
advantage because it is less expensive, can reach more Because lifestyle habits and perceived barriers to exercise
people, and offers an effective alternative for older adults are often so ingrained in the older population, long-term
who prefer not to attend exercise classes. Moreover, in a maintenance of any newly acquired behavior, including
comparison between the use of prompts and the use of exercise, is a challenge [34]. However, as the aging process
motivational or educational interventions, simple prompting continues, the frequency of contact between the elderly and
was found significantly more effective than lengthy educa- their physicians increases substantially. The elderly, in
tional sessions in encouraging exercise adherence [42]. general, also demonstrate great respect for their physicians.
In particular, they hold their doctor’s directives as orders ‘‘of
Music higher authority’’ and subsequently are greatly influenced
by their advice. Even though barriers to exercise may be
Incorporating appropriate music into exercise programs present, the older adult may be more likely to overcome
can add interest and may serve to facilitate exercise partic- these at the urging of their physician. Therefore, the physi-
ipation and adherence in the older adult. Music is reported cian and other healthcare providers can be the catalyst in the
to enhance the exercise experience by lessening the percep- behavioral change process for the elderly. Without their
tions of difficulty, monotony, and discomforts associated help, sedentariness will impact public health. The effects
with exercise. When exercise sessions are presented without will have widespread implications for a healthcare system
music, with vocal music, or with instrumental music, older already in crisis.
adults demonstrated greater adherence in the instrumental
music condition [43].
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