Healthy Aging: An Overview

### **Chapter 1**

Introductory Chapter: Healthy Aging, Physical Activity, Functional Fitness, Cognitive Function, and Assisted Living Technologies – The Ground for the Sustainability of Health and Quality of Life in Older People

*Élvio Rúbio Gouveia, Bruna R. Gouveia, Adilson Marques and Andreas Ihle*

#### **1. Introduction**

#### **1.1 Sociodemographic change**

Living a long and healthy life is considered the main challenge of societies worldwide. Accompanying a worldwide sociodemographic change, statistical data show an increase in the life expectancy of the most aged segment of the population [1]. Indeed, due to low birth rates, advancements in medical and pharmaceutical technology, health care, nutrition, and sanitation have resulted in lower death rates worldwide [2]. People are living longer, and the population worldwide is growing older. The current increase in the number of older people, combined with the increase in chronic diseases and disabilities associated with age (including limitations in functional fitness components, often due to falls and physical and cognitive alterations, predictors of immobility and dementia), present our societies with global social, economic, and health challenges.

#### **1.2 Healthy aging**

The WHO [3] defined healthy aging as the "ongoing process of developing and maintaining the functional ability that enables wellbeing in older age." Functional ability is a central concept in this approach since it comprises the interaction between physical and mental capacities in a particular environment. Nowadays, it is imperative to develop effective healthy aging strategies because, as previously mentioned, most people expect to live beyond 60 years. By 2050, 1 in 5 people will be 60 or older [1]. This means that more and more people live longer, which poses new challenges and opportunities to the community. However, there seems to be no doubt that a person's general health is a

significant factor to consider among successful aging strategies so that people can benefit from the extra years of life they have achieved, doing what they value.

#### **1.3 Physical activity and functional fitness relationships**

Evidence supports that an active and independent lifestyle in old age fundamentally depends on a person's functional fitness levels, for which balance and cognition are significant [4, 5]. Physical activity (PA) has been considered a key recommendation for developing sustainable policies and action programs for healthy aging. Increasing PA is necessary to maintain functional and cognitive abilities and social activities [4, 6].

Currently, a body of evidence has reported many health and performance-related benefits of engaging in regular PA. It has been shown that certain levels of functional fitness protect the individual from many chronic diseases, promote better performances in daily living activities, and enhance participation in various sports and recreational activities [2, 7]. Strategies to promote PA and functional fitness have been considered priorities for many organizations with worldwide expressions, such as ACSM, WHO, and the Centers for Disease Control and Prevention (CDC). These organizations have developed powerful campaigns centred on promoting exercise and regular physical activity as a means for older people to become healthier, maintain an independent lifestyle, and improve their quality of life and functional capacity.

Research efforts support that the association between PA and functional fitness is reciprocal; functional fitness provides the individual with the capability to engage in physical activities, whereas PA helps to maintain and, in some cases, improve functional fitness [4, 8, 9]. The health and performance-related benefits of regular participation in PA, particularly in older people, are well documented [9, 10]. People who manage to maintain a certain level of functional fitness gain some protection concerning various health conditions (e.g., heart disease, diabetes, obesity, cancers), as well as being able to guarantee the execution of activities of daily living in an independent and safe [11–13]. Additionally, benefits at the psychological level are also evident, especially concerning emotional well-being, increased cognitive function, and a high perception of quality of life [14].

Although this dose-response relationship between increased levels of PA and the onset of chronic diseases or functional disabilities is relatively well documented [15–17], only a small percentage of older people engage in regular physical activity. Older people continue to spend more time in sedentary activities (i.e., time sitting), directly affecting many physiological systems, such as cardiorespiratory and musculoskeletal health [18, 19]. Reference literature on the epidemiology of physical activity has reinforced the direct relationship between the increase in sedentary activity associated with morpho-functional limitations related to age and the onset of chronic diseases or disabilities [19]. This is a crucial subject because it is directly related to the loss of autonomy, reduced quality of life, and increased social support and health care costs.

#### **1.4 Assisted living technologies**

Assisted living technologies have been given special attention since innovative ICT-based products can make a real difference in people's physical, mental, and social lives. According to the World Health Organization, in 2019, the following diseases were among the top 10 causes of death in the world: (1) Ischaemic heart disease; (2) stroke; (3) chronic obstructive pulmonary disease; (4) lower respiratory infections; (5) trachea, bronchus, lung cancers; (6) Alzheimer's disease and other dementias; and (7) Diabetes

#### *Introductory Chapter: Healthy Aging, Physical Activity, Functional Fitness, Cognitive Function… DOI: http://dx.doi.org/10.5772/intechopen.111613*

mellitus. These causes of death have several common denominators, including frailty, physical immobility, and various risk factors associated with cardiovascular, metabolic, respiratory, and cognitive function. Practical actions and making the most of technologies to reverse these problems are priorities. In this context, many health organizations have tried to combat these problems through various disease prevention and control actions (i.e., educational actions, screenings, and wearable health devices) to delay their appearance or lessen their severity. This allows older people to remain a valuable resource in their families, communities, and economies while maintaining high levels of independence and quality of life. Additionally, and no less importantly, this proactive approach reduces the need for institutionalization and significantly contributes to the sustainability of Health Systems. It has been identified as a strategic priority to increase health and social responses to problems arising from demographic aging (such as frequent and prolonged hospitalizations and difficulties in reintegrating into the community after hospital discharge). Assisted living technologies focused on applications in the health area could significantly reduce the number of older people who overuse emergency health services.

Faced with this reality, which is a problem that cuts across many communities around the world, among strategies for the prevention and control of health signs, great attention and investment has been given to the development of Wearable Health Devices, with the function of assisting people in monitoring their health status, providing data with potential for diagnosis and early referral of treatment [20]. Some so-called developed countries have increasingly invested in developing this innovative monitoring system, integrating sensors capable of monitoring deficits and functional mobility, cardiovascular disease, metabolic disease, respiratory disease, and cognitive function, among others. It is for this reason that the revenue of the world wearable health devices market has already reached around 26 billion US dollars, with expectations of reaching 34 billion dollars still in 2019 [21].

Although there is great hope for the potential positive effects of using this type of Assisted Technologies in the monitoring and support of health care, which includes the integration of multimodal signal processing systems for the quantification and evaluation of human activity, physiological, behavioral, emotional and cognitive with real-time feedback, scientific evidence on the validation and effectiveness of the use of these devices is still insufficient for several reasons [20]. Firstly, there still needs to be a consensus regarding the evaluation parameters to be integrated into the monitoring systems and the validation of data collected for diagnosis and early referral in the therapeutic plan. Secondly, only a few wearable health devices have been concerned with integrating information from the user's interaction with the system, losing an essential source of information in the psychosocial area. Thirdly, most systems available on the market operate in isolation (i.e., in a disintegrated and modular way), and the associated costs are still high for the end user. Finally, fourth place, and not least, it is necessary to break down barriers and resistance to using assisted technology in people's daily lives. To this end, the extra concern is needed in developing more adapted and 'friendly' interfaces for the elderly.

#### **1.5 Final considerations**

Considering the multifaceted character of the phenomenon, all these predictors directly impact health-related quality of life. We identified priorities and challenges, boosting research, technological development, and innovation to create solutions in health and well-being adapted to the needs of older people. The future involves research, improving knowledge, and developing therapeutic resources centred on functional skills (mobility and cognitive performance) with positive implications for healthy aging.

### **Author details**

Élvio Rúbio Gouveia1,2,3\*, Bruna R. Gouveia2,3,4,5, Adilson Marques6,7 and Andreas Ihle3,8,9

1 Department of Physical Education and Sport, University of Madeira, Portugal

2 Laboratory of Robotics and Systems in Engineering and Science (LARSyS), Interactive Technologies Institute, Portugal

3 Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Switzerland

4 Saint Joseph of Cluny Higher School of Nursing, Portugal

5 Regional Health Directorate, Secretary of Health and Civil Protection of the Autonomous Region of Madeira, Portugal

6 Interdisciplinary Centre for the Study of Human Performance (CIPER), Faculty of Human Kinetics, University of Lisbon, Portugal

7 Instituto de Saúde Ambiental (ISAMB), University of Lisbon, Portugal

8 Department of Psychology, University of Geneva, Switzerland

9 Swiss National Centre of Competence in Research LIVES—Overcoming Vulnerability: Life Course Perspectives, Switzerland

\*Address all correspondence to: erubiog@staff.uma.pt

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Introductory Chapter: Healthy Aging, Physical Activity, Functional Fitness, Cognitive Function… DOI: http://dx.doi.org/10.5772/intechopen.111613*

#### **References**

[1] European Commission. European Commission Report on the Impact of Demographic Change. 2020. Available from: https://commission.europa.eu/ system/files/2020-06/demography\_ report\_2020\_n.pdf

[2] Jones CJ, Rose DJ. Physical Activity Instruction of Older Adults. Champaign, IL: Human Kinetics; 2005

[3] World Health Organization. World Report on Ageing and Health. Geneva: World Health Organization; 2015. Available from: https://apps.who.int/iris/ handle/10665/186463

[4] Gouveia ER, Maia JA, Beunen GP, Blimkie CR, Fena E, Freitas DL. Functional fitness and physical activity of Portuguese community-residing older adults. Journal of Aging and Physical Activity. 2013;**21**(1):1-19

[5] Ihle A, Ghisletta P, Gouveia ÉR, Gouveia BR, Oris M, Maurer J, et al. Lower executive functioning predicts steeper subsequent decline in well-being only in young-old but not old-old age. International Journal of Behavioral Development. 2021;**45**(2):97-108

[6] Gouveia ER, Ihle A, Gouveia BR, Kliegel M, Marques A, Freitas DL. Muscle mass and muscle strength relationships to balance: The role of age and physical activity. Journal of Aging and Physical Activity. 2019;**4**:1-7. DOI: 10.1123/japa.2018-0113

[7] Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, IL: Human Kinetics; 2013

[8] Rimmer JH. Assessment issues related to physical activity and disability. In: Zhu W, Chodzko-Zajko W, editors.

Measurement Issues in Aging and Physical Activity. Proceedings of the 10th Measurement and Evaluation Symposium. Champaign, IL: Human Kinetics; 2006. pp. 69-79

[9] Shepard RJ. Aerobic Fitness and Health. Champaign, IL: Human Kinetics; 1994

[10] Bouchard C, Shephard RJ. Physical activity, fitness, and health: The model and key concepts. In: Bouchard C, Shephard RJ, Stephens T, editors. Physical Activity, Fitness, and Health: International Proceedings and Consensus Statement. Champaign IL: Human kinetics; 1994. pp. 77-88

[11] He XZ, Baker DW. Body mass index, physical activity, and the risk of decline in overall health and physical functioning in late middle age. American Journal of Public Health. 2004;**94**:1567-1573

[12] Hillsdon MM, Brunner EJ, Guralnik JM, Marmot MG. Prospective study of physical activity and physical function in early old age. The American Journal of Preventive Medicine. 2005;**28**:245-250

[13] Leveille SG, Guralnik JM, Ferrucci L, Langlois JA. Aging successfully until death in old age: Opportunities for increasing active life expectancy. American Journal of Epidemiology. 1999;**149**:654-664

[14] Ihle A, Gouveia ER, Gouveia BR, Orsholits D, Kliegel M. Ageing and Reserves. In: Dario S, Eric W, editors. Withstanding Vulnerability throughout Adult Life – Dynamics of Stressors, Resources, and Reserves. Singapore: Palgrave Macmillan, Springer Nature; 2023. pp. 239-252

#### *Geriatric Medicine and Healthy Aging*

[15] Kampert JB, Blair SN, Barlow CE, Kohl HW. Physical activity, physical fitness, and all-cause and cancer mortality: A prospective study of men and women. Annals of Epidemiology. 1996;**6**(5):452-457

[16] Kushi LH, Fee RM, Folsom AR, Mink PJ, Anderson KE, Sellers TA. Physical activity and mortality in postmenopausal women. The Journal of the American Medical Association. 1997;**277**(16):1287-1292

[17] Paffenbarger RS, Hyde RT, Wing AL, Lee IM, Jung DL, Kampert JB. The association of changes in physicalactivity level and other lifestyle characteristics with mortality among men. The New England Journal of Medicine. 1993;**328**(8):538-545

[18] American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. Eleventh ed. Philadelphia: Lippincott Williams & Wilkins; 2022

[19] Dishman RK, Heath GW, Min LI. Physical Activity Epidemiology (2° Education). Champaign, IL: Human Kinetics; 2013

[20] Dias D, Cunha JP. Wearable health devices-vital sign monitoring, systems and technologies. Sensors (Basel). 2018;**18**(8):2414. DOI: 10.3390/s18082414

[21] Statista BI. Wearable Device Sales Revenue Worldwide from 2016 to 2022 (in Billion U.S.Dollars). New York, NY, USA: Statista Inc.; 2017

#### **Chapter 2**

## Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity Instructors

*Élvio Rúbio Gouveia, Bruna R. Gouveia, Adilson Marques, Priscila Marconcin and Andreas Ihle*

#### **Abstract**

To live a long and healthy life is now considered the main challenge of geriatric medicine worldwide. Exercise, aging, and health are key research topics to maintain functional ability that has been considered one of the strongest predictors of independence in old age. Functional ability comprises the interaction between physical and mental capacities in a particular environment. Increasing physical activity is considered a key recommendation in sustainable policies and action programs for healthy aging. Evidence shows that physical activity impacts functional and cognitive abilities and social activities. The contents of training courses related to Exercise Aging and Health are responsible for ensuring an intervention focused on the needs of older people. Healthcare professionals, physical activity instructors, or other health professionals who work directly with older people may need to understand deeply demography, theories, and current policies on aging, physical, and functional changes associated with aging, physical-psychosocial relationships, contextual determinants of physical activity, and exercise prescription in the older population.

**Keywords:** aging, exercise, functional ability, health, physical activity, training

#### **1. Introduction**

This chapter aims to present a content course proposal on the topic of "Exercise Aging and Health," to be taught to healthcare professionals, physical activity instructors, or other health professionals who work directly with older people. In a nutshell, the contents to be addressed include five main topics. The first topic addresses an introduction to the aspects of aging, including issues related to demography, theories, and current policies on aging. The second topic explores the physical and functional changes associated with aging. Morphological changes and physiological systems, i.e. body composition, cardiopulmonary, musculoskeletal, and nervous and sensory systems, are broadly described. Also, in this topic, functional changes are addressed,

i.e. functional fitness and mobility. Topic 3 presents research on physical-psychosocial relationships, exploring the relationships between aging, active life, cognitive function, physical activity, well-being, and health-related quality of life. Topic 4 is dedicated to studying the contextual determinants of physical activity in the elderly. Here, the models of adoption and maintenance of physically active lifestyles are explored, as well as the Age-friendly Environments. Finally, the last topic is dedicated to the study of guidelines for exercise prescription in the older population. Here, general guidelines for pre-exercise assessment are outlined, as well as key considerations for maximizing the effective development of exercise programs for older people.

It is expected that students who take this course should be able to properly use theoretical knowledge regarding exercise, aging, and health in different contexts of intervention with older people (i.e. health gyms, rehabilitation centers, elderly centers, city councils, parish councils, among others). They should be able to adopt a scientific attitude and a critical reflective method in the face of research results from the assessment of the physical dimensions (morphological and functional) of the older person. They must show the capacity for initiative, innovation, and acceptable use of information regarding protocols and techniques for assessing functional fitness and know-how to assess the scientificity of the information collected on the relationships and interrelationships of physical activity and chronic diseases, as well as the benefits and risks associated with the regular practice of physical activity and/ or exercise. They must systematically carry out a functional assessment of the older person, guaranteeing all safety conditions in the evaluation and intervention, as well as adequately interpreting the objective and subjective data of the physical dimensions assessment process, using this information to prescribe the exercise. Finally, they must be able to conceptualize an exercise plan adapted to a previously outlined functional profile.

#### **2. Topic 1: introductory aspects of aging**

#### **2.1 Demography of aging**

The demographic transition characterized by an aging population is a global phenomenon that directly impacts different sectors of society. The advancements in medical and pharmaceutical technology, nutrition, and sanitation have resulted in lower healthcare death worldwide. People are living longer, and the population worldwide is growing older. Recent key facts shown by the World Health Organization [1] underlines that between 2015 and 2050, the proportion of the population over 60 years will nearly double from 12 to 22%. Besides the mortality associated with COVID-19, people aged 60 years and older will outnumber children younger than 5 years by 2020. In the same document, it is written that all countries face significant challenges to ensure that their health and social systems are ready to deal with this demographic shift.

Cognitive, physical, and social stimulation can play a crucial role in delaying disability and maintaining the quality of life, allowing people to continue to do what they want, without pain and autonomously, for as long as possible. Additionally, age-related declines in cognitive, physical, and social function are an inevitable human condition that often results in socioeconomic and service overload. These age-associated changes increase the vulnerability of older people to chronic illness and mortality.

*Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

#### **2.2 Concepts and theories of aging**

Aging refers to a process or group of processes occurring in living organisms that, over time, lead to a loss of adaptability, functional impairments, and eventually death [2]. Taylor and Johnson [3] defined biological aging as slow, progressive, structural, and functional changes at the cellular, tissue, and organ levels, ultimately affecting the function of all body systems.

Numerous theories have been proposed to explain the process of aging but neither appears to be entirely satisfactory [4]. Taylor and Johnson [3] suggested that these can be grouped into five broad categories of aging: (i) wear and tear theories; (ii) genetics theories; (iii) general imbalance theories; (iv) accumulation theories; and (v) the dysdifferentiative hypothesis of aging and cancer.

Jones [5] divided the theories of aging into three main categories: biological, psychological, and sociological. Biological theories of aging—including genetic damage and gradual imbalance theories—focus on the factors that cause senescence of the body and increase the risk of morbidity and mortality with age. Psychological theories focus on the influence of psychological processes and personality characteristics on aging. Sociological theories focus on the impact of the social and physical environments on aging.

The modern biological theories of aging in humans fall into two main categories: programmed theories and damage or error theories [6]. The programmed theories imply that aging follows a biological timetable, perhaps a continuation of the one that regulates childhood growth and development. This regulation would depend on changes in gene expression that affect the systems responsible for maintenance, repair, and defense responses. The programmed theory has three subcategories: programmed longevity, endocrine theory, and immunological theory. The damage or error theories emphasize environmental assaults on living organisms that induce cumulative damage at various levels as the cause of aging. The damage or error theory includes wear and tear theory, rate of living theory, cross-linking free radical theory, and somatic DNA damage theory.

The complexity of aging derives from an aggregate of causes that led to the development and polarization of the theories of aging. In this context, Jones [5] and Jin [6] believe that no single theory thoroughly explains the phenomenon of the aging process, but each offers some clues. Many of the proposed theories interact with each other in a complex way.

#### **2.3 Policies on aging**

As previously mentioned, the WHO emphasizes the longevity achieved by the population, reinforcing that most people expect to live beyond 60 years. It is likely that by 2050 one in five people will be 60 years old or more [1]. This means that a longer life brings great opportunities. However, how each individual can benefit from the extra years depends largely on one key factor: *Health*. On the other hand, evidence suggests that older people do not have a better health status than earlier generations. Additionally, those who have experienced lifelong events have a higher risk of health problems.

In this context, the concept of "healthy aging" emerges, which is the focus of the WHO's work on aging for 2015–2030. "Healthy aging" is understood as a process of developing and maintaining the functional capacity that enables the well-being of the elderly adult. This central concept emphasizes, on the one hand, the need for action

focused on multiple sectors and, on the other hand, the possibility of older people continuing to be a valid resource in their families, communities, and economies. We understand that one of the most important messages that can be drawn from this WHO theory of healthy aging is that one of the main focuses of the work of gerontologists, and all professionals responsible for offering services to the elderly is to find strategies and concerted actions that help the older people to continue doing the things they value most for as long as possible [7]. Within the scope of policies for healthy aging, the WHO assumed five strategic goals: (1) commitment to action, that is, to establish models, strengthen the capacity to formulate evidence-based policies, and combat stigma and stereotype of aging; (2) aligning health systems with the needs of older adults, i.e. orienting health systems around individual needs and potential for involvement, ensuring accessibility to quality care, and ensuring the sustainability of healthcare; (3) develop age-friendly environments, through the promotion of autonomy, the involvement of older people, and the promotion of multisectoral actions; (4) strengthen long-term care, with a view to continuously improving a sustainable and equitable policy in terms of long-term care, also integrating caregivers; and (5) improve evaluation, monitoring, and research, defining the suitable instruments, methodologies, and protocols, strengthening research capacity and encouraging innovation, and sustaining evidence of the benefits of actions focused on healthy aging for the population.

As a continuing of the concept of healthy aging, in 2015 the WHO emphasized the concept of active aging, as a multidimension that involves physical functionality, urban environment, and social inclusion. The WHO defined active aging as "…the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age" [7]. The concept of Active and Healthy Aging (AHA) comprehends the results of the interaction between the physical and mental capacity of an individual and the context of each individual's life.

#### **3. Topic 2: physical and functional changes associated with aging**

#### **3.1 Morphological changes and physiological systems: Body composition and systems: Cardiopulmonary, musculoskeletal, nervous, and sensory**

Although it is difficult to distinguish the effects of aging on the physiologic function of the impact of deconditioning or disease, the aging process leads to profound changes in the cardiopulmonary, musculoskeletal, nervous, and immune systems. For example, the American College of Sports Medicine (2018) states that the incidence of stroke decreases about 30% from 25 to 85 years of age; there is a progressive reduction of ventilatory peak flow and lung capacity with advancing age; there is an increased bone loss resulting in reduced bone mineral density; about 25% of muscle function, defined as the highest lifetime force-generating capacity, is lost by around 65 years of age. Also, negative changes of the central nervous system are observed in neurotransmitters, nerve conduction, and fine functional-fitness control.

Regarding the body composition and musculoskeletal changes, one of the major age effects of body composition faced by older people is a gradual loss of skeletal muscle mass and strength that occurs with advancing age, called Sarcopenia. Sarcopenia increases the risk of falls [8], is associated with cardiac disease and respiratory disease [9, 10], and increased risk of death [11, 12]. In addition, it is accompanied by functional decline and disability [13, 14]. With increasing age and from about *Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

40–45 years old, lean soft tissue and skeletal muscle mass progressively decline [15]. Evidence shows that about 25% of muscle function, defined as the highest lifetime force-generating capacity, is lost by around 65 years of age [3].

Finally, it has been reported that cognitive functioning declines with age [2]. Cognitive function is the intellectual process by which a person becomes aware of ideas, perceives, and understands them. It involves all aspects of perception, thinking, remembering, learning, attention, vigilance, reasoning, and problem-solving. This concept includes psychomotor functioning (reaction time, movement time, and performance speed) [16]. There is evidence that regular physical exercise [17–19] and cognitive training [20, 21] are non-pharmaceutical interventions that attenuate agerelated cognitive decline and improve cognitive performance in older people.

According to Fernández-Ballesteros [22], active daily cognitive activity and social and leisure activities have a positive impact on the general functioning of cognitive abilities. Therefore, social contacts and good integration of people in the community are factors that contribute to greater protection of cognitive functioning. In addition, there is some literature to support that interventions based on cognitive stimulation programs associated with group physical activity programs have great potential in older people with identified dementia and healthy older people [2, 3].

#### **3.2 Functional changes: functional fitness and mobility**

Among older adults, functional fitness is defined as the ability to perform activities of daily living normally, safely, independently, and without fatigue [23]. Improving functional fitness in older adults (i.e. lower and upper limb muscle strength, aerobic capacity, flexibility, and dynamic balance) is a critical factor in maintaining their independence in daily living activities. In this sense, a reduction in functional fitness levels is generally associated with a decline in general functional capacity and basic activities of daily living such as climbing stairs, walking, carrying groceries, and many other common tasks [3, 23]. Normative functional fitness scores have been published for older adults in different countries: United States of America [24]; Portugal [25]; Brazil [26]; Poland [27]; and China [28]. Results revealed a pattern of decline across most age groups on all variables. The total decrease in muscular strength, cardiorespiratory endurance, and agility/balance was about 30–45% between 60 and 94 years of age. The pattern of decrease over age was similar in men and women. However, men scored better on muscular strength, aerobic endurance, and agility/balance, and women scored better on flexibility [24–28].

#### **4. Topic 3: physical-psychosocial relationships**

#### **4.1 Aging, active life, and cognitive function**

Owing to the inevitable well-documented age-related losses in cognitive and physical function [29, 30], one of the biggest challenges is to identify strategies to develop and maintain functional ability at later ages. Functional ability is determined by the individual's intrinsic capacity, which encompasses cognitive function and mobility, relevant contextual factors, and the interaction between the two [7]. There is evidence that a physically active lifestyle and, consequently, a high level of functional fitness are effective modifiable risk factors that may slow the increase of cognitive impairments in older age [31–33].

Therefore, from a healthy aging perspective, an early intervention strategy based on supportive environments and opportunities to increase physical activities are determinants of living a long and healthy life [7]. This is supported by physical activity being a modifiable risk factor for cognitive impairment in older age [32, 33]. For this reason, in the last decade, there has been a rapid increase in interest in the potential of physical activity to prevent cognitive decline and maintain good cognitive abilities.

Although it has been demonstrated that maintenance of higher levels of physical activity helps to protect against cognitive deterioration, even at an advanced age [34, 35], it is still an open question which frequency, intensity, time, type, volume, and progression of physical activity is more effective to improve cognition. Finally, the physiological mechanisms underlying the relationship between cognitive function, functional fitness, and physical activity at older ages are still poorly understood.

#### **4.2 Physical activity, well-being, and health-related quality of life**

Observational studies have shown an average 20 to 30% reduction in mortality risk when individuals spend at least 1000 kcal per week on physical activity [36]. The American College of Sports Medicine emphasizes the health benefits associated with higher levels of physical activity and aerobic exercise across physiological, metabolic, and psychological parameters. Additionally, there is a decreased risk of many chronic diseases and premature mortality. The variables studied show a lower risk for any cause of mortality in people who maintain higher levels of physical activity or physical fitness over time when compared to those who reduce or maintain low levels of physical activity or physical fitness over time [37, 38].

Some recognized benefits of participating in regular physical activity are slowing physiologic changes of aging that impair exercise capacity [37], optimizing agerelated changes in body composition [13], promoting psychological and cognitive well-being [20, 39], managing chronic diseases [40], reducing the risks of physical disability [25], and increasing longevity [41].

Despite the benefits of PA, older adults are the least physically active of all age groups, with only 11% of individuals aged ≥65 yrs engaging in aerobic and musclestrengthening activities that meet guidelines, and less than 5% of individuals aged 85 yrs and older meet the same guidelines [37, 38].

#### **5. Topic 4: contextual determinants of physical activity in the elderly population adopting and maintaining physically active lifestyle**

#### **5.1 Adoption and maintenance of physically active lifestyles**

Some physical activity is better than none, and an increase in the physical activity level, up to a point, is better than less. This supports the dose-response relationship between physical activity and health reported by the American College of Sports Medicine in conjunction with other important health organizations such as the Centers for Disease Control and Prevention (CDC), the US Surgeon General, and the National Institutes of Health [42]. The main purpose of healthcare professionals and physical activity instructors is to assist individuals in adopting and adhering to the exercise prescription recommendations made throughout the guidelines. And the main challenge is to overcome the barriers to the exercise.

*Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

There are well-known correlates that affect engagement in regular physical activity. Numerous demographic factors (e.g. age, gender, socioeconomic status, education, and ethnicity) are consistently related to the likelihood that an individual will keep their activity regularly [43, 44].

In the context of adopting and maintaining a physically active lifestyle in older people, it is important to focus on the role that modifiable factors have on exercise prescription recommendations, the behavioral theories and models that have been applied to enhance exercise adoption and maintenance, and behavioral strategies and approaches that can be used to increase physical activity behaviors.

Physical activity tends to decline with age, especially when people have age-related disabilities. Still, age does not necessarily predispose an individual to lower activity [45]. Several international studies provide insights on impediments to physical activity in older people. The most common barriers reported were enough other hobbies, too exhausting, risk of injury too high, no knowledge of opportunities, an attitude that sports are only for younger people, no time, and financial reasons, having too few friends to exercise with [46]. Pain is another common barrier to exercise [47]. Another critical point concerns the differences between men and women, reinforcing the importance of specific efforts to increase older adults' physical activity levels [46]. We recognized that it is crucial, in each context, to identify earlier relevant barriers to physical activity in older adults to better tailor measures to the specific needs and be successful in the promotion and intervention strategies.

People's physical activity during their leisure time is determined by genetic traits (20 to 70&), beliefs and motivation shaped by learning (25 to 75%), and physical and social environments (10 to 50%) [45]. Creating a friendly-environment that makes physical activity easy/affordable does not ensure that a person living in that environment will be motivated to use it. It is not easy to alter personal preferences or longstanding habits. Changing physical activity is not like changing most other behaviors.

Sustained participation in regular physical activity requires active behavior modification. Following [45] in the "physical activity epidemiology," most behavior modification techniques for changing physical activity center on (i) goal-setting based on personal characteristics; (ii) identification of personal costs and expected barriers to adoption and maintenance of an activity routine; (iii) strategies for preventing or minimizing the impact of barriers to participation and for increasing support and reinforcement from friends and family; (iv) planning a gradual progression of difficulty to optimize success so that the participant has growing confidence in both physical abilities and the ability to maintain the new pattern of activity; (v) feedback from fitness testing and self-monitoring of activity and progress by the participant; and (vi) personal strategies for returning to activity after relapse to inactivity due to flagging motivation, injury, vacation, and others.

#### **5.2 Age-friendly environments**

Promoting age-friendly physical and social environments where people live plays a vital role in whether people can remain healthy, independent, and autonomous long into their old age [7].

Healthcare professionals and physical activity instructors have the responsibility to think correctly about the promotion of age-friendly environments. Promote agefriendly environments means offering free physical and social barriers and support policies, services, products, or technologies that help promote health and build and maintain physical and mental capacities across the life course. Also, age-friendly

environments should enable people, even when experiencing capacity loss, to continue to do the things they value. When planning age-friendly practices, healthcare professionals and physical activity instructors must ensure that they are promoting/ offering opportunities for older people to meet their basic needs, learn, grow, and make decisions, be mobile, build and maintain relationships, and contribute to the community.

Good practices of Age-Friendly Communities are well documented. For example, the 2022–2027 Master Aging Plan marks the fifth strategic planning cycle for the Orange County Department on Aging [48]. This Master Aging Plan framework contains eight domains of livability that influence the quality of life for older adults: (1) outdoor spaces and buildings (include actions to optimize usability of outdoor spaces and buildings); (ii) transportation (include actions to increase access to and awareness of affordable, safe, and equitable mobility options); (iii) housing (include actions to improve choice, quality, affordability, and stability of housing); (iv) social participation (include actions to promote diverse and accessible opportunities for participation and engagement); (V) respect and social inclusion (include actions to uphold all older adults ages 55+ years as valuable members and provide equitable resources for the community); (vi) civic participation and employment (include actions to connect older adults with resources that help them achieve their diverse employment and career transition goals); (vii) communication and information (include actions to awareness of and access to available services and supports for older adults and their families will increase for everyone), and (viii) community and health services (include actions to ensure the community has accessible and affordable resources to support individual health and well-being goals throughout the aging process). This plan builds off of the 20-year history of formal age-friendly planning in Orange County. This is a model for comprehensive and successful aging and represents a comprehensive vision for the future of several communities that intend to be age-friendly communities.

#### **6. Topic 5: exercise prescription in the elderly population**

#### **6.1 Pre-exercise assessment**

When people are encouraged to engage in physical activity because of its multiple health benefits, attempts to reduce the risks inherent in more vigorous activities should be considered. Screening for risk factors and/or symptoms of cardiovascular, pulmonary, and metabolic diseases, as well as other conditions (e.g. musculoskeletal conditions), may be aggravated by exercise [38]. The primary goals of preparticipation health screening and risk stratification are to help develop an effective and safe exercise prescription and optimize safety during exercise assessment and performance.

A health screening before starting an exercise or physical activity program is a tiered process: (i) self-guided method via the Physical Activity Readiness Questionnaire (PAR-Q ) or the modified AHA/ACSM Health/Fitness Facility Questionnaire Preparticipation; (ii) assessment of risk factors for CVD and classification; and (iii) medical evaluation, including physical examinations and stress tests.

All older people who wish to start a physical activity program should be assessed at least through a medical history or self-reported health risk questionnaire; the responses to these self-guided methods determine the need and level of follow-up.

#### *Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

Older adults at moderate risk with two or more cardiovascular risk factors should be encouraged to consult a physician before starting a program of vigorous-intensity physical activity. Although medical evaluation is ongoing, most individuals can begin light to moderate-intensity exercise programs without consulting their physician. Older people at high risk with symptoms or diagnosed illnesses should consult their physician before starting a physical activity and/or exercise program.

Routine stress tests are recommended for individuals at high risk, including those with a diagnosis of cardiovascular disease, symptoms suggestive of new or unstable cardiovascular disease, diabetes mellitus, cardiovascular risk factors, advanced kidney disease, and specific lung diseases.

These recommendations reduce the barriers to adopting more active lifestyles because most of the risks associated with exercise can be lessened by adopting a progressive exercise training regimen. Generally, there is a low risk of participating in physical activity programs.

The assessment of the functional fitness of older adults is of particular importance. First of all, it can be used to identify at-risk participants. Many independent older adults, often due to their sedentary lifestyles, function dangerously close to their maximum ability level during normal activities. Climbing stairs or getting out of a chair requires near maximum effort for many older individuals [30]. More than onethird of community-dwelling older adults are at risk for mobility problems and falls [49]. Early identification of physical decline and appropriate interventions could help to prevent functional impairments, such as in walking and stair climbing, that often result in falls and physical frailty [30].

Second, assessing functional fitness for better program planning and evaluation is essential. A comprehensive functional fitness test provides specific information regarding a client's physical strength and weaknesses associated with functional tasks and activity goals important to everyday living. This information is necessary to design individualized, targeted exercise, or physical activity programs for clients. Baseline measures repeated during the program provide critical data to track clients' progress, make program adjustments, provide personalized feedback, and evaluate program effectiveness.

#### **6.2 Exercise programs for the older population**

There are important considerations for exercise programming in older people that must be considered at the beginning to maximize the effective development of an exercise program [38].

First, the intensity and duration of physical activity should be light at the beginning, particularly for older adults who are highly deconditioned, functionally limited or have chronic conditions that affect their ability to perform physical tasks. The intensity must be controlled not only by the use of a subjective effort scale but also by a pain scale. Respecting the pain limit is fundamental to ensure continuity in the practice of physical exercise. Second, the progression of physical activity should be individualized and tailored to tolerance and preference. A conservative approach may be necessary for older adults who are highly deconditioned or physically limited to prevent injury events.

A significant and well-documented age-related associated decline is muscular strength, especially after 50 yrs. [50]. This decline is directly connected with loss of strength due to the atrophy of muscle fibers, with a preferential incidence in type II fibers [51]. Practically, this supports the importance of including resistance training across the lifespan since it becomes more critical with increasing age. Strength

training involves using selected machines or free weights. Initial training sessions should be supervised and monitored by personnel sensitive to the special needs of older adults.

Once power training is the muscle fitness component that rapidly declines with aging and has been associated with a greater risk of accidental falls, older people benefit from this training. Some recommendations are underlined by ACSM, including single- and multiple-joint exercises (one to three sets) using light-to-moderate loading (30–60% of 1-RM) for 6–10 repetitions with high velocity.

Individuals with sarcopenia, defined as a progressive and widespread skeletal muscle disorder involving loss of muscle mass and function, are associated with several adverse outcomes including falls, functional decline, frailty, and mortality [52]. Sarcopenia has been considered a public health problem, affecting most older people and making them more vulnerable to falls [53]. For this reason, it is essential to increase muscular strength before older people are physiologically capable of engaging in aerobic training.

Another important recommendation for all older people, even if chronic conditions preclude activity at the recommended minimum amount, is that older adults should perform physical activity as tolerated to avoid being sedentary. Older people should gradually exceed the recommended minimum amounts of physical activity and attempt continued progression if they desire to improve and/or maintain their functional fitness. It is an important message for older people to inform them to exceed the recommended minimum amounts of physical activity to improve the management of chronic diseases and health conditions for which a higher level of physical activity is already known to confer a therapeutic benefit, for example, diabetes, blood pressure, obesity, depression, and other.

Regarding older people with identified cognitive declines, moderate-intensity physical activity should be encouraged. In the case of significant cognitive impairment, individualized assistance may require during the physical activity program.

Generically, ACSM recommends a structured physical activity session, with an appropriate cool-down, particularly among individuals with cardiovascular disease. The cool-down should include a gradual reduction of effort and intensity and, optimally, flexibility exercises.

It is high recommendable that the incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance participation in a regular exercise program. In addition, older people should be provided with regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence. These final recommendations will better contribute to a more consistent healthy aging program.

### **Author details**

Élvio Rúbio Gouveia1,2,3\*, Bruna R. Gouveia3,4,5, Adilson Marques6,7,8, Priscila Marconcin8,9 and Andreas Ihle3,10,11

1 Department of Physical Education and Sport, University of Madeira, Funchal, Portugal

2 Laboratory of Robotics and Systems in Engineering and Science (LARSyS), Interactive Technologies Institute, Funchal, Portugal

3 Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland

4 Regional Directorate of Health, Secretary of Health of the Autonomous Region of Madeira, Funchal, Portugal

5 Saint Joseph of Cluny Higher School of Nursing, Funchal, Portugal

6 Interdisciplinary Centre for the Study of Human Performance (CIPER), Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal

7 Instituto de Saúde Ambiental (ISAMB), University of Lisbon, Lisbon, Portugal

8 Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal

9 KinesioLab, Research Unit in Human Movement Analysis, Piaget Institute, Almada, Portugal

10 Department of Psychology, University of Geneva, Geneva, Switzerland

11 Swiss National Centre of Competence in Research LIVES—Overcoming Vulnerability: Life Course Perspectives, Lausanne, Switzerland

\*Address all correspondence to: erubiog@staff.uma.pt

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] World Health Organization. Ageing and Health. Geneva: WHO Press; 2021. Accessed at: https://www.who. int/news-room/fact-sheets/detail/ ageing-and-health

[2] Spirduso WW, Francis KL, MacRae PG. Physical Dimensions of Aging. Second ed. Champaign, IL: Human Kinetics; 2005

[3] Taylor AW, Johnson MJ. Physiology of Exercise and Healthy Aging. Champaign, IL: Human Kinetics; 2008

[4] Davidovic M, Sevo G, Svorcan P, Milosevic DP, Despotovic N, Erceg P. Old age as a privilege of the "selfish ones". Aging and Disease. 2010;**1**(2):139-146

[5] Jones CJ. Predictors of successful aging. In: Jones CJ, Rose DJ, editors. Physical Activity Instruction of Older Adults. Champaign, IL: Human Kinetics; 2005. pp. 11-21

[6] Jin K. Modern biological theories of aging. Aging and Disease. 2010;**1**(2):72-74

[7] World Health Organization. World Report on Ageing and Health. Geneva: WHO Press; 2015

[8] Schaap LA, van Schoor NM, Lips P, Visser M. Associations of sarcopenia definitions, and their components, with the incidence of recurrent falling and fractures: The longitudinal aging study Amsterdam. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2018;**73**(9):1199-1204. DOI: 10.1093/ gerona/glx245

[9] Bahat G, Ilhan B. Sarcopenia and the cardiometabolic syndrome: A narrative

review. European Geriatric Medicine. 2016;**7**(3):220-223

[10] Bone AE, Hepgul N, Kon S, Maddocks M. Sarcopenia and frailty in chronic respiratory disease. Chronic Respiratory Disease. 2017;**14**(1):85-99. DOI: 10.1177/1479972316679664

[11] De Buyser SL, Petrovic M, Taes YE, Toye KR, Kaufman JM, Lapauw B, et al. Validation of the FNIH sarcopenia criteria and SOF frailty index as predictors of long-term mortality in ambulatory older men. Age and Ageing. 2016;**45**(5):602-608. DOI: 10.1093/ ageing/afw071

[12] Visser M, Schaap LA. Consequences of sarcopenia. Clinics in Geriatric Medicine. 2011;**27**(3):387-399. DOI: 10.1016/j.cger.2011.03.006

[13] Gouveia ÉR, Gouveia BR, Maia JA, Blimkie CJ, Freitas DL. Skeletal muscle and physical activity in Portuguese community-dwelling older adults. Journal of Aging and Physical Activity. 2016;**24**(4):567-574. DOI: 10.1123/ japa.2015-0129

[14] Aagaard P, Suetta C, Caserotti P, Magnusson SP, & Kjaer M. Role of the nervous system in sarcopenia and muscle atrophy with aging: Strength training as a countermeasure. Scandinavian Journal of Medicine & Science in Sports. 2010;**20**(1):49-64. DOI: 10.1111/j.1600-0838.2009.01084.x

[15] Baumgartner RN. Body composition in healthy aging. Annals of the New York Academy of Sciences. 2000;**904**:437-448. DOI: 10.1111/j.1749-6632.2000.tb06498.x

[16] Chodzko-Zajko WJ, Moore KA. Physical fitness and cognitive

*Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

functioning in aging. Exercise and Sport Sciences Reviews. 1994;**22**:195-220

[17] Gouveia ÉR, Smailagic A, Ihle A, Marques A, Gouveia BR, Cameirão M, et al. The efficacy of a multicomponent functional fitness program based on exergaming on cognitive functioning of healthy older adults: A randomized controlled trial. Journal of Aging and Physical Activity. 2021;**29**(4):586-594. DOI: 10.1123/japa.2020-0083

[18] Bherer L, Erickson KI, Liu-Ambrose T. A review of the effects of physical activity and exercise on cognitive and brain functions in older adults. Journal of Aging Research. 2013;**2013**:657508. DOI: 10.1155/2013/657508

[19] Northey JM, Cherbuin N, Pumpa, KL, Smee DJ, Rattray B. Exercise interventions for cognitive function in adults older than 50: A systematic review with meta-analysis. British Journal of Sports Medicine. 2018;**52**(3):154-160. DOI: 10.1136/bjsports-2016-096587

[20] Ihle A, Gouveia ÉR, Gouveia BR, van der Linden B, Sauter J, Gabriel R, et al. The role of leisure activities in mediating the relationship between physical health and well-being: Differential patterns in old and very old age. Gerontology. 2017;**63**(6):560-571. DOI: 10.1159/000477628

[21] Ballesteros S, Kraft E, Santana, S, Tziraki C. Maintaining older brain functionality: A targeted review. Neuroscience and Biobehavioral Reviews. 2015;**55**:453-477. DOI: 10.1016/j. neubiorev.2015.06.008

[22] Fernández-Ballesteros R. Envejecimiento Activo: Contribuciones de la Psicología. Madrid: Ediciones Pirámide; 2009

[23] Rikli RE, Jones CJ. senior fitness test manual. Development and Validation of a Functional Fitness Test for Community-Residing Older Adults. Champaign, IL: Human Kinetics; 2001

[24] Rikli RE, Jones CJ. Functional fitness normative scores for communityresiding older adults, ages 60-94. Journal of Aging and Physical Activity. 1999;**7**:162

[25] Gouveia ÉR, Maia JA, Beunen GP, Blimkie CJ, Fena EM, Freitas DL. Functional fitness and physical activity of Portuguese community-residing older adults. Journal of Aging and Physical Activity. 2013;**21**(1):1-19. DOI: 10.1123/ japa.21.1.1

[26] Krause MP, Januário RS, Hallage T, Haile L, Miculis CP, Gama MP, et al. A comparison of functional fitness of older Brazilian and American women. Journal of Aging and Physical Activity. 2009;**17**:387-397

[27] Ignasiak Zofia, Sebastjan Anna, SÅawiÅ"ska Teresa, Skrzek Anna, Czarny Wojciech, KrÃ3l PaweÅ', Rzepko Marian, Duda-Biernacka Barbara, Marchewka Anna, Filar-Mierzwa Katarzyna, Nowacka-Dobosz Sylwia, Dobosz Janusz, Umiastowska Danuta (2020). Functional fitness normative values for elderly polish population. BMC Geriatrics, 20(1), 384. doi:10.1186/ s12877-020-01787-2

[28] Zhao Y, Wang Z, Chung P-K, Wang S. Functional fitness norms and trends of community-dwelling older adults in urban China. Scientific Reports. 2021;**11**(1):17745. DOI: 10.1038/ s41598-021-97320-5

[29] Glisky EL. Changes in cognitive function in human aging. In: Riddle DR, editor. Brain Aging: Models, Methods, and Mechanisms. Boca Raton (FL): CRC Press/Taylor & Francis; 2007

[30] Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, IL: Human Kinetics, Inc; 2013

[31] Blondell SJ, Hammersley-Mather R, Veerman JL. Does physical activity prevent cognitive decline and dementia?: A systematic review and meta-analysis of longitudinal studies. BMC Public Health. 2014;**14**:510. DOI: 10.1186/1471-2458-14-510

[32] Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer's disease prevalence. The Lancet Neurology. 2011;**10**(9):819-828. DOI: 10.1016/s1474-4422(11)70072-2

[33] Deckers K, van Boxtel MPJ, Schiepers OJG, de Vugt M, Sánchez M, Luis J, et al. Target risk factors for dementia prevention: A systematic review and Delphi consensus study on the evidence from observational studies. International Journal of Geriatric Psychiatry. 2015;**30**(3):234-246. DOI: 10.1002/gps.4245

[34] Stubbs B, Vancampfort D, Rosenbaum S, Firth J, Cosco T, Veronese N, et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Research. 2017;**249**:102-108. DOI: 10.1016/j. psychres.2016.12.020

[35] Umegaki H, Makino T, Uemura K, Shimada H, Cheng XW, Kuzuya M. Objectively measured physical activity and cognitive function in urban-dwelling older adults. Geriatrics & Gerontology International. 2018;**18**(6):922-928. DOI: 10.1111/ggi.13284

[36] Dishman RK, Washburn RA, Heath GW. Physical Activity Epidemiology. Champaign, IL: Human Kinetics; 2004

[37] Izquierdo M, Merchant RA, Morley JE, Anker SD, Aprahamian I, Arai H, et al. International exercise recommendations in older adults (ICFSR): Expert consensus guidelines. The Journal of Nutrition, Health & Aging. 2021;**25**(7):824-853. DOI: 10.1007/ s12603-021-1665-8

[38] Liguori G. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. Philadelphia: Lippincott Williams & Wilkins; 2020

[39] Gouveia É, Gouveia BR, Ihle A, Kliegel M, Maia JA, Badia I, et al. Correlates of health-related quality of life in young-old and old-old community-dwelling older adults. Quality of Life Research: an International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation. 2017b;**26**(6):1561-1569. DOI: 10.1007/ s11136-017-1502-z

[40] Gouveia ÉR, Ihle A, Kliegel M, Freitas DL, Jurema J, Tinôco MA, et al. The relationship of physical activity to high-density lipoprotein cholesterol level in a sample of community-dwelling older adults from Amazonas, Brazil. Archives of Gerontology and Geriatrics. 2017c;**73**:195-198. DOI: 10.1016/j. archger.2017.08.004

[41] Partridge L, Deelen J, Slagboom PE. Facing up to the global challenges of ageing. Nature. 2018;**561**(7721):45-56. DOI: 10.1038/s41586-018-0457-8

[42] Geidl W, Schlesinger S, Mino E, Miranda L, Pfeifer K. Dose-response relationship between physical activity and mortality in adults with noncommunicable diseases: A systematic review and meta-analysis of prospective observational studies. The International Journal of Behavioral Nutrition and

*Exercise Aging and Health: A Proposal Course for Healthcare Professionals and Physical Activity… DOI: http://dx.doi.org/10.5772/intechopen.108188*

Physical Activity. 2020;**17**(1):109. DOI: 10.1186/s12966-020-01007-5

[43] Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJ, Martin BW, et al. Correlates of physical activity: Why are some people physically active and others not? Lancet (London, England). 2012;**380**(9838):258-271

[44] Macera CA, Ham SA, Yore MM, Jones DA, Ainsworth BE, Kimsey CD, et al. Prevalence of physical activity in the United States: Behavioral risk factor surveillance system, 2001. Preventing Chronic Disease. 2005;**2**(2):A17

[45] Dishman RK, Heath GW, Lee I-M. Physical Activity Epidemiology. 2nd edition. Champaign, IL: Human Kinetics; 2013

[46] Moschny A, Platen P, Klaassen-Mielke R, Trampisch U, Hinrichs T. Barriers to physical activity in older adults in Germany: A crosssectional study. The International Journal of Behavioral Nutrition and Physical Activity. 2011;**8**:121. DOI: 10.1186/1479-5868-8-121

[47] Vader K, Doulas T, Patel R, Miller J. Experiences, barriers, and facilitators to participating in physical activity and exercise in adults living with chronic pain: A qualitative study. Disability and Rehabilitation. 2021;**43**(13):1829-1837

[48] Tyler J, Wood K, Dictus C. Orange county - master aging plan 2022-2027. 2022. Accessed in https://extranet.who. int/agefriendlyworld/wp-content/ uploads/2022/06/Final-2022-27- MASTER-AGING-PLAN-8.5x11.pdf

[49] Rose DJ. Fall Proof: A Comprehensive Balance and Mobility Training Program, 2nd ed. Champaign IL: Human Kinetics; 2010

[50] Keller K, Engelhardt M. Strength and muscle mass loss with aging process. Age and strength loss. Muscles, Ligaments and Tendons Journal. 2013;**3**:346-350. PubMed ID: 24596700. DOI: 10.32098/ mltj.04.2013.17

[51] Rice J, Keogh JW. Power training: Can it improve functional performance in older adults? A systematic review. International Journal of Exercise Science. 2009;**2**:131-151

[52] Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age and Ageing. 2019;**48**(1):16-31. DOI: 10.1093/ ageing/afy169

[53] Pelegrini A, Mazo GZ, Pinto AdA, Benedetti TRB, Silva DAS, Petroski EL. Sarcopenia: Prevalence and associated factors among elderly from a Brazilian capital. Fisioterapia em Movimento. 2018;**31**:e003102. DOI:10.1590/1980- 5918.031.ao02

#### **Chapter 3**

## Perspective Chapter: Geriatric Care in Africa

*Dabota Yvonne Buowari*

#### **Abstract**

There are an increasing number of people that are aging. This is also common in Africa. Therefore, they need specialist care from various categories of health care workers and other professionals on geriatric medicine and gerontology. There are few geriatricians in Africans. This is because there are few training centres in the continents. Also, most of the geriatricians are trained on the other side of the continent overseas.

**Keywords:** Africa, geriatric medicine, gerontology, population, aging

#### **1. Introduction**

As human beings are born, the aging process begins. There are many phases of life from being a neonate, infant toddler, adolescent, teenager, young adult, youth and then old age. As people age, there are challenges and problems associated with aging including health. The health needs of the elderly need to be cared for by medical doctors specially trained to care for the elderly persons who require special communication skills. Old age is a period in the lives of the elderly for rest after a long life of activity and service [1]. In some communities and societies, socio-cultural referents are used to define old age such as family status if the person has become a grandparent, physical appearances such as the appearance of gray hair and wrinkles [2].

Geriatric medicine is still a new medical specialty in most parts of the world; like any other career choice, there are still gaps in the knowledge, awareness and uptake as a profession [3, 4]. The elderly face a lot of challenges [5] physically, medically, socially, economically and otherwise. Geriatric medicine differs from typical adult medicine because it focuses specifically on the unique needs and health challenges of older adult [6]. There is generally a paucity of specialized healthcare services for the elderly in Africa, some of the reasons may be lack of training in most African countries, unawareness of the peculiar needs of the elderly and lack of human and material resources [7]. Geriatric medicine is important because most doctors deal with elderly patients no matter their specialty [8, 9].

Globally, the population is aging. It is therefore necessary that aged persons are healthy and physically active [10]. This longevity is due to several factors such as good sanitation, access to good healthcare, more people are getting educated, healthy eating and access to funds to provide the necessities of life. Some persons may become less physically active when they age. However, there is a connection between being less physically active and becoming frail [11]. Aging takes place throughout the

lifetime, as it creates an opportunity to improve and preserve the physical, health, mental well-being and improve the quality of life. The aging of the population leads to various challenges, which may be economic and social. Also, the health of the person getting older may be affected as the elderly is predisposed to certain illnesses. Governments globally need to set up the right policies that will address the challenges faced by the aged [11]. Some senior citizens are discriminated against in their communities in Africa especially if they are women and childless. Other social challenges senior citizens encounter in Africa are social isolation, elder abuse, neglect and abandonment. This is common because nursing homes and long-term care facilities are not common in Africa. Even in communities where they are available, they are underutilized. Geriatric care cannot be complete without the provision of long-term care facilities [12]. The populace needs to be educated and enlightened on the need for long-term care [12]. This is because the long-term care will provide relief for family members who have elderly persons that are frail or cannot carry out the activities of daily living by themselves or need assistance. Elderly persons in Africa generally encounter several difficulties in which their health, well-being and mental state are affected [13]. This is due to health system inadequacies and lack of care for older persons and unavailable long-term care facilities for older persons. Older persons in Africa are well respected [14]. Older women perform other roles in Africa especially carrying for their grandchildren especially if the mother of their grandchildren has passed away [14]. They are employed as babysitters and nannies. Sometimes they travel overseas to care for their grandchildren so that their children can go to work and not pay for child care.

As times are changing, many young people are getting formal employment, there will be an increased demand for long-term care facilities inform of nursing homes to care for the elderly [12]. This will help the elderly to maintain good health and access social support. Though, even the available nursing homes in some African communities are underutilized. This is due to several factors, people are not aware of their existence, beliefs and myths about nursing homes and discrimination and humiliation of people who take their elderly ones to nursing homes [15]. Some of the nursing homes in Africa are managed by religious organizations. In Africa, elders are cared for by their offspring, grandchildren and extended family members [12, 14].

#### **2. Population aging**

Population aging is a worldwide phenomenon with economic and social consequences, and it follows a decline in both birth and death rates [5, 16–20]. Globally, there is an increase in the number of elderly persons who will require geriatric care [5, 8, 17, 18, 21–30]. They make up a large number of the population in every country. This worldwide increase in the number of aged persons will increase the importance of the geriatric medicine specialty [26]. This is because old age comes with certain challenges, and chronic illnesses will become a major global public health challenge [19]. The increase in longevity is linked to the reduction in the death rate due to improved health systems and interventions [18, 28, 31].

Globally in 2017, the number of persons aged 60 years and above was 962 million, and this figure is expected to double by 2015 [2, 18, 20]. Population aging will have an impact on healthcare delivery both positively and negatively as there will be a shift from acute to chronic diseases associated with old age and the likelihood of a shortage of healthcare workers specially trained to look after the aged [19, 32, 33]. Like any

*Perspective Chapter: Geriatric Care in Africa DOI: http://dx.doi.org/10.5772/intechopen.105614*

other group of individuals in society, the aged require constant interaction with people around them [5]. Generally, in most societies and cultures including Africa, it is expected that older people are relieved from normal labour and allowed rest from active economic activities [1]. The aging population is of great concern for the health sector as health challenges are common among the elderly [17, 34] with different patterns of presentation which therefore requires special medical skills [8, 35].

#### **3. Demography of elderly persons in Africa**

It is not news that there are older persons in Africa. Worldwide, it is estimated in 2019 that there were 1 billion persons who are 60 years and above [36]. However it is estimated that this number will rise to 2 billion by 2050, there is also speculation that there shall also be an increase in the number of people that will live up to 80 years and beyond [37]. The number of older persons is increasing dramatically, especially in countries that are still developing. Most of which are African countries [38]. It is estimated by the United Nations that by the year 2045, there will be more people that will be over the age of 65 years which will outnumber the number of persons that will be below 15 years [38]. Older persons in recent times consist of a significantly larger population. In Africa, it was estimated in 2009 that 53.8 million individuals are aged 60 years and above [38]. Generally, few persons are trained in geriatric medicine and gerontology to care for the aging population in Africa.

#### **4. Who is an elder?**

The elderly are also known as senior citizens, the aged, older persons and elder statesmen. There is no precise and accurate definition of who is an elder [39] as there are different definitions for the elderly by several international organizations, and it varies from society to society [40]. The United Nations agreed that the cut-off age for an older person is someone who is 60 years and above [1, 2, 41], while the World Health Organization defines an elder to be 65 years and above [42, 43]. Most developed countries have accepted the chronological age of 65 years as a definition of elderly individuals [5, 42, 44]. In some countries, the definition of old age is linked to the age of retirement from the government civil service [5, 21]. For instance, the cut-off age for elderly persons in Nigeria is 60 years as this is the age for retirement from the Nigerian federal and state civil service. Though with the various definitions of old age or who is an elder, there is no general agreement on the age when a person becomes old [5].

#### **5. Aging in Africa**

Older persons play important roles in African societies as the African cultural systems give them high status [45]. They preserve cultural values, transmit knowledge and skills, dissolve conflicts and disagreements and also educate the young [2, 46]. The typical older adult in developing countries lives in poverty [7]. In some African countries, the kin of elderly people accuse them of witchcraft that they are the cause of misfortunes in the family [29]. This is worst for elderly women who do not have any living child; sometimes these older women are ostracized, tortured or even killed [29].

Over half of persons aged 60 years and above in Africa resided with a child either their biological children or grandchild [23] as the family and friends care for older persons [46]. Older persons in most African societies are accorded much respect [46]. Sometimes older persons are not called directly by their names. They are called mama, for women and papa or baba for men depending on the country. They are addressed as mothers or fathers irrespective of whether they have children or not. In Nigeria, there are different tribes and each tribe has a prefix added to the name of an older person. Among the Ibani people of Grand Bonny Kingdom and Opobo in Rivers State, Nigeria, the prefix 'Ada' is used for older men and 'Aya' for older women. Among the Igbo tribe of Eastern Nigeria, the prefix 'Dede' is used for older men and 'Dada' for older women. Baba is the prefix used for older men among the Yoruba people of Western Nigeria. It is an insult and also seen as a sign of disrespect in most African countries to address an older person directly by their names. The respect of older persons is also seen in several cultures including greeting and acknowledging them. For instance, among the Ibani tribe of southern Nigeria, a man must remove his hat when greeting an elder especially if the older is a man. Among the Yoruba, an older person is greeted by a female kneeling down or a male prostrating on the ground. This shows that Africans hold the older person in high esteem and these traditions have been passed down from generation to generation.

In Africa, the chronological definition of the older person sometimes causes some problems as due to illiteracy, most dates of birth are not recorded [5, 40]. Sometimes historic events are used to estimate the age. In some African countries, aging is associated with retirement and the receipt of pension [1]. Though not all African older persons have been involved in formal work, older persons in Africa are involved in transmitting oral, culture and traditions from one generation to another [2]. In Africa and other countries, senior citizens may be perceived as burdens due to their disability or dependence [21].

The elderly also known as older persons or senior citizens are persons aged 60 years and over [47]. Some others define the elderly as persons aged 65 years and above. In Nigeria, 60 years is used as this is the age of retirement from the Nigerian government civil service. Few other professionals in Africa retire above the age of 60 such as judges and lecturers.

Elderly persons are well respected as they are believed to be full of wisdom. During family and community conflicts, they are made head of locally constituted panels to deliberate on issues that range from marriage disputes, sibling rivalry and land disputes. Their verdicts are respected and taken as the final even if the decision is not reasonable. Most elderly persons in Africa do not have any form of pension or retirement benefits. They are cared for by their family members who are their biological children, nephews and nieces, community members and sometimes members of religious organizations. Therefore, they need social support as this will in turn affect their health and psychological well-being, mental health, quality of life, independence, interpersonal relationship and personality [48]. This is because social support will reduce boredom and loneliness. There will also be a reduction in elder abuse, neglect and mental health problems such as anxiety and depression.

In sub-Saharan Africa, most elderly women are not unemployed, therefore, they do not benefit from any form of social security, and hence, they are vulnerable [13]. Older persons in Africa are sometimes accused as the cause of misfortunes that happens or is experienced by their siblings and sibling children, especially if the older person is a woman and childless.

*Perspective Chapter: Geriatric Care in Africa DOI: http://dx.doi.org/10.5772/intechopen.105614*

Older persons tend to retire to their rural areas and villages when they retire from formal employment. Social amenities of life are absent in most African villages such as electricity, good pipe bore water and in recent times the internet and mobile telecommunication services. They do not have access to healthcare when they retire to the village as most of the healthcare facilities in Africa are located in urban areas and cities. The elderly are sometimes termed as witches and wizards that possess spiritual powers to inflict evil on whomsoever they want.

#### **6. Education and training in geriatric medicine in Africa**

Doctors who are specialists in geriatric medicine are known as geriatricians. There are few hospitals in Africa that provide special care for the elderly with a unit division or department of geriatric medicine. Such units are manned by doctors who have either trained abroad either in Europe or the United States of America in geriatric medicine or generalist either internal medicine physicians or family doctors with interest in caring for the elderly. There is a dilemma in Africa if generalists with an interest in caring for the elderly should be referred to as geriatricians.

Globally, there are few geriatricians. In a study among medical graduates to find out those interested in geriatrics in medical schools in the United Kingdom, only 0.9% (0.4% males, 1.3% females) after 1 year of qualification and 1.5% (1.2% males, 1.9%) females after 5 years were interested in becoming geriatricians [26].

Geriatrics is not relatively popular among medical students [9], especially in Africa where most medical students are not even exposed to geriatric medicine in medical school. In another study in South Africa, only 6.6% wanted to specialize in geriatric medicine [16].

Geriatric medicine is a relatively new medical subspecialty in most parts of the world including Africa [16, 49]. It is complex to train as a geriatrician [50]. Unlike many other physicians who have a high proportion of older patients in their practice, geriatricians place a high premium on improving the function of their patients and not just treating the disease [51]. Globally, there are several models of specialty training to become a geriatrician [6]. Some doctors enrol in residency training in geriatric medicine. Another career pathway is to complete the residency in either internal medicine or family medicine depending on what is obtainable in the country and then train in a 1 year clinical fellowship [6]. Another career pathway is to complete a postgraduate degree that is Diploma, Masters or Doctor of Philosophy (PhD) in geriatric medicine [6]. Another pathway which is that some African doctors have done is to write the diploma in geriatric medicine examination of the Royal College of Physicians of London. In Canada, only candidates certified by the Royal College of Physicians and Surgeons of Canada in internal medicine may be eligible for certification in geriatric medicine [52].

In most countries, geriatric medicine is hardly included in undergraduate training [16]. This may be due to the lack of geriatricians. Specialization in geriatric medicine has traditionally been within internal medicine but a trend in some countries is for geriatricians to be trained within family medicine [16]. Medical training should embrace a multidisciplinary perspective team with particular attention given to the special care needs of the elderly persons reflecting the fact that they include medical conditions unique to this age group [30]. Development of geriatric care should be enhanced in undergraduate and also at postgraduate levels of training [26]. A Diploma in Geriatric Medicine is awarded by the Royal College of Physicians of

London. The examination is designed to give recognition of competence in the provision of care of older people to general practitioners, trainees, middle-grade doctors working in non-consultant career posts in departments of geriatric medicine and other doctors with interest in or responsible for the care of older people [53]. Some Africans have passed this examination.

#### **7. Geriatric care in Africa**

Formalized care for the elderly is not adequate and well developed in Africa. There are few geriatricians in Africa including few training centres dedicated to the training for geriatric medicine. However, there are few training centres in African countries such as South Africa. In Nigeria, the training in geriatric medicine is still new and only a few hospitals are accredited by the West African College of Surgeons for the training of geriatricians in Africa. This is done after success in the junior residency emanations. Most geriatricians working in Africa have been trained overseas. In developed countries, some other doctors who have an interest in the care of the elderly but do not have the opportunity to have specialist training in geriatric medicine have attended refresher courses in geriatric medicine. There are family doctors and physicians who have gained their experience in geriatric medicine by interest in the specialty and devoting their time and energy to caring for the elderly. Most African societies are becoming urbanized, and this is affecting the care of older persons making them vulnerable, dissolution of the structure of the family and lack of access to good healthcare [13]. Even with experience in caring for older persons, their knowledge will be limited because they do not have any specialists training in geriatric medicine [38].

In a study conducted by Dotchin et al., on the services and training in geriatric medicine in Africa, in most African communities, there are limited specialist healthcare services for older persons [38]. Several medical specialties are encompassed in geriatric medicine such as family medicine, internal medicine, emergency medicine, surgery and dermatology. Geriatric medicine as a specialty is not taught in medical schools [38]. Governments in developing countries have an important role in the provision of healthcare for elder persons [12]. The governments need to enact policies and laws that will protect the vulnerability of senior citizens. Care of the elder citizens is not of importance to the policymakers in most African countries.

There are few geriatric centres or units in Africa. This may be because there are few training centres for geriatric medicine in Africa. In Nigeria, for instance, as at the time of writing this book, there is the Tony Anenih Geriatric Centre at the University College Hospital, Ibadan; Care of Elderly Person's Unit (CEPU) at the University of Port Harcourt Teaching Hospital and the Geriatric Unit at the University of Benin Teaching Hospital, Benin City, Edo State. The Geriatric Unit of the University of Benin Teaching Hospital was created in October; 2013 [7]. Other Nigerian hospitals have a special clinic for older persons but are not organized by the hospital management as a geriatric unit or department. In the face of limited resources, it is possible to establish a functional geriatric unit and achieve best practices in resource-limited settings by investing in improving available human resources and infrastructure [7].

In Nigeria, there is no organized training for geriatric medicine but doctors with an interest in caring for the elderly practice geriatric medicine and care for the health needs of the elderly. This includes family doctors and physicians. Anesthetists with an interest in geriatric medicine practise geriatric anesthesia. Few Nigerian doctors have

#### *Perspective Chapter: Geriatric Care in Africa DOI: http://dx.doi.org/10.5772/intechopen.105614*

trained to be geriatricians in the United Kingdom and the United States of America or have passed the diploma in geriatric medicine examination of the Royal College of Physicians. In March 2016, the University College Hospital, Ibadan, Nigeria, organized a 2 week certificate course on geriatric medicine to train family doctors and physicians in geriatric medicine. This introductory training to geriatric medicine has been done for some years after the maiden one.

Nursing homes are long-term care facilities for vulnerable groups of people for example children, motherless babies, the disabled, mentally retarded and the elderly. These are not common in Nigeria as most Nigerian nursing homes are established and managed by religious organizations and/or non-governmental organizations. Institutional homes for the elderly have their problems, therefore the residents need medical care. In Africa, due to the culture of the people, the elderly resist being kept in a home either as daycare or for long-term care instead they are to be taken care of by their children or other relatives [54]. This is also applicable to Nigeria as the Nigerian elderly are still cared for by their families [55]. One of the reasons why in countries such as Nigeria, the elderly person will not be kept in a long-term home is the belief that the elderly will place a curse on whoever brings the idea and support any placement in the long-term care facility or children or other family members [55].

Sometimes, some of the residents of the nursing homes are abandoned and neglected by their relatives. In this modern day, where young people both men and women have to be involved in circular work or businesses that keep them away from home, specialized long-term institutions are necessary to care for the vulnerable groups of people in the society including the elderly.

#### **8. Conclusions**

There are a rising number of people getting older and living up to 60 years and above. This group of people in Africa is faced with several challenges, and they are prone to vulnerability. They are faced with health and social problems. This is worst for women who are single as they are sometimes ostracized and even called witches. There are few geriatricians in Africa; however, most countries are developing strategies for various forms of training in geriatric medicine such as postgraduate courses, fellowship, refresher courses and workshops. There is need for more research on the elderly in Africa. The different states in the African continent should enact policies and laws to protect senior citizens in Africa.

*Geriatric Medicine and Healthy Aging*

#### **Author details**

Dabota Yvonne Buowari Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria

\*Address all correspondence to: dabotabuowari@yahoo.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

[1] Baloyi ME. A pastoral investigation into some of the challenges associated with ageing and retirement in the south African context. Indie Shriflig Art. 49 (3) Art # 1866. 10 pages. DOI: 10.4102/ ids.v.49.3.1866

[2] United Nations High Commissioner for Refugees, The United Nations Refugee Agency. Working with Older Persons in Forced Displacement. Geneva. 2013. Retrieved from: www.unhcr.org. [Accessed: October 2019]

[3] Byszewski A, Bezzina K, Latrous M. What kind of doctor do you want to be? Geriatric medicine podcast as a career planning resource. Biomedical Resource International. 2017:1-6. DOI: 10.115/ 2017/618348

[4] Brubaker JK. The birtf a new specialty: Geriatrics. Journal of Lancaster General Hospital. 2008;**3**(3):105-107

[5] Abiodum MG, Adekeye OA, Iruonagbe TC. Counselling services for remediating the biopsychosocial challenges of the aged in Nigeria. Journal of Functional Management. 2011;**3**(1):89-98

[6] Won CW, Kim S, Swagerty D. Why geriatric medicine is important for Korea: Lessons learned in the United States. Journal of Korean Medical Science. 2018;**33**(26):e17. DOI: 10.3346/ jkms.2018.33.e175

[7] Akoria OA. Establishing in-hospital geriatrics services in Africa: Insights from the University of Benin Teaching Hospital geriatrics project. Annals of African Medicine. 2016;**15**(3):145-153

[8] Cooper N, Forrest K, Muller G. ABC of Geriatric Medicine. 1st ed. Wiley; 2013. pp. 2-100

[9] Marjolein HJ, Joep L, Elise LK, Marcel GMO, Cornelia RMGF, Antonie LML. 2 lessons learned from narrative feedback of students on a geriatric training program. Gerontology and Geriatrics Education. 2018;**39**(1):21-34

[10] Naah FL, Njong AM, Kimengsi JN. Determinants of active and healthy ageing in sub-Saharan Africa: Evidence from Cameroon. International Journal of Environmental Research Public Health. 2020;**17**:3038. DOI: 10.3390/ ijerph17093038

[11] Tanyi PL, Andre P, Mbah P. Care of the elderly in Nigeria: Policy implications. Legent Social Sciences. 2018;**4**(1):1555201. DOI: 10.1080/ 23311886.2018.155521

[12] Towards Long-Term Care Systems in Sub-Saharan Africa: WHO Series on Long-Term Care. Geneva: World Health Organization; 2017 Licence: CCBY-NC-SA30

[13] Parmar D, Williams G, Dkhimi F, Ndiaye A, Asante FA, Arhinful DK, et al. Enrolment of older people in social health protection programs in West Africa - does social exclusion play a part? Social Science and Medicine. 2014;**119**:36-44

[14] Dotchin CL, Akinyemi RO, Gray WK, Walker RW. Geriatric medicine, services and training in Africa. Age and Ageing Advance. 2012;**6**:1-9. DOI: 10.1093/ ageing/afs119

[15] Help Age International. Discrimination against older women in Burkina Faso. Parallel Report Submitted to the 47th Session of the Committee on the Elimination of All Forms of Discrimination Against Women

(CEDAW) in relation to Burkina Faso's Sixth periodic report of States parties, CEDAW/C/BFA/6. 2009

[16] Ferreira M. Geriatric medicine in South Africa-a Cinderella subspecialty? South Africa Family Practice. 2008;**48**(8):18

[17] Sidik SM, Rampal L, Afifi M. Physical and mental health problems of the elderly in a rural community of Sepang. Selangor. Malaysian Journal of Medical Science. 2004;**11**(1):52-59

[18] Gerber AM, Mostert A, Botes R, Vorster A, Bustens E. A cohort study of elderly people in Bloemfontein, South Africa to determine healthrelated quality of life and functional abilities. South African Medical Journal. 2016;**106**(3):298-301

[19] Naja S, Makhlouf MMD, Chehab MAH. An ageing world of the 21st century: A literature review. International Journal of Community Medicine and Public Health. 2017;**4**(12):4363-4369

[20] D'Albis H, Collard F. Age groups and the measure of population ageing. Demographic Research. 2013;**29**(23):617- 640 www.demographic-research.org assessed 2018

[21] Men Ageing and Health. Geneva: World Health Organization. www.who. int Assessed October 2018

[22] Karthaus M, Falkenstein M. Functional changes and driving performance in older drivers: Assessment and interventions. Geriatrics. 2016:1-18. DOI: 10.3396/geriatrics/020012. Available from: www.mdpi.com/journal/geriatrics [Accessed: October 2018]

[23] Department of Economic and Social Affairs, Population Division. World

Population Ageing 2017 - Highlights (ST/ ESA/SER.A/397). United Nations; 2017

[24] Asthana S, Golden RN. The ageing imperative - innovations in research, education and care in geriatric medicine. World Medical Journal. 2018;**117**:92-93

[25] Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. The American Journal of Geriatric Pharmacotherapy. 2007;**5**:345-351

[26] Maisonneuve JJ, Pulford C, Lambert TW, Goldacre MJ. Career choices for geriatric medicine: National surveys for graduates of 1974 – 2009 from all UK medical schools. Age and Ageing. 2014;**43**:535-541

[27] Pillay NK, Maharaj P. Population ageing in Africa. In: Maharaj P, editor. Ageing and Health in Africa. International Perspectives on Aging. New York: Springer Science; 2013. pp. 11-51

[28] Chaudhary P, Lamba N. Critical review of geriatric care in Ayurveda with special reference to Jara. International Research Journal of Pharmacy. 2017;**8**(4):5-8

[29] Towards Long-Term Care Systems in Sub-Saharan Africa: WHO Series on Long-Term Care. Geneva: World Health Organization; 2017 www.who.int License: CCBY-NC-SA.3.0190. assessed October 2018

[30] Keller I, Makipaa A, Kalenscher TM, Kalache A. Global Survey on Geriatrics in the Medical Curriculum. Geneva: World Health Organization; 2002 www.who.int assessed October 2018

[31] Vellas B, Morleg JE. Geriatrics in the 21st century. Journal of Nutrition and Healthy Aging. 2018;**22**(2):186-190

*Perspective Chapter: Geriatric Care in Africa DOI: http://dx.doi.org/10.5772/intechopen.105614*

[32] Musunuru K, Mallela J. A systematic review on the role of healthcare administration in geriatric care. Open Journal of Geriatric Medicine. 2018;**4**(2):1-3

[33] Nishinaga M. Comprehensive geriatric assessment and team intervention. JMAJ. 2007;**50**(6):461-466

[34] Wilber ST, Gerson LW, Terrel KM, Carpenter CR, Shah MN, Heard K, et al. Geriatric emergency medicine and the 2006 Institute of Medicine reports from the committee on the future of emergency care in the US health system. Academy of. Emergency Medicine. 2006;**13**(12):1345-1351 www.aemj.org assessed October 2018

[35] Fisher JM, Garside M, Hunt K, Lo N. Geriatric medicine workforce planning: A giant geriatric problem or has the tide turned? Clinical Medicine. 2014;**14**(2):1026

[36] World Health Organization. Ageing. www.who.int

[37] Ssensamba JT, Mukuru M, Nakafeero M, Sseryonga R, Kiwanuka SN. Health systems readiness to provide geriatric friendly care services in Uganda: A cross-sectional study. BMC Geriatrics. 2019;**19**:256. DOI: 10.186/ s12877-019-1272-2

[38] Assumcao M, Pinto S, Jose H. Public and health policy for the aged in Africa to the south of Saraa. Revista Brasileira de Enfermagem. 2020;**73**(Suppl 3): e20190313. DOI: 101590/0034-7167- 2019-0313

[39] Singh S, Bajorek B. Defining elderly in clinical practice guidelines for pharmacotherapy. Pharmacy Practice. 2014;**12**(4):489-490 www. pharmacypractice.org accessed October 2018

[40] Ayokunle AM, Oyeyemi FT, Onipede W, O TF, Olagunju AE, Makinde GB, et al. The definitions and onset of an old person in South-Western Nigeria. Educational Gerontology. 2015;**41**(7):494-503. DOI: 10.1080/03601277.2014.1003492

[41] www.un.org Assessed October 2018

[42] www.who.int Assessed October 2018

[43] Raveendra L. A clinical study of geriatric dermatoses. Our Dermatology Online. 2014;**5**(3):235-239

[44] Sobokta L, Schneider SM, Berner YN, Cederholm T, Krznaric Z, Shenkin A, et al. ESPENN guidelines on parenteral nutrition: Geriatrics. Clinical Nutrition. 2008;**28**:461-466

[45] Adeleke RO, Adebowale TO, Oyinlola O. Profile of elderly patients presented with psychosocial problems in Ibadan. MOJ Gerontology and Geriatrics. 2017;**1**(1):26-36

[46] Abanyam NL. The changing privileges and challenges of older persons in contemporary African society. Global Journal of Art and Human Social Science. 2013;**1**(41):34-43

[47] Asagba A. Research and the formulation and implantation of ageing policy in Africa: The case of Nigeria. British Society of Gerontology. 2005;**16**(2):39-41

[48] Gyasi RM, Phillips DR, Abass K. Social support networks and psychological well-being in community-dwelling older Ghanaians cohorts. International Psychogeriatrics. 2019;**31**(7):1047-1057

[49] The American Geriatric Society. Why Geriatrics as a Career Choice? www.

#### *Geriatric Medicine and Healthy Aging*

americangeriatrics.org Assessed October 2018

[50] The Canadian Geriatrics Society. Geriatric Medicine Profile. www. canadiangeriatrics.ca Assessed October 2018

[51] Misha AA. The concept of successful aging. International Journal of Human and Health Sciences. 2017;**01**(01):22-25

[52] Royal College of Physicians and Surgeons of Canada. Objectives of Training in the Subspecialty of Geriatric Medicine. www.royalcollege.ca

[53] Royal College of Physicians of London. The Diploma in Geriatric Medicine. www.rcplondon.ac.uk Assessed October 2018

[54] Adedokun MO. Caring for the elderly: Towards a better community. European Journal of Educational Services. 2010;**2**(3):283-291

[55] Okoye UO. Community-based care for homebound elderly persons in Nigeria. A policy option. International Journal of Innovative Research in Science, Engineering and Technology. 2013;**2**(12):7086-7091

## Section 2
