BACKGROUND

Exercise interventions to prevent walking difficulty in community-dwelling older adults have focused mainly on improving strength and endurance and have overlooked an important component of walking, namely the timing and coordination of movement. Based on previous research and with critical input from providers and older adults, the group exercise program was developed. The program includes timing and coordination components and focuses on improving walking.

OBJECTIVES

To compare the effectiveness and sustainability of against a Standard group exercise program consisting of seated strength, endurance, and flexibility exercises in community-dwelling older adults who reside in independent living facilities and senior apartment buildings, and who live elsewhere but regularly attend senior community centers. We will also explore the effectiveness of compared with a Standard program when taught by staff activity personnel, and the effectiveness of the program when delivered by staff activity personnel compared with delivery by exercise leaders (when feasible), using a quasi-experimental design. The acceptability and risks associated with exercise participation are also of interest.

METHODS

The study was a cluster randomized, single-blind intervention trial that compared the effects on function, disability, and mobility of a Standard group exercise program and the group exercise program in community-dwelling older adults. Randomization to intervention was at the facility level. We had planned to examine the sustainability of the program by randomly assigning participants within each facility to either class 1, taught by an exercise leader, or class 2, taught by staff activity personnel. As we could not randomize to instructor in all facilities as planned, instructor assignment should be considered quasi-experimental. Exercise leaders were research staff who were physical therapists, physical therapist assistants, or exercise physiologists. Staff activity personnel were employees of the facilities themselves who were involved in providing services to the residents. They could be fitness staff, activity directors, social workers, outreach coordinators, care coordinators, or other employees with a similar role. At facilities that did not have staff activity personnel available, we identified (an) older adult(s) from the facility to be trained as a peer leader. Exercise classes were held twice weekly for 12 weeks and were delivered by study exercise leaders (class 1) or staff activity personnel (class 2). The Standard program consisted of warm-up, aerobic, strengthening, and stretching exercises all done while seated. The program consisted of warm-up, timing and coordination (stepping and walking patterns), strengthening, and stretching exercises completed primarily while standing. The primary outcome of function and disability were the Late Life Function and Disability Instrument (LLFDI) overall function and disability frequency scores, and the primary outcomes of mobility were the 6-minute walk test (6MWT) and gait speed. Outcomes were assessed preintervention and postintervention. Thirty-two facilities were randomized, encompassing 424 individuals.

RESULTS

The mean ± SD age of the participants was 80.7 ± 7.8 years. The group had greater improvements than the Standard group in 6-minute walk distance (18.3 ± 60.5 vs 1.9 ± 55.8 m; adjusted difference = 15.3 ± 6.7; = .0228). There were no significant differences between groups in gait speed (the other primary measure of walking ability), self-reported function, and disability primary outcome or any of the secondary outcomes. When taught by an exercise leader, the group had greater improvements than the Standard group in the primary measures of mobility, the 6MWT (20.6 ± 57.1 vs 4.1 ± 55.6 m; adjusted difference = 16.7 ± 7.4; = .0262), and gait speed (0.05 ± 0.13 vs −0.01 ± 0.11 m/s; adjusted difference = 0.05 ± 0.02; = .0008). The between-group differences were adjusted for the baseline value of the outcome and represent a small but meaningful difference. There were no significant differences in self-reported function and disability as measured by the LLFDI scores. Of the 32 facilities included in the study, we could identify staff activity personnel to train to lead the exercise class at fewer than half of the facilities (15/32 [46.9%]). We could not recruit suitable facility staff at all facilities as planned, thus making the sustainability model—the ability of the facility to continue the program once the research staff was gone—infeasible and the aim exploratory and quasi-experimental rather than randomized. When taught by staff activity personnel, only when we could identify and train someone at the facility, there were no greater gains in any of the primary or secondary outcomes from (all > .10). In both programs, attendance (≥20 classes) was greater in the classes taught by the exercise leader compared with the staff activity personnel (65.1% vs 52.0%; 50.0% vs 24.5%). Overall satisfaction was greater in classes taught by exercise leaders than in those taught by staff activity personnel, as measured by: reporting benefit from class (68.4% vs 42.9%, OR, 2.29 [95% CI, 1.09-4.82]; = .0294); sufficient individualized instruction (84.2% vs 51.0%, OR, 11.55 [95% CI, 2.17-61.63]; = .0042); satisfaction with the class (84.2% vs 53.1%, OR, 9.62 [95% CI, 4.05-22.88]; < .0001); and likelihood of continuing the class if it were to be offered in the future (74.3% vs 53.1%, OR, 1.84 [95% CI, 1.29-2.61]; = .0007).

CONCLUSIONS

The group exercise program elicited greater improvements in mobility, as measured by the 6MWT, than the Standard group exercise program when both instructor types were considered together. When taught by exercise leaders, the group exercise program was more effective at improving mobility than the Standard group exercise program, more safe, and well-liked by community-dwelling older adults, but differences between groups should be interpreted cautiously because we did not a priori plan or statistically power for testing for instructor type × intervention interaction effects and because assignment to an exercise leader or staff activity personnel was not randomized. The group exercise program did not improve self-reported function or disability. The small number of staff activity personnel, recruited and trained, were unable to sustain a similar level of effectiveness. Therefore, given the difficulty of identifying and training staff activity personnel to deliver the program and the lack of effectiveness when delivered by staff activity personnel, we believe is best delivered by an exercise leader. Other modalities of recruiting and training community personnel need to be considered and evaluated for wider dissemination, implementation, and sustainability of .