This study aimed to investigate how the exercise programs for older adults are usually implemented in LTC care institutions (Mask for Review). Also, to estimate to what extent the professionals know and use the WHO recommendations and guidelines for exercising among older people in LTC facilities. And, lastly, to know the limitations identified by health professionals regarding the application of the WHO guidelines in clinical practice.
The results showed that, as shown in the literature [30], exercise programs are generally performed in groups in almost every institution. The centers generally had one or two exercise groups, and these were usually quite large (10–20 people per group). The groups were mainly separated by functional and cognitive ability of the users, which could make it easier to carry out the exercises recommended in the guidelines. However, the groups were mostly monitored by just one professional, which could hinder the compliance of the recommendations in the guidelines and reduce the ability of professionals to tailor exercise to users [24]. Regarding the characteristics of the exercise programs, a significant proportion of the participants claimed to perform the exercise in a seating position whereby some recommendations such as balance exercises or gait training could not be performed. In addition, the time devoted to exercise programs was highly variable, with some centres spending less than three hours per week and others more than six hours per week. This finding appeared to be relevant for the ability to implement the exercises recommended in the WHO guidelines (aerobic exercise, strength exercises, and multicomponent physical activity).
The findings highlight significant gaps between the WHO guidelines and the implementation of exercise programs in LTC facilities. Exercises are often scheduled less than twice a week, moreover, the prevalent use of seated positions indicate potential areas for improvement.
The data also revealed that the recommendations and guidelines were not frequently known and followed by the health professionals when they organized and directed the exercise programs. These results are consistent with the literature [25], as some studies indicate that the implementation of evidence-based recommendations in clinical practice is challenging and not always performed correctly. Our findings show that knowing the specific guidelines leads to greater compliance. However, in contrast to the literature [31], in this study, professional training did not appear relevant in terms of knowledge and implementation of the guidelines.
It should be noted that in this study, the socio-demographic and educational characteristics of the health professionals were not relevant, thus neither supporting or refuting previous studies [32].
Professionals commonly schedule the following types of exercise more than two times a week in group programs: aerobic, strength, balance, mobility, flexibility, coordination, breathing, exercises and gait training [33]. They consider the recommendations on exercise Guidelines to Counteract Physical Deconditioning in LTC facilities [33]. Some of the exercises were also recommended by the WHO guidelines. However, the study participants seemed to include them in different ways during their daily training at the centres. These differences mainly concern the frequency of the sessions, the duration of the sessions, or the intensity applied. For instance, for aerobic exercise, the WHO guidelines recommend older adults to practice at least 150–300 minutes of moderate-intensity exercise or 75–150 minutes of vigorous exercise. Nevertheless, a very low number of respondents monitored the users’ heart rate or considered any intensity control system, therefore, despite claiming to perform aerobic exercise, the recommendations were not followed appropriately. Furthermore, gait training was carried out by a low number of participants; despite the fact that previous studies have shown that gait training is one of the activities that is most demanded by older people as it increases their sense of independence [34–37]. Gait disorders may lead to rapid loss of activities of daily living, and are also related to higher risk of disabilities, falls and mortality. A study that analysed the characteristics of gait in LTC facilities, showed that the gait speed parameters of institutionalized older people placed them at risk of falling and other adverse events [38]. Concerning muscle strength exercises, multiple benefits have been demonstrated in the literature [39], such as the maintenance of normal blood parameters, improvement of cardiovascular functioning, prevention of osteoporosis and sarcopenia and even the prevention of mental disorders, which is why strength exercises are highly recommended in the guidelines. In this sense, a high number of participants in our study reported that this type of exercise was included in their exercise program and, moreover, they performed it at the recommended frequency. In contrast to the low monitoring of aerobic exercise, some respondents considered the number of strength exercises and the number of repetitions when monitoring exercise intensity. This could be because most users performed the exercise in a seated position and strength exercise supervision may be easier to monitor by a single professional compared to aerobic exercise.
The WHO guidelines recommend multicomponent physical activity, which includes balance training. This component was performed by a high number of participants and, apparently, with the recommended frequency. However, as mentioned above, a considerable percentage of residents (25%) carried out the exercise in a seated position and gait training was not performed very frequently. It would be interesting to know how balance training is performed.
Evidence-based practice is essential in the health care setting as it supports the quality of patient care. There are currently several clinical guidelines and recommendations [14, 20, 23] that indicate the recommended amount and types of exercise for each population group, including older people. However, these recommendations are not usually adapted to institutionalized older people [24, 25]. Due to the great heterogeneity of this population, together with comorbidities and decreased independence, the implementation of exercise recommendations is very difficult. Thus, as shown in the results of our study and in previous studies [25, 40], not all health professionals follow these recommendations closely in their daily practice of the exercise programs [40].
Professionals with full-time contracts may have more availability to schedule exercise sessions more frequently compared to those with part-time contracts. The correlation between professional working hours and exercise frequency suggests that increasing staff capacity could enhance program delivery.
In this sense, the participants of our study, similar to other studies [41], found some limitations in updating to new guidelines or in using the guidelines in their clinical practice. According to most participants, as supported by the literature [42], this could be due to lack of time and large exercise groups, among other reasons. These factors could significantly impact the ability of professionals to effectively adhere to the guidelines.
The availability of exercise equipment was associated with greater weekly time spent on certain tasks in Australian residential aged care facilities. This highlights the importance of the availability of equipment and spaces in facilities for quality care for older adults [43].
Related to the lack of implementation of clinical guidelines in institutionalized older people, the results of our study also show a correlation between the hours per week that the professional works and the number of hours spent on the different types of exercises included in the programs. This finding is interesting and could be considered by the management of LTC centers to offer users a better quality of care.