Feasibility and benefits of group-based exercise in residential aged care adults: a pilot study for the GrACE programme

Introduction

Ageing can lead to an impaired physical function, mobility and reduction in quality of life (Krist, Dimeo & Keil, 2013). A decrease in mobility may prompt a vicious cycle of sedentary behaviours, reduced physical activity and deconditioning, with residential aged care (RAC) adults shown to be more sedentary than their community-dwelling counterparts (Reid et al., 2013). The mobility decline may reflect the emergence of sarcopenia, which is defined as the progressive and generalised loss of skeletal muscle mass and subsequent muscle function (muscle strength and physical performance) associated with the ageing process (Cruz-Jentoft et al., 2010). The preferred sarcopenic measure for physical performance in older adults is gait speed, which is also considered a primary precursor to age-related adverse events including disability, cognitive impairment, falls, mortality, institutionalisation and hospitalisation (Abellan van Kan et al., 2009; Cruz-Jentoft et al., 2010; Peel, Kuys & Klein, 2013). The threshold to be considered as having normal or above habitual gait speeds is 0.8 m/s (Kuys et al., 2014), a value almost identical to the 0.82 m/s cut-off proposed as being predictive of death within two years for older men (Stanaway et al., 2011).

A meta-analysis of 2,888 long-term ambulant RAC residents reported a mean habitual gait speed of 0.48 m/s (95% confidence interval (CI) 0.40–0.55) (Kuys et al., 2014). However, it was cautioned that the true mean gait speed of RAC adults may be even less than 0.48 m/s as many of the reviewed studies utilised non-randomly selected samples, meaning the participants were likely to be more mobile than those who did not consent to participate. Consistent with such a view, a recent study of 102 randomly selected RAC residents reported a mean gait speed of 0.37 m/s (Keogh et al., 2015). The widespread low gait speed documented for RAC adults and the link between low gait speed and many adverse age-related effects suggests that further research needs to be conducted to examine feasible and efficacious approaches to improving or at least offsetting the expected annual decline in gait speed of 0.03–0.05 m/s per year (Auyeung et al., 2014; Onder et al., 2002).

Two recent reviews have examined the potential for exercise, and specifically progressive resistance training (e.g. strength) and weight bearing exercise (e.g. balance and mobility) to improve many aspects of muscle function including gait speed in RAC/frail older adults (Chou, Hwang & Wu, 2012; Valenzuela, 2012). In their meta-analysis of 225 participants across four studies, Chou, Hwang & Wu (2012) reported that exercise produced a significant 0.07 m/s (CI 0.02–0.11) increase in gait speed compared to the control group (−6% change). However, a limitation of this literature is that the implementation of these exercise programmes in RAC is still relatively uncommon. This lack of translation may reflect the many barriers to the sustainability of resistance combined with weight bearing training programmes in RAC (Federal Interagency Forum on Aging-Related Statistics, 2004) and to our knowledge, a complete lack of research quantifying the feasibility of this form of exercise in this setting.

A possible exception is an exercise programme, which was targeted at respite care older adults in Australia (Henwood, Wooding & de Souza, 2013). Older adults accessing respite care are unable to completely care for themselves due to the adverse effects of ageing, chronic disease, physical and/or cognitive disability and are at increased risk of entry into RAC. These individuals typically access respite day care for several hours per day for one or more days per week to allow their carer the opportunity to attend to other everyday activities or to have a break from their caregiving responsibilities. An analysis of the exercise programme demonstrated a high feasibility for translation into an ongoing respite day care centre and that 2 h of participation per week for 20 weeks significantly improved functional capacity and balance among participants (Henwood, Wooding & de Souza, 2013). While this programme was feasible and effective in a disabled community-dwelling population, it is yet to be trialled amongst RAC adults. Given the demonstrated uptake of this exercise programme by a low functioning older adult population at risk of entry into RAC, it was hypothesised that the Group Aged Care Exercise (GrACE) programme would exhibit similar levels of feasibility and benefits in RAC adults (Henwood, Wooding & de Souza, 2013).

The primary aim of this study was to determine the feasibility of the GrACE programme in RAC, with the secondary objective of measuring the programme benefits on gait speed, sit to stand and handgrip strength.

Material and Methods

Study design and recruitment

This study compared the delivery feasibility and outcomes of a 12-week combined resistance and weight bearing exercise programme, which we named the GrACE programme. Participant recruitment and assessment occurred over a five-month period. The flow of recruitment to assessment is represented in Fig. 1.

The RAC was approached about participation via email and telephone follow-up. Potential participants were identified at a meeting with the facility Service Manager. Participants were screened via the inclusion criteria at the meeting with the Service Manager and a Registered Nurse, whom also deemed who would be able to perform the exercises due to the inclusion and exclusion criteria. The Service Manager and a Registered Nurse created two lists from the eligible participants, one that contained the names of residents who could be recruited for the exercise group and one for the recruitment of the control group. This group allocation was based on the location of their bedroom with respect to the training room, as the Service Manager and a Registered Nurse felt that only participants who resided on the same level as the exercise room were likely to join and adhere to the GrACE programme. As we wished to get some idea on the number of participants who would enrol in such an exercise program, the sample obtained in the current study reflected the maximum number of participants who were eligible and provided their informed consent to participate. The final sample obtained was a convenience sample from one RAC facility. Following an explanation of the procedures, purposes, benefits and associated risks of the study, participants had the opportunity to ask questions. A total of 37 older RAC adults (86.8 ± 6.1 years, range 72–99 years, 30 females) provided written informed consent for the study. The exercise group contained 20 participants (86.9 ± 5.7 years, range 72–97 years, 15 females) and the control group 17 participants (86.3 ± 6.6 years, range 75–99 years, 15 females). Ethical approval to conduct this study was attained from Bond University’s Human Ethics Research Committee (RO 1823). The protocol for this trial was published at Clinical Trial Registry ID NCT02640963.

Measures

Results

Descriptive characteristics of the sample, provided in Table 1, showed no significant difference between groups at baseline. Of the 62 individuals put forward for participation by the RAC Service Manager, 47 were found to be eligible and 37 consented to involvement. At follow-up, three participants in the control group had passed away, resulting from falls complications (n = 1) and pre-existing heart disease (n = 2). Apart from these three deaths, the study experienced a 100% retention rate of surviving participants and final analysis was conducted on 34 individuals (20 intervention and 14 control). Seventeen (85%) participants in the exercise group attended 18 or more exercise sessions, with three (15%) of these 17 participants attending all 24 training sessions.

Participant responses to the exercise programme questionnaire, measured by the Likert scale questions are summarised in Table 2. Acceptability of the programme was very high with 100% of exercise participants and staff who had been involved with the programme (i.e. nurses who helped bring the residents from their rooms to the GrACE programme or observed the class from the nurses’ station) strongly agreeing that the participants “Benefited from the GrACE programme” and “Happy to continue participating.” Refer to Appendix 2 to see the full responses to the open-ended questions. With respect to diary completion, all diaries were returned with five partially completed (ranging from 50–80%) and 15 fully completed. There were no adverse events reported by any participants during the exercise sessions.

The exercise group had significantly greater improvements in habitual gait speed (F(4.078) = 8.265, p = 0.007), sit to stand performance (F(3.24) = 11.033, p = 0.002) and handgrip strength (F(3.697) = 26.359, p < 0.001) when compared to the control group. Pre- and post-intervention muscle function measures data are presented in Table 3.

Discussion

This study demonstrated a combined weight bearing and resistance training exercise programme which we called the GrACE programme, designed and tested in community-dwelling respite day care older adults, is feasible, safe and effective in improving gait speed, sit to stand performance and handgrip strength in RAC adults. Findings from this study may assist RAC providers and care staff to develop and implement feasible, safe and effective exercise programmes for their residents.

The recruitment rates for this exercise trial appeared similar or better than other similar trials in respite care, hospital inpatient or RAC populations (Bower et al., 2014; Henwood, Wooding & de Souza, 2013; Peddle-McIntyre et al., 2012; Suttanon et al., 2013). Sixty-two of the 151 residents were identified by the service manager as being potentially eligible for the study, a proportion equating to approximately 40% of total population of the RAC facility. The other 89 RAC residents were deemed ineligible due to the following: being in a wheelchair or restricted to bed duties, not being able to follow simple instructions, lack of attention or unpredictable behaviour. It is interesting to note that some residents (n = 10) refused to participate due to fear of change in their schedule, fear of never doing resistance training before and not wanting to try and after being in the RAC facility for over five years had declared they weren’t doing exercise anymore. Suggested ideas to overcome this were through word of mouth via residents to other residents, especially at communal times such as breakfast, where the residents remind each other of exercise class.

Of the 62 residents identified by the service manager as being eligible to participate, 37 (60%) provided informed consent and were placed into either the exercise or control groups. While a recruitment rate of 60% of the eligible participants may appear relatively low, this value appeared comparable (Henwood et al., 2015) or slightly higher (Álvarez-Barbosa et al., 2014; Bossers et al., 2014; Sievänen et al., 2014) than previous exercise trials in RAC. The reason provided by the 25 (40%) potentially eligible participants who declined to participate included: not being interested in the study or exercise programme, lack of time: didn’t want to commit to the 12 weeks, didn’t want to try something different/that was out of the normal routine and were happy with their current lifestyle. The reasons reported by the potential participants who declined participation in this project should be taken into account by future researchers considering conducting RAC exercise RCTs if they wish to ensure maximum participant recruitment and statistical power of the resulting analyses.

For the 20 participants who were enrolled into the GrACE programme, adherence rates were high with 85% of the participants attending at least 18 (75%) of the required 24 exercise classes. This relatively high attendance rate appeared similar (Álvarez-Barbosa et al., 2014; Bossers et al., 2014; Sievänen et al., 2014) or greater than (Hassan et al., in press; Henwood et al., 2015) previous feasibility exercise studies involving RAC older adults. Such results suggest that many exercise class options (if offered) may be well attended by residents of RAC facilities. The acceptability of the programme was further assessed by using a five-point Likert scale questionnaire that focused on the participants’ perceptions of the exercise sessions. All exercise participants strongly agreed that they obtained substantial benefits from their participation and that they wished to continue being involved in the programme. These results are consistent with previous studies reporting high acceptability of RAC exercise participation (Álvarez-Barbosa et al., 2014; Bossers et al., 2014; Henwood et al., 2015; Sievänen et al., 2014). However, in contrast, our study supports the feasibility of an in-centre delivery using targeted supervision and inexpensive equipment, where previous work has employed more complicated deliveries. Specifically, Bossers et al. (2014) delivered individualised, supervised walking and strength training programmes five days per week, Sievänen et al. (2014) and Álvarez-Barbosa et al. (2014) delivered their interventions using relatively expensive whole body vibration devices, Hassan et al. (in press) used expensive resistance training machines and Henwood et al. (2015) trialled aquatic exercise that required participants to be transported to and from a community pool and change in and out of swimming attire. Our study required only one qualified trainer; the exercises were conducted at the RAC facility so there was no transport needed and delivery was not affected by busy times or school holidays such as experienced by Henwood et al. (2015). Further, our study didn’t need to have a personalised exercise programme developed for each individual resident or require the purchase and storage of expensive equipment (Álvarez-Barbosa et al., 2014; Hassan et al., in press; Sievänen et al., 2014). The acceptability of the programme was further demonstrated by the lack of any adverse effects reported within the exercise group. This lack of adverse effects is again consistent with the literature on a variety of exercise programmes for RAC residents (Álvarez-Barbosa et al., 2014; Bossers et al., 2014; Hassan et al., in press; Henwood et al., 2015; Sievänen et al., 2014). Therefore, our study further supports the safety of supervised exercise in this population, and demonstrates that the perception held by some care staff that exercise is a dangerous for RAC residents is not based on the current peer-reviewed evidence.

However, it must be acknowledged that although the GrACE programme was found to be feasible for those who participated in this study, this amounted to only ˜25% of the population of the RAC facility. Collectively, the results of this study suggest that further feasibility trials may need to target RAC residents who were ineligible for this study (Gibbs et al., 2015) and also examine some of the issues influencing recruitment rates from those who were eligible to participate (Kalinowski et al., 2012).

While the primary focus of this study was to demonstrate feasibility and acceptability of the GrACE programme in RAC, we were also interested in further quantifying the benefits of exercise in this population as such data may inform future RCTs in this area. Significant between-group differences were reported for gait speed, sit to stand performance and handgrip strength, all of which favoured the exercise over the control group. Such results are impressive due to the relative simplicity of the GrACE programme performed in the current study and the importance of these outcome measures for older adults, particularly those living in RAC who wish to maintain their health and independence.

The significant between group effect for gait speed was a promising finding, with the relative 0.07 m/s improvement in gait speed for the exercise group was identical to the results of a recent meta-analysis involving exercise for RAC residents (Chou, Hwang & Wu, 2012). However, results of the within-group analysis indicated that the exercise group experienced an increase in gait speed of 0.03 m/s (˜5%), whereas the control group experienced a decline of 0.04 m/s (˜6%). As the control group’s decline of 0.04 m/s was consistent with the expected annual decline of 0.03–0.05 m/s per year for older adults (Auyeung et al., 2014; Onder et al., 2002), the GrACE programme appears able to maintain or perhaps slightly increase gait speed in this population.

The significantly greater improvement in sit-to-stand performance for the exercise group was of considerable interest, with none of the residents being able to perform the sit-to-stand with their hands on the chest during baseline assessments. The ability to safely rise from a chair and sit down is a prerequisite for maintaining Activities of Daily Living (ADL) function (Zijlstra et al., 2012). Specifically, older adults who are unable to perform the sit to stand are considered below the capacity for independence and at risk of accelerated physical deterioration associated to extended sedentary behaviours (Zijlstra et al., 2012). The RAC participants’ lack of leg strength (as demonstrated by their initial inability to perform even one sit to stand) was consistent with previous research that observed over 70% of RAC adults were unable to rise from a chair without assistance (Sabol et al., 2011).

The exercise group’s significantly greater improvement in handgrip strength was also considered important, as lower handgrip strengths have predicted an accelerated decline in ADL disability and cognition as well as functional limitation and physical disability in older adults (Bohannon et al., 2007; Hairi et al., 2010; Taekema et al., 2010). The exercise-related increase in handgrip strength was also consistent with a previous exercise study in RAC (Justine et al., 2012).

Conclusion

The GrACE programme, consisting of progressive weight bearing combined with resistance training, was shown to be feasible, safe and effective in improving muscle function in RAC residents. Improved muscle function measurements are valuable client outcomes, and may have significant cost saving benefits to the RAC setting, as increased muscle function could reduce the RAC residents’ degree of disability, care needs and risk of falls (Chou, Hwang & Wu, 2012). This work has direct measurable benefits for RAC residents, staff and providers and other health professionals working with older adults. Our findings addressed a number of previously unanswered and understudied questions in relation to the feasibility, safety and benefits of exercise classes that could be offered by RAC facilities to their residents. By having a greater understanding of these issues, RAC providers can better target interventions (e.g. exercise for maintaining gait speed or to reduce falls risk) to their residents. We would therefore encourage other RAC providers to strongly consider implementing similar programmes.

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