Factors influencing adherence to home-based strength and balance exercises among older adults with mild cognitive impairment and early dementia: Promoting Activity, Independence and Stability in Early Dementia (PrAISED)

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Abstract

Background

Older adults with dementia are at a high risk of losing abilities and of accidental falls. Promoting Activity, Independence and Stability in Early Dementia (PrAISED) is a 12-month person-centred exercise and activity programme which aims to increase activity and independence whilst reducing falls in people with early dementia. In this patient group, as well as many others, poor adherence to exercise interventions can undermine treatment effectiveness. We aimed to explore patterns of barriers and facilitators influencing PrAISED participants’ adherence to home-based strength and balance exercises.

Methods

Participants were a subsample of 20 individuals with mild cognitive impairment or early dementia and their carer(s) taking part in the PrAISED programme. Participants (with the support of a carer where necessary) kept a daily exercise diary. Participants’ adherence were categorised based upon reported number of times a week they undertook the PrAISED strength and balance exercises over a 4 month period (<3 times a week = low adherence, 3–4 = meeting adherence expectations, >5 = exceeding adherence expectations). Semi-structured interviews were conducted in month 4 of the PrAISED programme to explore barriers and facilitators to adherence. A mixture of deductive and inductive thematic analysis was employed with themes categorised using the Theoretical Domains Framework.

Findings

Participants completed on average 98 minutes of home-based strength and balance exercises per week, 3.8 sessions per week, for an average of 24 minutes per session. Five participants were categorised as exceeding adherence expectations, 7 as meeting adherence expectations, and 8 as low adherers. Analysis of interview data based on self-reported adherence revealed six interacting themes: 1) routine, 2) practical and emotional support, 3) memory support, 4) purpose, 5) past experiences of sport and exercise, and 6) belief in and experience of benefits.

Conclusions

Identifiable cognitive, psychological, and practical factors influence adherence to exercise, and should be addressed in future development of interventions with this population.

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Most cited references 22

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Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial

Lindy Clemson, Maria Fiatarone Singh, Anita Bundy … (2012)

Objectives To determine whether a lifestyle integrated approach to balance and strength training is effective in reducing the rate of falls in older, high risk people living at home. Design Three arm, randomised parallel trial; assessments at baseline and after six and 12 months. Randomisation done by computer generated random blocks, stratified by sex and fall history and concealed by an independent secure website. Setting Residents in metropolitan Sydney, Australia. Participants Participants aged 70 years or older who had two or more falls or one injurious fall in past 12 months, recruited from Veteran’s Affairs databases and general practice databases. Exclusion criteria were moderate to severe cognitive problems, inability to ambulate independently, neurological conditions that severely influenced gait and mobility, resident in a nursing home or hostel, or any unstable or terminal illness that would affect ability to do exercises. Interventions Three home based interventions: Lifestyle integrated Functional Exercise (LiFE) approach (n=107; taught principles of balance and strength training and integrated selected activities into everyday routines), structured programme (n=105; exercises for balance and lower limb strength, done three times a week), sham control programme (n=105; gentle exercise). LiFE and structured groups received five sessions with two booster visits and two phone calls; controls received three home visits and six phone calls. Assessments made at baseline and after six and 12 months. Main outcome measures Primary measure: rate of falls over 12 months, collected by self report. Secondary measures: static and dynamic balance; ankle, knee and hip strength; balance self efficacy; daily living activities; participation; habitual physical activity; quality of life; energy expenditure; body mass index; and fat free mass. Results After 12 months’ follow-up, we recorded 172, 193, and 224 falls in the LiFE, structured exercise, and control groups, respectively. The overall incidence of falls in the LiFE programme was 1.66 per person years, compared with 1.90 in the structured programme and 2.28 in the control group. We saw a significant reduction of 31% in the rate of falls for the LiFE programme compared with controls (incidence rate ratio 0.69 (95% confidence interval 0.48 to 0.99)); the corresponding difference between the structured group and controls was non-significant (0.81 (0.56 to 1.17)). Static balance on an eight level hierarchy scale, ankle strength, function, and participation were significantly better in the LiFE group than in controls. LiFE and structured groups had a significant and moderate improvement in dynamic balance, compared with controls. Conclusions The LiFE programme provides an alternative to traditional exercise to consider for fall prevention. Functional based exercise should be a focus for interventions to protect older, high risk people from falling and to improve and maintain functional capacity. Trial registration Australia and New Zealand Clinical Trials Registry 12606000025538.

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Exercise programs for people with dementia.

Dorothy Forbes, Scott C. Forbes, Catherine M. Blake … (2015)

This is an update of our previous 2013 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings.

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Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial.

Kaisu H Pitkälä, Minna Pöysti, Marja-Liisa Laakkonen … (2013)

Few rigorous clinical trials have investigated the effectiveness of exercise on the physical functioning of patients with Alzheimer disease (AD). To investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with AD and to explore its effects on the use and costs of health and social services. A randomized controlled trial. A total of 210 home-dwelling patients with AD living with their spousal caregiver. The 3 trial arms included (1) group-based exercise (GE; 4-hour sessions with approximately 1-hour training) and (2) tailored home-based exercise (HE; 1-hour training), both twice a week for 1 year, and (3) a control group (CG) receiving the usual community care. The Functional Independence Measure (FIM), the Short Physical Performance Battery, and information on the use and costs of social and health care services. All groups deteriorated in functioning during the year after randomization, but deterioration was significantly faster in the CG than in the HE or GE group at 6 (P = .003) and 12 (P = .015) months. The FIM changes at 12 months were -7.1 (95% CI, -3.7 to -10.5), -10.3 (95% CI, -6.7 to -13.9), and -14.4 (95% CI, -10.9 to -18.0) in the HE group, GE group, and CG, respectively. The HE and GE groups had significantly fewer falls than the CG during the follow-up year. The total costs of health and social services for the HE patient-caregiver dyads (in US dollars per dyad per year) were $25,112 (95% CI, $17,642 to $32,581) (P = .13 for comparison with the CG), $22,066 in the GE group ($15,931 to $28,199; P = .03 vs CG), and $34,121 ($24,559 to $43,681) in the CG. An intensive and long-term exercise program had beneficial effects on the physical functioning of patients with AD without increasing the total costs of health and social services or causing any significant adverse effects. anzctr.org.au Identifier: ACTRN12608000037303.

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Author and article information

Contributors

Jennie E. Hancox:

ORCID: http://orcid.org/0000-0001-5938-5265

Role: Data curationRole: Formal analysisRole: MethodologyRole: Writing – original draftRole: Writing – review & editing

Veronika van der Wardt:

ORCID: http://orcid.org/0000-0003-3995-7056

Role: Formal analysisRole: MethodologyRole: Writing – review & editing

Kristian Pollock: Role: Formal analysisRole: MethodologyRole: Writing – review & editing

Vicky Booth:

ORCID: http://orcid.org/0000-0002-5338-0196

Role: Writing – review & editing

Kavita Vedhara: Role: Writing – review & editing

Rowan H. Harwood: Role: Funding acquisitionRole: Writing – review & editing

Maw Pin Tan: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 23 May 2019

Publication date Collection: 2019

Volume: 14

Issue: 5

Electronic Location Identifier: e0217387

Affiliations

[1 ] Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, United Kingdom

[2 ] Division of Rehabilitation, Ageing and Well-being, School of Medicine, University of Nottingham, Nottingham, United Kingdom

[3 ] School of Health Sciences, University of Nottingham, Nottingham, United Kingdom

University of Malaya, MALAYSIA

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: jennie.hancox@ 123456nottingham.ac.uk

Author information

Jennie E. Hancox http://orcid.org/0000-0001-5938-5265

Veronika van der Wardt http://orcid.org/0000-0003-3995-7056

Vicky Booth http://orcid.org/0000-0002-5338-0196

Article

Publisher ID: PONE-D-18-19992

DOI: 10.1371/journal.pone.0217387

PMC ID: 6532965

PubMed ID: 31120953

SO-VID: 1b18634a-6ce7-4240-b89f-fb1ec97b8727

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 5 July 2018

Date accepted : 10 May 2019

Page count

Figures: 1, Tables: 2, Pages: 19

Funding

Funded by: funder-id http://dx.doi.org/10.13039/501100007602, Programme Grants for Applied Research;

Award ID: RP-PG-0614-20007

Award Recipient : Rowan H. Harwood

This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Reference Number RP-PG-0614-20007). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funding was awarded to Professor Rowan H Harwood.

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Data Availability The paper presents findings from a qualitative study in which patients were not asked to consent to use of their data outside the research project, so we cannot make it available without restriction. Due to these restrictions, access to data would be subject to discussion with investigators. Please contact the project administrator Melanie Heeley ( M.Heeley@ 123456nottingham.ac.uk ) for details.

Factors influencing adherence to home-based strength and balance exercises among older adults with mild cognitive impairment and early dementia: Promoting Activity, Independence and Stability in Early Dementia (PrAISED)

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Most cited references 22

Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial

Exercise programs for people with dementia.

Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial.

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