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

Date Published: May 23, 2019

Publisher: Public Library of Science

Author(s): Jennie E. Hancox, Veronika van der Wardt, Kristian Pollock, Vicky Booth, Kavita Vedhara, Rowan H. Harwood, Maw Pin Tan.


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

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

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

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

Partial Text

Dementia is a clinical syndrome caused by neurodegenerative diseases and is characterised by an irreversible and progressive loss of cognitive functions (e.g., short-term memory, executive function) and associated neuropsychiatric symptoms (e.g., depression, anxiety) which can impair individuals’ ability to perform everyday activities [1]. In 2015, there were 46.8 million people worldwide living with dementia with the prevalence set to rise to 131.5 million people by 2050 [2]. The rising number of individuals living with dementia poses personal, social and economic challenges in terms of meeting increased demands and costs of care. The worldwide cost of dementia was estimated at US$ 818 billion in 2015 and projected to rise to US$ 2 trillion by 2030 [2]. Thus, dementia is a global public health priority with a pressing need for interventions aimed at preventing functional deterioration and dependency to help people live well with dementia [3].

In the first four months of taking part in the PrAISED programme, on average participants completed 98 minutes of PrAISED exercises per week (range = 22–464), 3.8 sessions per week (range = 0.9–7.0), for 24 minutes per session (range = 14.5–66). Five participants’ adherence exceeded expectations (4 male, 1 female; mean age = 75.40, range = 70–80 years; mean sMMSE score = 25.20, range 21–27; 3 medium intensity, 2 high intensity programme). Seven participants met adherence expectations (all male, mean age = 79.00, range = 69–91 years; mean sMMSE score = 26.43, range = 24–30; 1 medium intensity, 6 high intensity programme), and 8 participants had low adherence (5 male, 3 female; Mage = 75.25, range = 68–86 years; mean sMMSE score = 23.87, range = 20–29; 6 medium intensity, 2 high intensity programme) (Table 1).

This paper analysed barriers and facilitators to adherence to home-based strength and balance training among older adults with mild cognitive impairment and early dementia. In line with previous research [15, 16] the study revealed a range of barriers and facilitators to exercise adherence, spanning all 14 TDF domains. This study builds on previous research [15, 16] through an examination of how barriers and facilitators varied according to levels of adherence.

This study advances our understanding of the barriers and facilitators to adherence to home-based strength and balance exercises in older adults with early dementia. Findings suggest that individuals who develop an exercise routine, have strong practical and emotional support from clinicians and carers, use of memory supports, have positive past experience of sport and exercise involvement, have a purpose for doing the exercises, and believe in and experience benefits are likely to adhere to a programme of strength and balance exercises. However, individuals below a threshold of cognitive capacity who do not have adequate practical and emotional support and/or do not identify with a meaningful purpose for doing the exercises are unlikely to adhere. The findings can be used to refine current interventions with the target population or be considered in the development of new interventions, so that home-based exercise interventions with older adults with MCI and early dementia more effectively target the key determinants of adherence and are designed and delivered in a way which promotes optimal motivation and adherence.