The Problem, The Solutions
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Q & A: Exercise with Residents
Having spent the last 15 years conducting research in nursing homes, spending more time in some facilities than the residents themselves, we at the Center for Quality Aging are nothing if not realists. So here are our pointed answers to some pertinent questions about exercise with frail nursing home residents.
Q.Will offering regular exercise to residents require more time than providing usual care?
A.Yes, without question (1,2).
Q. Will regular exercise help restore function so that impaired residents are more independent as a result?
A. Probably not; it’s unlikely BUT regular exercise can help to slow functional decline among residents who are already frail and at great risk for further decline and physical dependency (1,2).
Q. Will regular exercise reduce the incidence of common healthcare problems in residents such as pressure ulcers, falls, cardiovascular conditions, and the like?
A. It’s unlikely (3).
Q. Then why the heck should our facility strain already limited resources to offer regular exercise to residents who you say will probably not improve their health as a result?
A. Here’s our most pointed answer of all: Because if you do nothing, then so will many of your residents. As a result, their mobility, strength, and endurance will inevitably decline, and then so probably will their health and quality of life (1-3). Call it a sin of omission.
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CMS to Nursing Homes: "Try to Improve Functional Ability"
These days the federal Centers for Medicare & Medicaid Services (CMS) is encouraging long-term-care consumers to use their purchasing power to hold nursing homes accountable for poor quality of care. Its Nursing Home Compare website exerts pressure on the industry by reporting, for each facility in the nation, the percentage of residents whose need for help with Activities of Daily Living (ADLs) has increased. A bad score signals potential problems and may steer consumers away from the facility.
Delve a few pages into this website and you find that CMS is also educating consumers to be discerning nursing home shoppers. “Nursing homes should always strive, with every resident, to try to improve functional ability as much as possible…,” it advises. “When you visit the nursing home, ask what programs are in place to maintain and improve the physical function of the residents.” (4)
The message from CMS is clear: Your facility needs to do something to help residents accomplish such basic daily activities as walking, transferring, and moving in bed. The benefits of such support programs, typically exercise programs, include enhancing self-image and increasing activity levels. The chief benefit, however, may lie not in what these programs improve but in what they prevent: further functional decline.
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At the Very Least, Prevent Decline
These days no one is expecting miracles from your facility. Those of us who work in long-term care have come to realize that the functional abilities of long-stay nursing home residents have worsened in recent years as housing options for more independent seniors have expanded. With today’s very frail nursing home population, the first goal is not so much to improve ADL function (though that would be great) as it is to prevent its decline.
Even the folks at CMS seem to recognize this new reality. Its quality measure doesn’t bother to look at long-stay residents who have improved their ADL function, just those who have gone downhill. In a statement to consumers, CMS notes: “Regardless of how much effort a nursing home program puts into improving function in their population of frail elderly residents, some residents will inevitably experience a loss in function over time. This is especially true of very sick or very frail residents…” And, we might add, that’s most of them.
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Use it or Lose it
The question now is not whether to offer programs that help residents maintain their ADL function but what kinds of programs to offer. Ultimately, it boils down to that wise adage: Use it or lose it. If residents are to maintain their ability to walk, transfer, use the toilet, or move in bed, then they must continue to engage in these activities or something very much like them.
This training module provides instructions for implementing two programs that help residents maintain ADL function. The first is a walking program, appropriate for the minority of nursing home residents who are ambulatory. The second is an exercise intervention aimed at the 50-60% of nursing home residents who are incontinent. Unlike many other exercise programs in nursing homes, this one welcomes residents who are severely cognitively impaired.
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Program Prerequisites
Three pre-requisites are recommended before you start:
Pre-Requisites for Residents
Preliminary to participating in either program, residents should be treated if they have a current medical problem such as an infection or pain (see our Pain Screening Module).
A pharmacist’s or physician’s review of their medications is also helpful. This review may prevent or minimize such side-effects as drowsiness and confusion, which can undermine participation in exercise programs.
Your Assignment
This is often an eye-opener for medical directors and nurse supervisors: Stroll down your facility’s hallways at 10 a.m. and again at 4 p.m. on the same day. Each time, note the names or room numbers of residents whom you observe in bed. Compare the two lists to identify those residents observed in bed at both times. Our research indicates that these residents spend an estimated 16 or more hours a day in bed and these residents are not “bed-bound” for medical reasons (5). These residents definitely are not “using it.” There’s a good chance they’re “losing it.” It’s time to exercise.
Back to the Top or Proceed to A Walking Program
- Q&A: Exercise with Residents
- CMS to Nursing Homes: "Try to Improve Functional Ability"
- At the Very Least, Prevent Decline
- Use it or Lose it
- Program Prerequisites
- Your Assignment
Q & A: Exercise with Residents
Having spent the last 15 years conducting research in nursing homes, spending more time in some facilities than the residents themselves, we at the Center for Quality Aging are nothing if not realists. So here are our pointed answers to some pertinent questions about exercise with frail nursing home residents.
Q.Will offering regular exercise to residents require more time than providing usual care?
A.Yes, without question (1,2).
Q. Will regular exercise help restore function so that impaired residents are more independent as a result?
A. Probably not; it’s unlikely BUT regular exercise can help to slow functional decline among residents who are already frail and at great risk for further decline and physical dependency (1,2).
Q. Will regular exercise reduce the incidence of common healthcare problems in residents such as pressure ulcers, falls, cardiovascular conditions, and the like?
A. It’s unlikely (3).
Q. Then why the heck should our facility strain already limited resources to offer regular exercise to residents who you say will probably not improve their health as a result?
A. Here’s our most pointed answer of all: Because if you do nothing, then so will many of your residents. As a result, their mobility, strength, and endurance will inevitably decline, and then so probably will their health and quality of life (1-3). Call it a sin of omission.
Back to the Top
CMS to Nursing Homes: "Try to Improve Functional Ability"
These days the federal Centers for Medicare & Medicaid Services (CMS) is encouraging long-term-care consumers to use their purchasing power to hold nursing homes accountable for poor quality of care. Its Nursing Home Compare website exerts pressure on the industry by reporting, for each facility in the nation, the percentage of residents whose need for help with Activities of Daily Living (ADLs) has increased. A bad score signals potential problems and may steer consumers away from the facility.
Delve a few pages into this website and you find that CMS is also educating consumers to be discerning nursing home shoppers. “Nursing homes should always strive, with every resident, to try to improve functional ability as much as possible…,” it advises. “When you visit the nursing home, ask what programs are in place to maintain and improve the physical function of the residents.” (4)
The message from CMS is clear: Your facility needs to do something to help residents accomplish such basic daily activities as walking, transferring, and moving in bed. The benefits of such support programs, typically exercise programs, include enhancing self-image and increasing activity levels. The chief benefit, however, may lie not in what these programs improve but in what they prevent: further functional decline.
Back to the Top
At the Very Least, Prevent Decline
These days no one is expecting miracles from your facility. Those of us who work in long-term care have come to realize that the functional abilities of long-stay nursing home residents have worsened in recent years as housing options for more independent seniors have expanded. With today’s very frail nursing home population, the first goal is not so much to improve ADL function (though that would be great) as it is to prevent its decline.
Even the folks at CMS seem to recognize this new reality. Its quality measure doesn’t bother to look at long-stay residents who have improved their ADL function, just those who have gone downhill. In a statement to consumers, CMS notes: “Regardless of how much effort a nursing home program puts into improving function in their population of frail elderly residents, some residents will inevitably experience a loss in function over time. This is especially true of very sick or very frail residents…” And, we might add, that’s most of them.
Back to the Top
Use it or Lose it
The question now is not whether to offer programs that help residents maintain their ADL function but what kinds of programs to offer. Ultimately, it boils down to that wise adage: Use it or lose it. If residents are to maintain their ability to walk, transfer, use the toilet, or move in bed, then they must continue to engage in these activities or something very much like them.
This training module provides instructions for implementing two programs that help residents maintain ADL function. The first is a walking program, appropriate for the minority of nursing home residents who are ambulatory. The second is an exercise intervention aimed at the 50-60% of nursing home residents who are incontinent. Unlike many other exercise programs in nursing homes, this one welcomes residents who are severely cognitively impaired.
Back to the Top
Program Prerequisites
Three pre-requisites are recommended before you start:
- First, enlist top-level support from a managerial “champion” to facilitate acceptance of the new programs by direct care staff. One way to recruit help: Hand the likely champion a printed copy of the mobility decline prevention module and ask if you two can discuss it after he or she has read it. Have you considered that you yourself might be the champion? Also consider social activities personnel and restorative nurse aide staff.
- Second, read through all steps of the walking program and/or all steps of the exercise intervention so that, from beginning to end, you know what’s needed to achieve success. Print the module in full if you want to browse through the programs when you’re away from your computer.
- Finally, allow extra time at the beginning to climb the learning curve; trust us—both programs consume less staff time the longer your facility administers them.
Pre-Requisites for Residents
Preliminary to participating in either program, residents should be treated if they have a current medical problem such as an infection or pain (see our Pain Screening Module).
A pharmacist’s or physician’s review of their medications is also helpful. This review may prevent or minimize such side-effects as drowsiness and confusion, which can undermine participation in exercise programs.
Your Assignment
This is often an eye-opener for medical directors and nurse supervisors: Stroll down your facility’s hallways at 10 a.m. and again at 4 p.m. on the same day. Each time, note the names or room numbers of residents whom you observe in bed. Compare the two lists to identify those residents observed in bed at both times. Our research indicates that these residents spend an estimated 16 or more hours a day in bed and these residents are not “bed-bound” for medical reasons (5). These residents definitely are not “using it.” There’s a good chance they’re “losing it.” It’s time to exercise.
Back to the Top or Proceed to A Walking Program
