strength training

The effect of an educational program on strength-training adherence in older adults Charilaos Papadopoulosa and Johnna M. Jagerb

aDepartment of Kinesiology, Pacific Lutheran University, Tacoma, Washington, USA; bDepartment of Nutrition, Exercise and Health Sciences, Central Washington University, Ellensburg, Washington, USA

ABSTRACT The purpose of this study was to compare the effects of a strength-training program combined with an educational intervention on resistance-training knowledge, adherence, psychological parameters, and functionality in older individuals residing in assisted living facilities. Twenty-four (mean age: 83.8 ± 8.0 years) participants were divided into three groups; one group participated in strength-training plus an educational program, the second group participated in a strength-training program, and the third group served as a reference group. Both strength-training groups completed an 8-week training program using elastic tubing twice per week. The educa- tional program was offered once a week for 20 minutes and consisted of various strength-training topics. All participants completed the Up and Go test; handgrip strength test; questionnaires to determine quality of life, depression and fatigue; and a strength-training knowledge test before and after 8 weeks of training. Repeated Measures ANOVA was used to determine differences. The strength training plus education group had a significantly (p = .03) higher (87.5%) attendance rate compared to the strength training only group (69.2%). After 8 weeks of training, the partici- pants in the combined strength and education group experienced a sig- nificant (p > .05) increase in strength-training knowledge, functional ability, and quality of life compared to baseline testing. The results showed that an educational intervention has a positive effect on strength knowledge, func- tion, and attendance rate. Additional research is needed to determine the long-term effect of such educational components when added to regular strength-training programs.

Older adults (65 years and older) in the United States are the fastest growing segment of the population and are projected to continue to increase for the next 20–30 years compared to other segments of the population (Nelson et al., 2007; Skelton, Greig, Davies, & Young, 1994). As the human body ages, the functions of the respiratory, cardiovascular, and muscular systems are affected. The decline in skeletal muscle begins in the 4th decade of life (Doherty, 2003; Nair, 2005). As muscle mass is reduced, the ability to generate force decreases, therefore, reducing the individual’s ability to participate in activities of daily living (Doherty, 2003; Nair, 2005; Narici, Maganaris, Reeves, & Capodaglio, 2003). Porter, Vandervoort, and Lexell (1995) reported that by the age of 70, cross-sectional muscle area decreases by 25% to 30%. The functional implication is that muscular strength is decreased by 30% to 40% (Porter et al., 1995). Aging affects an individual’s ability to complete daily and leisurely activities, which directly impacts quality of life (Nair, 2005). Aging is influenced by genetics, environmental conditions, and social habits. While the aging process

CONTACT Charilaos Papadopoulos papadoha@plu.edu Department of Kinesiology, Pacific Lutheran University, Tacoma, WA, 98447 USA. © 2016 Taylor & Francis

EDUCATIONAL GERONTOLOGY 2016, VOL. 42, NO. 5, 342–351 http://dx.doi.org/10.1080/03601277.2015.1121752

cannot be stopped, in many cases the impact on an individual’s life can be decreased with regular participation in physical activities.

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend that physical activity, which includes aerobic and strengthening exercises, is vital for a healthier lifestyle (Haskell et al., 2007; Nelson et al., 2007). However, research has revealed that in the United States individuals over the age of 65 participate in the least amount of physical activity (Troiano et al., 2008). Furthermore, of the small number of older adults who are physically active, only 12% participate in muscle-strengthening activities two times per week (Centers for Disease Control and Prevention (CDC), 2004). Previous studies and review papers have indicated that muscle-strengthening exercises are essential to prevent loss of muscle mass and maintain indepen- dent functioning (Aagaard, Magnusson, Larsson, Kjaer, & Krustrup, 2007; Narici et al., 2003; Nelson et al., 2007).

The negative consequences of aging, whether in the skeletal muscle system or any other system of the body, can be attenuated with proper exercise. Many researchers have implemented educational interventions for older adults in order to increase knowledge and create greater compliance to exercise and, therefore, improve health within that population (Benson et al., 1989; Maurer, Stern, Kinossian, Cook, & Schumacher, 1999; Miller, Edwards, Kissling, & Sanville, 2002). The present study was designed to include an educational component during an 8-week strength-training program for older adults residing in assisted living facilities. Assisted living facilities provide support services (e.g., meals; help with bathing, dressing, and eating; medication management; social services; housekeeping; and maintenance) for older adults who wish to remain independent, but still need some assistance with daily living (Park-Lee et al., 2011). In 2010, there were 31,100 assisted living facilities in the U.S. servicing 733,400 residents with various levels of ability to perform activities of daily living (Park-Lee et al., 2011). The purpose of the study was to examine the effectiveness of adding an educational program into a strength-training program on adherence rates and compare strength-training knowledge, functionality, strength, and psychological parameters (i.e., quality of life, depression, and fatigue) to a strength-training-only group and a reference group.

Methods

Participants

A total of 32 participants were recruited from three separate locations via advertisement in the form of a flyer in their respective facilities. All participants were informed of potential benefits and risks with participation and signed an informed consent form. The Human Subjects Review Committee of Central Washington University approved all procedures for this study. All participants were func- tionally and cognitively independent and were cleared to participate by a registered nurse.

This was a quasiexperimental study. Participants were placed into one of three groups based on location. Individuals living independently and attending an adult activity center served as the reference group (R). Individuals from an assisted living facility served as the strength-training- only group (ST), and individuals from another assisted living facility received both a strength training and educational program (EST). All participants were instructed to maintain their normal daily activities throughout the 8-week study.

Resistance-training program

Both the ST and EST groups participated in a resistance-training program using elastic tubing. Both groups were educated during four separate group meetings at their respective locations on proper methods to perform the exercises with the elastic resistance bands (Thera-band; Hygienic Corporation, Akron, OH). The resistance program was adapted from Mikesky, Topp, Wigglesworth, Harsha, and Edwards (1994) and consisted of six lower body and five upper body

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exercises performed twice per week for 8 weeks. The initial 2 weeks were lead by the primary investigator in order to teach the participants and the activities directors the exercises. Following this instructional period, the activities directors (individuals who were hired by the administration of each respective facility to coordinate and instruct fitness and recreational activities for the residents and who were not part of the research team) led the exercises in their respective locations from week 3 through 8. Each exercise session was preceded by a 5-minute warm-up, followed by 50 minutes of muscle-strengthening exercises using the elastic tubing, and a 5-minute cool down. Participants were asked to exercise at a light to moderate level of effort. The muscle-strengthening exercises that were performed included chair squats, hip lifts, knee extensions, hamstring curls, seated foot raises, chest press, seated back rows, lateral shoulder raises, triceps extensions, and bicep curls. Standing calf- raises were performed using body weight as resistance.

Starting tubing size varied with each exercise and was selected on the individual’s ability to perform 10 repetitions using proper form. The participants were instructed to begin with the least resistive tube during the initial meeting. If no soreness was experienced in the days following, they were instructed to increase to the next level. Participants performed one set of each exercise during weeks 1 and 2, two sets during weeks 3 and 4, and three sets during the remaining weeks. Following the initial instruction and choice of tubing, subjects were instructed to move to the next larger tubing size when they could perform 12 repetitions with proper exercise form during their last set. All participants were asked to complete an exercise log on each exercise training day to record the number of repetitions they successfully completed, the band color used, and associated symptoms or progress.

In this study, the use of a reference group was employed in a nontraditional sense to serve as a standard for the subjects in assisted living facilities. The reference group participated in the Stay Active Independent for Life (SAIL) program. The SAIL program is an evidence-based program emphasizing in strength and balance development (Shumway-Cook et al., 2007) The exercise class consisted of 5 minutes of warm-up, 20 minutes of aerobics, 10 minutes of scripted balance exercises, 15 minutes of strength-training exercises, and 10 minutes of flexibility exercises. A trained SAIL instructor led the exercise class.

Educational program

In addition to the resistance exercise program, the EST group received an educational program once a week prior to the supervised exercise session. The educational program started on week 3 and continued through week 8. These sessions were presented by the same primary investigator and lasted approximately 20 minutes. The topics that were covered included benefits and principles of resistance-training, effects of resistance-training on quality of life and fatigue, effects of resistance- training on arthritis and osteoporosis, effects of resistance-training on falling, atrophy and detrain- ing, and a review.

Instruments

All groups were assessed at baseline and after the 8-week program using the same instruments. A search for an instrument that effectively measured knowledge of basic training principles, recom- mendations, and benefits of exercise for older adults failed. Thus, a test was developed by the researchers and completed by all individuals. The test was developed by identifying questions related to strength knowledge of first-year undergraduate students enrolled in a health and fitness course; it consisted of 20 true/false and multiple choice questions.

Each participant completed three questionnaires. One was The Quality of Life Profile-Seniors Version survey (QOL-SV), a 27-item questionnaire to determine quality of life. This questionnaire uses a 5-point Likert scale ranging from 1 being not at all important or satisfied to 5 being extremely important or satisfied. The scores from nine domains were calculated and then summed and

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averaged for an overall quality of life score. An overall QOL-SV score ≥ 1.50 is considered as very good, 1.50–0.51 as acceptable, 0.50 to −0.50 as problematic, and finally, an overall score ≤ −1.50 as very problematic. Raphael et al. (1997) reported high internal consistency (Cronbach’s alpha > .90) in three areas: importance, satisfaction, and overall score of quality of life. Participants also completed the Geriatric Depression Scale-Short Form (GDS-S), a 15-item questionnaire to evaluate depression. For clinical purposes, a score greater than 5 points out of the 15 questions is suggestive of depression and further evaluation should be considered. This questionnaire has been found to have a high level of internal validity (Cronbach’s alpha = .80) (D’Ath, Katona, Mullan, Evans, & Katona, 1994). The sum of depressive answers is reported. The last questionnaire used was the Fatigue Questionnaire. The questionnaire consists of a 100-millimeter line with descriptors from no fatigue at all to worst fatigue ever experienced at each extreme. Participants were asked to score their level of perceived fatigue in the preceding week by placing a perpendicular marking along the line. Scores were calculated by measuring the distance in millimeters from the lower extreme to the marked line.

Functional ability was evaluated using the Up and Go test. In this test, the participants were instructed to rise from a chair, walk a distance of 3 meters, turn, return to the chair, and sit down again as quickly as possible. Time was measured beginning at the verbal command “GO” of the primary investigator and terminated when the participant returned and sat down on the chair. Participants completed 3 trials and the average time to the 10th of a second was used. Finally, strength was assessed using a handgrip dynamometer. The participants were instructed to squeeze the handgrip dynamometer as hard as they could by using their dominant hand. Each participant completed three attempts and the average score to the nearest kilograms was used.

Statistical analysis

All data is presented as mean and standard deviation. The independent variables are the strength- training program and time. The dependent variables are handgrip strength (average score to the nearest kilogram using a handgrip dynamometer), time to complete the Up and Go test, fatigue (distance in millimeters from the lower extreme to the marked line using the Fatigue Questionnaire), depression (total number of depressive answers from the GDS-S), quality of life (score from the QOL-SV survey), adherence (percentage of attendance rates), and resistance knowledge (percentage of correct answers). A Repeated Measures ANOVA within one factor (pre-post) and one between factor (groups) was used to determine differences between pre- and postintervention and among the groups. When significance was found, Bonferoni post hoc test was used to determine differences between groups. In addition, paired t test was used as post hoc test to determine differences between baseline and post intervention. An independent t test was used to determine differences on adherence rates between the EST and ST groups. Level of significance was set at p < .05.

Results

A total of 28 participants completed the study. Two individuals did not complete the study due to medical reasons, and two of the participants did not complete because they moved out of the assisted living facilities. The two strength-training (EST and ST) groups were equal with 9 (8 women, 1 man) participants in the EST group and 9 (7 women, 2 men) participants in the ST group. Ten participants (7 women, 3 men) served as the reference group (R). The average age of participants was 83.8 ± 8.0 years among the three groups. There were no statistically significant differences in age among the groups (p = .07).

On average, the EST group had higher attendance (87.5%) to the strength-training class compared to the ST group (69.2%), and this difference was statistically significant (p = .03). Attendance records were not collected from the R group. Results for the knowledge test are presented in Figure 1. Initially, the knowledge scores of the ST and EST groups were 73.3% and 72.2%, respectively. After 8

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weeks, the average score for the ST and EST groups was 74.7% and 79%, respectively. A Repeated Measures ANOVA determined that after 8 weeks, the mean knowledge score was statistically different from baseline (p < .01). Post-hoc paired t tests revealed that for the EST group the average resistance knowledge score after eight weeks was significantly higher (p < .01) than the baseline score. There was no significant (p > .05) difference in knowledge scores between baseline and posttraining for the ST and R groups (Figure 1).

The average Quality of Life scores significantly (p < .05) increased after 8 weeks of training for both the ST and EST groups (Table 1), but not for the R group (p = .83). Quality of life was not significantly (p > .05) different among groups at baseline and after 8 weeks of training (Table 1). Even though both fatigue and depression scores decreased, the difference was not statistically significant (p > .05) among groups and between baseline and eight weeks (Table 1).

A Repeated Measures ANOVA revealed that the mean handgrip strength of the ST and EST groups was not significantly different from the R group at baseline (p > .05). Mean handgrip scores increased for all groups, but they were not significantly (p > .05) different from each other after eight weeks of training (Table 2). The Repeated Measures ANOVA, however, indicated that the mean

Figure 1. Strength training knowledge results for the education plus strength training (EST), strength training (ST), and reference (R) groups pre- and postintervention (N = 28). *Significantly different from preintervention (p < .05)

Table 1. Quality of life (QOL), depression and fatigue scores for all groups pre- and postintervention (N = 28).

EST ST R

Pre Post Pre Post Pre Post

QOL 1.1 ± 0.7 1.5 ± 0.6* 1.1 ± 0.5 1.5 ± 0.4* 1.7 ± 0.6 1.7 ± 0.5 Depression 4.6 ± 3.8 3.3 ± 3.8 6.0 ± 2.2‡ 5.7 ± 2.5 2.4 ± 3.1 1.9 ± 2.2 Fatigue (mm) 32.5 ± 29.3 31.9 ± 23.4 44.8 ± 24.2 36.2 ± 23.4 42 ± 17.4 40.7 ± 25.8

Values are presented as means ± SD. EST = education plus strength training; ST = strength training; R = reference. *Significantly different from preintervention (p < .05).

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handgrip strength differed significantly between pre-test and post-test (p < .01). Post-hoc paired t test showed that after 8 weeks handgrip strength was significantly (p < .01) different for the EST group compared to the baseline strength. There was no significant difference in handgrip strength between baseline and posttraining for the ST and R groups (Table 2).

Finally, the Repeated Measures ANOVA revealed that the average time to complete the Up and Go test was significantly different (p < .01) among groups both at baseline and after 8 weeks of training (Table 2). Bonferroni’s post hoc test showed that at baseline the average times for both EST and ST groups were significantly (p < .01) higher (10.6 seconds and 8.6 seconds, respectively) compared to R group (Table 2). After 8 weeks, the average decrease in time for ST and EST groups was 3.3 seconds and 3.6 seconds, respectively. However, both groups were significantly (p < .01) slower when compared to the reference group (Table 2). Additionally, the Repeated Measures ANOVA revealed significant (p < .01) differences between pretest and posttest. Post-hoc paired t test showed that after 8 weeks of training all groups significantly (p < .01) improved their time to complete the Up and Go test compared to the baseline time—suggesting increased functional ability.

Discussion

The major result of this study was that adherence rates, as measured by attendance, were signifi- cantly higher in the group that received the educational intervention compared to the exercise only group. In addition, after 8 weeks of strength training, handgrip strength significantly increased for the EST group only, and time to complete the Up and Go test significantly decreased for both the EST and ST groups—suggesting an improved functionality. Quality of life significantly increased for both the EST and ST groups following 8 weeks of training. Finally, strength knowledge was significantly improved for the EST group only.

Older adults are the fastest growing population in the United States and currently the least physically active. An abundance of information is available on the benefits of physical activity for this population, as well as very clear and direct recommendations by the AHA and ACSM (Nelson et al., 2007). It is imperative that older adults increase their physical activity levels in order to maintain an independent and functional lifestyle. To date, many studies have examined the effects of resistance training on older adults; yet, none have examined the impact of an educational interven- tion paired with a resistance exercise program.

The overall focus of this study was to increase participation in strength training among older adults. Compared to the exercise alone group, the educational intervention was effective in main- taining a higher attendance rate. A study by Mikesky et al. (1994) divided a group of older adults into strength training and a control group and found that the strength-training group had a 90% attendance rate. In 2006, Chin A Paw et al. found a 76% attendance rate in a group of older adults that participated in a strength-training intervention and suggested that educating older adults about the benefits accomplished from regular exercise may increase attendance. In this study, the atten- dance rate of the group that received both the strength and educational intervention was 87.5%, which is similar to the attendance rate reported by Mikesky et al. (1994) and higher than the rates reported by Chin A Paw, Van Poppel, Twisk, and Van Mechelen (2006). The results from the

Table 2. Up and Go and Handgrip test scores for all groups pre- and postintervention (N = 28).

EST ST RT

Variable Pre Post Pre Post Pre Post

Up & Go (sec) 19.9 ± 4.2# 16.3 ± 4.6*# 17.9 ± 7.1# 14.6 ± 6.4*# 9.3 ± 3.0 8.5 ± 3.0 Handgrip (kg) 13.6 ± 4.8 17.2 ± 6.5 14.6 ± 5.1 15.9 ± 5.3* 20.9 ± 5.8 22.3 ± 6.1

Values are presented as means ± SD. EST = education plus strength training; ST = strength training; R = reference. *Significantly different from preintervention (p < .05). #Significantly different from R group (p < .05).

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current study suggest that the educational program improved adherence to recommended amounts of strength training.

A possible reason for the improved attendance to the strength-training program could be due to increased knowledge by the participants on the benefits of strength training and how it could improve their daily activities. Following the 8-week program, there was a significant difference on strength-training knowledge for the EST group compared to the baseline knowledge group. Similarly, in other groups (diabetics and general population) educational interventions have resulted in significant increases in knowledge of participants within the intervention group. Miller et al. (2002) showed that 10 weekly nutrition education meetings improved blood glucose and lipoprotein concentration in type II diabetics (≥ 65 yr). The researchers concluded that educating the partici- pants on proper nutrition as it relates to their disease resulted in increased glycemic control. Similarly, Benson et al. (1989) reported significant increases in health-related knowledge among participants following 11 educational sessions compared to a control group. Based on the results from the above studies and the results from the current study, it is evident that educational interventions result in increased knowledge among participants and can lead to better management of a disease and possible better adherence to current recommendations.

Moreover, Maurer et al. (1999) randomly assigned patients who suffered from osteoarthritis of the knee to an exercise or education group. The exercise group performed exercises designed to strengthen the extensor muscle of the knee while those assigned to the education group were given informative pamphlets on osteoarthritis produced by the Arthritis Foundation and participated in four lecture/discussion periods (Maurer et al., 1999). Interestingly, the education group experienced similar increases in strength as the exercise group and the authors noted that the education may have motivated the participants to engage in exercise programs independently (Maurer et al., 1999). These studies illustrate that educational interventions produce positive results including increased health and strength. In the present study, the increase in strength knowledge in the EST group may have been a direct result of the educational sessions that were offered. These educational sessions may also have increased motivation and desire to participate in the strength-training sessions as well as increase an older adult’s sense of control over their health. However, the educational program in this study was only 8 weeks and the long-term impact of the program on adherence was not evaluated.

Functionality and strength as assessed by the Up and Go and Handgrip tests, respectively, for the ST and EST groups improved over the 8-week period. This is in accordance with other studies (Galvao & Taaffe, 2005; Mroszczyk-McDonald, Savage, & Ades, 2007). Typically, sig- nificant increases in function can become apparent in as little as 2 weeks, but they are reported more commonly in 4–6 weeks (Mian, Baltzopoulos, Minetti, & Narici, 2007). Improved function noted in participants in both groups can be attributed to increased strength due to the resistance-training program. Strength training generally causes neurological adaptations and increases in muscle size that produces greater muscular force resulting in an increased function. Mikesky et al. (1994) showed that after 12 weeks of resistance training using elastic bands, isokinetic eccentric knee extension and flexion increased by 11.7% and 10.1%, respectively. Trappe et al. (2001) reported increases in the size, strength, and maximum power of both slow- and fast-twitch muscle fibers in older adults following a progressive resistance-training program. In contrast, Slivka, Raue, Hollon, Minchev, and Trappe (2008) showed minimal increases in cross-sectional area in very old adults (> 80 years) and concluded that the increase in strength experienced as a result of the program was mostly neurological. According to the above studies, it appears that older adults under the age of 80 may still experience increases in muscle size, whereas older adults over the age of 80 experience more neurological adaptations. The average age of the participants in this study was 83.8 years, and the improvements in functional ability could be most likely explained by neurological training.

In adults 65 years of age and older, handgrip strength is highly correlated with independent physical function (Mroszczyk-McDonald et al., 2007). In the current study, participants performed

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three exercises specifically to ellicit an increase in upper body strength. Several studies have found that handgrip strength increases after a strength-training program (Arai, Obuchi, Kojima, Matumoto, & Inaba, 2006; Brill, Probst, Greenhouse, Schell, & Macera, 1998). Interestingly, after 8 weeks of strength training, handgrip strength significantly increased for the EST group only. This increase in upper body strength can be attributed to higher adherence rates for the EST group.

Initially, the average QOL scores for the EST and ST groups were lower compared to the R group. After 8 weeks of strength training, QOL significantly increased for both EST and ST groups and approached the QOL scores of the R group. The increase in QOL for both strength-training groups in this study is similar to the results by Beniamini, Rubenstein, Zaichkowsky, and Crim (1997). The researchers in that study compared a 12-week resistance-training program to a flexibility training on many dimensions of quality of life (self-efficacy, mood profile, health domain) in cardiac rehabilitation patients. They found that the strength training resulted in 30–100% improvement while the flexibility training group experienced no changes in QOL. However, not all studies support an improvement in QOL following a strength-training program. Damush and Damush (1999) strength trained a group of older women (average age 68 years old) for 8 weeks using elastic tubing. While there was an increase in strength for the strength-training group compared to the control group, there was no significant increases in QOL. Chin A Paw, van Poppel, Twisk, and van Mechelen (2004) also reported no improvements in QOL in older adults living in assisted living facilities following a strength-training program. QOL consists of many dimensions, and there are several factors that can influence it including physical, psychological, spiritual, personal family matters, social, leisure time activities, support systems, and opportunities for growth. A possible explanation for the differences between the above studies and the present one could be a difference in the instrument used to evaluate QOL. The above studies used a health-related QOL instrument, but in the present study the instrument used evaluated overall QOL.

This study implemented an education and strength-training intervention, and there are some limitations that need to be addressed. These include experimental design, personality of the activities directors at the separate facilities, and lack of standardized strength knowledge test for older adults. This was a quasiexperimental study involving a small number of volunteers residing in assisted living facilities. Therefore, the sampling methodology and the sample size may limit generalizability. Even though the participants in the EST and ST groups did not significantly differ in any of the dependent variables at baseline, there was not an attempt to match the participants. One clear difference was between the activities directors. These employees were leading the exercise sessions twice a week. A difference in personality between the EST and ST facility activities directors could have influenced participation by the individuals. Interestingly, in a follow-up questionnaire, 57% of the EST participants reported their activities director had a poor attitude and did not care about the program. None of the participants in the ST group mentioned any negative traits of their activities director. It is also possible that the personality of the activities directors has created socially cohesive groups. The effect of social interactions was not measured in this study and, therefore, we cannot determine how social factors may have influenced attendance. QOL, fatigue, and depression are all transient and are influenced on how the participants feel at the moment they are being assessed. There are uncontrolled factors that may impact the quality and state of their answers. Finally, the strength knowledge test used in this study was created by the investigators and was not previously tested and validated.

Conclusions and practical applications

In conclusion, this study has shown that attendance rates increased in the strength training plus education group. Although small increases in resistance knowledge were observed in the education group, this difference was significant after 8 weeks. The results also revealed that functional ability improved with mild resistance training using progressive bands and chair exercises. Although fatigue and depression did not increase significantly for the EST and ST groups, QOL did, and it approached the reference group. The human body is able to adapt to a stimulus regardless of chronological age. Participation in physical activity decreases the rate of decline in function accompanied by age. The

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results of the present study provide a glimpse of the effectiveness of educating this population in order to increase adherence to strength-training recommendations. It is possible that educational interventions paired with strength-training programs may produce greater adherence rates than exercise alone. Ability to maintain adherence to strength training following the completion of a study is a vital area that needs to be studied. Further research is needed to evaluate the effects of a long-term educational program on knowledge, adherence, and functional ability. In addition, it is important to examine the effect of social factors on long-term participation to a strength-training program. Finally, creating a program focusing on educating and training the activities coordinators as well as the residents may have a greater impact on exercise adherence.

Acknowledgments

The authors would like to thank Dr. Jeff Penick and Dr. Timothy Burnham for their assistance in the preparation of this manuscript. The authors would also like to thank Marquis Vintage Suites at Hawthorne Gardens and Marquis Vintage Suites at Wilsonville. Finally we would like to thank all the participants and acknowledge the assistance of the activities directors at each location.

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EDUCATIONAL GERONTOLOGY 351

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