Barriers and Facilitators to Exercise Participation Among Frail Older African American Assisted Living Residents

Group exercise in long-term care facilities, alignment with World Health Organization recommendations: a cross-sectional survey

BACKGROUND

Maintaining functional status in institutionalized older people is a challenge for long-term care (LTC) institutions. In this regard, exercise may have positive effects. The World Health Organization (WHO) has issued guidelines which include recommendations of exercise for each population group. Nonetheless, the literature shows that the levels of exercise among institutionalized population are still low.

AIMS

This study sought to determine: (1) the characteristics of exercise programs for older people performed by health professionals in LTC facilities, (2) the knowledge and use of the WHO recommendations and guidelines for exercising among older people in LTC facilities; (3) the limitations identified by health professionals regarding the application of the WHO guidelines.

MATERIALS AND METHODS

A cross-sectional national survey following STROBE guideline was performed.

SAMPLE

professionals developing exercise programs for institutionalized older people. A Delphi study was conducted to create the survey which included sociodemographic data, exercise characteristics, knowledge about WHO recommendations and limitations regarding their application. Descriptive statistics were used on the data, such as Pearson's χ2 and independent t- test.

RESULTS

Many professionals do not know (27,5%) or do not follow (52%) the guidelines proposed by the WHO. There is a low weekly frequency for strength exercises (30%) and aerobic exercise (51%). The professional contract influences the weekly frequency of exercise. Most identified limitations for using the WHO recommendations were the lack of time and large groups.

DISCUSSION AND CONCLUSIONS

Recommendations of WHO guidelines are familiar to many professionals, however, some are difficult to implement in exercise programs in LTC facilities.

Motivation, barriers and preferences of lifestyle changes among older adults with frailty and mild cognitive impairments: A scoping review of qualitative analysis

Lifestyle intervention has proven effective in managing older adults' frailty and mild cognitive impairment issues. What remains unclear is how best to encourage lifestyle changes among older adults with frailty and Mild Cognitive Impairment (MCI). We conducted searches in electronic literature searches such as PubMed, Scopus, Cochrane Reviews, ProQuest, and grey resources to find articles published in English between January 2010 and October 2023. This review focused on research using a qualitative study design. We extracted data on publication year, location, the aim of the study, study population, involved intervention, barriers, motivations, and preferences reported in the articles. Out of 5226 retrieved, 253 articles were selected after the deletion of duplicates, title, abstract screening, and. We included fourteen articles for final analysis at the end of the review process. The two main themes generated from this review are intrinsic and extrinsic factors in motivations and barriers to lifestyle changes. The most reported motivators were the perceived benefits of lifestyle intervention and self-efficacy. Among the obstacles participants face are perceived adverse effects of intervention, lack of knowledge, existing impairment (physical or mental), and social support. Lifestyle change motivations and barriers among older adults mainly were intrinsic factors such as the perceived benefit of the intervention, self-efficacy, knowledge, familial commitment, and existing impairments. There is a need to empower older adults to overcome the barriers with support from healthcare professionals, the community, and the family.

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

Early in our longitudinal qualitative study on meaningful engagement and quality of life among assisted living (AL) residents with dementia, researchers observed differences between the activities scheduled on monthly engagement calendars and those taking place. Yet, we were unable to identify any research examining such deviations or their implications. Thus, drawing on data from three diverse AL communities studied over a one-year period, we aim to: 1) examine deviations in scheduled engagement programming; 2) identify influential factors; and 3) understand resident outcomes. Our analysis identified general adherence to calendars but also deviations involving cancellations and substitutions. Factors influencing deviations included staff and staffing, engagement capacity, programming guidance and support, care staff attitudes and beliefs, and unforeseen circumstances. Cancellations typically meant resident inactivity and sometimes boredom, disappointment, and anxiety; substitutions appear less detrimental. This analysis has implications for research and practice and underscores the significance of engagement among persons living with dementia.

Barriers and Facilitators to Physical Activity Among Older Adults in Residential Aged Care Facilities: A Mixed Methods Systematic Review Using the Social Ecological Model

OBJECTIVE

To ascertain the barriers and facilitators to physical activity (PA) for older adults in Residential Aged Care Facilities (RACFs), from the perspective of residents, staff, and family.

METHODS

A mixed-methods systematic review, underpinned by the Social Ecological Model (SEM). Five databases were searched from inception to May 2024. Data synthesis followed a convergent integrated approach, with relevant quantitative data 'qualitised' and synthesised with qualitative data using thematic synthesis.

RESULTS

This review included 67 studies (40 qualitative, 16 mixed-methods, and 11 quantitative). Thematic synthesis identified 51 key themes (27 facilitators and 24 barriers), spanning all levels of the SEM. Intrapersonal factors (e.g. poor general health) were the most commonly cited barriers (n = 53 studies), and interpersonal factors (e.g. social support) the most commonly reported facilitators (n = 55 studies) to PA in RACFs.

DISCUSSION

An interplay of multi-level factors must be addressed in the development and implementation of strategies to promote PA in RACFs.

The COVID Pandemic Worsened Physical Activity Disproportionately in Frailer Adults: A Canadian Longitudinal Study on Aging

INTRODUCTION

Frailty is associated with increased hospitalization and mortality and may be exacerbated with physical inactivity. The COVID-19 pandemic has heterogeneously impacted peoples' physical activity level, but the impact on the frail population is unclear.

OBJECTIVE

The objective of this study is to test the hypothesis that higher frailty levels were associated with worse changes in physical activity, ability to move around the home, and do housework during the pandemic.

METHODS

We included 23,303 Canadians (age: 69.1 ± 9.5 years, 53% females) who participated in the Canadian Longitudinal Study on Aging COVID-19 Questionnaire study. Frailty prior to the pandemic (follow-up 1: 2015-2018) was measured via 52-item frailty index and grouped into 0.00-0.05, 0.05-0.10, 0.10-0.20, and >0.20 scores. Participants were asked whether they changed their levels of physical activity, ability to move at home, and ability to do housework during the pandemic.

RESULTS

The average frailty level was 0.09 ± 0.06. Compared with the lowest frailty group, participants with frailty levels >0.20 reported worse physical activity (17% vs. 45%), worse ability to move at home (3% vs. 26%), and perform housework (3% vs. 27%). Covariate-adjusted logistic regression models demonstrated that higher frailty level was associated with a greater odds of reporting worse physical activity (reference: 0.00-0.05; odds ratio for frailty index >0.20:4.03, 95% confidence interval [3.33, 4.87]), worse ability to move in home (odds ratio = 11.16, 95% confidence interval [8.28, 15.03]), and worse ability doing housework (odds ratio = 12.58, 95% confidence interval [9.24, 17.13]).

CONCLUSIONS

The adverse changes in physical activity levels and ability to move at home among frail older adults during the pandemic document the need for strategies to help vulnerable populations move more.

Acceptance of physical activity virtual reality games by residents of long-term care facilities: a scoping review

PURPOSE

This scoping review aims to identify evidence on older adults' acceptance of PA VR games in LTC facilities, describe research designs used, define key acceptance concepts, and identify knowledge gaps for future research.

MATERIALS AND METHODS

Following Arksey and O'Malley's framework, data from published and unpublished articles (Jan 2000-May 2023) were collected. Twelve databases and additional sources were searched for studies on LTC residents (≥65 years), PA video games (including VR and console games), acceptance, and attitudes. Data extraction included article details, design, population, intervention, outcomes, and limitations.

RESULTS

Five studies met inclusion criteria from 1628 initial titles. They assessed acceptance of PA VR games among older adults in LTC facilities, showing varying levels of acceptance. Most studies used analytical designs, including RCTs. Key concepts of VR acceptance were poorly defined, with only one study using a validated TAM questionnaire. Knowledge gaps highlight the need for further research to understand PA VR acceptance among older adults in LTC facilities.

CONCLUSION

Validated acceptance questionnaires are needed in study of VR acceptance by older adults. Use of qualitative and quantitative methods can enhance understanding of technology acceptance, alongside exploration of individual, environmental, and age-related factors. Detailed reporting of VR interventions is recommended to comprehend acceptance factors.

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to change PA/SB in older adults living in ALF. Twenty articles representing 15 unique studies were identified from eight electronic databases and grey literature. Residents in ALF spent 96-201 min/day in light PA (n = 2 studies), 1-9.74 min/day in moderate to vigorous PA (n = 2 studies), and 8.5-11.01 hr/day of SB during waking hours (n = 3 studies). Factors associated with PA included 16 personal factors (n = 6 articles), one social factor (n = 2 articles), and two environmental factors (n = 2 articles). Factors associated with SB included 14 personal factors (n = 4 articles) and one social factor (n = 1 article). No intervention successfully changed PA/SB.

Resident and Caregiver Dyads Talk About Death and Dying in Assisted Living: A Typology of Communication Behaviors

BACKGROUND

In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL).

OBJECTIVE

To understand communication behaviors used by AL residents and their informal caregivers (i.e., family members or friends) related to death and dying, and address communication needs or opportunities applicable to EOL care in AL.

DESIGN

A thematic analysis of in-depth interviews and fieldnotes from a subsample of data from a 5-year NIA-funded study.

SETTING/SUBJECTS

Participants included 15 resident-caregiver dyads from three diverse AL communities in Atlanta, Georgia in the U.S.

MEASUREMENTS

Interview transcripts were coded for communication behavior. Concordances and discordances within dyads were examined.

RESULTS

We identified a typology of four dyadic communication behaviors: Talking (i.e., both partners were talking with each other about death), Blocking (i.e., one partner wanted to talk about death but the other did not), Avoiding (i.e., each partner perceived that the other did not want to communicate about death), and Unable (i.e., dyads could not communicate about death because of interpersonal barriers).

CONCLUSIONS

Older residents in AL often want to talk about death but are blocked from doing so by an informal caregiver. Caregivers and AL residents may benefit from training in death communication. Recommendations for improving advance care planning and promoting better EOL communication includes timing these conversations before the opportunity is lost.

Turning It Over to God: African American Assisted Living Residents' End-of-Life Preferences and Advance Care Planning

OBJECTIVES

Assisted living (AL), a popular long-term care setting for older Americans, increasingly is a site for end-of-life care. Although most residents prefer AL to be their final home, relatively little is known about end-of-life preferences and advance care planning, especially among African American residents. Our research addresses this knowledge gap.

METHODS

Informed by grounded theory, we present an analysis of qualitative data collected over 2 years in a 100-bed AL community catering to African American residents. Data consisted of field notes from participant observation conducted during 310 site visits and 818 observation hours, in-depth interviews with 25 residents, and a review of their AL records.

RESULTS

Residents varied in their end-of-life preferences and advance care planning, but united in the belief that God was in control. We identified "Turning it over to God" as an explanatory framework for understanding how this group negotiated end-of-life preferences and advance care planning. Individual-level resident factors (e.g., age, pain, and function) and factors reflecting broader cultural and societal influences, including health literacy and care experiences, were influential.

DISCUSSION

Contradictions arose from turning it over to God, including those between care preferences, planning, and anticipated or actual end-of-life outcomes.

Understanding Capacity and Optimizing Meaningful Engagement among Persons Living with Dementia

Meaningful engagement is a key dimension of quality of life among persons living with dementia, yet little is known about how to best to promote it. Guided by grounded theory methods, we present analysis of data collected over a 1-year period in four diverse assisted living (AL) communities as part of the study, "Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia." Our aims are to: (a) learn how meaningful engagement is negotiated among AL residents with dementia and their care partners; and (b) identify how to create these positive encounters. Researchers followed 33 residents and 100 care partners (formal and informal) and used participant observation, resident record review, and semi-structured interviews. Data analysis identified "engagement capacity" as central to the negotiation of meaningful engagement. We conclude that understanding and optimizing the engagement capacities of residents, care partners, care convoys, and settings, are essential to creating and enhancing meaningful engagement among persons living with dementia.

Physical Activity Programming for Older Adults in Assisted Living: Residents' Perspectives

Decreasing sedentary behavior and increasing light physical activity could promote the maintenance of functional abilities for older adults in assisted living (AL). The purpose of this qualitative study was to gather residents' recommendations about a proposed self-efficacy enhancing intervention to replace sedentary behavior with light physical activity. We interviewed 20 residents (mean age 83.1; 60% women). Topics included their current activities and thoughts about physical activity. We presented the intervention and asked questions to inform its modification. Data were analyzed with content and thematic analysis. Specific recommendations included shorter one-hour sessions and framing the intervention as increasing light physical activity rather than decreasing sedentary behavior. The thematic analysis identified multiple factors that could influence intervention implementation, including motivation to be active, safety concerns, ageist attitudes about physical activity, varying abilities of residents, social influences, and limited opportunities for physical activity. These results will inform physical activity intervention implementation for AL residents.

"You gotta have your cry": Administrator and direct care worker experiences of death in assisted living

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and 38 direct care workers (DCWs) in 7 diverse settings. As assisted living administrators and DCWs experienced resident death, they engaged in a dynamic and individualized process of "managing the normalization of death," which refers to the balance of self-identity and workplace identity. The process of reconciling these opposing contexts in AL involved several individual- and community-level conditions. Administrators and DCWs would benefit from additional resources and training around death. Increasing collaboration with hospice and clarifying policies about death communication would better prepare the workforce to acknowledge the end of life in assisted living.

Assisted Living Administrators' Approaches to Advance Care Planning

OBJECTIVES

This project examined administrator processes, barriers, and facilitators for conducting advance care planning in assisted living.

METHOD

Data from qualitative interviews with 27 administrators from seven diverse assisted living communities in the metropolitan Atlanta area were linked with descriptive and administrative data collected from each site and analyzed using thematic analysis.

RESULTS

Although administrators generally contended with a lack of staff training and stakeholders' reluctance to discuss advance care planning and end-of-life care, important facilitators of advance care planning in some assisted living communities included periodic follow-up discussions of residents' wishes and successfully educating consumers about the importance of planning. Three study communities whose administrators discussed planning with residents and informal caregivers during regular care plan meetings had more advance care planning documents on file.

DISCUSSION

These findings demonstrate the potential for nonmedical organizations, such as assisted living, to successfully promote advance care planning among their members.

Wishes and perceptions about exercise programs in exercising institutionalized older adults living in long-term care institutions: A qualitative study

The level of exercise among older adults is low, particularly among those living in health-care institutions. To gain insight into the perceptions of institutionalized older adults towards the exercise programs developed in long-term care institutions and to identify their wishes and needs regarding these programs, we conducted a qualitative study using focus group discussions. Thirty-six institutionalized participants (≥ 65 years) were recruited. Six common themes emerged: participants' attitudes and motivations towards the exercise programs, self-perceived health, knowledge of the concept of physical exercise, perceived effects of the exercise programs, and wishes or expectations for the exercise programs. The main wishes were to increase frequency of exercise sessions, to exercise outdoor and to increase walking times. The results suggest the need for changes in the development of exercise programs, including changes in the frequency, performance environment and types of exercises performed.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

Given an observed tension between perceived privacy restrictions and meaningful social connection in assisted living (AL) and using a relational perspective, we conducted a secondary thematic analysis of health information sharing practices among residents and their care partners in one large urban AL community in metropolitan Atlanta. Data included in-depth interviews with residents (n = 26), family members (n = 20), AL staff (n = 11), and external care workers (n = 4) as well as ethnographic data from observations and informal conversations conducted with these participants and others. Findings showed that health information sharing among residents was helpful in building social relationships; barriers to this communication contributed to isolation. Inappropriate public exchange of residents' healthcare information hindered building these relationships. Negotiating privacy boundaries for health information sharing was an ongoing confusing process across the community. Based on the findings, we propose new guidelines for health information sharing and additional privacy training for residents and care partners.

Assisted Living Residents with Dementia: Being Out in the World and Negotiating Connections

BACKGROUND AND OBJECTIVES

Persons living with dementia, including long-term care residents, and their care partners emphasize the importance of meaningful engagement and stress the need for activity and opportunities to go outdoors or offsite. Yet, little is known about getting out in this population. Here, our objectives are to: 1) identify residents' opportunities for, and experiences with, getting out; 2) understand the significance of getting out; and 3) explain influential factors.

RESEARCH DESIGN AND METHODS

Guided by grounded theory methods, we analyzed qualitative data collected over a one-year period in four diverse assisted living communities. We followed 33 residents with dementia and their care partners. Data include detailed fieldnotes capturing 1,560 observation hours, 114 interviews with residents (where possible), assisted living staff, family members, and other visitors, and record review.

RESULTS

We identified the centrality of "being out in the world and negotiating connections," which characterizes residents' experiences with the outside world as a process of 'working out' engagement with nature, others, and the community. Being out in the world was consequential to well-being and quality of life. Most residents got out at least occasionally; some lacked opportunities. Among residents who got out, most benefitted from ensuing connections. Yet, not all experiences were positive. Being out in the world varied over time and by individual-, convoy-, AL community-, and neighborhood-level factors.

DISCUSSION AND IMPLICATIONS

We discuss the implications of our findings for research and practice surrounding meaningful engagement among persons with dementia, including during crises such as the pandemic.

Assisted Living: Optimal Person-Environment Fit

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].