Swimming to Happiness: Frailty Prevention in Older Adults

Abstract

Frailty is an important geriatric syndrome that can adversely affects the quality of life of older adults. Lifestyle interventions, such as physical activity, healthy diet and medications optimization have strong evidence in prevention, treatment, and reversal of frailty. While physical activity is the most important, inactivity among older Americans remains high. We present a case in which successful approach to frailty prevention, through regular swimming, showed meaningful improvement. Collaboration between the patient, family and physician, was also important. Collectively, these efforts lead to improvement in patient’s mood, quality of life, and medication use.

Introduction

“Older age and frailty may be perceived as a disadvantage to stay physically active. However, physical activity promotes health and prevents frailty. It is never too late to pick up sports.”

Frailty in older adults has been well recognized for more than half a century. Evolving research over the last 20 years clearly distinguishes the differences between age, aging, and frailty.

The aging process seen with increasing chronological age is a physiological process, while frailty is not considered a normal part of aging. Frailty is a medical condition, viewed as gradual decline in reserve of multiple physiological systems that leads to increased vulnerability to various health stressors and adverse life events. ¹

The estimated prevalence of physical frailty among community-dwelling older Americans is approximately 15% and risk increases with older age, women, racial and ethnic minorities, individuals in supportive residential settings, and lower income status. In addition, about 45% of community-dwelling older adults are considered prefrail, indicating a substantial at-risk population. ²

Poor nutrition, physical inactivity, polypharmacy, loneliness, social isolation, and depression are all interrelated risk factors that contribute to frailty in older adults, with evidence showing bidirectional links especially between loneliness, social isolation, depression, and frailty.^3,4

Exercise is the single most modifiable lifestyle factor to prevent frailty. Despite this, inactivity among older Americans remains high. Only 15.3 % of American men and 10.8% of women aged 65 are compliant with the physical activity guideline. ⁵ Only one-third of patients report that they have received physical activity counseling by their primary care physician. ⁶

Barriers to sufficient physical activity in older adults are due to various factors involving both patients and primary care providers (PCP). PCPs attitudes and beliefs about counseling affect the referral process. For example, some PCPs believe that they have insufficient knowledge about counseling, or that counseling is not effective which can affect decisions to refer patients for physical therapy. The most common barrier to recommending physical activity was patient-related, which included a perceived lack of interest by the patient, and that the patient had other immediate health needs. ⁷ Older adults usually perceive their advanced age or presence of chronic medical conditions as a disadvantage to exercise. Examples cited include “I am too old or too sick to exercise. Sports are for young people.” ⁸

We present an inspiring story of 96-year-old woman who began swimming in her seventies, and continues to swim for an hour every day, as she ages gracefully.

Patient’s Story

A 96-year-old woman presented to our geriatric clinic in significant emotional distress with increasing anxiety, depressed mood and crying spells. In despair, she stated that “I can’t swim.” She took the sport up in her seventies following the death of her husband, who was her high school sweetheart, and she was married to him for 53 years. In the tough grieving process, she felt better when she got into the lake near their cottage. Since then, she started going to a local pool and swimming. She found swimming to be relaxing and reduced her anxiety, helping her in grieving to the point that it was the reason she felt she could live at home alone, independent in all her instrumental activities of daily living. Since then, she continued to swim at a local indoor pool for an hour every day.

However, due to the lockdown during the COVID-19 pandemic, public activities including gyms and pools were closed. Since then, she was no longer able to swim and lost the one activity that calmed her mind. Her self-esteem decreased, and anxiety and depression kept worsening. Despite psychotherapy and anti-depressant medicine, her suffering persisted. She knew that the only way to improve her symptoms was if she could swim again.

During the meeting with the patient and her family, we supported her desire to continue swimming, assuming it might be a therapeutic approach. Finally, her family moved with her to the lakes and assisted her in swimming in the lake. After that, her local gym re-opened, and she started her one-hour daily swimming in the pool. Finally—she felt better and found emotional solace. We note that she has a history of major depression and anxiety disorder and that her medications include low dose of nortriptyline and alprazolam prescribed by her primary doctor about 30 years ago. In the past despite many attempts, she could not wean them off. Now, with continuing encouragement and support we were able to deprescribe them.

At the age of 99, she continues to swim in a pool for an hour a day and continues to age healthy and gracefully.

Discussion

Physical activity (PA) is defined as any movement of the body done through skeletal muscle contraction that causes energy expenditure to be beyond baseline. ⁹ This term is often used interchangeably with exercise. Physical activity in all humans is essential to well-being and health. Immediate health benefits of PA include reduced feelings of anxiety, reduced blood pressure and improved sleep quality.10 Long-term health benefits lower risk of chronic diseases such as T2D and cardiovascular diseases, depression, and dementia.11

Health Benefits of Physical Activity

Physical activity is essential to maintain health, independence, well-being and health-related quality of life. There is robust evidence supporting its role in preventing chronic diseases (including type 2 diabetes, hypertension, cardiovascular diseases, and some cancers), improving mood and cognitive function, preserving functional independence, and reducing risk of all-cause and cardiovascular mortality. ¹⁰ A systematic review in 2013 identified multiple long-term longitudinal studies that identified inverse relationships between physical obesity, coronary artery disease, type 2 diabetes, and neurodegenerative conditions. ¹¹ Physical activity is a cornerstone for safe and healthy aging. Regular physical activity is associated with lower risk of depression and dementia, falls prevention, higher level of functional independence, and better quality of life. ¹²

For community-dwelling older adults aged 65 and older regular exercise interventions, such as aerobic exercise and muscle strengthening at a frequency of one to four sessions per week for 30 to 60 minutes each, as well as yoga and tai chi, are likely to enhance mobility and muscle strength, improve activities of daily living, reduce falls and therefore prevent frailty. ¹³

Benefits of Swimming and Water-Based Activities

Swimming is particularly beneficial in older adults, especially those with musculoskeletal limitations, for example, debilitating arthritis, as water buoyancy reduces joint loading, pain and risk of injury while still providing both aerobic and resistance exercise. ¹⁴

Water-based training (WT) programs are being increasingly recommended for enhancing health and physical fitness in both healthy adults and adults with chronic diseases such as diabetes, hypertension, coronary artery disease as well as people and special health conditions, such as stroke, multiple sclerosis or Parkinson’s disease. ¹⁵

ACELA II Study randomized controlled trials revealed that in a community-dwelling older adults, regular swimming exercise plays significant role in improving micro- and macrovascular function, therefore might contribute to age-related cardiovascular disease risk reduction. ¹⁶ Water-based exercise, including swimming, combines both aerobic and resistance training, that increases maximal oxygen uptake, promotes cardiovascular health, enhances bone and muscle strength, joint flexibility, and endurance. ¹⁷

Although swimming itself is not HITT training, it can be considered a form of HITT workout by incorporating high-intensity intervals with short recovery periods. This type of workout can suit older people with different fitness levels and swimming skills. For older adults who cannot perform laps or HITT swimming, other alternatives such as aquatic aerobics may be more beneficial.

Water-based exercise is as effective as land-based exercise in improving physical fitness, with statistically significant improvements in muscle strength, endurance, balance, flexibility, and aerobic capacity. ¹⁸ The psychological benefits of water-based exercise include improved health-related quality of life, mood, tension, anxiety, and depression are also well documented. These benefits were noticed by our patient shortly after “getting into the water.” ¹⁹

Benefits of Social Activity for Isolation Particularly in Older Adults

Being in a poll, especially while performing group-based aquatic exercise provides great opportunity for social connectedness. Social connectedness plays critical role in preventing, maintaining and reversing mental health issues. On the other hand, loneliness and social isolation have been associated with increased risk of anxiety, depression, cognitive decline, as well as diabetes, heart disease, stroke, diabetes and overall poor health outcomes. ²⁰

Systematic reviews with meta-analysis have been shown that group-based aquatic activity could significantly improve mental health, especially mood and anxiety, lower the risk of loneliness and social isolation, reduce psychological distress, and depressive symptoms. These benefits are uniquely helpful to older adults in whom loneliness and social isolation are more prevalent and linked to anxiety, depression, and cognitive decline.^21,22

Current scientific evidence also supports that exposure to or engagement with water environment (“blue spaces” such as rivers, lakes, and costal environments) is beneficial for humans’ health. Systematic reviews and large cohort studies revealed that being in or near water is positively associated with increased physical activity level, improved mood and mental well-being.^23,24,25 “Blue spaces” physical activity with enhanced nature connectedness is reducing stress and enhancing psychological restoration, which in turns provides health benefits.

There is also emerging evidence that leaving near “blue spaces” can improve longevity, as a study showed a 12%–17% reduced risk of non-accidental mortality among urban Canadians, especially women and older adults, particularly against stroke and respiratory death. ²⁶ Although most available data suggest “Blue spaces” health of benefits, the field is still emerging, and more robust evidence is needed to establish causality.

While swimming and water-based exercise have numerous positive effects on physical and mental health, the field is still emerging, and its mechanism of action is not clearly understood.

Studies suggest that swimming, like other forms of exercise, improves well-being by increasing endorphins and decreasing cortisol levels in the body. Endorphins act as a natural mood-boosting chemical in the brain, creating a sense of happiness, relaxation, and well-being. Swimming also stimulates the release of other neurotransmitters, such as dopamine and serotonin, which are associated with mood regulation and a sense of pleasure. ²⁷

One of the leading researchers of the health benefits of water, Dr Wallace J. Nichols, revealed an evidence-based connection between water and happiness, “being near, in, on, or under water can make you happier, healthier, more connected, and better at what you do.” According to the Blue Mind theory, being near water decreases the level of cortisol, stress hormone, and increases release of dopamine and oxytocin, “feel good” hormones. The buoyancy of water alleviates pressure points and tension in the body and additionally reduces stress and increases relaxation.

Aquatic Exercises Promote Healthy Aging

There is molecular evidence for the benefits of aquatic exercise in animal studies. Specifically in mice and rats, in mice and rats, aquatic exercise improves health primarily by reducing inflammation and oxidative stress, enhancing mitochondrial function, and modulating metabolic pathways. It demonstrated anti-inflammatory effect, improvement of insulin sensitivity which reduces the risk of chronic disease, such as T2D and non-alcoholic fatty liver diseases. ²⁸

By reducing brain inflammation, swimming has been found to enhance cognitive function and protect against neurodegeneration. ²⁹ It also increases levels of brain-derived neurotrophic factor (BDNF) and insulin-like growth factor (IGF-1), ³¹ which are associated with enhanced cognitive function in older adults and therefore may have a role in the prevention of dementia. ³⁰ Through its oxidative stress mitigation, regular swimming exercise has been associated with reduction in arterial stiffness, systolic and diastolic blood pressure, and improvement in vascular function. ³²

Conclusion

Healthy lifestyle practices may be adopted at any stage to promote healthy aging. Our patient’s story emphasizes the importance of physical activity in frailty prevention and underlies special values of resilience, the ability to bounce back from life adversities. Older adults, including people with frailty possess resilience, and lifestyle pillars play significant role in promoting cognitive, physical, and psychological resilience.

Healthcare providers can promote older adults’ engagement in physical activity and healthy lifestyle by educating themselves about the topic, increasing knowledge and awareness of its health benefits. Brief counseling can increase physical activity and bring considerable clinical benefits to patients. Older adults value their physicians’ recommendations and therefore primary care providers can be a meaningful catalyst for behavioral change to optimize health and promote healthy aging through physical fitness.

Regular exercise minimizes the effects of sedentary lifestyle and increases active life expectancy. Swimming is a means to improve both physical and mental well-being and offers a holistic approach to prevent frailty and promote healthy aging.

When choosing the type of physical activity, water-based exercises are as effective as land-based exercises, and they are highly recommended to older adults. They are effective in frailty prevention, and promoting physical, mental and psychological resilience.

Our case demonstrates that water-based exercises are highly effective in frailty prevention and promoting physical and psychological resilience.

ORCID iD

Halina Kusz https://orcid.org/0000-0002-2181-0497