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Exercise and team rehabilitation in older people with dementia: applicability, motivation and experiences
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Section of Physiotherapy.ORCID iD: 0000-0002-0654-4661
2019 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Träning och teamrehabilitering för äldre personer med demens : genomförande, motivation och erfarenheter (Swedish)
Abstract [en]

The world’s population is aging. With the growing population of older people, dementia disorders are becoming increasingly common. Dementia disorders are progressive and include impairments in cognitive and physical function, which lead to increased risks of inactivity, falls, fractures, and comorbidity. Dementia is also the leading cause of dependency in activities of daily living. Therefore, rehabilitation including exercise is needed for this population. To obtain optimal effects on the functional ability of older people, exercise should be task specific, functional, performed at high intensity at sufficient frequency and duration, and include both balance and strength training. Motivation to participate is important for exercise program participation, the fulfillment of exercise recommendations and facilitation of motor learning in order to achieve exercise response. However, exercise recommendations for older people are based mainly on findings from studies conducted with people without dementia. Exercise may be challenging for some people with dementia due to complicating symptoms, such as cognitive deficits, depression, apathy or lack of motivation, and behavioral and psychological symptoms of dementia (BPSD). Studies exploring the applicability of exercise programs have been called for to optimize exercise programs; knowledge about motivation is lacking, and how this together influences exercise response in this group. Additionally, dementia disorders significantly affect all aspects of life for the affected persons and their informal caregivers, friends, and family members in their immediate networks. Furthermore, the care and rehabilitation needs of community-dwelling people with dementia must be considered due to the decreasing proportion of nursing home residents in Sweden today. Scientific knowledge and clinical experiences regarding the use of interdisciplinary team rehabilitation for people with dementia are limited, despite the urgent need for rehabilitation and its proven effects after events such as hip fracture. The effects of person-centered multidimensional interdisciplinary rehabilitation programs for people with dementia, including education and counseling for informal primary caregivers, have not been evaluated and need to be explored.

The overall aim of the thesis was to evaluate exercise and team based rehabilitation among older people with dementia. Specifically, the objectives were to evaluate motivation to participate in and applicability of a high-intensity functional exercise program, and to explore participants’ experiences with a multidimensional interdisciplinary team rehabilitation program including high-intensity functional exercise, among older people with dementia.

In the Umeå Dementia and Exercise (UMDEX) study, a cluster-randomized controlled trial including 186 people with dementia in nursing homes, the effects of the High-Intensity Functional Exercise (HIFE) Program and a seated social activity, both lasting for 45 minutes and held five times fortnightly for 4 months, were compared. Participants’ motivation to go to activity sessions and motivation during sessions were assessed using a five-point Likert scale. The applicability of the exercise program (with regard to attendance, achieved intensity, and adverse events) was assessed with a focus on dementia type and reasons for non-attendance and for not achieving high intensity, based on exercise diary data. Balance exercise response was investigated using the Berg Balance Scale, assessed at baseline and 4 month follow-up. In the Multidimensional InterDisciplinary Rehabilitation in Dementia (MIDRED) study, a randomized controlled study, a person-centered multidimensional interdisciplinary rehabilitation program for community-dwelling older people with dementia, including education and counseling for informal primary caregivers, was evaluated. With the aim of exploring experiences with program participation, 16 participants with dementia were interviewed and data were analyzed using qualitative content analysis.

The UMDEX study showed that motivation during activities was quite high, with no overall difference between groups; over time, however, motivation increased in the exercise group and decreased in the social activity group. Motivation during activity sessions was greater than motivation to go to sessions in both groups. The exercise program was applicable, with high attendance rates, moderate to high intensity achieved, and the occurrence of only minor and temporary adverse events. Dementia subtype, low motivation, pain, and presence of BPSD seemed to affect applicability. The exercise response varied widely, with many participants showing improved balance after the intervention. The applicability of the exercise program and motivation did not seem to be associated with paramount balance response. Four categories emerged from the MIDRED study analysis: being empowered through challenges; gaining insight, motives and rising concerns about the future; to participate is worthwhile, if you are seen; and togetherness in prosperity and adversity.

In conclusion, for older people with dementia living in nursing homes, who have a high prevalence of medical conditions and functional limitations, motivation to participate in a high-intensity exercise program was high and did not differ from motivation to participate in a less physically demanding social activity. The exercise program seems to be applicable with regard to attendance, achieved intensity, and adverse events. The prediction of balance exercise response based on program applicability and participant motivation does not seem to be possible. The promotion of strategies to encourage people with dementia to join exercise groups is of great importance, and more knowledge about strategies is needed to overcome low pre-exercise motivation levels. An interdisciplinary rehabilitation program for community-dwelling older people seems feasible, according to reported experiences. The participants had positive experiences and perceived improvement and empowerment due to the rehabilitation, which can influence well-being in daily life in this population. The results of this research support the inclusion of this population in team rehabilitation and high-intensity functional exercise programs.

Place, publisher, year, edition, pages
Umeå: Medicinska fakulteten, Umeå universitet , 2019. , p. 76
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2065
Keywords [en]
Dementia, Exercise, Rehabilitation, Residential Facilities, Postural Balance, Frail Elderly, Motivation
National Category
Physiotherapy
Research subject
physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-166115ISBN: 978-91-7855-156-9 (print)OAI: oai:DiVA.org:umu-166115DiVA, id: diva2:1377377
Public defence
2020-01-10, Aulan Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-12-18 Created: 2019-12-11 Last updated: 2021-05-21Bibliographically approved
List of papers
1. Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes
Open this publication in new window or tab >>Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes
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2018 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 13, no 11, article id e0206899Article in journal (Refereed) Published
Abstract [en]

Background: Motivation to participate in exercise among people with dementia has not been well studied. The symptoms of dementia, including apathy, may lead to low motivation to participate in exercise. The aim of this study was to evaluate the motivation of older people with dementia to participate in a high-intensity exercise program compared with motivation of those participating in a social group activity.

Methods: The Umeå Dementia and Exercise Study (UMDEX) was a cluster-randomized controlled intervention trial including 186 people (mean age; 85, 75% female) with dementia in nursing homes. Participants were randomized to participate in the High-Intensity Functional Exercise (HIFE) Program (n = 93) or a seated social group activity (n = 93). The activities were conducted in groups of 3–8 participants for 45 minutes, five times per two-week period, for 4 months (40 sessions in total). Participants’ motivation to go to and during activity sessions were assessed by the activity leaders and nursing homes staff using a five-point Likert scale. Data were analyzed using cumulative link mixed models.

Results: Motivation was high or very high during 61.0% of attended sessions in the exercise group and 62.6% in the social activity group. No overall significant difference between groups was observed, but motivation increased over time in the exercise group and decreased in the social activity group (p < 0.05). Motivation during the sessions was significantly higher than motivation to go to the sessions, especially in the exercise group [OR 2.39 (95% CI 2.38–2.40) and 1.50 (95% CI 1.32–1.70), respectively].

Conclusions: Among older people with dementia in nursing homes, motivation to participate in a high-intensity functional exercise program seems to be high, comparable to motivation to participate in a social activity, and increase over time. Since motivation during activity sessions was higher than motivation to go to sessions the promotion of strategies to encourage people with dementia to join exercise groups is of great importance.

National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-153346 (URN)10.1371/journal.pone.0206899 (DOI)000450138500071 ()30427894 (PubMedID)2-s2.0-85056542914 (Scopus ID)
Funder
Swedish Research Council, K2009-69P-21298-01-4Swedish Research Council, K2009-69X-21299-01-1Swedish Research Council, K2009-69P-21298-04-4Swedish Research Council, K2014-99X-22610-01-6Forte, Swedish Research Council for Health, Working Life and WelfareVårdal FoundationThe Dementia Association - The National Association for the Rights of the DementedVästerbotten County Council
Available from: 2018-11-16 Created: 2018-11-16 Last updated: 2023-03-24Bibliographically approved
2. The Applicability of a High-Intensity Functional Exercise Program among Older People with Dementia living in Nursing Homes
Open this publication in new window or tab >>The Applicability of a High-Intensity Functional Exercise Program among Older People with Dementia living in Nursing Homes
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2019 (English)In: Journal of Geriatric Physical Therapy, ISSN 1539-8412, E-ISSN 2152-0895, Vol. 42, no 4, p. E16-E24Article in journal (Refereed) Published
Abstract [en]

Background and Purpose: Exercise programs for people with dementia need to be optimized. We therefore evaluated the applicability of a high-intensity functional exercise program among people with dementia in nursing homes with regard to attendance, achieved exercise intensity, adverse events, a focus on dementia type, and whether symptoms of dementia or other medical conditions common in this population were associated with program applicability.

Methods: The Umeå Dementia and Exercise study, a cluster-randomized controlled trial set in 16 nursing homes in Umeå, Sweden. Ninety-three people with dementia (mean [SD] Mini-Mental State Examination score of 15.4 [3.4]) were randomized to the exercise intervention. Thirty-four participants had Alzheimer's disease (AD) and 59 non-Alzheimer's dementia (non-AD). High-Intensity Functional Exercise (HIFE) program was conducted in groups of 3 to 8 participants. Two physiotherapists led 5 sessions (45 minutes each) per fortnight for 4 months (total 40 sessions).

Results: Median attendance rate was 82.5%. Lower limb strength exercises were performed at high or medium intensity at a median interquartile range of 94.7% (77.8%-100%) of attended sessions. Participants with non-AD performed more sessions with high intensity in strength exercises than participants with AD (median interquartile range, 53.8% [25.7%-80%] vs 34.9% [2.02%-62.9%]; P = .035). Balance exercises were performed at high intensity at a median interquartile range of 75% (33.3%-88.6%). Adverse events (all minor and temporary, mostly musculoskeletal) occurred during the exercise sessions in 16% of attended sessions. Low motivation was the most common barrier for attendance. Buildup period, low motivation, and pain were common barriers for achieving high intensity in balance and strength exercises, and fear was a barrier in balance exercises. Of medical conditions, only behavioral and psychological symptoms of dementia, including apathy, were negatively associated with applicability.

Conclusion: A group-based, supervised, and individualized high-intensity functional exercise program seems to be applicable with regard to attendance, achieved intensity, and adverse events during the exercise sessions, in people with mild to moderate dementia in nursing homes. Effective strategies to enhance motivation to participate in exercise, as well as prevention and treatment of pain and behavioral and psychological symptoms of dementia, are important when promoting exercise participation in this population.

Place, publisher, year, edition, pages
Wolters Kluwer, 2019
Keywords
dementia, exercise, long-term care, mobility limitation, rehabilitation
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-153347 (URN)10.1519/JPT.0000000000000199 (DOI)000497704600003 ()29851748 (PubMedID)2-s2.0-85072946590 (Scopus ID)
Funder
Swedish Research Council, K2009-69P-21298-01-4Swedish Research Council, K2009-69X-21299-01-1Swedish Research Council, K2009-69P-21298-04-4Swedish Research Council, K2014-99X-22610-01-6Forte, Swedish Research Council for Health, Working Life and WelfareVårdal FoundationVästerbotten County Council
Available from: 2018-11-16 Created: 2018-11-16 Last updated: 2019-12-19Bibliographically approved
3. Is the Effect of a High-Intensity Functional Exercise Program on Functional Balance Influenced by Applicability and Motivation Among Older People with Dementia in Nursing Homes?
Open this publication in new window or tab >>Is the Effect of a High-Intensity Functional Exercise Program on Functional Balance Influenced by Applicability and Motivation Among Older People with Dementia in Nursing Homes?
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2019 (English)In: The Journal of Nutrition, Health & Aging, ISSN 1279-7707, E-ISSN 1760-4788, Vol. 23, no 10, p. 1011-1020Article in journal (Refereed) Published
Abstract [en]

Background and Objectives: Exercise can be an important way of maintaining balance function in people with dementia, but further investigation is needed to determine the optimal way of exercising. The objective was to evaluate whether exercise applicability (i.e., attendance, exercise intensity, and adverse events) and motivation were associated with the effect on functional balance of a high-intensity functional exercise program for older people with dementia in nursing homes.

Design, Setting and Participants: Exercise intervention participants (n = 81; 60 women, 21 men) from a randomized controlled trial (UMDEX) were included. Their mean age was 84 and mean Mini-Mental State Examination score was 15.

Intervention: Groups of 3–8 participants participated in the High-Intensity Functional Exercise (HIFE) Program, with 5 sessions per 2-week period, for 4 months (total, 40 sessions).

Measurements: Outcome was the Berg Balance Scale (BBS), assessed at baseline and follow up, and the score difference, dichotomized to classify participants into two groups: responders (≥5-point increase) and non-responders (<5-point increase). Target variables were measures of applicability and motivation. Associations between each target variable and the outcome were analyzed using multivariable logistic regression. Baseline characteristics and new medical conditions developing during the intervention period were compared between responders and non-responders and included in the analyses when p < 0.10.

Results: The BBS score was 28.6 ± 14.3 at baseline and 31.2 ± 15.3 at follow up, with the difference between follow-up and baseline scores ranging from −35 to 24. Twenty-nine (35.8%) participants were responders. The multivariable models showed no significant association between responders vs. non-responders and any target variable.

Conclusion: Participation in a 4-month high-intensity functional exercise program can improve balance in many individuals with dementia in nursing homes, despite the progressiveness of dementia disorders and several co-existing medical conditions. Predicting balance exercise response based on applicability and motivation seem not to be possible, which lends no support for excluding this group from functional exercise, even when exercise intensity or motivation is not high.

Keywords
Dementia, exercise, postural balance, residential facilities
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-165681 (URN)10.1007/s12603-019-1269-8 (DOI)000489514700001 ()2-s2.0-85074321732 (Scopus ID)
Funder
Swedish Research Council, K2009-69P-21298-01-4Swedish Research Council, K2009-69X-21299-01-1Swedish Research Council, K2009-69P-21298-04-4Swedish Research Council, K2014-99X-22610-01-6
Available from: 2019-12-10 Created: 2019-12-10 Last updated: 2023-03-24Bibliographically approved
4. Experiences in community-dwelling older people with dementia on participating in a multidimensional interdisciplinary rehabilitation program
Open this publication in new window or tab >>Experiences in community-dwelling older people with dementia on participating in a multidimensional interdisciplinary rehabilitation program
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(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-166178 (URN)
Available from: 2019-12-13 Created: 2019-12-13 Last updated: 2019-12-13Bibliographically approved

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