Before looking at the literature on exercise programs in assisted living, congregate housing, and nursing homes, I will discuss studies related to programs for the community-dwelling frail elderly.

    Several short-term studies found that training improves performance. Two trials tested multicomponent training, including walking, low-tech resistance, and balance exercises in classes in a senior center or an outpatient rehabilitation center. Both studies showed improved performance on a battery of common physical tasks after 10 or 12 weeks of training.5,6 Home-based strength training improved lower extremity strength and mobility.6 In a post hoc analysis, lower extremity strength gain was associated with improved chair rise time, gait velocity, transfers, stooping, and stair climbing.7 A second home-based trial in older women involved strength training, balance, and walking. The women who exercised had lower fall and injury rates at one and two years. The relative risk for falls and fall-related injury was reduced to 0.69 and 0.63 at years one and two, respectively.8 The women volunteers maintained good exercise adherence for two years, with 44% adherence despite very little support from the study personnel during the second year of the trial. This study suggests that women who are motivated to begin a home program are able to maintain good adherence to exercise for a long period of time. The protocol was simple to learn. Another home-based resistance training study enrolled more than 200 frail elderly.9 Physical therapists made two home visits and provided a video and printed instructions. Strategies to increase adherence included individualized goal-setting and cognitive restructuring. Participants identified their concerns and how to generate alternatives to self-defeating thoughts. Goals were tailored for different baseline ability levels, and participants signed a behavioral contract. Following the two visits, the participants used a videotape that included all 11 exercises.9 This was a moderate-intensity training program that used Thera-band ®. Adherence was reported at 89% over the six-month intervention period. Exercisers improved leg strength by 6-12%, improved tandem gait performance by 20%, and reduced physical and overall disability by 15-18% at six-month follow-up. No adverse health effects were encountered. The evidence from home-based trials in frail older persons suggests that exercise programs can work if the exercises are simple enough and if there is sufficient support for the older individual to continue to exercise. However, elderly patients must pay for any ongoing support to sustain exercise because Medicare does not cover this support. Assisted Living and Congregate Housing Congregate and assisted-living centers are ideal locations for secondary and tertiary prevention strategies to delay further loss of function due to inactivity. Most residents in assisted living want to maintain their independence. The opportunity for classes in the facility overcomes the obstacles of travel to exercise, and can provide social support for long-term adherence. O’Hagan and associates10 found that three-times-weekly exercise classes, led by a physiotherapist, improved sit–stand time in a one-year randomized, controlled trial in rest homes in New Zealand. A 12-week program of resistance and balance training improved gait velocity in a congregate-living trial.11

LONG-TERM CARE FACILITIES

     Two of the FICSIT trials were conducted in nursing homes. The nursing home study with the stronger results found that the volunteers tolerated a 12-week program of heavy resistance training using resistance machines. The volunteers improved their leg muscle strength by 113%. Most importantly, stair-climbing power—a quantitative measure of effective leg power—increased by 28% at the end of training.12 This intense intervention used dedicated trainers and other personnel to transport the volunteers to the exercise center within the large nursing home; high adherence was achieved. The second FICSIT trial tested a physical therapist (PT)–based intervention in nursing home residents. The PT trial achieved only very modest improvement (15-18%) in the physical subscale of the Physical Disability Index, but did not improve the major outcomes (the overall Physical Disability Index, activities of daily living [ADLs], or the score on the Sickness Impact Profile).13 A recent study tested 12 weeks of isokinetic strength training and endurance training in nursing home residents.14 The residents increased isokinetic strength by 32%, compared to 10% in the control group (P < .05). Few residents could complete the endurance training goals for frequency or duration, and there was no evidence of any endurance effect of the training measured by heart rate response to walking. In a post hoc analysis, the most impaired subjects improved most on functional tests.14
A recent quasi-experimental study involving six nursing homes found that either a weight-training protocol or an aggressive nursing rehabilitation program slowed the rate of ADL loss, as noted on the quarterly Minimum Data Set, compared to control nursing homes that provided usual nursing care.15

COMPONENTS OF EXERCISE

     Goals will be discussed in the areas of posture and flexibility, endurance, resistance and power training, and balance. Table I represents a daily log that patients can complete in order to stay focused on their specific goals.

Posture and Flexibility

     The goal of these exercises is to reduce the risk of injury with increased activity and to improve posture during everyday activities such as vacuuming, sweeping, or carrying groceries. Many exercise programs begin with simple spinal posture movements that reinforce "standing tall," with the head in a "neutral" position, the cervical and thoracic spine in normal alignment, the pelvis in a neutral position, and the shoulders rotated back. Shoulder and spine range-of-motion exercises start from a neutral or good standing posture.

     This neutral standing position is different from a standing position with an anterior pelvic tilt (open pelvis), lumbar lordosis, thoracic kyphosis, cervical hyperextension, and shoulders rotated forward. Spinal flexibility can improve with targeted flexibility training.16 Postures that flex the thoracic spine in older persons raise concern about thoracic compression fractures in women who may have osteoporosis. Exercise can improve control of the torso if all the abdominal muscles and the lumbar muscles are trained. These exercises are performed on a mat and require older persons to lie on the floor (or on a low platform if they cannot get on and off the floor). Those frail persons who cannot get up from or down to the floor should be trained to do so. They will thus gain confidence if they fall, and they will reduce the risk of "lying on" injury associated with falling and not being able to rise. The key exercises in the supine position include pelvic tilts and pelvic bridging, double hip rotations, and single leg flexions. In pelvic tilts, the pelvis is rotated posteriorly or up using abdominal and iliopsoas muscles. Single leg flexions begin with one leg fully extended and the opposite leg flexed at knee and hip; this position stabilizes the pelvis. The leg is raised and then flexed toward the torso. Double hip rotations begin in the supine position with knees flexed about 90º , and both legs are rotated to the left and then back to neutral and then to the right.
Stretching of the large muscle groups of the legs—hamstrings, hip flexors, and calf muscles (Figure 1)—is usually done at the end of the exercise session, as part of the "cool down." At least 15 seconds per muscle group is recommended.

 

Endurance

     The goal of these exercises is to extend life and to improve the ability to travel, visit friends, or shop without fatigue. For older persons, walking is the most appropriate activity to maintain or improve endurance function. Walking can be done alone or with a group. Stationary bicycling or reciprocal bicycle and arm movement machines are standard equipment for cardiac rehabilitation and are safe and appropriate for use by older persons. Water aerobics can also improve endurance. Neither bicycle exercise nor water aerobics has been shown to improve walking or balance, however. Rowing machines can improve endurance, but there are few data on benefit, and there is potential for injury to back muscles in older persons who have no prior rowing experience.
A large study of older persons with osteoarthritis of the knee found that walking reduced knee pain and improved endurance and physical performance.17 Similar results were seen with resistance training.17 Most people with knee arthritis need to walk to maintain independence, and they should be encouraged to walk.

     Initiation. It is recommended that inactive older persons start walking at the pace at which they feel comfortable. The first goal is to increase the time spent walking every week (duration). This strategy is likely to be successful, because it is not usually more difficult; it simply requires more time. For frail elderly, the initial goal may be as little as six or 10 minutes of sustained walking every day or twice a day.

     Progression. Once regular walking is part of the person’s usual schedule, duration and intensity can be increased. The first goal is to reach 30 minutes of sustained walking six days a week, or 60 minutes every other day. Progression in intensity is needed to provide a continued training stimulus after the older person can walk for at least 30 minutes without stopping. Increasing intensity can be accomplished either by walking faster, walking up hills, or climbing stairs. Healthy older people with good balance and confidence can achieve sustained walking speeds of 3.5-3.8 mph (approximately 1.6-1.8 meters per second-1; equivalent to about 16-17 minutes per mile, or about 9-10 minutes per kilometer). Many older persons are not comfortable walking at these speeds because of balance limitations or knee or foot pain. It is important that older persons walk at a speed that they feel is safe. Hill walking or stair climbing can increase intensity without requiring an increase in speed; these activities provide a training stimulus and should help maintain proximal muscle strength as well.

Resistance and Power Training

     The goal of this training is to improve the ability to rise from a chair without using one’s arms, to lift and carry objects, move furniture, climb stairs, or push and pull open heavy doors (Table II). For inactive older persons, muscle weakness is due to loss of muscle mass and poor muscle contractility. Resistance training can improve muscle contractility over a short period of training (eight weeks), and contractility can continue to improve over several months, depending on the characteristics of the training program. Muscle hypertrophy plays a smaller role in improvement in function. The frailer the person becomes, the greater the importance of strength training. Sometimes flexibility and strength training are the only types of exercise in which very frail elderly can engage.
Recently, there has been greater emphasis on power training rather than strength training. Power training uses lower resistances, and exercises are done at faster speeds.18,19 The rationale behind power training is that most functional activities require muscles to move the person’s body, not heavy weights. To recover from a loss of balance, the older person must move a limb quickly or develop muscle force quickly to prevent a fall. Chair rises, plantar flexion (Figure 2), and chair dips (Figure 3) are examples of using body weight to increase strength or power. The creative use of body weight with added waist belt and ankle weights for resistance may be the best that can be offered in settings without the space or funding for standard resistance equipment.

    Intensity. To increase muscle strength, exercising the muscle to a state of fatigue is recommended. Muscle fatigue occurs when the muscle can no longer generate force, despite maximal voluntary neural drive. The higher the resistance, the faster the muscle fatigues and the lower the number of lifts that can be performed. Resistance training to fatigue involves performing a series of lifts (a set) until a lift cannot be completed with correct form. A set is defined as the number of lifts performed with little or no rest between lifts. Most successful programs have trained muscles at 70-80% of the maximum single lift, termed one repetition maximum, or 1RM . At 70-80% of 1RM, fatigue occurs after eight to 14 lifts. High-intensity training programs begin training at about 50% of the participant’s 1RM and increase to 70-80% of 1RM over several weeks. Two or three sets of each exercise are performed during a session.

     Frequency-Duration. Successful training studies have trained five or fewer muscle groups. The resistance session should not exceed 45 minutes unless substantial rest periods are included.

 

Balance

 

    The goal of balance exercises is to improve confidence in performing everyday tasks and to reduce the risk of falls and injury.

     Recommendations. Balance is the ability to control the person’s center of mass during stance and motion. Balance improves with training, and balance training as a component of exercise programs reduces fall rates in older persons. While the literature has focused on leg strength and balance, muscles that control the torso (lumbar and abdominal muscles in particular) are also important. The exercises listed in the Posture and Flexibility section support the more complex balance exercises listed in this section. Because many injurious falls occur during standing and turning, exercises that improve the ability to turn and lean without falling over make sense. A wide variety of balance exercises have been tested. It is important to identify the contributors to poor balance and falls for each person. The common key findings are muscle weakness, sensory deficits, postural hypotension, strokes, fear of falling, dementia, and physical inactivity. Muscle weakness should be addressed by resistance training simultaneous with balance exercises. The exercises in Table III represent a small sample of exercises that have been incorporated into different trials.

Balance training programs have included Tai Chi, or Tai Chi–like movements, tandem walking, weight shifting that progresses to single stance (initially with support), and turns. Dancing may stimulate balance responses and may help balance in a variety of ways. Dance usually includes steps to the side, crossover steps, turning, and weight shifts. There are many anecdotes but no data to support dance as a strategy to reduce falls. However, because most people enjoy moving to music, many exercise programs incorporate dance or rhythmic movement into the program.

     Progression. Progression of difficulty should occur; progression includes reducing the need for support during an exercise. The patient should progress from full support (eg, holding on to the kitchen counter), to a light touch on the support, to mere proximity to the support, as balance improves. Exercises are practiced until mastered, and then more difficult exercises can be attempted. Most balance exercises can be performed safely in a kitchen using the counter for support. Tai Chi training or other exercises that include concentration and attention to movement are also recommended.

"NATIONAL BLUEPRINT"

     On May 1, 2001, the Robert Wood Johnson Foundation (RWJ) released "The National Blueprint for Increasing Physical Activity Among Adults Aged 50 and Older."20 The Centers for Disease Control and Prevention, the American Association of Retired Persons, the American College of Sports Medicine, the American Geriatrics Society, and the National Institute on Aging assisted RWJ in the development of this Blueprint. The Blueprint will serve as a guide to increase physical activity among older Americans. It provides information on physical activity and its impact on people 50 years of age or older. It also provides barriers to increasing physical activity, and suggests strategies to enhance physical activity related to research, home and community, workplace, medical systems, public policy, and advocacy.

CONCLUSION

     The evidence is clear that helping inactive persons become active is important. A well-designed program will include endurance, posture and flexibility, strength, and balance components. The frailer the individual, the more important are strength and balance exercises. Assisted living and other long-term care facilities can provide opportunities for residents to become active and prolong independence in ADLs. Physicians can also play an important role in encouraging persons to become active.

Acknowledgement

     I acknowledge the cooperation of the National Institute on Aging for providing the figures in this article from its Exercise Book. The full book is available.

References

1. American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998;30:992-1008.

2. Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients: A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273:1341-1347.

3. Tinetti ME, Baker DI, Gottschalk M, et al. Systematic home-based physical and functional therapy for older persons after hip fracture. Arch Phys Med Rehabil 1997;78:1237-1247.

4. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: An investigation of Tai Chi and computerized balance training: Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc 1996;44(5):489-497.

5. King MB, Judge JO, Whipple R, Wolfson L. Reliability and responsiveness of two physical performance measures examined in the context of a functional training intervention. Phys Ther 2000;80:8-16.

6. Brown M, Sinacore DR, Ehsani AA, et al. Low-intensity exercise as a modifier of physical frailty in older adults. Arch Phys Med Rehabil 2000;81:960-965.

7. Chandler JM, Duncan PW, Kochersberger G, Studenski S. Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders? Arch Phys Med Rehabil 1998;79:24-30.

8. Campbell AJ, Robertson MC, Gardner MM, et al. Falls prevention over 2 years: A randomized controlled trial in women 80 years and older. Age Ageing 1999;28:513-518.

9. Jette AM, Lachman M, Giorgetti MM, et al. Exercise—It’s never too late: The strong-for-life program. Am J Public Health 1999;89:66-72.

10. O’Hagan CM, Smith DM, Pileggi KL. Exercise classes in rest homes: Effect on physical function. N Z Med J 1994;107(971):39-40.

11. Judge JO, Underwood M, Gennosa T. Exercise to improve gait velocity in older persons. Arch Phys Med Rehabil 1993;74:400-406.

12. Fiatarone MA, O’Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994;330:1769-1775.

13. Mulrow CD, Gerety MB, Kanten D, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271(7):519-524.

14. Meuleman JR, Brechue WF, Kubilis PS, Lowenthal DT. Exercise training in the debilitated aged: Strength and functional outcomes. Arch Phys Med Rehabil 2000;81:312-318.

15. Morris JN, Fiatarone M, Kiely DK, et al. Nursing rehabilitation and exercise strategies in the nursing home. J Gerontol A Biol Sci Med Sci 1999;54(10):M494-M500.

16. Taunton JE, Rhodes EC, Wolski LA, et al. Effect of land-based and water-based fitness programs on the cardiovascular fitness, strength and flexibility of women aged 65-75 years. Gerontology 1996;42:204-210.

17. Ettinger WH Jr, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST). JAMA 1997;277:25-31.

18. Evans WJ. Exercise strategies should be designed to increase muscle power. J Gerontol A Biol Sci Med Sci 2000;55:M309-M310.

19. Earles DR, Judge JO, Gunnarsson OT. Velocity training induces power-
specific adaptations in highly functioning older adults. Arch Phys Med Rehabil 2001;82(7):872-878.

20. Robert Wood Johnson Foundation. The National Blueprint for Increasing Physical Activity Among Adults Aged 50 and Older. Available at: http://www.rwjf.org/app/rw_publications_and_links/rw_pub_other.jsp. Accessed July 11, 2001.

Internet Resources

        Exercise: A Guide from the National Institute on Aging. A fully downloadable book with instructions and figures. Available at: http://www.nih.gov/nia/ health/pubs/nasa-exercise/toc.htm. Accessed July 11, 2001.

   National Institute on Aging Exercise Age Page. Available at: http://www.nih. gov/nia/health/agepages/exercise.htm. Accessed July 11, 2001.

      National Institute on Aging Exercise Video Preview and Order Page: Available at: http://www.maillist.org/exercise. Accessed July 10, 2001.

         Surgeon General’s Recommendations for Physical Activity in Older Persons. Available at: http://www.cdc.gov/nccdphp/sgr/olderad.htm. Accessed July 10, 2001.

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