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CLINICAL CONSULTATION

Evaluation of an Exercise Program for Older Adults in a Residential Environment Juh Hyun Shin, PhD, RN College of Nursing, Ewha Womans University, Seoul, Korea

Keywords

Abstract

Evaluation; exercise; residential setting; older adults. Correspondence Juh Hyun Shin, Assistant Professor, College of Nursing, Ewha Womans University, 120750, Daehyundong, Seodaemoongu, Seoul, Korea. E-mail: [email protected] Accepted September 15, 2016. doi: 10.1002/rnj.312

[This article was corrected in February 2017 after initial online publication because the grant number in the acknowledgments was incorrect.]

Purpose: The aim of this study was to examine the effectiveness of an olderadult exercise program in a senior-living complex campus. Design: A longitudinal one-group design was used. Methods: To supply residents with tools to maintain or improve general quality of life, balance, endurance, depression, and functional mobility, the Wellness and Fitness Center at the research setting provided a wide assortment of user-friendly equipment with many options. One fitness director in the selected setting evaluated participants every 6 months with 33 participants using the Senior Fitness Test (SFT). Findings: Repeated ANOVAs identified factors impacting the effects of the exercise program using PROC MIXED SAS 9.0. The improvement or deterioration rate of SFT scores was tested as a time effect in balance, upper body strength, and lower body flexibility. A statistically significant gender effect emerged on the 6-minute walk, which measured aerobic endurance and the chair-sit-and-reach test, which measured lower body flexibility. Conclusions: The 8-foot-up-and-go, arm-curl, chair-stand, and chair-sit-andreach tests showed statistically significant improvement over time, which means balance, upper body strength, lower body strength, and lower body flexibility improved. Clinical Relevance: Developing customized exercise protocols and using standardized measurement tools should be encouraged to enhance effective research and consistent measurement of exercise programs.

Background As they age, older adults experience deteriorated health and physical function and suffer from chronic disease, exacerbating their needs for institutionalized care (De Carvalho & Filho, 2004). Older adults experience significant changes, including physical and psychological dysfunction, immobility, and a need for nursing care they had not required previously. However, most older adults (about 88%) want to stay in their homes without moving (American Association of Retired Persons survey, 2010). Although 670,000 older adults live in senior complexes in the United States (Handy, 2012–2013), healthcare professionals expect to have more older adults in senior © 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9

complex campuses, due to a burgeoning older-adult population. These professionals must work to meet the needs of older adults, to enhance their ability to stay at home, as much as possible. Many studies investigated the impact of exercise programs on community-dwelling older adults and showed benefits for older adults in physical and cognitive functioning (Lam et al., 2009), learning and memory (Kasai et al., 2010; Man, Tsang, & Hui-Chan, 2010; Reid-Arndt, Matsuda, & Cox, 2012), mental health (Choi, Kang, & Young, 2007), quality of life (Choi et al., 2007; Kim, 2007; Kim, 2011), balance (Shim et al., 2014), range of motion, and the immune system (Kim, 2007). The beneficial effects of exercise on cognitive outcomes were

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supported in a meta-analysis for Alzheimer’s older adults (Farina, Rusted, & Tabet, 2014). Researchers reported that exercise was beneficial to older adults, especially in activities of daily living (ADL) at a daycare center in Taiwan (Chang, Chen, Shen, & Chiou, 2011), functional balance and ADLs in assisted-living facilities in the United States (Wallmann, Schuerman, Kruskall, & Alpert, 2009), disability in some ADLs in a long-term care setting in the United States (Stevens & Killeen, 2006), the effect of tai chi in the continuing-care retirement community (Wallsten, Bintrim, Denman, Parrish, & Hughes, 2006), and on mental health (Helbostad, Sletvold, & Moe-Nilssen, 2004), powerlessness, and self-esteem of older-adult residents in long-term care settings (Kim & Kim, 2012). Matthews et al. (2011) focused on participants’ overall quality of life rather than specific clinical results and investigated the effects of exercise from the health-promotion viewpoint to maintain independent living for older adults in a residential setting by increasing quality of life. In sum, researchers studied effects of different exercise programs using consistent instruments to measure results. Researchers conducted current studies mainly in North and South America and Asia (Miller & Taylor-Piliae, 2014). Although characteristics of older adults who live in different settings (nursing homes, assisted-living, continuing-care retirement communities, etc.) are quite different, limited research has studied older adults living in senior-living-complex campuses. To improve older adults’ overall function and quality of life, continuing-care retirement-community facilities have implemented exercise (Windle, Hughes, Linck, Russell, & Woods, 2010). However, little is known about the effects of exercise on older adults living in senior-living-complex campuses. Insufficient research has been conducted about older adults who stay in senior-living-complex campuses. This study fills that gap, investigating the effects of an exercise program on the physical outcomes of older adults who stay in a senior-living-complex campus. Purpose The purpose of this study was to examine the effectiveness of exercise for older adults in a residential setting. The three research questions follow: 1 Do older adults who participate in a fitness program increase their physical-performance scores over time? 2 What are the characteristics of participants attending a fitness program, including gender, age, medications, and disease groups?

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3 What are the effects of age, gender, number of medications, and number of diseases on Senior Fitness Test (SFT) scores? Methods Study Design A longitudinal one-group design was used. Sample and Setting Convenience sampling was used. The fitness director collected all data in the selected setting. The selected setting provides a continuum of living accommodations at various levels of service and care. This institution has independent-living settings, assisted living, and a skillednursing unit. This study included and provided analysis of data for the independent-living setting and assisted-living setting because the nursing-home setting did not participate in this program. Nursing-home residents received bedside exercise programs, which was beyond the purview of this study. Inclusion criteria included older adults who (a) participated in the exercise program for more than 3 months, (b) participated in a wellness and fitness center and simultaneously in one of the classes at least two times per week, (c) were cognitively unimpaired with more than 25 points on the Mini Mental Status Examination (total score of Mini Mental Status Examination of 30, Kurlowicz & Wallace, 1999), and (d) were ambulatory without assistive devices. Exclusion criteria were (a) residents in the skilled-nursing unit, (b) those diagnosed with end-stage dementia, (c) those under hospice care, and (e) those advised not to exercise by physicians. Intervention To supply residents with tools to maintain or improve general quality of life, balance, endurance, depression, and functional mobility, the Wellness and Fitness Center at the research setting (the senior-living-complex campus) provided a wide assortment of user-friendly equipment with many options to meet members’ needs and goals whenever residents desired. For example, this center offers free weights, treadmills, elliptical trainers, Nustep crosstrainers, recumbent and upright bicycles, and inner/outer thigh machines. In addition to wellness and fitness-center activities, the director of the selected center leads five classes (yoga, © 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9

J. H. Shin

stretching, etc.) for flexibility, endurance, and relaxation; each class lasts 1 hour, provided two to three times per week. The exercise program includes merry muscle makers, bodies in motion, serenity (tai chi), yoga, stretch and tone class, boost fitness health, and happiness and hobbies, in addition to regular fitness-center activities like aerobic exercise. The first four of these are conducted to improve strength, flexibility, and endurance. Serenity and yoga classes focus on relaxation and endurance with deep breathing. Although the name of the classes differed, the contents did not deviate greatly. The fitness director managed and guided the entire exercise program. Classes generally consist of stretching, walking, weight bearing, and meditation. To encourage continuous exercise, the fitness staff gives one star each time a resident comes to the fitness center. If they have 10 stars, the staff gives them a larger star, and the stars are displayed below the resident’s photo in the hallway in front of the fitness center. This might motivate residents to continue exercising. Staff invites all residents to voluntarily participate in the structured exercise program; those residents who participated in the fitness center (at least two times per week regardless of different classes) and one of the structured exercise programs per week were included in the sample for this study. Instrument One fitness director in the selected setting evaluated participants every 6 months using the SFT developed at California State University, Fullerton (Rikli & Jones, 2001). The fitness director is an expert in exercise, specializing in older adults, and was trained to use the SFT. This study included six categories of the SFT: chair stand, arm curl, 6-minute walk, chair sit and reach, back scratch, and 8-foot-up-and-go. The 6-minute walk measures aerobic endurance, and distance in meters across 6 minutes (Rikli & Jones, 1999). Convergent validity was good for treadmill performance (.71 < r < 82), with good test–retest reliability (.88 < r < .94; Rikli & Jones, 1998). The director uses the 30-second chair stand to assess lower body strength, counting the number of times an older adult comes to a full standing position in 30 seconds from a chair, with hands on the opposite shoulders crossed at the wrists (Langhammer & Stanghelle, 2011). Researchers supported criterion validity for this test (Bohannon, 2002; Csuka & McCarty, 1985). The arm-curl test measures upper body strength, counting the number of bicep curls completed © 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9


in 30 seconds with 2.27 kg weights for women and 3.63 kg weights for men. The 1RM cybex test supported the concurrent validity of the arm-curl test with r = .82 (James,1999; Rikli & Jones, 1999). The chair-sit-and-reach test assesses lower body flexibility, measuring the vertical distance between fingers and toes: older adults sit on the edge of a chair, keeping their knees straight, and stretching their arms up until they feel pain (Langhammer & Stanghelle, 2011). Criterion validity was moderate to high (.61 < r < .89; Jackson & Baker, 1986; Jackson & Langford, 1989; Patterson, Wiksten, Ray, Flanders, & Sanphy, 1996). The back-scratch test is used to assess upper body flexibility, measuring the distance between right and left hands with one hand behind the head and back over the shoulder and the other behind the back under the shoulder (Langhammer & Stanghelle, 2011). Researchers reported the test–retest of the back-scratch test to be R = .96 (Baumgartner, Jackson, Mahar, & Rowe, 2007). The 8-foot-up-and-go test assesses balance and measures the time required for an older adult to stand from a chair and walk as fast as possible about 8 feet, return to the chair, and sit down (Langhammer & Stanghelle, 2011). Researchers reported the test–retest to be R = .95 (Baumgartner et al., 2007). The 6-minute walk, the 8-foot-upand-go test, and the 30-second chair-stand test require an even, nonslip walking area, free of obstacles and marked with cones, a chair without armrests, and a timer (American College of Rheumatology, 2013; Topendsports, 2013). For the arm-curl test, 2.27 kg and 3.63 kg weights are needed, and the back-scratch and sit-and-reach tests require a ruler (Topendsports, 2013). Procedure To examine the degree of improvement in SFT performance outcomes, the fitness director repeated the tests three times at 6-month intervals at a residential setting with 47 older adults. The director met the requirements for the Health Insurance Portability and Accountability Act. The researcher obtained Institutional Review Board approval to evaluate the programs. The fitness director assessed the degree of improvement of participants in the exercise programs. Approximately, 53.19% of older adults in the residential center attended (75 of 141 older adults). Each month, between 25 and 67 residents participated. Data from the 47 older adults met the inclusion criteria for this study and were included in the analysis of this study. Of 47, 14 datasets were removed because three of

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the summer. Many residents were on vacation and some experienced the death of a spouse or significant other. Thus, this analysis includes the first (baseline), second (6 month), and fourth tests (18 month) to assess the time effect. The average number of prescribed medications was 4.02 (SD = 1.32, min = 0, max = 7), and the average number of diagnosed diseases was 2.12 (SD = 1.32, min = 0, max = 4). The average exercise time of each participant was 19.61 minutes (SD = 12.33) per day and they usually participated two to three times per week. Table 1 summarizes participants’ demographic information. The improvement or deterioration rate of SFT scores over time was tested as a time effect (see Table 2). For the 8-foot-up-and-go test (F = 11.34, p = .002), the 6-month test score showed a decrease of about 4.2%, but the 18-month test score showed improvement from the second test score by 8.75%. The 18-month test score improved from the first score by 4.4%. For the arm-curl test (F = 15.34, p = .001), the mean scores (standard deviation) of the baseline, 6-month, and 18-month tests were 16.0 (3.8), 17.26 (3.93), and 19.82 (4.93), respectively. The 6-month test showed improvement of about 8.81% from the baseline; the 18-month test showed improvement of about 23.49% from the baseline, and about 13.49% from the 6-month test. For the chair-sit-and-reach test, a time effect emerged (F = 9.16, p = .023). The mean score (SD) of the baseline, 6-month, and 18-month tests were 1.06 (4.05), 2.9 (4.27), and 2.09 (4.09), respectively. Dramatic improvement showed only between the baseline

four SFT tests were not completed for seasonal reasons, vacations, loss of significant others, and the refusal to complete SFT tests. The sample size was justified at a = .05, effect size of .65, and power of .95. Sample size was determined by power analysis, calculating the number of participants required to reject the null hypothesis exactly (Fitzner & Heckinger, 2010). Data Analysis Repeated ANOVAs identified factors impacting the effects of the exercise program using PROC MIXED SAS 9.0 (SAS Institute Inc., Cary, NC). Descriptive statistics describe demographic characteristics of participants. Sample characteristics addressed covariance. The Tukey test tested for significant differences. Results The average age of the 33 participants was 81.6 years. The researcher divided the 33 participants’ ages into three groups: young old (65–75), middle old (76–85), and oldest old (over 85). The majority of participants were among the middle old (42.2%) and oldest old (39%). Of 33 participants, 24 (72.73%) were women. The majority (81.82%) of participants (27 of 33) lived in independent living; only six lived in assisted living. The average number of medications per participant was 4.02 and participants had, on average, 2.12 diseases. The third test was removed from analysis because approximately 60% of participants did not take the SFT during Table 1 Characteristics of participants (N = 33) Characteristics

N

Total participants Average age Average participation time in the program (minutes) during 6 months Average exercise time per day (minutes) 65–75 old 76–85 old 86 and over Female Male Number of participants who live independent living Average length of stay in independent living Number of participants who live assisted living Average length of stay in assisted living

33

4

%

6 14 13 24 9 27

18.00 42.20 39.00 72.73 27.27 81.82

6

18.18

SD

Mean

Minimum

Maximum

11,820

81.6 941.25

9.23 35.74

0

19.61

5.7

0

3.2 years

8.4 months

2.1 years

3.7 months

© 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9


3.00 14.29 2.9

4.940 3.001 4.050

13.09

1.06

4.27

4.50

4.16

3.93

121.81 1.97

SD

*Male > female. † p < .05 were regarded as statistically significant. ‡ Below three meds > above three meds. § c,a > b. ¶ c > a. **Above three meds > below three meds. †† b,c > a. ‡‡ Female > male. §§ Fewer than two diseases < more than two diseases.

16

2.67

521.61 6.18

120.090 2.200 17.26

500.47 6.41

6 min (meter) 8 ft up go (seconds) Arm curl (number) Back scratch (cm) Chair stand (number) Chair sit and reach (cm)

Score

SD

6 months

3.800

Score

Variable

Baseline

2.09

14.67

3.07

19.82

506.97 6.55

Score

4.09

4.49

4.24

4.93

121.32 2.13

SD

18 months

.001†

15.89¶

9.57

.021† .023†

7.94 9.16†† 46.34

3.59

2.68

‡‡

74.56* 5.349

F

.918

3.46

.99 .002†

p

2.15 11.34§

F

.0002†

.935

.153

97.65

43.75

84.12

334.74

24.33 54.63

.0030† .269 .12

F

Age p

Gender

.585

.207

.829

.567

.89 .936

p

50.02**

14.77

13.15

60.06**

32.74‡ 42.17‡

F

.007†

.962

.469

.016†

.022† .004†

p

Medications

Table 2 The scores of Senior Fitness Test by age, gender, number of medications, and number of diseases from results of analysis of variances (N = 33)

58.15§§

3.63

7.36

4.46

7.91 5.28

F

p

.050†

.962

.822

.458

.97 .351

Diseases

J. H. Shin Evaluation of an Exercise Program for Elders

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and 6-month test (24.73%). The decreased score at the 18-month test from the 6-month, and the score between the 6-month and 18-month tests were not statistically significant, so deterioration scores on the SFT were not statistically meaningful. For the chair-stand test (F = 7.94, p = .021), the 6-month scores improved 10.1% from baseline and the 18-month scores improved by 0.38% from the 6-month scores and 10.52% from the baseline. The mean score (SD) of the baseline, 6-month, and 18-month tests were 13.09 (3.001), 14.29 (4.5), and 14.67 (4.49), respectively, with no statistically significant data for the 6-minute-walk or back-scratch tests. The 6-minute-walk mean scores (SD) of the baseline, 6-month, and 18-month tests were 500.47 (120.09) meters, 521.61 (121.81) meters, and 506.97 (121.32) meters, respectively. The back-scratch test mean scores (SD) on the baseline, 6-month, and 18-month tests were 2.67 (4.94), 3.0 (4.16), and 3.07 (4.24), respectively. Overall, scores for the back-scratch test worsened, but the change was not statistically significant. To investigate the effects of age, gender, number of medications, and number of diagnoses of diseases or illness on SFT scores, two participant groups were older and younger than 75, female and male, fewer and more than three medications, and fewer and more than two diseases (see Table 2). The level of significance was the likelihood of rejecting a true null hypothesis. Most researchers accept a level of significance at a = .05, which means that the null hypothesis is likely to be incorrect five times in 100 trials (LoBiondo-Wood & Haber, 2014). For this test, the significance level was .05. A statistically significant gender effect emerged on the 6-minute walk, measuring aerobic endurance (F = 74.56, p = .003), and the chair-sit-and-reach test, measuring lower body flexibility (F = 46.34, p = .002). For the 6-minute walk, the mean score for men (528.17) was approximately 100 points higher than that for women (437.21) during the study period. For the chair-sit-andreach test, the mean score for women was higher by 4.07 points than for men. The test showed clear improvement only for male participants. However, the back-scratch test for upper body flexibility was not statistically significant for gender. For number of prescribed medications, two groups of participants were divided by the number of medications taken: those with fewer and more than three medications. Statistically significant effects emerged for the number of prescribed medications and the 6-minute walk (aerobic

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endurance, F = 32.74, p = .022), 8-foot-up-and-go (balance, F = 42.17, p = .004), arm-curl test (upper body strength, F = 60.06, p = .016), and chair-sit-and-reach test (lower body flexibility, F = 50.02, p = .007). Thus, test scores for those who had three or fewer medications were better (19.02%) than for those with more than three medications (see Table 2). In this study, none of the six tests showed any age effect. Improvements in SFT scores during the exercise program accrued for balance, upper body strength, and lower body flexibility. Furthermore, gender and number of prescribed medications were significant factors that impacted outcomes. However, age was not statistically significant. Conclusions Older adults in a senior-complex campus may have different lifestyles from those in their previous homes. Thus, the provision and management of customized exercise programs for older adults in senior-living-complex campuses is paramount because it optimizes physical and psychological health, and postpones the placement of older adults in skilled-nursing facilities or hospitals, thereby improving older adults’ quality of life. Furthermore, the development of customized exercise protocols and standardized measurement tools such as the SFT should be encouraged to enhance effective research about exercise programs, as well as precisely and consistently measure the effects of exercise programs. Discussion It is timely to evaluate the effects of exercise programs for older adults in senior-complex campuses scientifically. Improvement or deterioration rates in SFT scores over time were tested as a time effect (see Table 2). The 8-foot-up-and-go, arm-curl, chair-stand, and chair-sitand-reach tests showed statistically significant improvement over time, which means balance, upper body strength, lower body strength, and lower body flexibility improved, consistent with previous studies (Chang et al., 2011; Choi et al., 2007; Kim, 2007; Kim, Han, & So, 2009; Kim, So, & Song, 2010; Kim, 2011; Santana-Sosa, Barriopedro, Lopez-Mojares, Perez, & Lucia, 2008; Stevens & Killeen, 2006; Wallmann et al., 2009; Wallsten et al., 2006). Balance, measured by the 8-foot-up-and-go test, improved after applying exercise, aligned with Shim et al. (2014). Gender differences arose for aerobic endurance and lower body flexibility. Consistent with a previous study © 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9

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(Langhammer & Stanghelle, 2011), statistically significant gender effects emerged on the 6-minute walk and chairsit-and-reach in this study. For the 6-minute walk and the chair-sit-and-reach test, the mean score for men was statistically better than the performance of women. Men usually have more robust physical strength than women, and this strength emerged in this study (Langhammer & Stanghelle, 2011). However, as there were more female participants (72.73%) than male, it seems that the decrease in scores from the second to the fourth test reflected women’s score results. Previous research usually supported better performance on flexibility, especially for women (Langhammer & Stanghelle, 2011; Sierpowska, Ciechanowicz, & CywinskaWasilewska, 2006), but this study was not consistent for upper body flexibility. Decreased scores on the backscratch test indicated lack of flexibility in this study. Thus, facilities should generally encourage exercise programs or classes like yoga to increase flexibility in the future. Interestingly, certain differences showed in test scores between those who have three or fewer medications and those who have more than three medications in the 6-minute-walk, 8-foot-up-and-go, arm-curl, and chair-sitand-reach tests. Previous researchers did not investigate this effect. This result may reflect that participants who take fewer medications are healthier than participants who take more medications. Healthier participants can, presumably, exercise more often and more efficiently, and test scores are better for those who are healthier. Consequently, this study also demonstrated that it is very difficult to investigate the exact factors that increase or decrease exercise effects for older adults. In this study, none of the six tests showed any age effect, which means that every age group over 65 showed improvement in the exercise program, inconsistent with previous research (Langhammer & Stanghelle, 2011). Prior researchers supported the scores of SFT as statistically significantly different for those of different ages, especially for the oldest older adult groups. Exercise interventions have implications for rehabilitation nurses and other healthcare professionals, emphasizing their preventive role for older adults. Recently, many senior-living-complex campuses for older adults have begun to implement exercise and wellness centers and diverse programs to optimize the quality of life for older adults (Resnick & D’Adamo, 2011). One important strategy of exercise intervention is to have continuity in an exercise program. To encourage continuing exercise in © 2016 Association of Rehabilitation Nurses Rehabilitation Nursing 2016, 0, 1–9


this study, the fitness staff gives one star each time a resident comes to the fitness center. If they have 10 stars, the staff gives them a larger star, and the stars are displayed below the resident’s photo in the hallway in front of the fitness center. This might motivate residents to continue exercising. Staff invited all residents to voluntarily participate in the structured exercise program. Rehabilitation nurses may discuss health-related issues with fitness directors and reflect these discussions in the daily assessment and nursing plan for each older adult as a health facilitator. Moreover, the availability of the exercise program, with continuous emphasis on the benefits of regular exercise, was one important factor in older adults’ engagement in an exercise program (Resnick & D’Adamo, 2011). Rehabilitation nurses in residential settings should foster the development of exercise programs in the future. Limitations This study depended on data that had already been collected by the fitness director in the selected sample setting. Thus, it was not possible to get data that accrued before the exercise program was applied, thereby requiring that pretest data should be reported. Future study with a more rigid research design that includes a pretest and control group might ensure more valid research results. Another major limitation to this study was that the small sample size decreased validity. Repeated measures might offset this limitation. Future research should include a large sample in diverse settings. This study was conducted in only one facility. Future studies should be conducted in many long-term-care settings to examine the effects of exercise programs on older adults. Many other confounding factors may overshadow the correlation between exercise and test scores. Factors such as season, death of a spouse or significant other, medical appointments, emotional events, and vacations affected not only the attendance at the fitness program, but also participants’ test scores. The concrete description of which classes/programs were most attended was not collected in this study because it was beyond the researchers’ scope. The proposed exercise intervention program used in this study is not a single program, but a mixture of many different programs. This mixture may also reduce the validity of this study. Future studies should increase segmentation of the data collection regarding medications and number of

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Key Practice Points One important strategy of exercise intervention is to have continuity in an exercise program. Exercise interventions have implications for rehabilitation nurses and other healthcare professionals, emphasizing their preventive role for older adults. The 8-foot-up-and-go, arm-curl, chair-stand, and chairsit-and-reach tests showed statistically significant improvement over time, which means balance, upper body strength, lower body strength, and lower body flexibility improved. Developing customized exercise protocols and using standardized measurement tools should be encouraged to enhance effective research and consistent measurement of exercise programs.

diseases. For example, researchers should divide categories of disease into cardiopulmonary and musculoskeletal to be more clinically indicative, but data collection of this type was not possible in this secondary-analysis study. Acknowledgments This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (grant # 2014R1A11002389).

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