The purpose of this study is to determine whether a daily exercise regimen reduces future risk of heart attacks among adults over 65 years. In the proposed research study, the Health Locus of Control (HLC) will be utilized as the main theory whereas the Activity Theory will be employed as supporting in the framework that will guide the research process. The research design for the proposed study is the randomized controlled trial, which will be used in determining the effectiveness of a daily exercise regimen in reducing the heart attack risk. The population for this research comprises of elderly patients who are at a risk of heart attacks. Sixty participants will be recruited using random sampling from patients attending a cardiac rehabilitation program. The outcome measures for this research will include the HLC, physical activity, cardiac exercise self-efficacy, blood pressure and heart rate at rest, exercise capacity, as well as body mass index. The data collected will be put into the Statistical Package for Social Sciences (SPSS) for further analysis. The Repeated Measures ANOVA will be utilized to compare the differences in the outcome measures between the treatment and control groups.
Keywords: exercise regimen, Health Locus of Control, heart attack
Place New Order
Heart disease is one of the most serious health risks that increase with aging. The most recent statistics published by the Centers for Control and Prevention (CDC) indicates that heart disease is the leading cause of deaths among individuals aged 65 years and above, contributing to 488,156 deaths in 2013 (Xu, Murphy, Kochanek, & Bastian, 2016). The prevalence of heart disease is 26% and 37% among women and men aged 65 years and above (Xu et al., 2016). The risk factors for heart attacks and disease, such as high cholesterol and high blood pressure, increase with aging (Dahlof, 2010). One of the modifiable risk factors for heart attacks is lack of physical activity. However, the elderly constitute the age group that is least physically active (Shiroma & Lee, 2010). Essentially, regardless of age, being physically active plays an instrumental role in staying healthy.
Statement of the Problem
The demographic structure of the US is projected to undergo drastic changes in the coming decades. The notable trend expected is a near two-fold increase of the elderly population aged 65 years and above by 2050 (Andersen, Rice, & Kominski, 2011). In 2000, those aged 65-84 years comprised of 10.9 % of the US population. However, in 2050, it is projected that this proportion will be about 16 % (Andersen, Rice, & Kominski, 2011). Additionally, it is projected that those aged 85 years and above will constitute 4.3 % of the entire US population as of 2050, which denotes more than a double-fold increase relative to 2010 (Andersen, Rice, & Kominski, 2011). Simply stated, the number of people aged 85 years and above will be 19 million in 2050, up from about 5.8 million as of 2010, which represents an increase of about 228 % (Andersen, Rice, & Kominski, 2011). These expected demographic changes will pose a considerable burden in regard to the costs, mortality, and morbidity associated with heart diseases. The age-related increase in the mortality and morbidity of heart diseases poses the need to devise effective interventions to help reduce the risk for developing heart attacks in the future (Dahlof, 2010). One of the potential interventions that can be used to decrease the risk for developing heart attacks among the elderly adults is daily exercise regimen. However, the majority of studies evaluating this intervention focus primarily on young adults. It is because older patients are often underrepresented in clinical trials. Carro & Kaski (2014) note that the participation of elderly patients in heart disease trials has remained stagnant for the 1970-2010 period although this population is expanding. Therefore, there is no reliable data to guide treatment for elderly patients, which results in the elderly individuals receiving more conservative treatment interventions despite being high-risk individuals. In some instances, the treatment offered to the elderly deviates from the recommendations outlined in the accepted guidelines (Carro & Kaski, 2014). The consequence is that, relative to younger patients, elderly patients suffering from heart disease are less likely to receive evidence-based treatments. Therefore, the current research is aimed at addressing this gap in literature.
Purpose of the Study
The purpose of this study is to determine whether a daily exercise regimen reduces the future risk of heart attacks in adults over 65 years. The research is topical and important because of the expected demographic changes and the increased risk factors for cardiovascular events associated with aging. Therefore, the findings of this research will provide the insights about the effectiveness of a daily exercise regimen in reducing the risk factors for heart attacks among the elderly population. In order to achieve the aim of this research, a randomized controlled trial (RCT) design will be used, wherein the elderly patients participating in the research will be randomly placed in the treatment and control groups. The treatment group will be subjected to a daily exercise regimen whereas the control group will be subjected to the usual physical exercise program or lack thereof.
For the purpose of this research, the following research question will be addressed:
1. Does a daily exercise regimen reduce future risk for heart attacks in adults over 65 years compared to those who do not exercise?
As part of the proposed research, the investigation included one research hypothesis:
Ha: Adults over 65 years subjected to a daily exercise regimen will have a lower risk for heart attacks when compared to those who do not.
H0: Adults over 65 years subjected to a daily exercise regimen and those who do not exercise will have the same risk for heart attack.
Definition of Terms
1. Physical activity refers to any bodily activity movement as a result of skeletal muscles using energy (Shiroma & Lee, 2010).
2. Aging can be chorological or functional. Chronological aging denotes the number of years one has lived whereas the functional aspect aging represents the individuals functional capability (Carro & Kaski, 2014).
In this research, the Health Locus of Control (HLC) will be utilized as the main theory whereas the activity theory will be employed as supporting in the framework that will guide the research work. The HLC theory elucidates how an individual comprehends the reasons for events that occur in life (Rydlewska et al., 2013).Moreover, this theory offers an explanation of the significance of personal responsibility and choice in daily activities. The HLC outlines the values influencing the health actions of a person, which include the internal and external health of control. The internal HLC refers to the persons perception that his/her behavior influences his/her actions, and that ones health status is attributed to his/her control (Rydlewska et al., 2013). On the other hand, the external HLC denotes a scenario where a person is of the belief that his/her actions do not have influence on their future health status, and that his/her health is under the control of other people such as caregivers (Rydlewska et al., 2013).
The Activity Theory posits that staying physically and mentally active will lead to the increase in happiness. The Activity Theory posits that, when an elderly individual is more active, he/she shows higher levels of satisfaction with life (Sannino, 2011). This theory suggests that elderly individuals should continue living a middle-age lifestyle and reject the limitations associated with aging. Moreover, the Activity Theory stipulates that activities, such as physical exercises, help in engaging the elderly, which in turn results in overall improvement of the wellbeing (Sannino, 2011).
The relationship between these two theories is extremely important in the sense that when the reasons for life events (aging) are understood properly, a person can make a fundamental choice to be responsible for his own health and body. The Multidimensional HLC Scale draws upon the notion that health status depends on two aspects internal factors like being self-determined to live a healthy lifestyle, and external factors like a caregiver or luck. The HLC relates to how individuals comprehend and measure the relationship between the health status and behavior. The HLC has been correlated with high levels of exercise (Rydlewska et al., 2013). The HLC affects the thinking and reactions of people towards their health as well as health choices. The elderly individuals experience deterioration in their health, which subsequently has an effect on their locus of control. Helpers and caregivers have the responsibility and duty to encourage the elderly to have internal locus of control to enable them live healthy lifestyles, particular in the domain of physical activity. A positive relationship exists between physical exercising and internal locus of control, which subsequently results in improved perceived health outcomes (Rydlewska et al., 2013).
Researchers and scholars pay close attention to the prevention and delay of chronic illnesses among the elderly in order to prolong the duration of their healthy life expectancy and functional wellbeing. One of the areas that has received immense attention in the literature relates to physical activity patterns among the elderly and its relationship with cardiac health. Heart diseases constitute the leading factor causing deaths among the elderly and those aged 65 years and above.
Risk Factors for Heart Attacks
Heart attack has various risk factors. O'Donnell et al. (2010) outlined some of the most significant risk factors associated with heart attacks, which include diabetes, blood pressure, diet, being overweight, physical activity, smoking tobacco, family history, sex and age. These risk factors can be grouped into either modifiable or non-modifiable. Modifiable risk factors denote the conditions that can be changed using changes in lifestyle whereas non-modifiable risk factors are those that cannot be changed.
The modifiable risk factors associated with heart attacks include high concentration of blood glucose; high concentration of blood lipids and dietary fat; high blood pressure; malnutrition; lack of physical activity; alcohol abuse; and smoking tobacco (O'Donnell et al., 2010). Moreover, using oral contraceptives, regular migraine, and abrupt stress have been associated with heart attacks. A research by Dahlof (2010) indicated that negative emotions, sudden stress, anger, and abrupt changes in the posture of the body increase the risk of heart attacks. A study performed by O'Donnell et al. (2010) explores the relationship between the likely risk factors and heart attacks and revealed that the two most significant risk factors for heart attacks are cigarette smoking and high levels of blood lipids concentration. The combination of these two factors accounts for about 66 % of the risk for heart attacks globally. The other seven risk factors identified in the research include diabetes, obesity, hypertension, physical inactivity, psychosocial factors including stress and depression, and diet (lack of vegetable and fruit consumption) (O'Donnell et al., 2010). All these factors were established to account for about 90% of the risk for heart attack globally. Numerous studies have provided evidence that heart attacks can be prevented changing the lifestyle (Dahlof, 2010; O'Donnell et al., 2010; Shiroma & Lee, 2010). The findings by O'Donnell et al. (2010) showed that about 90% of heart attacks are attributed to modifiable risk factors, which can be reduced significantly due to regular physical activity, healthy diet, and quitting smoking.
The non-modifiable risk factors for heart disease are age, type 1 diabetes, and age. Yazdanyar and Newman (2009) point out that aging is a predisposing factor for the majority of chronic illnesses due to the body deterioration with time, which makes it susceptible to chronic diseases. With aging, the body is predisposed to numerous stressors and strains that accelerate the breakdown of the functions of organs and cells (Andersen, Rice, & Kominski, 2011). Epidemiological research has established that individuals having a family history of heart attacks are at more risk of suffering from cardiac events including heart attacks. Type 1 diabetes is also associated with a higher risk of heart attacks (Dahlof, 2010). It is because type 1 diabetes compromises numerous body functions, especially glucose tolerance and fat metabolism. These metabolic disorders increase the risk of heart attacks.
Relationship between Physical Activity and Heart Health
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Numerous evidence-based studies indicate a positive association between good health and physical activity. Moreover, a plethora of research studies affirm the important role that physical activity plays in ensuring the overall wellbeing of an individual. Research studies consistently indicate the relationship between the occurrence of heart diseases and physical activity levels (Fogelholm, 2010; Rahman, Bellavia, Wolk, & Orsini, 2015). In particular, these studies show that the increase in physical activity decreases the risk of developing heart diseases. The benefits of physical activity have been documented in the literature. For instance, Fogelholm (2010) linked physical activity with the decrease in blood pressure. In another research, physical activity was found to reduce the concentrations of triglyceride and cholesterol, which are risk factors for heart attacks (Rajati et al., 2013). Other heart attack risk factors reduced by physical activity include increased exercise tolerance, reduction of the body weight, and increased insulin sensitivity (Carro & Kaski, 2014). Fogelholm (2010) found that physical exercise improves muscular strength and function as well as aerobic capacity, which is essentially important for individuals with a history of heart attacks since their exercise capacity is generally lower when compared to others. Apart from exploring the effect of physical exercise on the risk factors for heart attacks, some studies have examined the relationship between physical exercise and heart attack risk. For instance, Sattelmair et al. (2011) reported that vigorous physical activity significantly lowered the risk of cardiac events among adults aged 75 years and above.
Physical Activity Levels among the Elderly
Despite the importance of physical activity, especially for the high-risk elderly population, individuals aged 65 years and above have been reported to be less physically active when compared to any other age group (Rahman, Bellavia, Wolk, & Orsini, 2015). Hallal et al., (2012) indicated that 63% of girls and 72%of boys aged between 2 and 15 years met the recommended one hour of physical activity every day target. The same research reported that grown-ups aged between 16 and 64 years did not fare well with respect to meeting the recommended guidelines for physical exercise, with 28% of women and 40% of men meeting the recommended physical activity levels for adults of at least five sessions of moderate physical activity lasting for 30 minutes a week (Hallal et al., 2012). A remarkable finding by the research is that the elderly performed physical activity poorly. The research showed that only 13% of women and 17% of men aged 65 and above met the recommended guidelines for physical activity (Hallal et al., 2012). Another study by Van Cauwenberg et al. (2011) revealed that 44% of adults aged 70 and above take a 20-minute walk less than once on a yearly basis, sometimes never. Another research study that sought to explore physical activity patterns among the elderly indicated that about 66% of older individuals exercise; however, they are focusing solely on one physical activity, which means that they miss the key health benefits associated with physical activity. The study showed that the majority of the elderly preferred aerobic activity, majorly walking, with only 2.6% indicating that they combined aerobic, strength, and balance activities. The authors concluded that the majority of elderly people engage in low-impact physical exercises that are unlikely to offer optimal protection against age-related health risks (Van Cauwenberg et al., 2011). From these observations, it can be inferred that, as individuals age, their physical activity levels decrease, which in turn increases their health risks.
The research design adopted for the current research is the randomized controlled trial (RCT). This design is a form of scientific experiment characterized by allocating participants randomly in either treatment group or the control group receiving standard or alternative treatment (Farrokhyar et al., 2010). This design helps in minimizing selection. It is often used in determining the effectiveness of treatment or intervention, which is consistent with the purpose of this research in the sense that it seeks to ascertain the effectiveness of a daily exercise regimen in reducing the heart attack risk. The theoretical model that will guide the research is the HLC. The HLC has been linked to physical activity; thus, it is expected that elderly patients who exercise regularly will have a higher health of locus control; hence, lower risk factors for heart attacks when compared to those who do not exercise.
The population for this study comprises of elderly patients who are at a risk of heart attacks. The participants from this research will be selected among the patients attending a particular cardiac rehabilitation (CR) program, who will be allocated to the two groups, with participants in the treatment group being subjected to daily exercise regimen while those in the control group receiving normal care. Purposive sampling will be used for selecting participants since the proposed research targets only the elderly individuals having a past history of heart attacks; thus, a set of inclusion and exclusion criteria will be used in this research. Patients will be eligible for participation in this research if they are 65 years old and above; can speak English; and have a history of heart attacks. Participants will be excluded from the research if they are unable to speak English; taking part in another physical exercise program; have mental illness; participating in another research study; and having neuromuscular conditions that hinder them from participating in physical exercise. The sample size for this research is based on Pozehl, Duncan, Hertzog and Norman (2010), who used 80% power coupled with a two-tailed significance of 0.05 to notice an effect size of 0.47 in an outcome for two participant groups. Therefore, an estimated sample size 30 patients for each group.
In this study, the independent variable is participation in a daily exercise regimen. The outcome measures for this research will include the HLC, physical activity, cardiac exercise self-efficacy, blood pressure and heart rate at rest, exercise capacity, and body mass index. These outcomes will be measured at baseline prior to the randomization, and after one, three, and six months follow up. The baseline assessments will include demographics and general information such as age, medications used, and medical history.
The Multidimensional HLC Scale (MHLC). This instrument will be used to assess participants beliefs as to whether his/her health status is influenced by his/her actions, and whether the HLC is external or internal. This instrument has been established to have high internal consistency, with an alpha coefficient that exceeds 0.9 (Rydlewska et al., 2013).
International Physical Activity Questionnaire (IPAQ). This instrument will be used to assess physical activity during the past seven days in four domains including leisure/recreation, housework, transportation, and occupation. This instrument has been found to be reliable, with a reliability coefficient of 0.80 (Rajati et al., 2013).
Cardiac Exercise Self-Efficacy Scale (CESE). This instrument will be used to measure the exercise self-efficacy of patients. It focuses on the opinions of patients concerning their ability to tolerate physical exercise following a heart attack event. CESE has a substantial internal consistency having an alpha coefficient of 0.9 (Rajati et al., 2013).
Blood Pressure and Heart Rate at Rest. It is a measure of the risk factor for heart attack. It will entail measuring the heart rate/minute. Blood pressure will be measured using a standard mercury sphygmomanometer. Blood pressure will be measured twice between five-minute intervals and the two values averaged (Rajati et al., 2013).
Body Mass Index. It is a measure of the risk factor associated with heart attack. It will be computed by dividing the patients weight in kilograms by his/her height in square meters (Rajati et al., 2013).
Data Collection and Analysis Procedures
Data for the proposed research will be collected at baseline prior to the randomization, and after one, three, and six months follow up. Eligible participants will be required to complete the informed consent letter before participating in the research. No incentives will be offered for the participation. Data collected will be put into the Statistical Package for Social Sciences (SPSS) for analysis. The Repeated Measures ANOVA will be used to compare the differences in the outcome measures between the treatment and control groups for analyzing before and after the intervention data.
Protection of Human Rights
Participation in this research will be on a voluntary basis, which means that no participant will be coerced into taking part in the research. Moreover, the participants will be informed of their right to withdraw from the study at any time without being subjected to any penalties. in addition, confidentiality will be protected by refraining from collecting personal information that could be used to identify the participants. No direct references to participants will be made when reporting the findings. A copy of the study will be mailed to the participants after the research completion.
Discussion/Significance of the Study
There is a need to identify and develop evidence-based interventions to help enhance physical activity among the elderly suffering from heart attacks. The current research evaluates potential intervention daily exercise regimen that could help reduce heart attack risks. This intervention could yield significant benefits for the elderly, especially those having heart attacks. The study makes a contribution to an underexplored area in literature. In case the intervention is reported to reduce heart attack risks during the follow-up periods, future experimental research might be needed to help identify the most crucial component of the daily exercise regimen intervention. The findings presented in this research will offer helpful insights regarding the important role that regular physical exercise could help in enhancing the cardiac health of the elderly. If found successful, this intervention might be implemented to improve health conditions of other patient populations such as diabetics. The limitation relates to the difficulty in making participants to adhere to the daily exercise regimen program; thus, a high rate of attrition is expected.
The proposed study as aimed at exploring the relationship between physical exercise regimen and the risk of heart attacks among the elderly aged 65 years and above. The elderly are at a higher risk of cardiac events when compared to any other age group. Moreover, they are the least physically active. Hence, there is a need to examine whether physical exercise regimen can help decrease the future risk of heart attacks among the elderly. The research design adopted for the proposed research is the randomized controlled trial, with the outcome measures including the HLC, physical activity, cardiac exercise self-efficacy, blood pressure and heart rate at rest, exercise capacity, and body mass index.
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