This study examined adherence to a daily walking program in community-dwelling persons with AD and their caregivers. Results indicate that a majority of individuals with dementia can implement and sustain a daily walking program with caregiver support. However, establishing a regular walking program is difficult for some individuals. Although most caregivers stated that the intervention had not required too much effort, and 47% of participants were still walking 5 or more days per week at 6-month follow-up, a substantial percentage of participants did not walk at all, and that percentage increased over time. Exploratory analyses of participant and caregiver factors associated with walking adherence indicated that participants who walked more had lower levels of behavioral disturbance and were less depressed. The caregivers of walking participants tended to be spouses and reported less perceived stress.
It is worthwhile noting that several of these factors associated with participant non-adherence to walking recommendations are potentially modifiable. For example, our data suggest that persons who are less depressed may be more likely to walk. There is considerable evidence that psychosocial treatments can directly reduce depression in persons with dementia. 30–32
Such treatments can also help caregivers identify ways to make exercise more enjoyable and less likely to trigger resistance or agitation. Partnering the person with dementia with an “exercise buddy” other than the caregiver could further minimize the stress that caregivers might experience from trying to implement a regular walking program with their family member. In some cases, non-caregiver helpers may even be more motivated or better able to encourage the individual with dementia to exercise than an immediate family member, as was found by Arkin, 5
who reported 100% compliance to an exercise program that paired community-dwelling AD participants with college students who received college credit for coordinating and supervising exercise activities.
This study did not collect systematic data regarding individual dyads’ life circumstances or physical environment that could influence walking adherence, such as competing caregiver family or work time demands, neighborhood walkability (sidewalks, hills, etc.), or local weather conditions. In follow-up evaluations, caregivers identified several obstacles to walking, including dealing with inclement weather, finding suitable walking routes, caregiver or participant physical limitations, and participant resistance. Some participants and caregivers enthusiastically embraced the walking program, but others did not. Future studies should examine the individualized factors that influence exercise adherence in persons with dementia and caregivers, and strategies that may be effective in overcoming adherence difficulties. Future studies are also needed to determine whether addressing factors associated with walking non-adherence might improve not only exercise participation, but ultimately have a positive impact on other important patient and caregiver outcomes as well.
Results of this investigation should be considered exploratory. The sample size was relatively small and did not provide sufficient power to observe small or moderate effects. Sample size also limited the number of predictor variables that could be examined, and including different variables might have produced different outcomes. For example, we were unable to include all three caregiver management subscales of the DMSS in our analyses, and selected the one that we hypothesized would be most associated with walking adherence. We subsequently tested our choice by rerunning regressions substituting the Criticism and Active Management subscales in place of encouragement. Similar to encouragement, Criticism was not associated with any adherence outcome, but Active Management showed a positive trend for days walked (p = .06), and was significantly associated with number of days walked 30 minutes or more (p = .04). Lastly, subjects enrolled in this study all had physician-confirmed diagnoses of AD or related dementia, but varied widely in level of cognitive impairment, from being newly diagnosed to in very advanced stages of disease. The sample size limited our ability to analyze data separately for persons at different dementia stages, although in the longitudinal analyses there was a trend for persons with less cognitive impairment to walk more minutes per day.
Participating dyads were recruited as part a study examining the treatment of sleep and nocturnal disturbances in persons with dementia. It could be that participants without the burden of co-morbid cognitive impairment and sleep problems would have a different walking response than subjects in the current study. However, our subjects represented a range of ages and pre-morbid level of physical activity typical of community-dwelling persons with dementia. Study trainers were not exercise professionals or physical therapists, but they were experienced in working with older adults with dementia, and their ability to help caregivers and participants problem-solve obstacles that arose with walking programs were comparable or superior to what would be generally available in the community. Caregiver reports and daily logs may also be subject to reporting bias or error, but their use is standard in sleep intervention studies.
In summary, there is a growing literature investigating whether exercise benefits older adults with dementia by slowing cognitive decline, reducing risk for falls and other age-related morbidities, and improving mood and behavior. However, not all persons with dementia are necessarily good candidates for exercise participation. The current study provides preliminary evidence that both participant and caregiver factors may contribute to the ability of community-dwelling individuals with dementia to adhere to a regular exercise routine. Programs or health care providers who wish to encourage their clients to be more physically active should consider these dyadic contributions rather than focusing on participant characteristics alone.