Discussion
cognitive decline, dementia, cognitive impairment
PROGRESSION, AIDS, RECRUITMENT
In this pilot feasibility study, an innovative approach was examined as a way to engage people living with dementia in a physical and social activity program (the ENJOY program) using outdoors Seniors Exercise Park equipment. While this approach has been quite successful in people living in the community demonstrating physical, social and health benefits [There is growing evidence for the importance of lifestyle factors such as social and physical activities in positively influencing on mental health, quality of life, and rate of cognitive decline in people living with dementia, including after diagnosis [While the study results are promising, sustainable usage of the equipment on an ongoing basis will require commitment from aged care staff to allow residents to continue to exercise in some capacity under suitable supervision. In addition, a follow up study will be required with a larger sample size to further identify potential social, physical, and health benefits of the ENJOY program for people living with dementia.As part of the feasibility aspect of this study, we also examined the delivery of the ENJOY program and factors that needed adjustments to optimise usage of the equipment in this cohort. Close supervision was required in the initial 12-week program, which gradually reduced as the program progressed into the maintenance phase with a ratio of one staff to two residents being safe and practical. During the maintenance phase, participants seemed comfortable with the exercises and needed minimal instructions and guidance on how to perform the exercises. An alternative option to assist with supervision might include training family members and friends to support and supervise the person with dementia in using the Seniors Exercise Park, after a formal training period with therapists/staff. This might assist in reducing the resources/staffing required for longer term supervision and might also benefit the family members/friends if exercising together.Progression of the exercises was the most challenging aspect of delivering the program as participants sometimes had difficulty recalling the level they were at from the last session. This created a challenge to the ENJOY program implementation as exercise progression is an important element of physical activity training which aims to increase overload over time to facilitate ongoing improvement. As the ENJOY Seniors Exercise Park program is a progressive exercise program, the ability of the participant to progress with the increasing difficulty of the exercises was often impacted by their cognitive impairment, particularly regarding their memory of their previous performance/level of difficulty. This, in turn, sometimes inadvertently impacted their confidence and willingness to attempt more challenging tasks. Adjustments of communication and usage of external aids were tested and individualised to ensure they were positively contributing and not distracting and confusing for individual residents. Overall, implementing strategies to assist with exercise progression is an important factor to consider for exercise prescription for people with cognitive impairment and those living with dementia.Based on the present exercise program delivery experience and associated modifications, the following practical recommendations will enable safe and pleasant exercise sessions for people with cognitive impairment and those living with dementia: 1) ensure the environment is quiet and welcoming (training in small groups and maintaining distance where exercise participants cannot overhear conversations of others), 2) provide simple, short and concise instructions, 3) maintain a routine and use repetition (e.g., same morning routine for the exercise days, preparation), 4) be patient and allow sufficient time (several weeks) for participants to feel comfortable performing the exercise with ease, 5) minimise the instructions as the weeks progress, gradually shifting towards giving control to the individual to self-manage their own exercise routine, 6) personalise the communication techniques as every person responds differently to instructions and feedback (example strategies are knowing the resident, and knowing what they respond well to, and what they do not respond well to). A summary of these recommendations is provided in this educational video People with dementia have lower physical activity levels than older people with no cognitive impairment [This study has several limitations. Firstly, the COVID-19 pandemic and associated restrictions and lockdowns resulted in recruitment challenges and a lower sample size to what was targeted. Illness or isolation of the residents due to COVID-19 also impacted attendance and may have prevented potential improvement. Although 12-weeks of consistent progressive exercise is commonly sufficient to produce improvement in physical mobility in older people without dementia, it is possible that a longer supervised program duration is required to create a significant change in physical or cognitive capacity in this population [