One method for optimizing LTC home architecture to promote movement is to provide therapeutic outdoor spaces, such as gardens. Indeed, therapeutic gardens have been studied as a nonpharmacological method of engaging LTC residents with dementia and have been shown to benefit mood, pain, and fall prevention.47 Secure therapeutic gardens or outdoor spaces provide opportunities for various activities to increase movement, including gardening, animal care, and walking.48 However, there is a higher propensity for residents who use walkers or wheelchairs to slide off paths or become stuck in mud or mulch.49 Residents with physical limitations may require additional supervision in garden spaces, and as such spaces should be designed with improved safety in mind (eg, barriers between paths and places where mud could accumulate). The number of available indoor (eg, a physical therapy gym) and outdoor (eg, gardens) spaces was also found to be positively related to residents’ physical activity levels.50 However, these relationships were mediated by the number of activity programs available in the LTC homes.50 Therefore, having staff available to facilitate activities is also important for promoting physical activity.
Chemical and Physical Restraints
Physical and chemical restraints (eg, antipsychotics and sedatives) are sometimes used to manage the behavioral and psychological symptoms of dementia,51,52 which many residents in LTC experience.3 Though there has been an emphasis in North America to decrease their use, physical and chemical restraints are still used in LTC.53 Physical restraint use is associated with a higher risk of functional and cognitive decline.53,54 Residents who are both physically and chemically restrained through antipsychotic use are at even higher risk for these declines.54 Thus, to improve opportunities for movement in LTC, physical restraint use should be minimized. The risks and benefits of using psychotropic medications that often decrease residents’ physical activity levels must be evaluated individually, and other nonpharmacological strategies should be used to manage the behavioral and psychological symptoms of dementia. These could include functional analysis-based interventions (ie, individualized interventions aimed at identifying unmet needs, causes, antecedents, and consequences of the behavior),55 music therapy,55 or other interventions described above.
Emerging Innovative Interventions
Robots are an emerging nonpharmacological intervention for improving the behavioral and psychological symptoms of dementia and facilitating physical activity in LTC. Robotic animal interventions, where LTC residents interact with robotic animals in an individual or group setting, have been shown to reduce negative behaviors and increase positive mood.56 Additionally, robots are being used in rehabilitation to provide exercise post-stroke57 and could easily be transitioned to do similar tasks in LTC. Robotic interventions are attractive for the LTC sector as they could help relieve the workload demands on an often overloaded sector, and, in the case of pet therapy, surmount regulations for bringing live animals into a LTC home. Though studies examining the use of robots in LTC have mainly focused on the effect of pet therapy on reducing behavioral symptoms, the use of robots to promote physical activity and exercise in LTC is a natural progression for the work that has been done in inpatient rehabilitation.57 On a similar note, an interactive technology (similar to a Kinect system) used to promote 30-minute, twice-weekly physical activity sessions has demonstrated improvements in physical function (Short Physical Performance Battery [SPPB]) for pre-disabled (SPPB of 6 to 9) residents in LTC without dementia.58 The role of technology to promote physical activity in LTC is an emerging area of interest, and future innovations in this area will continue to help facilitate movement.
Quality of Evidence
Most studies aimed at improving physical activity for LTC residents to date are small, have nonrandomized designs, and have limited generalizability and evidence to support the efficacy of the interventions. For example, most studies included in systematic reviews for function-focused care, dance, group exercise, and music therapy are small, observational, or quasi-experimental studies with methodological issues resulting in bias.18,21,23,24 Likewise, the evidence surrounding nonpharmacological interventions for reducing behavioral and psychological symptoms of dementia is of very low to moderate quality.55 Innovative interventions, such as robotics and interactive technology, to promote physical activity in LTC are in their infancy. There are no data syntheses available to date to summarize the available literature on this topic, and conclusions rely on small, nonrandomized designs or extrapolations of results from similar sectors (eg, inpatient rehabilitation). Thus, the studies described in this review can be used as preliminary evidence to support the implementation of interventions to improve physical activity, but discretion should be used when interpreting the efficacy of these interventions.
