How to get residents into a weight training program.

Sound bizarre? This facility has found a way to do it - and it just might be working.

For many years, we thought that the elderly became frail and weak simply because they are old and deterioration is part of old age. Two important clinical studies have disproved this and, in the process, changed our facility's approach to the nursing home resident.

The first, entitled, "Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People," published in the June 23, 1994 New England Journal of Medicine, found that a "high intensity, progressive regimen of resistance exercise training improves muscle strength and size in frail elderly people." The other, "Weight Training Improves Walking Endurance in Healthy Elderly Persons," a study conducted at the University of Vermont College of Medicine, and reported in the March 15, 1996 Annals of Internal Medicine, noted that "Resistance training for three (3) months improves both leg strength and walking endurance in healthy, community-dwelling elderly persons." Both studies indicate that resistance exercise (weight training) improves strength, therefore impacting on the elderly's mobility, quality of life, self-sufficiency, mood and outlook, overall happiness and general health.

Anticipating these and other benefits - increased customer satisfaction, some marketing advantages and improved staff morale - we started our own weight training program here at Washington Manor Nursing and Rehabilitation Center, a 240-bed facility located in Hollywood, FL and owned by Beverly Enterprises. Our administrator, a progressive thinker, saw the potential of this program. As consultant to the Center, I was asked to develop and coordinate the Pilot Program and design it to become an ongoing component of the Center's operation.

Our goal was to develop a strength-building program that would demonstrate, in a measurable way, improved quality of life for our resident participants. We felt that the program's intrinsic benefits would follow naturally from attainment of our primary goal. We named our resistance exercise program S.T.E.P. (Strength Training Exercise Program) to differentiate it from other exercise or physical training activities that are routinely conducted at our center.

Difficulties are always inherent to starting any new programs or services in a facility. The main problem we encountered with this program: Who is going to do it? Many facilities contract out their rehabilitation services. To begin a program such as this one, the rehab company's support would be essential. The company would have to supply additional staff, equipment and monitoring, all of which might be difficult to obtain. We were fortunate in that Washington Manor has its own in-house rehabilitation department. The department had the equipment and staff already on board to facilitate the program without disrupting the usual flow of the staff or departmental functions.

Cost is, of course, always an issue. However, the costs of a resistance exercise program are rather low, considering the benefits to the residents and facility for dollars spent. Our staff time was already budgeted. New staff did not have to be hired, only rescheduled. Our total cost for equipment was small ($600-$1,000). Comparing that cost to the derived benefits, a resistance exercise program seemed to be a reasonable expenditure.

A program of this type requires pre-planning to ensure established protocols, consistency, coordination, accurate documentation and outcomes measurement. We decided therefore to make this an interdisciplinary effort, involving numerous departments and personnel. We felt that by involving different departments, we would generate more facility enthusiasm for the program, increase staff communication and build teamwork and morale. We also felt that we would avail ourselves of different ideas and viewpoints that would help to ensure the program's success. Participating departments include Nursing, Physical Therapy, Occupational Therapy, Respiratory Therapy, Quality Assurance, Social Services, Nutritional Services and Recreational Services.

Next, we sought volunteer residents to participate. We decided to begin with eight residents. We felt that this number would be logistically easy to manage and small enough to allow us to iron out the bugs, while still providing measurable data indicating progress. Initially, three men and five women volunteered.

You should realize that, at this point, obtaining resident volunteers for such a program may cause apprehension among caregiving staff as they consider the determining factors for participation, such as resident age, medical condition, psychological status and mobility. In truth, many residents can benefit from this approach, even in small ways. In the last analysis, though, you, your medical staff and resident's physician are best positioned to determine the appropriateness of a particular resident for a program of this type.

Our eight residents ranged in age from 77 to 98 years, average 87. Five were chair-bound, but could ambulate with assistance; the remaining three were ambulatory.

We prepared specific forms for data collection to be completed prior to the program's inception and for use throughout the program. Specifically, we developed a Resident Consent for Participation form to be signed by the resident; a Family Consent Form to be mailed to family members for their information and signature; a letter to the resident's physician, informing him/her of the program and the resident's participation; a form on which we recorded baseline values; and a Resident Participant Information Package which was distributed to residents, families, physicians and all other interested parties. This package included a full description of our resistance exercise program, with all exercises fully explained, along with the benefits we expected to achieve.

We decided to measure a variety of values throughout the program in order to measure progress or change. These included:

1. Muscle mass

2. Blood pressure

3. Pulse rate 

4. Functional ability (range of motion)

5. Mobility

6. Weight

7. Sleep meds

8. Pain meds

9. Resident falls - the S.T.E.P. Program is coordinated with the Center's established Falls Program

10. Lifting ability

11. Lifting ability increase

12. Food intake

13. [O.sub.2] saturation rates

14. Calorie needs and changes

15. Nutritional supplements 

Each of the departments participating in the program had a specific role, including:

1. Nursing - Obtain and monitor physiological values and maintain contact with our participants' physicians.

2. Respiratory Therapy - Obtain and monitor [O.sub.2] saturation levels.

3. Physical Therapy - Conduct and monitor S.T.E.P. Program exercises.

4. Occupational Therapy - Assist Physical Therapy staff with exercises and supervision.

5. Recreational Services - Assist in transporting resident participants to and from the exercise room.

6. Social Services - Interface with family members.

7. Quality Assurance - Assist in monitoring of program protocols.

8. Nutritional Services - Develop and monitor caloric and nutritional supplement values.

We chose to utilize the protocol of services developed by Dr. Maria A. Fiatarone, et al in their study "Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People." Dr. Fiatarone was very generous in forwarding to us all materials used in her study. This was certainly a great help to us in developing our own program format.

The Exercise Regimen

The "Fit For Your Life Program" protocol forwarded to us by Dr. Fiatarone provided an excellent format for our residents to follow. It described an order of exercises, stressing that it is preferable to start with smaller muscles and move to larger muscle groups as residents have warmed up. The outlined order of exercises that we followed included: dorsiflexors, biceps, knee extensions, triceps 1 and triceps 2, leg lifts, shoulders, plantar flexors, hip flexors, knee flexors, hip abductors and hip flexors.

Each exercise is accompanied with a picture demonstrating the correct procedure. This simple method enabled our PT personnel to demonstrate the correct exercise method, and the resident to actually see and read about this for each exercise. Incidentally, this approach may be carried over for short-stay residents to continue using in their homes.

As for an exercise schedule, we had numerous considerations. The most immediate were: where, when, how and for how long?

Where: We set aside a specific room in the facility to be used as our S.T.E.P. Program Center. This allowed us to separate the S.T.E.P. Program from normal PT activities and add a special environmental quality to it. This also enabled us to schedule PT personnel for specific timeframes for the Program.

When and How Long: We scheduled our Program times according to the protocol utilized in the materials provided by Dr. Fiatarone. It consisted of 10 weeks, three days per week (Monday, Wednesday and Friday, thus eliminating the problem of limited staffing on weekends), one hour per session, in a group format. We scheduled our sessions from 10:30-11:30 a.m. This enabled participants to have eaten breakfast 3-1/2 hours earlier, as well as allowing them enough time to rest and be ready for lunch at 12:00-12:30 p.m.

How: We wanted to add an extra dimension to our philosophy of building strength and health in our residents, and therefore included nutritional supplements. We felt that anti-oxidants, such as Vitamin C and E, along with magnesium for improved heart and muscle function, were indicated.

An added consideration, of course, was Resistance Apparatus and Equipment: Numerous choices were available to us in determining which apparatus of resistance to use in our program. Our choices were resistance machines (too costly) or free weights (a possibility and reasonably priced). We chose VELCRO [R] bands that contained interchangeable lead weights. This enabled us to contain costs, and to increase or decrease weight using the same VELCRO [R] band for all participants. We could also use the same VELCRO [R] bands for both upper and lower body exercises.

Results

In fact, the response from our residents, families and physicians has been excellent. The Program is viewed as an innovative technique provided by a facility that strives to improve its residents' quality of life. Our physicians view the facility as providing a very special service that is a meaningful adjunct to the care they provide. Our community, our referral sources and Beverly corporate leadership view our S.T.E.P. Program as a progressive service, an excellent marketing tool, and a resident health enhancement activity.

Washington Manor will be publishing the complete results of our program once all of our values have been computed and the extent of success for individual and group participants has been determined. However, it has already become apparent that our resident participants, families and facility have benefited.

The first few sessions were, not surprisingly, quite difficult for the participants. Because of their age and accustomed sedentary lifestyles (some in wheelchairs, others with limited ambulation), their musculature had been compromised and/or atrophied from lack of use. Most of our residents couldn't complete the full circuit of exercises and became easily fatigued. Some soreness was evidenced, and ice was used to effectively diminish this common symptom.

We had hypothesized, though, that participants should, with repetition and consistency, diminish muscle fatigue and increase the amount of weight used. That this was in fact so became evident within the first two weeks of the program. Our 98-year-old participant became our "Star" - she doubled her exercise repetitions and increased weight with no ill effects. Her motivation was exemplary: "I want to walk better and do for myself." Her ambulation did increase, and today she appears to be able to walk longer distances than prior to beginning the exercises.

Another of our participants, a 94-year-old man, demonstrated progress as well. Upon initial baseline information, our respiratory team determined that his [O.sub.2] saturation level was low (88%), and that supplemental oxygen during exercise was recommended. This resident used oxygen throughout the day and, during exercise, we kept a canister near him. Supplemental oxygen was not indicated during his exercise regimen, though. He was able to increase the amount of repetitions using 1/2 lb. weights and to complete all exercises.

Another of our participants, at age 75, suffered from senile dementia, ambulated throughout the facility with an unsteady gait and was prone to falls. Although we were not certain that she fully comprehended her purpose in doing resistance exercises, she participated well and, using 1 lb. weights, doubled her repetitions in the first few weeks; also, her ambulation improved as her lower extremities became stronger. Decreased falls is, of course, our goal. (Interestingly, this resident's native language is Italian and, as she conducted her repetitions, we counted in Italian with her. This apparently brought back many happy memories of her childhood in Italy.)

A general level of success is seen, as we have brought together a group of people who now socialize together, look forward to the exercise sessions, and enjoy the new outlook the experience has provided. We would conclude, therefore, as an initial observation, that we and our resident participants have experienced progress in a very short time. As they continue the program, even beyond the initial 10-week sessions, we expect that improved health, ambulation and quality of life through enhanced independence will be an experience shared by many if not all.

Alan Meyers, PhD, is a staff development consultant based in North Miami, FL. A member of the Nursing Homes Editorial Board, he is a clinical psychologist and practicing psychotherapist.