Active Ageing; An Underserved Concept in Our Local Community

INTRODUCTION

The ageing population in North Carolinais at a critical point in history.  The number of persons aged 65 and older in NC increased 25.7% between 2000 and 2010, to 12.9% of the state’s total population (UNC, 2011).  In addition, the North Carolina metropolitan areas of Raleigh-Cary and Charlotte-Gastonia-Concord were #1 and #10, respectively, in national rankings for fastest growth in the 65+ population between 2000 and 2010 (UNC, 2011).  During this same decade, those considered very old, over the age of 85, grew in numbers by 40%(UNC, 2011).  With these staggering statistics, it is imperative that our state address the pressing issues in which this population will face.  According to the UNC Institute on Ageing, 43.4% of persons aged over 65 have a disability(UNC, 2011).  It is also predicted that North Carolinians with Alzheimer’s disease will increase in population by almost 24% by the year 2025 (UNC, 2011).  With the facts before us on how this population will expand in the next 10-15 years, it is critical that we address age related impairments globally in order to sustain individual’s function and grossly improve their quality of life.

One of the key factors to keeping seniors more functional addresses the concept of active aging.  Historically, in this country, retirement age came around the age of 65 and at that time, it was acceptable to “rest” after all the hard years of labor.  But with populations ageing well into their 80’s, resting for 20+ years may not be an option.  Older generations need to be encouraged to age in a healthy life style that can support many more years of functionality.  Engaging in exercise, healthy eating, volunteering, and even remaining employed can benefit the physical and mental changes that come with age.  My community assessment inDurhamof programs for the ageing population revealed not only a lack of services but also a reduction in services over the past year due to a struggling economy.  According to Champee Rigsbee, the Director of the Adult Day Center at the Durham Senior Center, approximately 10 state scholarships were cut to fund the program as well as multiple VA scholarships thus placing families in even more dire circumstances in caring for their older family members.

My capstone project developed a simple exercise prescription for older Americans with dementia. In caring for the advancing needs of this population, health care alternatives such as adult day centers appear to be a growing concept.  This setting is also a perfect platform to introduce evidence based exercise to maintain and/or advance function.  Incorporating the evidence behind an exercise program to establish key factors that can reduce individual impairments will help sustain function, thus easing the burden of ageing on not only the individual but also the systems that support it.

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PURPOSE

There has been an abundance of research on the effects of exercising with the ageing population that have dispelled many of the myths associated with the process.  It is well known that even the oldest old can build muscle mass and improve cardiovascular fitness.  For the purposes of this capstone project, the evidence was focused on older adults with dementia.  These individuals are a growing population with a unique set of impairments.  Understanding the exercises that can best affect their function and possibly reduce their dementia is important.  Although exercise does not cure dementia, there are many research projects associated with understanding the benefits of cardiovascular exercises and the benefits to the brain. This capstone set out to assess several different areas.  These areas include:

1)  Establish the evidence behind exercise programs for people with dementia

2) Development of an exercise program to be integrated at my place of work in the Alzheimer’s unit

3) Educate the activities department on the exercise program to establish long term benefits to this ageing population

4)  Perform a community needs assessment to establish future needs of residents in the Durham County area.

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THE EVIDENCE

Establishing an exercise program for people who are older and have dementia can be challenging.  Often there are decreased attention spans, behavioral issues and non-compliance that easily alter the effectiveness of a program.  The growing body of research continues to recommend exercise to improve strength, flexibility and endurance in order to maximize the benefits of a program.  The difficult part is to develop of program that fits this criterion and engages the individual.

Research recommends a group ratio of 1:4 for an exercise prescription of individuals with cognitive impairments (Lazowski, et. al.., 1999).  It is also recommended that groups be structured and repetitive with constant cueing both verbal and visual (Lazowski, et. al., 1999).  According to Lazowski, et. al. inexpensive equipment such as hand held weights and theraband are an effective way to add resistance to increase strength (Lawzowski, et. al., 1999).  A review of the literature also showed that only 35% of programs incorporated weight bearing exercises (Lazowski, et. al., 1999).  Encouraging standing exercises verses seated exercises appears to provide an additional benefit for participants.  A study by Billinger, et. al., concluded that individuals with early stages of Alzheimer’s respond similarly to the nondemented individuals during the initial stages of exercise (Billinger, et. al., 2011).  They continued to recommend low to moderate intensity activities (Billinger, et. al., 2011).  This level of exercise intensity promotes aerobic capacity and has associated health benefits as well(Billinger, et.al., 2011).  Those individuals with Alzheimer’s appear to have limited benefit from high intensity exercise with noted decreased peak exercise capacity according to a study by Billinger, et. al. (Billinger, et. al., 2011).  It was recommended that high intensity exercises only be performed with individuals with a MMSE score of 10 or greater (Potter, et. al., 2011) .  Another study by Rolland,et. al., found evidence that a moderate exercise program, conducted only 2 times a week, slowed the progressive deterioration of activities of daily living by one third in a population with Alzheimer’s living in institutionalized care (Rolland, et. al. 2007).  The research is abundant with positive results from exercise in individuals with dementia.  A continued qualm of the research is that most programs are individualized and cannot be interpreted into a group program and the absolute benefit it may have.  The few studies that do exist in regards to group exercise have promising results.

In addition to the physical benefits of exercise, there appears to be recent evidence that exercise can also benefit the mental aspects of an individual.  Researchers tend to agree that there is a neuro-protective benefit of exercise.  Adults who exercise routinely in midlife carry a significantly lower risk of dementia in later years (Ahlskog, et. al., 2011).

The effects of resistive exercises do not appear to have the benefits of aerobic exercise when addressing properties of dementia.  Aerobic exercise in human trials with individuals with Alzheimer’s appears to provide a protection from progressive dementias and possibly slow the dementia process (Ahlskog, et. al, 2011).

The evidence leads to the establishment of routine exercise programs for individuals with various dementia types.  Resistance training is beneficial for overall strength and balance.  Aerobic exercise has shown to be a protective mechanism to the progressive deterioration of dementia.  Even the act of participating in groups provides a social outlet that can benefit an individual.

References

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THE EXERCISE PRESCRIPTION

There are several well established exercise programs out there that incorporate range of motion (ROM) as well as strengthening exercises or preach the benefits of walking for older individuals.  I was unable to find a program that was geared to individuals with dementia.  I choose to format my exercise prescription around the Fitness for Long Term-Care (FFLTC) model and not re-create the wheel.  Although specifics of the program are revealed in a specialized training (which I have not attended), I chose to incorporate the same time line for training principles to address strength, flexibility and cardiovascular fitness. There are several aspects of this exercise prescription that I felt would be beneficial for individuals with dementia.  One aspect was that each segment of exercise was timed.  For instance, the warm was 5 minutes, lower body resistance training was 5 minutes, upper body resistance training was 5 minutes and so on.  Having timed intervals of exercise will be beneficial in exercising in increments if the population does not adhere to a full 30 minute or 60 minute program.  If performed start to finish, the modified program would take 60 minutes.  Although I recognize that this is a slightly longer time frame per the research (most studies averaged 30-45 minutes in populations with dementia), I feel the way the exercises are divided will allow segmental implementation if it needs to be modified.  Splitting this program into 2 sessions could provide additional benefits for participants.

The second aspect of the FFLTC program was that it was adaptable to standing or seated exercises.  The research encourages standing exercises when able, but there is a large portion of nursing home residents that are unable to stand or require significant supervision to do so and this was not practical for safety purposes in even the smaller group setting.

The FFLTC program also incorporated all aspects of evidence based research into the program.  Stretching, resistive exercises, cardiovascular exercise and balance exercises are all incorporated in the program.  Providing the full program or even increments of the program will provide evidence based exercises that can potentially benefit the lives of individuals with dementia and grossly improve their quality of life.

The breakdown of the exercises includes the following:

Warm up/Stretch                     5minutes

Walking                                      15 minutes

Lower Body Strengthening     5minutes

Upper Body Strengthening     5 minutes

Balance                                        10 minutes

Cool down/stretching               5 minutes

The strengthening portion was modified to perform 10 exercises (5 upper body and 5 lower body).  Each exercise is performed for 1 minute with a 1 minute break in between.  This aspect of the program allows repetition of task with minimal changes throughout the program, thus aiding in the ability of individuals to remain focused and complete the task.  The walking segment of the program incorporates various games and activities that keep individuals moving for 15 minutes (i.e. parachute, kickball, etc).  The balance exercises as specific to either standing or sitting without support.  Exercise that is  focused on balance challenging activities has been demonstrated as feasible and safe in those with significant cognitive impairments (Shubert, 2011).

Exercise Training Program

Pictures of Exercises Only

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OUTCOME

Due to unforeseen circumstances, I was unable to perform the originally established plan as developed.  During the implementation phase of this project, it was announced that the facility where I worked was going to be ceasing operations.  This announcement interfered with two aspects of my project; 1) the activities department whom I wished to train was dissolved and 2) the number of patients in the building was dramatically reduced, thus leaving very few residents appropriate for this exercise program.  The suitability of materials form (SAM) was performed on the PowerPoint presentation with a score of 82%.  There were modifications made to the wording of the presentation.  In light of these circumstances, I have posted a link to feedback form for the activities department as well as the participants.  I was unable to perform this aspect of my capstone.

Most of the participants of the exercise group were also discharged very abruptly, leaving one participant with mild dementia to perform the exercise group.  The participant was able to complete the exercise program.  She enjoyed the program overall but fatigued easily.  She also required constant cueing in order to continue for a full minute of exercise.  A modification to the program would be to reduce the overall time of the exercise program (60 minutes verses 30/45 minutes) or to split the program into 2 sessions during the day.

Participant Questionnaire

Staff Feedback Form

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REFLECTIONS

This capstone project was initiated in order to accomplish four different tasks.

1)      Establish the evidence behind exercise programs for people with dementia

• There is well established literature supporting the benefits of exercise in a population with dementia. There is even research suggesting benefits to the mental aspects of an individual with mild dementia.

2)      Development of an exercise program to be integrated at my place of work in the Alzheimer’s unit

• The program was developed but unfortunately was not able to be implemented to the degree I was hoping for due to unforeseen circumstances.  It was my original intent to perform the program with a group of 3-5 people with underlying Alzheimer’s diagnoses.  My hope was that if this program was successful, it could be something that could be used in an Adult Day Program or long term care in order to keep people active.

3)      Educate the activities department on the exercise program to establish long term benefits to this ageing population

• The educational component to this capstone was unfortunately disrupted as well with the announcement of closing of the building.  Conversations with staff prior to the announcement showed interest in participating in the program.  Some preliminary meetings were done in order to establish which residents would be most appropriate.  Unfortunately, before the program could be implemented at this level, staff was laid off.

4)      Perform a community needs assessment to establish future needs of residents in the Durham County area.

• I was able to interview the director at the Durham Adult Day Center.  She provided very useful information into the needs of our community and how imperative it is that changes occur to assist the population that is ageing with mild cognitive deficits.  The most concerning aspect of this interview was the fact that not only does Durham lack in facilities to assist this population, but funding has also been consistently cut due to recent budget constraints.  The research supports small groups of physical exercise in populations with dementia.  At the Durham Day Center, they exercise daily, but it is one group of approximately 30+ people.  There is a lot of opportunity to provide educational materials on exercise to various staff members.  Logistically, it would be very difficult to perform 30-60 minutes of exercise with 3-5 people in this setting without utilizing the entire day to get everyone done.

As we encounter the baby boomers ageing and witness the tremendous growth that is occurring with this population, it will be imperative to educate the public on the importance of exercise and the benefits associated with it.  It is an area that continues to require much attention nationally as well as in our local communities.  Government and private industries will have to prepare for the changing needs of this population.  Implementation of something as simple as an exercise program will benefit the individuals and the system as a whole as it reduces impairments and dysfunction.