ORIGINAL ARTICLE
Perceptions of exercise for older people living with dementia in Bangkok, Thailand: an exploratory qualitative study Sirikul Karuncharernpanit
RN, PhD.
Boromarajonani College of Nursing, Chakriraj, Thailand
Joyce Hendricks
RN, RM, MN, PhD.
Senior Lecturer, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
Christine Toye
RN, BN (Hons.), PhD
Associate Professor, Older Persons’ Health Care, School of Nursing, Midwifery and Paramedicine, Curtin University and Adjunct Associate Professor, School of Nursing and Midwifery, Edith Cowan University, Australia
Submitted for publication: 7 May 2014 Accepted for publication: 31 March 2015
Correspondence: Joyce Hendricks School of Nursing and Midwifery Edith Cowan University Joondalup, WA, Australia Telephone: +61 8 63043511 E-mail: [email protected]
© 2015 John Wiley & Sons Ltd
KARUNCHARERNPANIT S., HENDRICKS J. & TOYE C. (2015) Perceptions of exercise for older people living with dementia in Bangkok, Thailand: an exploratory qualitative study. International Journal of Older People Nursing doi: 10.1111/opn.12091
Background. Dementia is a significant issue globally, including in Thailand, and exercise is known to have health benefits for people living with dementia. However, little is known about exercise acceptable to, and feasible for, this population group in low-to-middle income countries although, more broadly, it is recognised that health-related behaviours are influenced by the perceptions of the individual, which exist within a cultural context. Objectives. To explore and describe perceptions of appropriate exercise for people living with dementia in Bangkok, Thailand. Design. Qualitative exploratory descriptive. Setting. Bangkok, Thailand. Participants. Nine professionals – experts in exercise, dementia care and relevant policy development – and nine dyads of people with dementia and their family caregivers all recruited using purposive sampling. Methods. Semi-structured interviews subjected to thematic analysis. Results. Three themes emerged: how exercise was defined, perceived benefits of exercise and how exercise should be implemented. Professionals recognised three exercise elements: aerobic exercise plus balance and strength training. Dyads recognised home-based activities (e.g., housework) and walking. Both groups recognised benefits of exercise in maintaining health and function and improving mood and sleep. Only health professionals identified falls risk reduction. There was limited appreciation of benefits for caregivers by maintaining function in care recipients. Professionals deemed that exercise should address all three elements, using easily accessible low-cost resources. The need for safety was emphasised, and there was agreement that in-home exercise was appropriate. Family/cultural values were evident that could present barriers to exercise implementation. Conclusion. Changing health-related behaviours requires an understanding of individual perspectives, which exist within a cultural context. This study has illuminated the Thai context and has implications beyond this. Findings emphasise a 1
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need for potential benefits to be sufficiently understood by family caregivers to overcome any culturally based reluctance to promote exercise in older people. Implications for practice. Nurses have a key role in supporting care givers of older persons with dementia supervise home based exercise. Nurses need to develop knowledge of aerobic exercise to teach caregivers and the older person with dementia. Muscle strength and aerobic exercise assists in the older person’s ability to undertake ADL. Key words: caregiver, dementia, exercise, health professionals, older person, perceptions, Thai culture
What does this research add to existing knowledge in gerontology?
• • •
Perceptions of health professions, older people with dementia and caregivers are revealed in relation to the cultural understanding of exercise for older people with dementia. The use of exercise with the older people with dementia must be considered from the cultural context. An exercise programme for Thai older people with dementia should be home based, be individualised and use a mix of types of exercise.
What are the implications of this new knowledge for nursing care with older people?
• • •
Caregivers may be taught how to supervise and encourage an exercise regime for the older person with dementia at home. The use of a home-based exercise programme may be a viable alternative to expensive and often unattainable medications in third world countries. Caregiver burden is reduced because the older person with dementia sleeps better at night if they have undertaken the exercise programme during the day. Also undertaking exercises at home reduces the burden of having to take the older person across town to exercise in third world countries where transport systems are poor and hectic.
How could the findings be used to influence policy or practice or research or education?
• • • 2
The findings of this research suggest that nurses, in third world countries, may play a vital role in promoting exercise for caregivers and the older person with dementia. The importance of exercise as different to undertaking activities of daily living will influence education related to care of the older person with dementia. Policymakers can be influenced to support exercise programmes for older people with dementia in Thailand.
Introduction Dementia has multiple causes, the most common being Alzheimer’s disease and vascular changes within the brain; it is typically progressive, affecting memory, cognition and functional status (Draper, 2011). Dementia is a critical problem and is particularly common in older person people (Ferri et al., 2005). The number of people living with dementia worldwide is currently estimated at 35.6 million. This number is projected to double by 2030 and more than triple by 2050 (World Health Organisation, 2012a). In Thailand, as in many other countries, the prevalence of dementia has increased following growth and ageing of the population (Ferri et al., 2005; Access Economics, 2006; Jitapunkul et al., 2009; World Health Organisation, 2012b). The resultant increased demand for (limited) health services substantially impacts upon service/treatment accessibility for people experiencing dementia and their caregivers (Krairit & Chansirikarnjana, 2007). Costs borne by families are also likely to curtail access. The potential for exercise to be used as a helpful, low-cost treatment to delay functional deterioration in people with dementia, and how this may be supported by family caregivers and health professionals, therefore merits urgent attention. This study describes an early phase of a larger study that developed and trailed a targeted exercise programme in the Thai context. This early phase was necessary to inform programme development.
Literature review To inform this review, the following databases were searched to access study findings relevant to the notion of introducing exercise for people living with dementia in Thailand: MEDLINE, CINAHL, AGELINE, ProQuest, Informit-elibrary and PubMed. The terms ‘dementia’ and ‘exercise or aerobic exercise or strength training or physical therapy’ were used as the keywords. The National Research Committee of Thailand’s database and Thai journal databases – Journal of © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
Exercise for older people with dementia in Thailand
How it is defined
Daily activities
Formal exercise
How it should be implemented
Perceived benefits
Improving or maintaining physical function
Reducing caregiver workload
A home-based program
Cultural considerations
Equipment and safety
Figure 1 Themes and sub-themes.
mixture of aerobic, muscle strength and stretching or balance training. Dyads, however, thought that walking plus daily physical activities was sufficient. Aerobic training (especially walking) was agreed by both groups as being appropriate. Views on duration, intensity and frequency of exercise differed between groups. Health professionals remarked that walking is the last skill lost during the progression of dementia and is easy to undertake as it does not require specialised equipment. A few health professionals gave reasons to support walking. One said: ‘. . . choose an easy exercise such as walking, because they can walk and don’t need to use speed. . .’ (HP9). Needing no extra equipment and requiring low skills were specified by another health professional stating: ‘. . .endurance activity, particularly walking . . .is relevant to their previous experiences and no specific postures or positions are required’ (HP9). The dyads’ comments concentrated on the ease of walking and its familiarity to older people with dementia. Three health professionals, but no family care or older person with dementia, suggested that strength training played a major role for older adults with dementia. These professionals said that benefits included direct improvement of muscles and bones, with subsequent improvements in activities of daily living (ADLs) and independence; benefits for brain function were also articulated: Strength training is also important because [it] . . . improves their competence to . . .care for themselves. . . .will train specific muscles . . . will promote learning to control specific muscles . . . as well as improve their memory function . . . Their brain, which controls their movement, will be activated and records new data or this pattern [doing exercise regularly], so it will help to improve their brain function. (HP1)
Health professionals also identified balance training as useful prior to doing exercise to increase the safety of the person with dementia. Dyads did not address balance training. © 2015 John Wiley & Sons Ltd
Theme 2: Benefits of exercise for people with dementia While the widespread benefits from exercise are known, this theme considers benefits specific to older Thai people who have dementia. Most health professionals in exercise and dementia care agreed on the importance of exercise for people with dementia, with four saying that it was crucial. One health professional said: ‘. . . people [with dementia] who have exercised regularly live longer with a better quality of life’ (HP4). Likewise, dyads agreed on the importance of exercise, but not as strongly. One caregiver compared the advantages of doing exercise with disadvantages of being sedentary, asserting: ‘. . .if she (her mother) is active and does activities . . . she doesn’t have any loneliness or vagueness. . . when she didn’t do anything, her condition seemed to be worse’ (C9). Three subthemes emerged relating to the benefits of exercise: the potential to improve or maintain physical function, enhance mood/behaviour and reduce caregiver workloads. Improving or maintaining function Professionals and dyads agreed that exercise provided benefits by assisting with maintaining ADLs and brain function and improving health. One health professional said: ‘older adults with dementia will get worse very easily if they don’t exercise, and their caregivers can (sic) see deterioration in 2– 3 years. . .’ (HP5). One caregiver explained the importance of exercise for older people by saying: ‘their bodies are deteriorating. So, they should take care of them by exercising’ (C9). The importance of maintaining physical function was also seen to assist with ADLs by health professionals and dyads. A professional stated: ‘. . . if they can exercise their hands, arms, or legs . . . these organs can function and this is important for doing ADL by themselves’ (HP5). A caregiver said: ‘. . .doing physical activity and exercises helps. . . maintain their activities. . .’(C3). One participant who suffered from mild dementia pointed out that exercise helped her to be more active 5
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who is bilingual; each participant was interviewed once. Interview questions addressed exercise experience and views on exercise for older adults living with dementia (see Appendix). Interviews with health professionals lasted approximately 1 hour; those with dyads were variable in length, taking into consideration participants’ cognitive ability, patience and attention span. For dyads, interviews were undertaken at the dementia clinics they visited routinely. For the health professionals, interviews were at places of their choosing.
Data analysis Interviews were transcribed verbatim (in Thai) and then translated into English. All audio tapes were repeatedly played, and the interview transcriptions in Thai were read many times by the researcher to gain a feeling for the whole. In each case, words, phrases, sentences or paragraphs that stood out were highlighted and then coded manually. Coded data were organised into themes and subthemes using a mind map (Braun & Clarke, 2006).
Trustworthiness Trustworthiness was demonstrated by addressing transferability, dependability, and credibility (Oaks et al., 2004; Cresswell, 2014). To ensure transferability, the researcher provided a detailed description of the study’s setting, plus contextual information about participants and details of how they were selected. To support dependability, a detailed description of the study’s methodology is provided and the analysis process was reviewed by two language experts and qualitative researchers. To increase credibility, supervisory consultants in Thailand validated the translation and interpretation of transcripts by reading Thai descriptions and discussing the emergent themes with the researcher until a consensual interpretation was agreed.
Findings Nine dyads and nine health professionals residing in Bangkok, Thailand, were recruited, but one dyad was excluded before interview data were collected because the person with dementia had difficulty responding to the questions (N = 25). Characteristics of participants are in Table 1. Dyad interviews lasted from 15 minutes to 1.5 hours. Three main themes relating to exercise for older people with dementia in the Thai context emerged. These themes are illustrated in Fig. 1 and are as follows: how exercise is defined, perceived benefits of exercise and how exercise should be implemented. Exemplars from health professionals are 4
Table 1 Characteristics of participants (n = 25)
Indicators
Health professionals (9)
Gender Male 5 Female 4 Age Range 32–62 (years) Educational level (frequency) Primary 0 Secondary 0 Vocation 0 Bachelor’s 0 Postgraduate 9 Experience of dementia 5 years 9
People with dementia (8)
Caregivers (8)
Overall (25)
2 6
1 7
8 17
64–81
29–64
29–81
4 0 0 4 0
1 1 1 4 1
5 1 1 8 10
4 2 1 1
6 0 1 1
10 2 2 11
signified by ‘HP’, those from people with dementia are assigned ‘P’, and those from family caregivers are allocated ‘C’.
Theme 1: How exercise for older people with dementia is defined in the Thai context This theme documents perceptions of what is viewed as exercise for the older person with dementia in the Thai context. Two subthemes emerged: daily activities and formal exercise. Daily activities Two health professionals and all dyads equated daily activities with formal exercise. One person with dementia stated, ‘. . . [If I want to exercise], I will use a small cloth to scrub the floor. . .. [because] it is [more] difficult. . . I won’t use a big cloth’. (PT5). In addition, one caregiver indicated that hanging up wet laundry was exercise, stating: ‘. . .when she hangs out the washing and turns the washing around [frequently], she is doing exercise for her joints’. (C9). A change over time in the physical nature of ‘work related’ roles was acknowledged by a health professional, who stated: ‘Approximately 40–50 years ago, exercise and work could be done together, for example farmers and gardeners. However, at present exercise will need to stand alone from occupations. . . .’ (HP2). Formal exercise Most health professionals highlighted that, in Thailand, formal exercise for people with dementia should comprise a © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
Exercise for older people with dementia in Thailand
How it is defined
Daily activities
Formal exercise
How it should be implemented
Perceived benefits
Improving or maintaining physical function
Reducing caregiver workload
A home-based program
Cultural considerations
Equipment and safety
Figure 1 Themes and sub-themes.
mixture of aerobic, muscle strength and stretching or balance training. Dyads, however, thought that walking plus daily physical activities was sufficient. Aerobic training (especially walking) was agreed by both groups as being appropriate. Views on duration, intensity and frequency of exercise differed between groups. Health professionals remarked that walking is the last skill lost during the progression of dementia and is easy to undertake as it does not require specialised equipment. A few health professionals gave reasons to support walking. One said: ‘. . . choose an easy exercise such as walking, because they can walk and don’t need to use speed. . .’ (HP9). Needing no extra equipment and requiring low skills were specified by another health professional stating: ‘. . .endurance activity, particularly walking . . .is relevant to their previous experiences and no specific postures or positions are required’ (HP9). The dyads’ comments concentrated on the ease of walking and its familiarity to older people with dementia. Three health professionals, but no family care or older person with dementia, suggested that strength training played a major role for older adults with dementia. These professionals said that benefits included direct improvement of muscles and bones, with subsequent improvements in activities of daily living (ADLs) and independence; benefits for brain function were also articulated: Strength training is also important because [it] . . . improves their competence to . . .care for themselves. . . .will train specific muscles . . . will promote learning to control specific muscles . . . as well as improve their memory function . . . Their brain, which controls their movement, will be activated and records new data or this pattern [doing exercise regularly], so it will help to improve their brain function. (HP1)
Health professionals also identified balance training as useful prior to doing exercise to increase the safety of the person with dementia. Dyads did not address balance training. © 2015 John Wiley & Sons Ltd
Theme 2: Benefits of exercise for people with dementia While the widespread benefits from exercise are known, this theme considers benefits specific to older Thai people who have dementia. Most health professionals in exercise and dementia care agreed on the importance of exercise for people with dementia, with four saying that it was crucial. One health professional said: ‘. . . people [with dementia] who have exercised regularly live longer with a better quality of life’ (HP4). Likewise, dyads agreed on the importance of exercise, but not as strongly. One caregiver compared the advantages of doing exercise with disadvantages of being sedentary, asserting: ‘. . .if she (her mother) is active and does activities . . . she doesn’t have any loneliness or vagueness. . . when she didn’t do anything, her condition seemed to be worse’ (C9). Three subthemes emerged relating to the benefits of exercise: the potential to improve or maintain physical function, enhance mood/behaviour and reduce caregiver workloads. Improving or maintaining function Professionals and dyads agreed that exercise provided benefits by assisting with maintaining ADLs and brain function and improving health. One health professional said: ‘older adults with dementia will get worse very easily if they don’t exercise, and their caregivers can (sic) see deterioration in 2– 3 years. . .’ (HP5). One caregiver explained the importance of exercise for older people by saying: ‘their bodies are deteriorating. So, they should take care of them by exercising’ (C9). The importance of maintaining physical function was also seen to assist with ADLs by health professionals and dyads. A professional stated: ‘. . . if they can exercise their hands, arms, or legs . . . these organs can function and this is important for doing ADL by themselves’ (HP5). A caregiver said: ‘. . .doing physical activity and exercises helps. . . maintain their activities. . .’(C3). One participant who suffered from mild dementia pointed out that exercise helped her to be more active 5
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without tiring, saying that ‘after exercise. It [my body] is not tired. It [exercise] can help me be much more active’ (P8). Falls prevention is a salient issue for older people in the Thai context, but only two health professionals, and no dyads, discussed the role of exercise in preventing falls. In particular, muscle strength training was identified as helping to prevent falls: ‘If their muscles are strong and function well, it [muscle improvement] will prevent falls. . .. (HP5)’. One health professional identified the importance of doing exercise during the day to assist in the older people with dementia having a restful night: ‘[a] broken sleep cycle leads to forgetfulness. . . .. adequate exercise . . . will help people to reach the 4th stage of non-REM [which is] better than tranquilizers’ (HP4). This also maintains brain function, cognition and memory improvement. Three health professional also recognised the potential of exercise in addressing behavioural issues; one said: ‘Exercise can help them to have . . . better sleep, better appetite, weight control and a reduction of difficult behaviors at night’ (HP3). Caregivers, in this study, did not mention change or reduction in troublesome behavioural symptoms from exercise, but did mention an improvement in sleep pattern as a likely positive outcome. The caregiver said: ‘. . . if she (mother) is less active, she has only two activities, eating and sleeping . . ..and will be more forgetful’ (C9). This caregiver also stated that doing activities helped reduce her mother’s daytime sleep, saying: ‘. . .when she has these activities, she won’t sleep in the day time’ (C9). Enhancing mood and behaviour Health professionals and dyads agreed that exercise helped improve the mood of people with dementia. One health professional, said: ‘their mood will be better because sufficient exercise [is like] special medicine’ (HP4) and a caregiver stated: ‘I noticed that she [mother] is happier when she does this job [physical activity] than in the past’ (C9). One health professional also summarised negative impacts from a sedentary lifestyle, saying: ‘they fear falling and [thus] become sedentary; their condition becomes worse and leads to more depression because movements and mobility can be the key health factors for people’ (HP4). One caregiver shared this perception, saying: ‘. . .when she didn’t do anything she was usually irritated. If she doesn’t have anything to do, she will be quiet, lonely and depressed. I realised that if she is active . . . she will be better’ (C9). Moreover, two caregivers believed that preventing loneliness in people with dementia was important. Reducing caregiver workload Only two participants, a health professional and a caregiver, noted the indirect positive effect of exercise in reducing 6
caregiver workload by maintaining function in people with dementia. The professional stated: ‘There are many reasons to encourage them to do exercises . . .they can do their Activity of Daily Living by themselves’ (HP5). The caregiver said, ‘I realized that if she is active and does activities, I can reduce my workload in caring for her and my house is cleaner than in the past’ (C9).
Theme 3 How exercise for older people with dementia should be implemented in the Thai context When considering exercise programme implementation in the Thai context, the need for a home-based approach was articulated. Cultural perspectives and needs for equipment and safety were also addressed. A home-based exercise programme Home-based exercise was agreed by both health professionals and dyads to be the most suitable approach for older adults with mild to moderate dementia in the Thai context for three reasons. Firstly, the use of the home setting was seen to reduce caregiver workload because preparing people with dementia and then transporting them from their homes, in the Bangkok environment, where traffic is busy and parking is limited, is problematic. This point is supported by the following statements: ‘. . .older adults with dementia . . . depend on their caregivers. If you establish the exercise program at the clinic or outside their homes, it will increase the workload of caregivers’. (HP3). ‘. . . [there is] difficulty travelling, such as calling a taxi . . .. Otherwise, they need to ask their cousin who has a car to drive them. . .some caregivers need to absent themselves from their own job for one or 2 days’ (HP5). Secondly, it was expressed that there may be issues with disorientation, fear, forgetfulness and dressing appropriately. For example, one person with dementia said: ‘If I need to travel on my own, I am afraid of taxi drivers. I am a woman and don’t know where the driver will drive to. So, I won’t go out on my own. . . .. I feel that I am foolish’ (PT8). A health professional observed: ‘You may notice that even in a quiet place, people with dementia [become] agitated and can’t relax . . .. People with dementia differ from older people in general. If they can exercise in their own homes with familiar caregivers, they will be benefitted’ (HP2). Cultural considerations Thai views of ageing as a period during which relaxation is appropriate were articulated. One caregiver said: ‘from the children’s perspective, we want our parents to have a relaxing time and don’t want them to work too hard’ (C9). A health © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
professional agreed, ‘the first misconception [about exercise is that] older adults do not need to exercise because they are too old’ (HP2) and another stated: ‘I found that most Thai family caregivers would rather be cautious and overly protect their parents. . .’ (HP2). This perspective was emphasised strongly by a person with dementia who complained that her grandson did not allow her to do any physical activities such as household chores, saying: ‘I don’t exercise much. . ..my grandson told me that Ya [grandmother] doesn’t need to do anything, you should have a sleep or a rest because you have worked so hard for a long time . . .’ (PT3). Equipment and safety Two health professionals discussed details of appropriate strength-training equipment adapted from household items and the criteria to choose appropriate equipment (size, safety and colour) for people with dementia. Comments made included ‘stairs can be used as exercise equipment. . . .body weight can be categorized as a weight’ (HP1) and ‘another important point is the size of equipment. . . . if it is too big, they may be frightened and if it is too small, they can’t grasp it. . ..Furthermore, . . . think about suitable colours. I would suggest you use blue, yellow, bright, relaxing or calm colours’ (HP2). Dumb-bells, which are used widely, and Thai elastic bands (rubber rings with two handles that users pull) were identified as a potential safety issue by family caregivers in terms of their potential to cause injuries at some stages of dementia, especially the moderate and severe stages, although the caregivers did not identify issues of safety for themselves. However, a health professional said: ‘. . . hitting [the caregivers – either unintentionally or in anger] may occur. But for hurting themselves, no, it is rare for older people with dementia to hurt themselves. . .. [and only] when they are frustrated. Most of them would be in the moderate to moderately severe stage [before this happens]’ (HP2). A second health professional stated: ‘. . .. . . the sticks (Thai elastic bands) can be very dangerous if they recoil towards the eyes. The use of [medical] elastic band . . . this will reduce the risk of injury’ (HP9). Strategies for strength training were outlined, included starting from the use of body weight or light weights, then gradually increasing weights, for safety. One health professional said: ‘. . . you may need to start by practicing with the correct position, posture and movement without any weight or equipment. Then you can gradually increase the resistance. . . . if they use the incorrect muscle group . . . there will be many problems’ (HP1). Another health professional addressed balance as a safety issue: ‘. . .you need to test and train their balance. . . to consider safety. . . .There are two ways of balance training. The first way is chair rises. The © 2015 John Wiley & Sons Ltd
second way is taking short steps in the same place with their legs reaching an upright position each time’ (HP4).
Discussion There is growing evidence of the benefits from exercise for people living with dementia, particularly in high-income countries (Teri et al., 2003; Stevens & Killeen, 2006; Steinberg et al., 2009; Kemoun et al., 2010). There is also recognition that obtaining information from those who have dementia is pivotal to understanding their needs (Clare et al., 2008) and, more broadly, that individuals’ perceptions must be considered when implementing health promotion initiatives (Pender et al., 2006). In this study, perceptions of exercise as a health promotion strategy were obtained from people living with dementia in Thailand, their family caregivers and health professionals involved in relevant policy and practice areas. Consideration is now given to the transferability of these findings and, therefore, any implications beyond the Thai context. Consistent with the assertion of Chunharas (2007), that an understanding of the benefits of formal exercise will be limited when information is provided only in English (in nonEnglish speaking countries) and/or literacy rates are low, people living with dementia and their family caregivers in our study did not recognise strength and balance training, in particular, as exercise elements relevant to them. This finding is likely transferable to populations in other low-to-middle income countries with low literacy rates and to cultural subgroups in Western countries with similar characteristics (e.g. refugees or migrant groups with limited English). The implications are clear for the provision of information in appropriate languages included in alternative media presentations. The cultural context that became evident from our study findings illustrated the high status of parents and older people (Knodel & Chayovan, 2009) in Thailand and the social norm of not expecting parents to undertake activities [Fox (2005), Kespichayawattana and Jitapunkul (2009) and Knodel and Chayovan (2009)]. Such findings could only be transferable to other cultural groups with similar values and illustrate clearly the relevance of the theoretical underpinnings of our study that require perceptions to be understood so that behavioural change can be successfully promoted. In this instance, a logical recommendation is that an understanding of positive outcomes for people with dementia from exercise (e.g. a lowered risk of falls) in their family caregivers might promote a view that encouraging and facilitating exercise programmes for people living with dementia is a one way of showing esteem. 7
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Perhaps because of Thai values that stress the high status of older people, how exercise for the person with dementia might positively impact upon caregivers was addressed only in a limited way by the participants in this study. Caregivers did stress the benefits of preventing sleeplessness, which is consistent with the findings of Fang and Swartwood (2012), who reported that exercise assisted the older person with dementia to sleep, with caregivers reporting a reduction in caregiver burden. However, caregivers did not discuss or link the benefits of exercise in managing distressing behaviours, despite health professionals recognising this as an important benefit. There is some controversy in the literature on this point, with Kalapatapu and Neugroschl (2009) asserting that there is a lack of strong evidence to support the reduction of behavioural symptoms using exercise despite the claims of Aman and Thomas (2009) that exercise can reduce agitation in people with severe dementia. More recently, Fang and Swartwood (2012) and Langlois et al. (2012) found that an exercise programme led to improved attitudes in older adults with AD. Further research is needed to explore this issue. For example, it may be that encouraging exercise implementation for people living with dementia in the Thai culture – or in other cultures valuing rest for older people – may cause resistance in the person with dementia that is manifested in behaviours that are distressing.
Conclusion In conclusion, three main themes were recurrent in study findings: the importance of exercise, the benefits of exercise for people with dementia and the cultural issues related to exercise. The benefits of exercise, in general, were recognised by both groups – professional and caregivers/care recipients – but there were differences in understandings of appropriate exercise. Whereas professionals’ understandings were generally consistent with Western perspectives, the cultural values exhibited by people living with dementia and their caregivers provided insights into potential barriers to the implementation of formal exercise programmes. Some of these study findings are likely to be transferable to other cultural groups with similar values and to those with limited understanding of English and/or literacy skills. Pender et al. (2006) assert that perceptions – including perceived benefits – influence the motivation and commitment to making a change in healthrelated behaviour. This assertion supports the recommendation from our study findings that implementing exercise programmes for people living with dementia requires an indepth understanding in caregivers of the recognised benefits for the person with dementia so that they will be motivated to offer appropriate support. Our study also serves to 8
emphasise the need to tailor the introduction of interventions known to have benefits for people with dementia to the cultural perspective and context of the individual and their family.
Implications for practice Nurses have a key role in supporting care givers of older persons with dementia supervise home based exercise. Nurses need to develop knowledge of aerobic exercise to teach caregivers and the older person with dementia. Muscle strength and aerobic exercise assists the older person’s ability to undertake ADL.
References Access Economics. (2006). Dementia in the Asia Pacific Region: the Epidemic is Here: Asia Pacific Members of Alzheimer’s Disease International. Aman E. & Thomas D.R. (2009) Supervised exercise to reduce agitation in severely cognitively impaired persons. Journal of the American Medical Directors Association 10, 271–276. Braun V. & Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101. Buchner D. M. (2010). Promoting Physical Activity in Older Adults. American Family Physician, 8(1), 24. Chunharas S. (2007). Situation of the Thai older people. Available at: http://tgri.thainhf.org/document/edoc/edoc_771.pdf (accessed 6 July 2014). Clare L., Rowlands J., Bruce E., Surr C. & Downs M. (2008) ‘I don’t do like I used to do’: a grounded theory approach to conceptualising awareness in people with moderate to severe dementia living in long-term care. Social Science & Medicine 66, 2366– 2377. Cresswell J.W. (2014) Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Sage Publications, Thousand. Draper B. (2011). Understanding Alzheimer’s and Other Dementias. Woollahra, New South Wales Australia. Fang Y. & Swartwood R. (2012) Disease feasibility and perception of the impact from aerobic exercise in older adults with Alzheimer’s. American Journal of Alzheimer’s Disease and other Dementia 27 (6), 397–405. Ferri C.P., Prince M., Brayne C., Brodaty H., Fratiglioni L., Ganguli M., Hall K., Hasegawa K., Hendrie H., Huang Y., Jorm A., Mathers C., Menezes P.R., Rimmer E., Scazufca M. & Alzheimer’s Disease International (2005) Global prevalence of dementia: a Delphi consensus study. Lancet, 366, 2112–2117. Fox N.J. (2005) Culture of ageing in Thailand and Australia. (What Can an Ageing Body Do?). [Journal Aricle]. Sociology 39, 481– 498.
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Perception of Exercise for Older People with Dementia in Thailand Jitapunkul S., Chansirikanjana S. & Thamarpirat J. (2009) Undiagnosed dementia and value of serial cognitive impairment screening in developing countries: a population-based study. Geriatr Gerontol Int 9, 47–53. Kalapatapu R.K. & Neugroschl J.A. (2009) Update on neuropsychiatric symptoms of dementia: evaluation and management. Geriatrics 64, 20–26. Kemoun G., Thibaud M., Roumagne N., Carette P., Albinet C., Toussaint L., Paccalin M. & Dugue B. (2010) Effects of a physical training programme on cognitive function and walking efficiency in elderly persons with Dementia. Dementia and Geriatric Cognitive Disorders 29, 109–114. Kespichayawattana J. & Jitapunkul S. (2009) Health and health care system for older persons. Ageing International 33, 28. Knodel J. & Chayovan N. (2009) Intergenerational relationships and family care and support for Thai elderly. Ageing International 33, 15. Krairit O. & Chansirikarnjana S. (2007). Dementia: An Epidemic on the horizon C. Kanchanachitra, C. Podhisita, K. Archavanitkul, U. Pattaravanich, K. Siriratmongkon & H. Seangdung (Eds.), Thai Health 2007 Available at: http://www.hiso.or.th/ hiso/HealthReport/report2007-ENG.php?manu=4 (accessed 10 March 2015). Langlois F., Vu T.T.M., Chasse K., Dupuis G., Kergoat M.J. & Bherer L. (2012) Benefits of physical exercise training on cognition and quality of life in frail older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences May;68(3), 400–4. doi:10.1093/geronb/gbs069. McKhann G. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on AgingAlzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease (1st ed., pp. 263–269). PMC. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312024/on 6/05/ 2014 Oaks C.A., Graneheim U.H. & Lundman B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Pender N.J., Murdaugh C.L. & Parsons M.A., eds. (2006) Health Promotion in Nursing Practice, 5th edn. Pearson Education, New Jersey. Perneczky R., Wagenpfeil S., Komossa K., Grimmer T., Diehl J. & Kurz A. (2006) Mapping Scores Onto Stages: Mini-Mental State Examination and clinical dementia rating. The American Journal of Geriatric Psychiatry, 14, 139–144.
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Rolland Y., van Kan G.A. & Vellas B. (2008) Physical activity and Alzheimer’s disease: from prevention to therapeutic perspectives. Journal of the American Medical Directors Association 9, 390–405. Steinberg M., Leoutsakos J.M.S., Podewils L.J. & Lyketsos C.G. (2009) Evaluation of a home-based exercise program in the treatment of Alzheimer’s disease: The Maximizing Independence in Dementia (MIND) study. International Journal of Geriatric Psychiatry 24, 680–685. Stevens J. & Killeen M. (2006) A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia. Contemp Nurse 21, 32–40. Suh G. H., Wimo A., Gauthier S., O’Connor D., Ikeda M., Homma A., Dominguez J., Yang B. M. & Mental Health Economics Task Force of the International Psychogeriatric Association (2009) International price comparisons of Alzheimer’s drugs: a way to close the affordability gap. International Psychogeriatrics, 21, 1116–1126. Sun Y., Lai M.S., Lu C.J. & Chen R.C. (2008) How long can patients with mild or moderate Alzheimer’s dementia maintain both the cognition and the therapy of cholinesterase inhibitors: a national population-based study. European Journal of Neurology 15, 278– 283. Taymoori P., Niknami S., Berry T., Lubans D., Ghofranipour F. & Kazemnejad A. (2008) A school-based randomized controlled trial to improve physical activity among Iranian high school girls. International Journal of Behavioral Nutrition and Physical Activity 5, 18. doi:10.1186/1479-5868. Teri L., Gibbons L.E., McCurry S.M., Logsdon R.G., Buchner D.M., Barlow W.E., Kukull W.A., LaCroix A.Z., McCormick W. & Larson E.B. (2003) Exercise plus behavioral management in patients with Alzheimer disease – A randomized controlled trial. Jama-Journal of the American Medical Association 290, 2015– 2022. World Health Organisation. (2012a) Facts on Dementia , Available at: http://www.who.int/features/factfiles/dementia/en/(accessed 27 April 2013). World Health Organisation . (2012b), Bulletin of the World Health Organization The health-care challenges posed by population ageing, Available at: http://www.who.int/bulletin/volumes/90/2/ 12-020212/en/ (accessed 27 April 2013). Wormald H., Waters H., Sleap M. & Ingle L. (2006) Participants’ perceptions of a lifestyle approach to promoting physical activity: targeting deprived communities in Kingston-Upon-Hull. BMC Public Health 6, 202.
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Appendix Appendix 1 Semi-structured interview guides for health professionals, dyads and caregivers Health professionals
Dyads
Caregivers
1. Have you ever had experience with exercise? Tell me, what is the exercise experience you have? 3. What is your perception of exercise for older adults with dementia?
1. What do you think about exercise for older adults with memory problems? 2. What makes the exercise suitable exercise for you when you think about: 2.1 where you should do the exercise? 2.2 what time of day is best? 2.3 how long does the exercise take? 2.4 how often you do the exercise? 2.5 what sort of equipment to use? 2.6 what do you try to avoid? 3. What do you think is the best exercise for you? 4. How can we encourage you to keep exercising?
1. What do you think about exercise for older adults with memory problems? 2. What makes the exercise suitable exercise for older adults with memory problems when you think about: 2.1 where to do the exercise? 2.2 what times of day are best? 2.3 how long the exercise takes? 2.4 how often they do the exercise? 2.5 what sort of equipment to use? 2.6 what do they try to avoid? 3. What do you think is the best exercise for older adults with memory problems? 4. How can we encourage older adults with memory problems to keep exercising?
5. Is there anything else you would like to say about exercise for older adults with dementia? Please explain.
5. Is there anything else you would like to say about exercise for older adults with memory problems? Please explain?
4. What do you think the most appropriate exercise for older adults with dementia is? 5. What are the characteristics of an appropriate exercise intervention for older adults with dementia in terms of place, appropriate time of day, length of the session, frequency and equipment? Also, what aspects of exercise might need to be avoided or modified for health or cultural reasons? 6. How should we encourage older adults with dementia to maintain their exercise program? 7. Do you have any other suggestions about exercise for older adults with dementia? Please explain.
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Perceptions of exercise for older people living with dementia in Bangkok, Thailand: an exploratory qualitative study Sirikul Karuncharernpanit
RN, PhD.
Boromarajonani College of Nursing, Chakriraj, Thailand
Joyce Hendricks
RN, RM, MN, PhD.
Senior Lecturer, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
Christine Toye
RN, BN (Hons.), PhD
Associate Professor, Older Persons’ Health Care, School of Nursing, Midwifery and Paramedicine, Curtin University and Adjunct Associate Professor, School of Nursing and Midwifery, Edith Cowan University, Australia
Submitted for publication: 7 May 2014 Accepted for publication: 31 March 2015
Correspondence: Joyce Hendricks School of Nursing and Midwifery Edith Cowan University Joondalup, WA, Australia Telephone: +61 8 63043511 E-mail: [email protected]
© 2015 John Wiley & Sons Ltd
KARUNCHARERNPANIT S., HENDRICKS J. & TOYE C. (2015) Perceptions of exercise for older people living with dementia in Bangkok, Thailand: an exploratory qualitative study. International Journal of Older People Nursing doi: 10.1111/opn.12091
Background. Dementia is a significant issue globally, including in Thailand, and exercise is known to have health benefits for people living with dementia. However, little is known about exercise acceptable to, and feasible for, this population group in low-to-middle income countries although, more broadly, it is recognised that health-related behaviours are influenced by the perceptions of the individual, which exist within a cultural context. Objectives. To explore and describe perceptions of appropriate exercise for people living with dementia in Bangkok, Thailand. Design. Qualitative exploratory descriptive. Setting. Bangkok, Thailand. Participants. Nine professionals – experts in exercise, dementia care and relevant policy development – and nine dyads of people with dementia and their family caregivers all recruited using purposive sampling. Methods. Semi-structured interviews subjected to thematic analysis. Results. Three themes emerged: how exercise was defined, perceived benefits of exercise and how exercise should be implemented. Professionals recognised three exercise elements: aerobic exercise plus balance and strength training. Dyads recognised home-based activities (e.g., housework) and walking. Both groups recognised benefits of exercise in maintaining health and function and improving mood and sleep. Only health professionals identified falls risk reduction. There was limited appreciation of benefits for caregivers by maintaining function in care recipients. Professionals deemed that exercise should address all three elements, using easily accessible low-cost resources. The need for safety was emphasised, and there was agreement that in-home exercise was appropriate. Family/cultural values were evident that could present barriers to exercise implementation. Conclusion. Changing health-related behaviours requires an understanding of individual perspectives, which exist within a cultural context. This study has illuminated the Thai context and has implications beyond this. Findings emphasise a 1
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need for potential benefits to be sufficiently understood by family caregivers to overcome any culturally based reluctance to promote exercise in older people. Implications for practice. Nurses have a key role in supporting care givers of older persons with dementia supervise home based exercise. Nurses need to develop knowledge of aerobic exercise to teach caregivers and the older person with dementia. Muscle strength and aerobic exercise assists in the older person’s ability to undertake ADL. Key words: caregiver, dementia, exercise, health professionals, older person, perceptions, Thai culture
What does this research add to existing knowledge in gerontology?
• • •
Perceptions of health professions, older people with dementia and caregivers are revealed in relation to the cultural understanding of exercise for older people with dementia. The use of exercise with the older people with dementia must be considered from the cultural context. An exercise programme for Thai older people with dementia should be home based, be individualised and use a mix of types of exercise.
What are the implications of this new knowledge for nursing care with older people?
• • •
Caregivers may be taught how to supervise and encourage an exercise regime for the older person with dementia at home. The use of a home-based exercise programme may be a viable alternative to expensive and often unattainable medications in third world countries. Caregiver burden is reduced because the older person with dementia sleeps better at night if they have undertaken the exercise programme during the day. Also undertaking exercises at home reduces the burden of having to take the older person across town to exercise in third world countries where transport systems are poor and hectic.
How could the findings be used to influence policy or practice or research or education?
• • • 2
The findings of this research suggest that nurses, in third world countries, may play a vital role in promoting exercise for caregivers and the older person with dementia. The importance of exercise as different to undertaking activities of daily living will influence education related to care of the older person with dementia. Policymakers can be influenced to support exercise programmes for older people with dementia in Thailand.
Introduction Dementia has multiple causes, the most common being Alzheimer’s disease and vascular changes within the brain; it is typically progressive, affecting memory, cognition and functional status (Draper, 2011). Dementia is a critical problem and is particularly common in older person people (Ferri et al., 2005). The number of people living with dementia worldwide is currently estimated at 35.6 million. This number is projected to double by 2030 and more than triple by 2050 (World Health Organisation, 2012a). In Thailand, as in many other countries, the prevalence of dementia has increased following growth and ageing of the population (Ferri et al., 2005; Access Economics, 2006; Jitapunkul et al., 2009; World Health Organisation, 2012b). The resultant increased demand for (limited) health services substantially impacts upon service/treatment accessibility for people experiencing dementia and their caregivers (Krairit & Chansirikarnjana, 2007). Costs borne by families are also likely to curtail access. The potential for exercise to be used as a helpful, low-cost treatment to delay functional deterioration in people with dementia, and how this may be supported by family caregivers and health professionals, therefore merits urgent attention. This study describes an early phase of a larger study that developed and trailed a targeted exercise programme in the Thai context. This early phase was necessary to inform programme development.
Literature review To inform this review, the following databases were searched to access study findings relevant to the notion of introducing exercise for people living with dementia in Thailand: MEDLINE, CINAHL, AGELINE, ProQuest, Informit-elibrary and PubMed. The terms ‘dementia’ and ‘exercise or aerobic exercise or strength training or physical therapy’ were used as the keywords. The National Research Committee of Thailand’s database and Thai journal databases – Journal of © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
Exercise for older people with dementia in Thailand
How it is defined
Daily activities
Formal exercise
How it should be implemented
Perceived benefits
Improving or maintaining physical function
Reducing caregiver workload
A home-based program
Cultural considerations
Equipment and safety
Figure 1 Themes and sub-themes.
mixture of aerobic, muscle strength and stretching or balance training. Dyads, however, thought that walking plus daily physical activities was sufficient. Aerobic training (especially walking) was agreed by both groups as being appropriate. Views on duration, intensity and frequency of exercise differed between groups. Health professionals remarked that walking is the last skill lost during the progression of dementia and is easy to undertake as it does not require specialised equipment. A few health professionals gave reasons to support walking. One said: ‘. . . choose an easy exercise such as walking, because they can walk and don’t need to use speed. . .’ (HP9). Needing no extra equipment and requiring low skills were specified by another health professional stating: ‘. . .endurance activity, particularly walking . . .is relevant to their previous experiences and no specific postures or positions are required’ (HP9). The dyads’ comments concentrated on the ease of walking and its familiarity to older people with dementia. Three health professionals, but no family care or older person with dementia, suggested that strength training played a major role for older adults with dementia. These professionals said that benefits included direct improvement of muscles and bones, with subsequent improvements in activities of daily living (ADLs) and independence; benefits for brain function were also articulated: Strength training is also important because [it] . . . improves their competence to . . .care for themselves. . . .will train specific muscles . . . will promote learning to control specific muscles . . . as well as improve their memory function . . . Their brain, which controls their movement, will be activated and records new data or this pattern [doing exercise regularly], so it will help to improve their brain function. (HP1)
Health professionals also identified balance training as useful prior to doing exercise to increase the safety of the person with dementia. Dyads did not address balance training. © 2015 John Wiley & Sons Ltd
Theme 2: Benefits of exercise for people with dementia While the widespread benefits from exercise are known, this theme considers benefits specific to older Thai people who have dementia. Most health professionals in exercise and dementia care agreed on the importance of exercise for people with dementia, with four saying that it was crucial. One health professional said: ‘. . . people [with dementia] who have exercised regularly live longer with a better quality of life’ (HP4). Likewise, dyads agreed on the importance of exercise, but not as strongly. One caregiver compared the advantages of doing exercise with disadvantages of being sedentary, asserting: ‘. . .if she (her mother) is active and does activities . . . she doesn’t have any loneliness or vagueness. . . when she didn’t do anything, her condition seemed to be worse’ (C9). Three subthemes emerged relating to the benefits of exercise: the potential to improve or maintain physical function, enhance mood/behaviour and reduce caregiver workloads. Improving or maintaining function Professionals and dyads agreed that exercise provided benefits by assisting with maintaining ADLs and brain function and improving health. One health professional said: ‘older adults with dementia will get worse very easily if they don’t exercise, and their caregivers can (sic) see deterioration in 2– 3 years. . .’ (HP5). One caregiver explained the importance of exercise for older people by saying: ‘their bodies are deteriorating. So, they should take care of them by exercising’ (C9). The importance of maintaining physical function was also seen to assist with ADLs by health professionals and dyads. A professional stated: ‘. . . if they can exercise their hands, arms, or legs . . . these organs can function and this is important for doing ADL by themselves’ (HP5). A caregiver said: ‘. . .doing physical activity and exercises helps. . . maintain their activities. . .’(C3). One participant who suffered from mild dementia pointed out that exercise helped her to be more active 5
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who is bilingual; each participant was interviewed once. Interview questions addressed exercise experience and views on exercise for older adults living with dementia (see Appendix). Interviews with health professionals lasted approximately 1 hour; those with dyads were variable in length, taking into consideration participants’ cognitive ability, patience and attention span. For dyads, interviews were undertaken at the dementia clinics they visited routinely. For the health professionals, interviews were at places of their choosing.
Data analysis Interviews were transcribed verbatim (in Thai) and then translated into English. All audio tapes were repeatedly played, and the interview transcriptions in Thai were read many times by the researcher to gain a feeling for the whole. In each case, words, phrases, sentences or paragraphs that stood out were highlighted and then coded manually. Coded data were organised into themes and subthemes using a mind map (Braun & Clarke, 2006).
Trustworthiness Trustworthiness was demonstrated by addressing transferability, dependability, and credibility (Oaks et al., 2004; Cresswell, 2014). To ensure transferability, the researcher provided a detailed description of the study’s setting, plus contextual information about participants and details of how they were selected. To support dependability, a detailed description of the study’s methodology is provided and the analysis process was reviewed by two language experts and qualitative researchers. To increase credibility, supervisory consultants in Thailand validated the translation and interpretation of transcripts by reading Thai descriptions and discussing the emergent themes with the researcher until a consensual interpretation was agreed.
Findings Nine dyads and nine health professionals residing in Bangkok, Thailand, were recruited, but one dyad was excluded before interview data were collected because the person with dementia had difficulty responding to the questions (N = 25). Characteristics of participants are in Table 1. Dyad interviews lasted from 15 minutes to 1.5 hours. Three main themes relating to exercise for older people with dementia in the Thai context emerged. These themes are illustrated in Fig. 1 and are as follows: how exercise is defined, perceived benefits of exercise and how exercise should be implemented. Exemplars from health professionals are 4
Table 1 Characteristics of participants (n = 25)
Indicators
Health professionals (9)
Gender Male 5 Female 4 Age Range 32–62 (years) Educational level (frequency) Primary 0 Secondary 0 Vocation 0 Bachelor’s 0 Postgraduate 9 Experience of dementia 5 years 9
People with dementia (8)
Caregivers (8)
Overall (25)
2 6
1 7
8 17
64–81
29–64
29–81
4 0 0 4 0
1 1 1 4 1
5 1 1 8 10
4 2 1 1
6 0 1 1
10 2 2 11
signified by ‘HP’, those from people with dementia are assigned ‘P’, and those from family caregivers are allocated ‘C’.
Theme 1: How exercise for older people with dementia is defined in the Thai context This theme documents perceptions of what is viewed as exercise for the older person with dementia in the Thai context. Two subthemes emerged: daily activities and formal exercise. Daily activities Two health professionals and all dyads equated daily activities with formal exercise. One person with dementia stated, ‘. . . [If I want to exercise], I will use a small cloth to scrub the floor. . .. [because] it is [more] difficult. . . I won’t use a big cloth’. (PT5). In addition, one caregiver indicated that hanging up wet laundry was exercise, stating: ‘. . .when she hangs out the washing and turns the washing around [frequently], she is doing exercise for her joints’. (C9). A change over time in the physical nature of ‘work related’ roles was acknowledged by a health professional, who stated: ‘Approximately 40–50 years ago, exercise and work could be done together, for example farmers and gardeners. However, at present exercise will need to stand alone from occupations. . . .’ (HP2). Formal exercise Most health professionals highlighted that, in Thailand, formal exercise for people with dementia should comprise a © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
Exercise for older people with dementia in Thailand
How it is defined
Daily activities
Formal exercise
How it should be implemented
Perceived benefits
Improving or maintaining physical function
Reducing caregiver workload
A home-based program
Cultural considerations
Equipment and safety
Figure 1 Themes and sub-themes.
mixture of aerobic, muscle strength and stretching or balance training. Dyads, however, thought that walking plus daily physical activities was sufficient. Aerobic training (especially walking) was agreed by both groups as being appropriate. Views on duration, intensity and frequency of exercise differed between groups. Health professionals remarked that walking is the last skill lost during the progression of dementia and is easy to undertake as it does not require specialised equipment. A few health professionals gave reasons to support walking. One said: ‘. . . choose an easy exercise such as walking, because they can walk and don’t need to use speed. . .’ (HP9). Needing no extra equipment and requiring low skills were specified by another health professional stating: ‘. . .endurance activity, particularly walking . . .is relevant to their previous experiences and no specific postures or positions are required’ (HP9). The dyads’ comments concentrated on the ease of walking and its familiarity to older people with dementia. Three health professionals, but no family care or older person with dementia, suggested that strength training played a major role for older adults with dementia. These professionals said that benefits included direct improvement of muscles and bones, with subsequent improvements in activities of daily living (ADLs) and independence; benefits for brain function were also articulated: Strength training is also important because [it] . . . improves their competence to . . .care for themselves. . . .will train specific muscles . . . will promote learning to control specific muscles . . . as well as improve their memory function . . . Their brain, which controls their movement, will be activated and records new data or this pattern [doing exercise regularly], so it will help to improve their brain function. (HP1)
Health professionals also identified balance training as useful prior to doing exercise to increase the safety of the person with dementia. Dyads did not address balance training. © 2015 John Wiley & Sons Ltd
Theme 2: Benefits of exercise for people with dementia While the widespread benefits from exercise are known, this theme considers benefits specific to older Thai people who have dementia. Most health professionals in exercise and dementia care agreed on the importance of exercise for people with dementia, with four saying that it was crucial. One health professional said: ‘. . . people [with dementia] who have exercised regularly live longer with a better quality of life’ (HP4). Likewise, dyads agreed on the importance of exercise, but not as strongly. One caregiver compared the advantages of doing exercise with disadvantages of being sedentary, asserting: ‘. . .if she (her mother) is active and does activities . . . she doesn’t have any loneliness or vagueness. . . when she didn’t do anything, her condition seemed to be worse’ (C9). Three subthemes emerged relating to the benefits of exercise: the potential to improve or maintain physical function, enhance mood/behaviour and reduce caregiver workloads. Improving or maintaining function Professionals and dyads agreed that exercise provided benefits by assisting with maintaining ADLs and brain function and improving health. One health professional said: ‘older adults with dementia will get worse very easily if they don’t exercise, and their caregivers can (sic) see deterioration in 2– 3 years. . .’ (HP5). One caregiver explained the importance of exercise for older people by saying: ‘their bodies are deteriorating. So, they should take care of them by exercising’ (C9). The importance of maintaining physical function was also seen to assist with ADLs by health professionals and dyads. A professional stated: ‘. . . if they can exercise their hands, arms, or legs . . . these organs can function and this is important for doing ADL by themselves’ (HP5). A caregiver said: ‘. . .doing physical activity and exercises helps. . . maintain their activities. . .’(C3). One participant who suffered from mild dementia pointed out that exercise helped her to be more active 5
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without tiring, saying that ‘after exercise. It [my body] is not tired. It [exercise] can help me be much more active’ (P8). Falls prevention is a salient issue for older people in the Thai context, but only two health professionals, and no dyads, discussed the role of exercise in preventing falls. In particular, muscle strength training was identified as helping to prevent falls: ‘If their muscles are strong and function well, it [muscle improvement] will prevent falls. . .. (HP5)’. One health professional identified the importance of doing exercise during the day to assist in the older people with dementia having a restful night: ‘[a] broken sleep cycle leads to forgetfulness. . . .. adequate exercise . . . will help people to reach the 4th stage of non-REM [which is] better than tranquilizers’ (HP4). This also maintains brain function, cognition and memory improvement. Three health professional also recognised the potential of exercise in addressing behavioural issues; one said: ‘Exercise can help them to have . . . better sleep, better appetite, weight control and a reduction of difficult behaviors at night’ (HP3). Caregivers, in this study, did not mention change or reduction in troublesome behavioural symptoms from exercise, but did mention an improvement in sleep pattern as a likely positive outcome. The caregiver said: ‘. . . if she (mother) is less active, she has only two activities, eating and sleeping . . ..and will be more forgetful’ (C9). This caregiver also stated that doing activities helped reduce her mother’s daytime sleep, saying: ‘. . .when she has these activities, she won’t sleep in the day time’ (C9). Enhancing mood and behaviour Health professionals and dyads agreed that exercise helped improve the mood of people with dementia. One health professional, said: ‘their mood will be better because sufficient exercise [is like] special medicine’ (HP4) and a caregiver stated: ‘I noticed that she [mother] is happier when she does this job [physical activity] than in the past’ (C9). One health professional also summarised negative impacts from a sedentary lifestyle, saying: ‘they fear falling and [thus] become sedentary; their condition becomes worse and leads to more depression because movements and mobility can be the key health factors for people’ (HP4). One caregiver shared this perception, saying: ‘. . .when she didn’t do anything she was usually irritated. If she doesn’t have anything to do, she will be quiet, lonely and depressed. I realised that if she is active . . . she will be better’ (C9). Moreover, two caregivers believed that preventing loneliness in people with dementia was important. Reducing caregiver workload Only two participants, a health professional and a caregiver, noted the indirect positive effect of exercise in reducing 6
caregiver workload by maintaining function in people with dementia. The professional stated: ‘There are many reasons to encourage them to do exercises . . .they can do their Activity of Daily Living by themselves’ (HP5). The caregiver said, ‘I realized that if she is active and does activities, I can reduce my workload in caring for her and my house is cleaner than in the past’ (C9).
Theme 3 How exercise for older people with dementia should be implemented in the Thai context When considering exercise programme implementation in the Thai context, the need for a home-based approach was articulated. Cultural perspectives and needs for equipment and safety were also addressed. A home-based exercise programme Home-based exercise was agreed by both health professionals and dyads to be the most suitable approach for older adults with mild to moderate dementia in the Thai context for three reasons. Firstly, the use of the home setting was seen to reduce caregiver workload because preparing people with dementia and then transporting them from their homes, in the Bangkok environment, where traffic is busy and parking is limited, is problematic. This point is supported by the following statements: ‘. . .older adults with dementia . . . depend on their caregivers. If you establish the exercise program at the clinic or outside their homes, it will increase the workload of caregivers’. (HP3). ‘. . . [there is] difficulty travelling, such as calling a taxi . . .. Otherwise, they need to ask their cousin who has a car to drive them. . .some caregivers need to absent themselves from their own job for one or 2 days’ (HP5). Secondly, it was expressed that there may be issues with disorientation, fear, forgetfulness and dressing appropriately. For example, one person with dementia said: ‘If I need to travel on my own, I am afraid of taxi drivers. I am a woman and don’t know where the driver will drive to. So, I won’t go out on my own. . . .. I feel that I am foolish’ (PT8). A health professional observed: ‘You may notice that even in a quiet place, people with dementia [become] agitated and can’t relax . . .. People with dementia differ from older people in general. If they can exercise in their own homes with familiar caregivers, they will be benefitted’ (HP2). Cultural considerations Thai views of ageing as a period during which relaxation is appropriate were articulated. One caregiver said: ‘from the children’s perspective, we want our parents to have a relaxing time and don’t want them to work too hard’ (C9). A health © 2015 John Wiley & Sons Ltd
Perception of Exercise for Older People with Dementia in Thailand
professional agreed, ‘the first misconception [about exercise is that] older adults do not need to exercise because they are too old’ (HP2) and another stated: ‘I found that most Thai family caregivers would rather be cautious and overly protect their parents. . .’ (HP2). This perspective was emphasised strongly by a person with dementia who complained that her grandson did not allow her to do any physical activities such as household chores, saying: ‘I don’t exercise much. . ..my grandson told me that Ya [grandmother] doesn’t need to do anything, you should have a sleep or a rest because you have worked so hard for a long time . . .’ (PT3). Equipment and safety Two health professionals discussed details of appropriate strength-training equipment adapted from household items and the criteria to choose appropriate equipment (size, safety and colour) for people with dementia. Comments made included ‘stairs can be used as exercise equipment. . . .body weight can be categorized as a weight’ (HP1) and ‘another important point is the size of equipment. . . . if it is too big, they may be frightened and if it is too small, they can’t grasp it. . ..Furthermore, . . . think about suitable colours. I would suggest you use blue, yellow, bright, relaxing or calm colours’ (HP2). Dumb-bells, which are used widely, and Thai elastic bands (rubber rings with two handles that users pull) were identified as a potential safety issue by family caregivers in terms of their potential to cause injuries at some stages of dementia, especially the moderate and severe stages, although the caregivers did not identify issues of safety for themselves. However, a health professional said: ‘. . . hitting [the caregivers – either unintentionally or in anger] may occur. But for hurting themselves, no, it is rare for older people with dementia to hurt themselves. . .. [and only] when they are frustrated. Most of them would be in the moderate to moderately severe stage [before this happens]’ (HP2). A second health professional stated: ‘. . .. . . the sticks (Thai elastic bands) can be very dangerous if they recoil towards the eyes. The use of [medical] elastic band . . . this will reduce the risk of injury’ (HP9). Strategies for strength training were outlined, included starting from the use of body weight or light weights, then gradually increasing weights, for safety. One health professional said: ‘. . . you may need to start by practicing with the correct position, posture and movement without any weight or equipment. Then you can gradually increase the resistance. . . . if they use the incorrect muscle group . . . there will be many problems’ (HP1). Another health professional addressed balance as a safety issue: ‘. . .you need to test and train their balance. . . to consider safety. . . .There are two ways of balance training. The first way is chair rises. The © 2015 John Wiley & Sons Ltd
second way is taking short steps in the same place with their legs reaching an upright position each time’ (HP4).
Discussion There is growing evidence of the benefits from exercise for people living with dementia, particularly in high-income countries (Teri et al., 2003; Stevens & Killeen, 2006; Steinberg et al., 2009; Kemoun et al., 2010). There is also recognition that obtaining information from those who have dementia is pivotal to understanding their needs (Clare et al., 2008) and, more broadly, that individuals’ perceptions must be considered when implementing health promotion initiatives (Pender et al., 2006). In this study, perceptions of exercise as a health promotion strategy were obtained from people living with dementia in Thailand, their family caregivers and health professionals involved in relevant policy and practice areas. Consideration is now given to the transferability of these findings and, therefore, any implications beyond the Thai context. Consistent with the assertion of Chunharas (2007), that an understanding of the benefits of formal exercise will be limited when information is provided only in English (in nonEnglish speaking countries) and/or literacy rates are low, people living with dementia and their family caregivers in our study did not recognise strength and balance training, in particular, as exercise elements relevant to them. This finding is likely transferable to populations in other low-to-middle income countries with low literacy rates and to cultural subgroups in Western countries with similar characteristics (e.g. refugees or migrant groups with limited English). The implications are clear for the provision of information in appropriate languages included in alternative media presentations. The cultural context that became evident from our study findings illustrated the high status of parents and older people (Knodel & Chayovan, 2009) in Thailand and the social norm of not expecting parents to undertake activities [Fox (2005), Kespichayawattana and Jitapunkul (2009) and Knodel and Chayovan (2009)]. Such findings could only be transferable to other cultural groups with similar values and illustrate clearly the relevance of the theoretical underpinnings of our study that require perceptions to be understood so that behavioural change can be successfully promoted. In this instance, a logical recommendation is that an understanding of positive outcomes for people with dementia from exercise (e.g. a lowered risk of falls) in their family caregivers might promote a view that encouraging and facilitating exercise programmes for people living with dementia is a one way of showing esteem. 7
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Perhaps because of Thai values that stress the high status of older people, how exercise for the person with dementia might positively impact upon caregivers was addressed only in a limited way by the participants in this study. Caregivers did stress the benefits of preventing sleeplessness, which is consistent with the findings of Fang and Swartwood (2012), who reported that exercise assisted the older person with dementia to sleep, with caregivers reporting a reduction in caregiver burden. However, caregivers did not discuss or link the benefits of exercise in managing distressing behaviours, despite health professionals recognising this as an important benefit. There is some controversy in the literature on this point, with Kalapatapu and Neugroschl (2009) asserting that there is a lack of strong evidence to support the reduction of behavioural symptoms using exercise despite the claims of Aman and Thomas (2009) that exercise can reduce agitation in people with severe dementia. More recently, Fang and Swartwood (2012) and Langlois et al. (2012) found that an exercise programme led to improved attitudes in older adults with AD. Further research is needed to explore this issue. For example, it may be that encouraging exercise implementation for people living with dementia in the Thai culture – or in other cultures valuing rest for older people – may cause resistance in the person with dementia that is manifested in behaviours that are distressing.
Conclusion In conclusion, three main themes were recurrent in study findings: the importance of exercise, the benefits of exercise for people with dementia and the cultural issues related to exercise. The benefits of exercise, in general, were recognised by both groups – professional and caregivers/care recipients – but there were differences in understandings of appropriate exercise. Whereas professionals’ understandings were generally consistent with Western perspectives, the cultural values exhibited by people living with dementia and their caregivers provided insights into potential barriers to the implementation of formal exercise programmes. Some of these study findings are likely to be transferable to other cultural groups with similar values and to those with limited understanding of English and/or literacy skills. Pender et al. (2006) assert that perceptions – including perceived benefits – influence the motivation and commitment to making a change in healthrelated behaviour. This assertion supports the recommendation from our study findings that implementing exercise programmes for people living with dementia requires an indepth understanding in caregivers of the recognised benefits for the person with dementia so that they will be motivated to offer appropriate support. Our study also serves to 8
emphasise the need to tailor the introduction of interventions known to have benefits for people with dementia to the cultural perspective and context of the individual and their family.
Implications for practice Nurses have a key role in supporting care givers of older persons with dementia supervise home based exercise. Nurses need to develop knowledge of aerobic exercise to teach caregivers and the older person with dementia. Muscle strength and aerobic exercise assists the older person’s ability to undertake ADL.
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Perception of Exercise for Older People with Dementia in Thailand Jitapunkul S., Chansirikanjana S. & Thamarpirat J. (2009) Undiagnosed dementia and value of serial cognitive impairment screening in developing countries: a population-based study. Geriatr Gerontol Int 9, 47–53. Kalapatapu R.K. & Neugroschl J.A. (2009) Update on neuropsychiatric symptoms of dementia: evaluation and management. Geriatrics 64, 20–26. Kemoun G., Thibaud M., Roumagne N., Carette P., Albinet C., Toussaint L., Paccalin M. & Dugue B. (2010) Effects of a physical training programme on cognitive function and walking efficiency in elderly persons with Dementia. Dementia and Geriatric Cognitive Disorders 29, 109–114. Kespichayawattana J. & Jitapunkul S. (2009) Health and health care system for older persons. Ageing International 33, 28. Knodel J. & Chayovan N. (2009) Intergenerational relationships and family care and support for Thai elderly. Ageing International 33, 15. Krairit O. & Chansirikarnjana S. (2007). Dementia: An Epidemic on the horizon C. Kanchanachitra, C. Podhisita, K. Archavanitkul, U. Pattaravanich, K. Siriratmongkon & H. Seangdung (Eds.), Thai Health 2007 Available at: http://www.hiso.or.th/ hiso/HealthReport/report2007-ENG.php?manu=4 (accessed 10 March 2015). Langlois F., Vu T.T.M., Chasse K., Dupuis G., Kergoat M.J. & Bherer L. (2012) Benefits of physical exercise training on cognition and quality of life in frail older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences May;68(3), 400–4. doi:10.1093/geronb/gbs069. McKhann G. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on AgingAlzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease (1st ed., pp. 263–269). PMC. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312024/on 6/05/ 2014 Oaks C.A., Graneheim U.H. & Lundman B. (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Pender N.J., Murdaugh C.L. & Parsons M.A., eds. (2006) Health Promotion in Nursing Practice, 5th edn. Pearson Education, New Jersey. Perneczky R., Wagenpfeil S., Komossa K., Grimmer T., Diehl J. & Kurz A. (2006) Mapping Scores Onto Stages: Mini-Mental State Examination and clinical dementia rating. The American Journal of Geriatric Psychiatry, 14, 139–144.
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Appendix Appendix 1 Semi-structured interview guides for health professionals, dyads and caregivers Health professionals
Dyads
Caregivers
1. Have you ever had experience with exercise? Tell me, what is the exercise experience you have? 3. What is your perception of exercise for older adults with dementia?
1. What do you think about exercise for older adults with memory problems? 2. What makes the exercise suitable exercise for you when you think about: 2.1 where you should do the exercise? 2.2 what time of day is best? 2.3 how long does the exercise take? 2.4 how often you do the exercise? 2.5 what sort of equipment to use? 2.6 what do you try to avoid? 3. What do you think is the best exercise for you? 4. How can we encourage you to keep exercising?
1. What do you think about exercise for older adults with memory problems? 2. What makes the exercise suitable exercise for older adults with memory problems when you think about: 2.1 where to do the exercise? 2.2 what times of day are best? 2.3 how long the exercise takes? 2.4 how often they do the exercise? 2.5 what sort of equipment to use? 2.6 what do they try to avoid? 3. What do you think is the best exercise for older adults with memory problems? 4. How can we encourage older adults with memory problems to keep exercising?
5. Is there anything else you would like to say about exercise for older adults with dementia? Please explain.
5. Is there anything else you would like to say about exercise for older adults with memory problems? Please explain?
4. What do you think the most appropriate exercise for older adults with dementia is? 5. What are the characteristics of an appropriate exercise intervention for older adults with dementia in terms of place, appropriate time of day, length of the session, frequency and equipment? Also, what aspects of exercise might need to be avoided or modified for health or cultural reasons? 6. How should we encourage older adults with dementia to maintain their exercise program? 7. Do you have any other suggestions about exercise for older adults with dementia? Please explain.
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