Strategies for Promoting Physical Activity
Leveraging Daily Activities
One approach to promoting physical activity in LTC homes is to systematically use simple strategies embedded within routine care to engage residents in movement.8 Function-focused, or restorative care,17 is a philosophy of care that promotes increasing physical activity and maintaining functional abilities based on the resident’s abilities. Examples include walking with residents to the dining room rather than pushing them in a wheelchair where appropriate, inviting residents to events that require them to leave their room, improving independent wheelchair propulsion for residents who cannot walk, and increasing opportunities for sit-to-stand activities where possible. These activities are scaled to the resident’s underlying physical and cognitive capabilities. A systematic review of function-focused care revealed that it can help maintain functional skills for residents in LTC, and there is no significant risk associated with implementation.18 In a study by Slaughter et al19 that examined the effectiveness of techniques to encourage mobility by residents’ usual caregivers, health care aides prompted residents to perform the sit-to-stand activity 4 times per day, with the number of repetitions individualized based on resident ability, fatigue, and motivation. Residents who completed the sit-to-stand activity had smaller declines in mobility and functional outcomes (ie, less decline on the Functional Independence Measure).19 This study included residents with Alzheimer’s disease and dementia who could transfer independently or with the assistance of one person,20 indicating that this type of intervention is feasible and appropriate for residents with cognitive impairment.
Group Activities
Group activities in LTC homes are another way of engaging residents in physical activity in a motivating and pleasant setting that also encourages social engagement among residents and LTC staff. Group exercise classes can be effective for improving mood and functional outcomes. For example, a systematic review of dance classes in LTC homes revealed an improvement in problematic behaviors, mood, cognition, communication, and socialization.21 Most studies included participants with dementia, and no adverse events were reported, supporting the feasibility and safety of implementing group dance activities for residents with cognitive impairment. Group exercise is the most common delivery method for exercise within LTC homes22 and has been demonstrated to have small positive effects on activities of daily living (ADL; ie, improvement in ADL independence equivalent to 1.3 points on the Barthel Index).23 Other group activities, such as music therapy, have demonstrated improvements in depressive symptoms, emotional well-being, and anxiety for LTC residents with dementia.24 Group activities also provide the opportunity for movement as residents leave their rooms, walk to a new location (if able), and return to their rooms when the activity is complete.
Barriers to Physical Activity and Strategies to Overcome Them
Caregiver-related Factors
LTC staff have limited time to spend promoting physical activity since residents often have complex health care needs and staffing levels are often constrained.25 Indeed, having lower staffing levels has been associated with lower levels of physical activity for residents.26,27 LTC staff have identified a lack of time to walk with residents28,29 and having other tasks to do (eg, clean) as barriers to promoting movement.28,29 However, asking residents to help staff with small household chores, such as folding laundry or clearing dishes, was a facilitator to promoting movement.30 Activating residents by helping them transfer to a wheelchair for independent mobilization around the home or by assisting them to walk where appropriate were also facilitators.30,31 Leveraging facilitators will help staff who have limited time to help residents engage in more physical activity.
Motivation of LTC staff can also be a barrier to encouraging physical activity for residents in LTC. Fear that increasing physical activity will cause adverse events like falls, illness, or exacerbation of symptoms often decreases motivation for staff to facilitate physical activity.32,33 Another potential barrier is the conceptualization of the role of nursing in LTC as protecting residents from harm by encouraging them to engage in “risk-free” activities like staying in bed.34-39 Strategies to increase staff motivation to engage LTC residents in physical activity that have been shown to be effective are verbal prompts, modelling behaviors, goal setting, and home champions to promote function-focused care.17,33,40-43
The Physical Environment
Aspects of the physical environment of LTC homes may facilitate or limit residents’ ability to be physically active. A 2017 systematic review examined elements of the physical environment that acted as barriers and facilitators to physical activity for older adults living in LTC.30 The authors found that the person-environment fit, security, accessibility, and comfort were key components of the physical environment that were associated with residents’ physical activity levels.30 First, an appropriate fit between the residents’ abilities and the demands of the environment was related to improved activity as measured by actigraphy.44 For example, having long hallways between residents’ rooms and common spaces discourages residents who can only walk short distances from walking to these locations. However, residents were more active in larger-scaled LTC homes with shorter distances between different areas (eg, resident rooms and dining rooms).45 Clearly, there must be enough space to encourage walking between areas, but not so much space that walking is not feasible. Residents participating in a focus group identified accessibility and comfort features as being facilitators for walking in the corridor, such as wide corridors, sturdy handrails, carpet, chairs placed at short intervals for seated breaks, windows to look out, plants, and accessible activity rooms and restrooms.45,46 On the other hand, limited things to see and do indoors and outdoors, along with restricted walking areas, were identified as barriers to corridor walking by residents.46