Journal of Sports Sciences, 2015 Vol. 33, No. 2, 116–124, http://dx.doi.org/10.1080/02640414.2014.928828
How much exercise are older adults living in nursing homes doing in daily life? A cross-sectional study
PHILIPE DE SOUTO BARRETO1,2,3, LAURENT DEMOUGEOT1, BRUNO VELLAS1,3 & YVES ROLLAND1,3 1
Gérontopôle of Toulouse, Institute of Aging, Toulouse University Hospital (CHU Toulouse), Toulouse, France, 2Laboratory of Biocultural – Anthropology, Law, Ethics and Health, UMR7268 Aix-Marseille University, Marseille, France and 3UMR INSERM 1027, University of Toulouse III, Toulouse, France (Accepted 24 May 2014)
Abstract Information on the amount of exercise practised by nursing home (NH) residents is scarce. This study aimed at describing NH residents’ participation in exercise classes, as well as to examine whether the presence of a professional exercise instructor in the facilities is associated with residents’ exercise habits. The cross-sectional data of 5402 residents (median age = 88 years; mostly women (75.2%)) from 163 NHs in France were analysed. Adjusted logistic and linear regressions were performed to examine whether the presence of a professional exercise instructor in the NH was associated with exercise habits: exercise participation, frequency, duration, and levels. From the 5402 participants, 1914 were participating in exercise classes provided in the NH. Most of them had an exercise frequency of 1x/week or less. Median duration of exercise sessions was 45 min. Exercise levels were rated as: highly active (n = 487), intermediately active (n = 1096), and poorly active (n = 331). The presence of a professional exercise instructor working in the facility was significantly associated with exercise participation and with higher exercise frequencies and levels, and session duration. In conclusion, the presence of professional exercise instructors is associated with better exercise habits in NH residents. Improved exercise habits may potentially be translated into better health in this population. Keywords: physical activity, elderly, long-term care, exercise frequency, exercise duration
1. Introduction An important amount of evidence (Abdulla et al., 2013; Crocker et al., 2013; Karinkanta, Piirtola, Sievänen, Uusi-Rasi, & Kannus, 2010; Rubenstein, 2006; Valenzuela, 2012; Warburton, Charlesworth, Ivey, Nettlefold, & Bredin, 2010; WeeningDijksterhuis, de Greef, Scherder, Slaets, & van der Schans, 2011) suggests that exercise should be implemented as a preventive and therapeutic intervention for older nursing home (NH) residents. Despite this, very little information is available about the real amount of exercise (i.e., planned and purposeful physical activities generally developed to improve participants’ physiological and physical capacities) NH residents do in their daily lives. Most information about exercise levels comes from intervention studies (Weening-Dijksterhuis et al., 2011), which are pre-planned (i.e., researchers preset the total volume of exercise they want to investigate) and have a limited time length (around 10 to
12 weeks overall). Clearly, we do not know how many residents are doing exercise in NH routine care; the amount of exercise performed is also unknown. After reviewing the literature, to our knowledge there have not been any studies that have investigated the impact of the presence of a professional exercise instructor, who has a deep knowledge on the science of exercise, on NH residents’ participation in exercise classes. This is of particular importance since staffing issues constitute one of the most important barriers for exercise in NHs (Benjamin, Edwards, & Caswell, 2009; Benjamin, Edwards, Ploeg, & Legault, 2014), and therefore exercise classes in routine care in NHs may rely on the work of professionals non-specialised in the exercise field (e.g., habitual care providers, such as nurse’s assistants, or professionals responsible for developing socialising activities, such as “animators” of board games); exercise classes provided by professionals other than exercise instructors are probably less effective in terms of health benefits, which can
Correspondence: Dr. Philipe de Souto Barreto, Gérontopôle de Toulouse, Institut du Vieillissement, Toulouse University Hospital (CHU Toulouse) 37, Allées Jules Guesde. 31000 Toulouse, France. E-mail: [email protected] © 2014 Taylor & Francis
Exercise in nursing homes impact NH residents’ adherence to exercise negatively. The present study aimed to describe NH residents’ participation in exercise classes in a large sample of NHs, as well as to examine whether the presence of a professional exercise instructor in the facilities would be associated with exercise participation, frequency, levels, and session duration when possible confounders are controlled for. We hypothesised that the presence of a professional exercise instructor would be associated with higher participation in exercise classes, and higher frequency, higher session duration, and then higher levels of exercise in NH residents. 2. Methods This is a cross-sectional study that used data collected in 2012/2013 and analysed in 2013 from the IQUARE (Impact d’une démarche QUAlité sur l’évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) study. IQUARE’s protocol was fully described elsewhere (De Souto Barreto et al., 2013). Briefly, IQUARE is a multicentric individually tailored controlled trial designed to improve quality indicators related to frequent medical problems faced by NH staff (Rolland et al., 2009) (e.g., behavioural disturbances, falls); it was developed in NHs from Midi-Pyrénées, France (trial registration number: NCT01703689). This is a 6-month intervention, with an 18-month follow-up. NHs were allocated to one of the following two groups: 1) audit and feedback intervention on quality indicators associated with cooperative work meetings between hospital geriatricians and NH staff (experimental group) or 2) audit and feedback only (control group). IQUARE followed the principles of the Declaration of Helsinki and complied with ethical standards in France; study protocol was approved by the ethic committee of the Toulouse University Hospital and the Consultative Committee for the Treatment of Research Information on Health (CNIL: 07–438). Data for the present work came from IQUARE’s second wave (Wave2) of data collection, i.e., the post-intervention assessment; data on exercise were not available at baseline (Wave1). It is important to note that the intervention in the IQUARE study did not focus on physical exercise. Therefore, information on exercise presented in this article corresponds to the reality about exercise practice found in the NH setting since it is unlikely that IQUARE’s intervention has impacted residents’ exercise habits (i.e., exercise participation, frequency, and levels). 2.1. Participants From the 6275 residents (n = 175 NHs) who had their data collected at Wave1, 2302 residents were
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no longer present at Wave2 (due to death or lost to the follow-up). NH residents who were no longer present at Wave2 were replaced by other residents (people who did not participate at Wave1) living in the same NH; for this, NH staff proceeded to the selection of the new participants by using the same methodological approach they had used at Wave1: residents were randomly selected on the basis of alphabetical order within each NH (at a pace of 1/2 or 1/3, depending on the total number of NH beds). Twelve NHs dropped out from the study (especially due to organisational problems, such as change in the leader medical and administrative staff), giving a total of 5737 residents from 163 NHs present at Wave2: 3973 participants were present at both Wave1 and Wave2, and 1764 were new participants (present only at Wave2). Among them, information on exercise practice was available for 5402 residents (see below 2.3); these residents are the participants of this study.
2.2. Procedures Data were collected by using two questionnaires, completed on-line by the NH staff: a questionnaire informing about the NH structure and internal organisation was completed by the NH administrative staff (e.g., NH administrator), whereas the other questionnaire, collecting information on residents’ health status, was completed by the NH medical staff (mainly the physician responsible for care coordination in the NH) by consulting the resident’s medical chart. Information on the residents’ exercise habits was recorded by the NH medical staff after discussion with other care providers, especially exercise instructors (when available in the NH), nurses, and nurses’ aide.
2.3. Outcomes Information on residents’ exercise habits were obtained from four questions: 1) “Does this resident usually participate in exercise classes provided by the NH?” (only one of the following responses was possible: yes, no, there are no exercise classes in the NH, or I do not know – residents for whom the NH medical staff responded “no exercise classes in the NH” (n = 230) or “I do not know” (n = 105) were dropped out from the study). In the case of response “yes”, the following two questions were asked: 2) “How frequently does the resident usually participate in the exercise class?” (≥2 times per week, 1 time per week, 2 times per month, 1 time per month, or < 1 time per month), and “How long has the resident participated in the exercise class?” (6 months). A fourth question, regarding the
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duration of exercise classes, was also asked: 4) “What is the usual duration (minutes) of an exercise class?” From these questions, we built four outcomes: Exercise participation: Binary outcome opposing the residents who participate in exercise classes provided in the NH vs. those who do not. Exercise frequency: Frequency of participation in exercise classes was coded as follows: ≥ 2 times per week, 1 time per week, or < 1 time per week. This variable was restricted to residents who participate in exercise classes. Exercise duration: Discrete variable in minutes indicating the duration of a single session of exercise. This is the only outcome obtained at the facility level rather than at the resident level. It was restricted to NHs that provided exercise classes to their residents. Exercise level: Categorical variable rating participants according to their exercise habits (restricted to residents who participate in exercise classes). People were rated as: highly active – people participating in exercise classes ≥ 2x/ week, for ≥ 1 month, in NHs where exercise classes have a duration of at least 30 min per session; intermediately active – those participating in exercise classes ≥ 2x/week for less than 1 month or doing exercise 1x/week; poorly active – all the other possible combinations of exercise frequency, exercise long-term participation, and session duration.
2.4. Independent variable of interest Presence of a professional exercise instructor: binary variable (yes vs. no) built from the question: “Is there currently a professional exercise instructor working in the NH?”. Professional exercise instructors in our study had either a 3-year graduate diploma on Science and Techniques of Physical Activity and Sports (from the French term STAPS) or a professional university diploma (in general, a 2-year training composed of about 400 h of theoretical classes on several aspects related to exercise, including exercise for the elderly, and several weeks of practical field work as a trainee). 2.5. Confounders Based on the literature about the correlates and predictors of exercise for older adults (Trost, Owen, Bauman, Sallis, & Brown, 2002; van Stralen, De Vries, Mudde, Bolman, & Lechner, 2009) and on the assumption that the high variation on the quality of the health care provided in institutions (Tolson
et al., 2011) is partly determined by NH structure and organisation, we selected the following variables as confounders: environmental and contextual aspects, NH ownership (public, private non-profit, and private for-profit), NH number of beds, length of stay in the NH (days); socio-demographic aspects, sex and age; health-related aspects. The Charlson Comorbidity Index (McGregor et al., 2005), Activities of Daily Living (ADL. e.g., bathing, toileting, transferring, feeding, dressing, and walking in the home (Ferrucci et al., 1996)) scores (for each item, participants’ ability to execute the activity was established as: “perform it alone, without difficulty” (score 1), “perform it alone, with some difficulty” (score 0.5), or “unable to perform it or needing help” (score 0). The addition of the 6 items gives a score varying from 0 to 6, with lower scores indicating higher disability levels), body mass index (BMI: undernormal weight: weight:
How much exercise are older adults living in nursing homes doing in daily life? A cross-sectional study
PHILIPE DE SOUTO BARRETO1,2,3, LAURENT DEMOUGEOT1, BRUNO VELLAS1,3 & YVES ROLLAND1,3 1
Gérontopôle of Toulouse, Institute of Aging, Toulouse University Hospital (CHU Toulouse), Toulouse, France, 2Laboratory of Biocultural – Anthropology, Law, Ethics and Health, UMR7268 Aix-Marseille University, Marseille, France and 3UMR INSERM 1027, University of Toulouse III, Toulouse, France (Accepted 24 May 2014)
Abstract Information on the amount of exercise practised by nursing home (NH) residents is scarce. This study aimed at describing NH residents’ participation in exercise classes, as well as to examine whether the presence of a professional exercise instructor in the facilities is associated with residents’ exercise habits. The cross-sectional data of 5402 residents (median age = 88 years; mostly women (75.2%)) from 163 NHs in France were analysed. Adjusted logistic and linear regressions were performed to examine whether the presence of a professional exercise instructor in the NH was associated with exercise habits: exercise participation, frequency, duration, and levels. From the 5402 participants, 1914 were participating in exercise classes provided in the NH. Most of them had an exercise frequency of 1x/week or less. Median duration of exercise sessions was 45 min. Exercise levels were rated as: highly active (n = 487), intermediately active (n = 1096), and poorly active (n = 331). The presence of a professional exercise instructor working in the facility was significantly associated with exercise participation and with higher exercise frequencies and levels, and session duration. In conclusion, the presence of professional exercise instructors is associated with better exercise habits in NH residents. Improved exercise habits may potentially be translated into better health in this population. Keywords: physical activity, elderly, long-term care, exercise frequency, exercise duration
1. Introduction An important amount of evidence (Abdulla et al., 2013; Crocker et al., 2013; Karinkanta, Piirtola, Sievänen, Uusi-Rasi, & Kannus, 2010; Rubenstein, 2006; Valenzuela, 2012; Warburton, Charlesworth, Ivey, Nettlefold, & Bredin, 2010; WeeningDijksterhuis, de Greef, Scherder, Slaets, & van der Schans, 2011) suggests that exercise should be implemented as a preventive and therapeutic intervention for older nursing home (NH) residents. Despite this, very little information is available about the real amount of exercise (i.e., planned and purposeful physical activities generally developed to improve participants’ physiological and physical capacities) NH residents do in their daily lives. Most information about exercise levels comes from intervention studies (Weening-Dijksterhuis et al., 2011), which are pre-planned (i.e., researchers preset the total volume of exercise they want to investigate) and have a limited time length (around 10 to
12 weeks overall). Clearly, we do not know how many residents are doing exercise in NH routine care; the amount of exercise performed is also unknown. After reviewing the literature, to our knowledge there have not been any studies that have investigated the impact of the presence of a professional exercise instructor, who has a deep knowledge on the science of exercise, on NH residents’ participation in exercise classes. This is of particular importance since staffing issues constitute one of the most important barriers for exercise in NHs (Benjamin, Edwards, & Caswell, 2009; Benjamin, Edwards, Ploeg, & Legault, 2014), and therefore exercise classes in routine care in NHs may rely on the work of professionals non-specialised in the exercise field (e.g., habitual care providers, such as nurse’s assistants, or professionals responsible for developing socialising activities, such as “animators” of board games); exercise classes provided by professionals other than exercise instructors are probably less effective in terms of health benefits, which can
Correspondence: Dr. Philipe de Souto Barreto, Gérontopôle de Toulouse, Institut du Vieillissement, Toulouse University Hospital (CHU Toulouse) 37, Allées Jules Guesde. 31000 Toulouse, France. E-mail: [email protected] © 2014 Taylor & Francis
Exercise in nursing homes impact NH residents’ adherence to exercise negatively. The present study aimed to describe NH residents’ participation in exercise classes in a large sample of NHs, as well as to examine whether the presence of a professional exercise instructor in the facilities would be associated with exercise participation, frequency, levels, and session duration when possible confounders are controlled for. We hypothesised that the presence of a professional exercise instructor would be associated with higher participation in exercise classes, and higher frequency, higher session duration, and then higher levels of exercise in NH residents. 2. Methods This is a cross-sectional study that used data collected in 2012/2013 and analysed in 2013 from the IQUARE (Impact d’une démarche QUAlité sur l’évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) study. IQUARE’s protocol was fully described elsewhere (De Souto Barreto et al., 2013). Briefly, IQUARE is a multicentric individually tailored controlled trial designed to improve quality indicators related to frequent medical problems faced by NH staff (Rolland et al., 2009) (e.g., behavioural disturbances, falls); it was developed in NHs from Midi-Pyrénées, France (trial registration number: NCT01703689). This is a 6-month intervention, with an 18-month follow-up. NHs were allocated to one of the following two groups: 1) audit and feedback intervention on quality indicators associated with cooperative work meetings between hospital geriatricians and NH staff (experimental group) or 2) audit and feedback only (control group). IQUARE followed the principles of the Declaration of Helsinki and complied with ethical standards in France; study protocol was approved by the ethic committee of the Toulouse University Hospital and the Consultative Committee for the Treatment of Research Information on Health (CNIL: 07–438). Data for the present work came from IQUARE’s second wave (Wave2) of data collection, i.e., the post-intervention assessment; data on exercise were not available at baseline (Wave1). It is important to note that the intervention in the IQUARE study did not focus on physical exercise. Therefore, information on exercise presented in this article corresponds to the reality about exercise practice found in the NH setting since it is unlikely that IQUARE’s intervention has impacted residents’ exercise habits (i.e., exercise participation, frequency, and levels). 2.1. Participants From the 6275 residents (n = 175 NHs) who had their data collected at Wave1, 2302 residents were
117
no longer present at Wave2 (due to death or lost to the follow-up). NH residents who were no longer present at Wave2 were replaced by other residents (people who did not participate at Wave1) living in the same NH; for this, NH staff proceeded to the selection of the new participants by using the same methodological approach they had used at Wave1: residents were randomly selected on the basis of alphabetical order within each NH (at a pace of 1/2 or 1/3, depending on the total number of NH beds). Twelve NHs dropped out from the study (especially due to organisational problems, such as change in the leader medical and administrative staff), giving a total of 5737 residents from 163 NHs present at Wave2: 3973 participants were present at both Wave1 and Wave2, and 1764 were new participants (present only at Wave2). Among them, information on exercise practice was available for 5402 residents (see below 2.3); these residents are the participants of this study.
2.2. Procedures Data were collected by using two questionnaires, completed on-line by the NH staff: a questionnaire informing about the NH structure and internal organisation was completed by the NH administrative staff (e.g., NH administrator), whereas the other questionnaire, collecting information on residents’ health status, was completed by the NH medical staff (mainly the physician responsible for care coordination in the NH) by consulting the resident’s medical chart. Information on the residents’ exercise habits was recorded by the NH medical staff after discussion with other care providers, especially exercise instructors (when available in the NH), nurses, and nurses’ aide.
2.3. Outcomes Information on residents’ exercise habits were obtained from four questions: 1) “Does this resident usually participate in exercise classes provided by the NH?” (only one of the following responses was possible: yes, no, there are no exercise classes in the NH, or I do not know – residents for whom the NH medical staff responded “no exercise classes in the NH” (n = 230) or “I do not know” (n = 105) were dropped out from the study). In the case of response “yes”, the following two questions were asked: 2) “How frequently does the resident usually participate in the exercise class?” (≥2 times per week, 1 time per week, 2 times per month, 1 time per month, or < 1 time per month), and “How long has the resident participated in the exercise class?” (6 months). A fourth question, regarding the
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duration of exercise classes, was also asked: 4) “What is the usual duration (minutes) of an exercise class?” From these questions, we built four outcomes: Exercise participation: Binary outcome opposing the residents who participate in exercise classes provided in the NH vs. those who do not. Exercise frequency: Frequency of participation in exercise classes was coded as follows: ≥ 2 times per week, 1 time per week, or < 1 time per week. This variable was restricted to residents who participate in exercise classes. Exercise duration: Discrete variable in minutes indicating the duration of a single session of exercise. This is the only outcome obtained at the facility level rather than at the resident level. It was restricted to NHs that provided exercise classes to their residents. Exercise level: Categorical variable rating participants according to their exercise habits (restricted to residents who participate in exercise classes). People were rated as: highly active – people participating in exercise classes ≥ 2x/ week, for ≥ 1 month, in NHs where exercise classes have a duration of at least 30 min per session; intermediately active – those participating in exercise classes ≥ 2x/week for less than 1 month or doing exercise 1x/week; poorly active – all the other possible combinations of exercise frequency, exercise long-term participation, and session duration.
2.4. Independent variable of interest Presence of a professional exercise instructor: binary variable (yes vs. no) built from the question: “Is there currently a professional exercise instructor working in the NH?”. Professional exercise instructors in our study had either a 3-year graduate diploma on Science and Techniques of Physical Activity and Sports (from the French term STAPS) or a professional university diploma (in general, a 2-year training composed of about 400 h of theoretical classes on several aspects related to exercise, including exercise for the elderly, and several weeks of practical field work as a trainee). 2.5. Confounders Based on the literature about the correlates and predictors of exercise for older adults (Trost, Owen, Bauman, Sallis, & Brown, 2002; van Stralen, De Vries, Mudde, Bolman, & Lechner, 2009) and on the assumption that the high variation on the quality of the health care provided in institutions (Tolson
et al., 2011) is partly determined by NH structure and organisation, we selected the following variables as confounders: environmental and contextual aspects, NH ownership (public, private non-profit, and private for-profit), NH number of beds, length of stay in the NH (days); socio-demographic aspects, sex and age; health-related aspects. The Charlson Comorbidity Index (McGregor et al., 2005), Activities of Daily Living (ADL. e.g., bathing, toileting, transferring, feeding, dressing, and walking in the home (Ferrucci et al., 1996)) scores (for each item, participants’ ability to execute the activity was established as: “perform it alone, without difficulty” (score 1), “perform it alone, with some difficulty” (score 0.5), or “unable to perform it or needing help” (score 0). The addition of the 6 items gives a score varying from 0 to 6, with lower scores indicating higher disability levels), body mass index (BMI: undernormal weight: weight:
