- Warm-up Walk
This is generally accomplished in the Elder Rehab program by walking from the hospital's parking lot to the wellness center. (Deliberately parking the car a certain distance from a destination is an excellent way to increase the amount of walking done by an individual.) - Resting Pulse
After entering the Center, the subject is seated for a few moments and a resting pulse is taken using an electrical pulse monitor. Pulse should normally be below 100, the upper limit of the normal range, before beginning exercise. Consult a physician if a would-be exerciser's resting pulse is consistently higher than that. It could be okay for that individual, or not. During the resting period, participants typically do a picture description activity, using one of a prescribed series of Norman Rockwell calendar pictures, supplemented by a series of prompt questions. - Stretches
Next, the subject is guided through a series of stretches, each one done twice and held for 15 seconds:
A group of older people are exercising - Neck to the right side, left side, forward, chin touching chest. Arm across chest-right (press upper arm above elbow with opposite hand); arm across chest-left.
- Hamstring stretch. Sitting at the edge of a chair, bend forward with head facing forward and slide arms down extended right leg towards ankle; repeat along left leg.
- Calf stretch right, calf stretch left (done facing and holding onto a bar). Front leg is bent, back leg held straight. Participant moves the bent leg forward, feeling the stretch in the opposite leg, which is extended backward.
- Calf raise: Strengthens calf muscles. Subjects stand straight, holding on to a bar or tabletop and raise themselves slowly up on toes so they feel a stretch all the way along their calves. Start with 10 repetitions and gradually increase. Ankle weights, fastened with velcro straps can be added to increase resistance as the person develops increasing strength.
- Step Box:
Provides lower-body strength, aerobic, and balance training and is functionally related to stair climbing. Participant stands alongside a Step box and mounts it with the left foot, brings the right foot alongside it and touches it to the left (without stepping on the box) and then steps back down with the right. This is repeated 10 times. The exercise is repeated with the other foot. Gradually increase the number of step-ups. - Balance Practice
This is the same activity that was described in the assessment section. Facing and holding lightly to a bar or tabletop, participant stands on one foot and, when he or she feels stable, lets go of the bar. Partner counts the number of seconds balance is held. Three trials with each foot are performed. - Aerobics
Two consecutive periods of aerobic exercise are recommended, one on the treadmill and one on a stationary bicycle with no rest period between them. Some individuals may prefer to substitute a rowing machine for the bicycle. If possible, the treadmill should be equipped with a clip-on safety device that stops the machine if the user falls. Exercisers should be spotted at all times by a monitor standing close by. The goal is to attain 20 minutes of fairly continuous aerobic exercise per session by the end of 10 weeks, and 30 minutes by the end of one year. (More than 30 minutes is not recommended, as it makes the total workout session too long. Additional aerobic exercise can be achieved by daily walking.) By offering two different aerobic activities, boredom is kept to a minimum.
- Treadmill: Most participants can begin at a speed of 1 mph. Elevation is started at 0,
with small incremental increases as tolerated by the participant. Five minutes is suggested as a beginning duration, with a one-minute increase per week, as tolerated, up to 15 minutes.
An older woman who has Alzheimer's Disease is exercising on a treadmill with the assistance of a staff and family member. - Stationary bicycles: Two types of bicycles can be used:
- Schwinn Airdyne bicycles, which require users to sit and pedal in an upright position, maintain balance on a rather narrow seat, and work their arms back and forth while pedaling; and
- Recumbent bikes, which provide a wide, stable seat, back support, legs only exercise, and pedaling with legs out front.
- Treadmill: Most participants can begin at a speed of 1 mph. Elevation is started at 0,
- Conversation Stimulation
Exercise assistants should talk with their partner throughout the program. Activities used to stimulate conversation include having participants associate thoughts and memories to a stimulus word, tell what's good or bad about different things, complete sentence stems, give the ending to a proverb after the first few words are given, name the category that two related objects belong to, name a famous person with a first name that is provided. Large-type song sheets can be used to enable participant to sing old, familiar songs while exercising.
During the rest period between the aerobic and the weight training session, participants can be encouraged to discuss their opinion on controversial topics such as free prescription drugs for the elderly or current events, i.e., the President's tax plan. These types of discussions do not depend on memory for specific events, which is often reduced in persons with Alzheimer's Disease. Rather, they draw on common sense, personal philosophy, and general life experience, about which persons with early- to moderate-stage dementia can generally communicate. The exercise assistant should contribute to these discussions so that there is a real dialogue. - Weight Training
The weight-training regimen described here uses five different weight-training machines by MedX. MedX equipment is especially suitable for older persons because it can be finely adjusted to body size, has 2-pound (instead of 5-pound) weight increments, and has a shorter lifting distance for the weight stack than other brands (i.e., Nautilus). However, other machines (or free weights) can be used to achieve the same goals. Consult a trainer at the facility you plan to use. The Elder Rehab program emphasizes exercise machines that strengthen large muscle groups:
- leg press, which strengthens muscles of the upper legs and buttocks;
- chest press, which strengthens muscles of the chest and shoulders;
- seated row, which strengthens muscles of the arm, shoulder, and upper back;
- torso arm (weights pulled down from above to shoulder level), which strengthens muscles of the arm, shoulder, and upper torso; and
- overhead press weights pressed upward from just above shoulder level), which strengthens muscles of the chest and shoulders.
Substitute exercises are prescribed for participants with specific problems such as arthritic knees or shoulder pain.
At each beginning weight level, participants should be asked to do two sets of 10 repetitions at each machine, with a rest period of least 30 seconds after each set. After two successful workouts at a given weight, increase repetitions to 12 for two workouts, then increase weights. For upper-body machines, increase weight by two pounds. On the leg press, an increase of 10 pounds is usually tolerated.
If a participant complains or seems to be working too hard, drop back to a lower weight. (Sometimes a complainer can be distracted by a trip to the drinking fountain or bathroom. By the time he or she returns, the complaint is forgotten and exercise can resume!)
One participant who had shoulder pain could not do exercises with arms raised above shoulder height; bicep and tricep machines were substituted. A woman with arthritic knees skipped the leg press and did wall squats instead. One post-surgical patient did just walking for one semester, then walking and strength and flexibility exercises on a raised mat for a second semester before resuming full participation in all of the program's exercises. This particular individual, Ida, before two falls and multiple fractures, was videotaped, at age 84, pressing 448 pounds 10 times on a MedX leg press machine, while her 21-year-old student partner could only manage three repetitions!
Another program participant, currently 90 years old, fell and broke a hip at home in January 2000. Within two weeks, with a pin in her hip, she was walking with a cane; soon after that she began water aerobics with her student partner. By the fall 2000 semester, she had resumed full participation in all of the program's exercises, though at a somewhat reduced level of intensity. (She was videotaped pressing 500 pounds on the MedX leg press machine pre-injury!) In February 2001, she covered 960 feet in her six minute walk test, one year post-injury. Her performance had been 1111.5 feet in December 1998, after one semester of participation.
The speedy and complete recovery of these two very elderly individuals from what are frequently disastrous and permanently disabling injuries is clearly attributable to the strength and stamina developed through regular and vigorous exercise. An amazing fact about Ida's recovery is that her mental status test score, as measured by a commonly used test, the Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1995), was actually one point higher after one semester of modified program participation with a student after her injury than at the beginning of the program. This occurred despite enormous disruptions in her life, including two surgeries and hospitalizations, a stay at a rehabilitation hospital, and a move from her cherished home of many years to an assisted living facility. Even one such disruption usually triggers a steep and often permanent decline in mental status for a person with dementia.
