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. 2023 Jun 26;9:23337214231184127. doi: 10.1177/23337214231184127

Effectiveness of Comprehensive Physical Activity Health Promotion Program on the Essential Physical Functions of Older Patients With Multiple Diseases and Dementia in Rural Area

Lain-Li Lin 1, Chih-Chi Liu 2,3,✉
PMCID: PMC10331075  PMID: 37435006

Abstract

Against the backdrop of aging populations worldwide, physical activity programs aimed at promoting the health of older adults have begun to flourish. However, few studies have focused on elderly residents in rural areas who may have multiple comorbidities. Therefore, the current study aimed to investigate the effects of a 12-week physical activity program on health promotion among rural elderly with multiple diseases. The study included 18 elderly participants, with a mean age of 82.39 years, who had dementia and one or more additional diseases. Among the participants, 89% were female. The results showed that the 12-week physical activity program intervention significantly improved participants’ walking speed and range of motion of the arm joints. Based on these findings, it is hoped that this study will provide a reference for future researchers and practitioners targeting rural or elderly populations who may have multiple diseases to develop more comprehensive physical activity programs.

Keywords: physical activity program, older adults, rural area, multiple diseases, dementia

Introduction

Lack of physical activity (PA) or a sedentary lifestyle is one of the causes of global mortality and disability (Boyle et al., 2007; Sanchez-Sanchez et al., 2020), and this includes dementia (Blondell et al., 2014; Nuzum et al., 2020). In addition, there are also multifunctional disabilities such as stroke (C. D. Lee et al., 2003), heart diseases, high blood pressure (LaCroix et al., 2019) and depression (de Oliveira et al., 2019). The symptoms of dementia encompass a wide range of cognitive and behavioral changes, including memory impairment (Mitchell et al., 2014), cognitive decline (Eshkoor et al., 2015), emotional changes (Moyle et al., 2013; Winchester et al., 2013) and language deficiency (Dijkstra et al., 2006) disturbances in perceptual abilities, and, in severe cases, loss of the ability to perform self-care and live independently (Mitseva et al., 2009; Patel et al., 2020).

Although an increasing body of research suggests that a well-designed physical activity program is associated with a reduced risk of dementia symptoms (e.g., de Almeida et al., 2020; Forbes et al., 2008; Kemoun et al., 2010; H. S. Lee et al., 2016), public awareness regarding the benefits of physical activity may still be inadequate and requires further dissemination (Godbey et al., 2010; Marcus et al., 1998), particularly among older adults (Franco et al., 2015) or rural populations (Veluswamy et al., 2014). Considering that dementia primarily affects the elderly population and with the rapid growth of the aging population, the increase in the number of these cases is expected to be significant. As a result, elderly patients with dementia may bring enormous pressure and cost to their families or social resources (Connolly et al., 2014; Wimo et al., 2013). Therefore, solutions to these issues are actively being developed and researched.

In particular, a physical activity program may be a significant contributing factor for individuals who were already diagnosed with dementia. For instance, Bossers et al. (2015) compared the cognitive function changes in dementia patients after a 9-week physical activity intervention versus a social visit intervention in a randomized controlled trial conducted in nursing homes. They found that a combined intervention of aerobic and strength training was more effective in improving cognitive function compared to the social visit intervention for dementia patients. Arcoverde et al. (2014) observed significant improvement in cognitive function in dementia patients through a treadmill-based exercise intervention. Additionally, in a randomized controlled trial by Holthoff et al. (2015), it was found that physical activity intervention was more effective in improving daily physical activity condition of dementia patients compared to standard care. In summary, the current study primarily focuses on the potential contribution of physical activity to improving physical activity levels in older adults with dementia.

Previous research has shown that it is common for elderly individuals with dementia to experience multiple comorbidities, including hypertension, diabetes, hyperthyroidism, heart disease, and degenerative joint disease (Richards & Brayne, 2010; Savva & Stephan, 2010; Skoog, 2000). However, previous research on dementia patients has paid less attention to whether their subjects also suffer from multiple comorbidities (Bunn et al., 2012). In other words, the current study has yet to explore the associations between the various diseases of dementia patients and their overall health, well-being, and quality of care they received (Valderas et al., 2009). In addition, a meta-analysis study has indicated that a comprehensive PA program is more effective than a single type of PA program in promoting the physical health of dementia patients (H. S. Lee et al., 2016). Furthermore, according to H. S. Lee et al. (2016), a comprehensive physical activity (PA) program should go beyond a single type of exercise and encompass both aerobic exercise and muscle training components. Therefore, the current study proposes a comprehensive PA program for elderly dementia patients with multiple comorbidities to examine whether implementing a comprehensive PA program can effectively promote their health.

Furthermore, considering the disparity of resources between urban and rural areas and the higher prevalence of an aging population in rural areas (e.g., Chen et al., 2016; Jensen et al., 2020; Jung et al., 2016; Qu et al., 2012), there is a necessity to allocate greater long-term care opportunities and resources specifically to rural areas.

In particular, the lack of convenient transportation in rural areas may result in older adults being unable to seek medical care or needing to spend longer time for it (Mattson, 2011; Smith et al., 2017). Additionally, the inadequate infrastructure in rural areas may exacerbate the negative consequences of aging, making it more difficult for older adults with multiple comorbidities, declined or impaired basic physical functions to live and receive treatment. In addition, as stated by Moholt et al. (2020), care delivery is more prevalent in urban areas than in rural areas. The above evidence supports the need for researchers and practitioners to pay more attention to the issue of long-term care in rural areas. Therefore, the present study aims to propose a comprehensive PA program targeting the promotion of basic physical functions of older adults with dementia and to implement it in rural areas. This is expected to provide practical contributions to relevant policy-making agencies and elderly care institutions.

Methods

Participant

The participants in this study were recruited from a long-term care institution located in a rural area of Taiwan through convenience sampling. Recruitment criteria include: (1) voluntary and the caregiver (after family or agency assessment) agrees to participate in a 12-week course; (2) having multiple comorbidities and being diagnosed with dementia; (3) non-bedridden. A total of 22 individuals were initially recruited, but four participants did not complete all the measurements, resulting in a final sample of 18 participants. All participants were elderly patients with multiple diseases and were diagnosed with dementia. Additionally, the participants also had other medical conditions, including hypertension, diabetes, hyperthyroidism, cardiovascular disease, prostate hyperplasia, depression, gout, osteoarthritis, osteoporosis, intellectual disability, hyperlipidemia, stroke, and left lower limb artery occlusion, as presented in Table 1 with de-identified basic information. Finally, all voluntary participants in this study are individuals who utilize the daycare service provided by long-term care institutions.

Table 1.

Basic Information of Participants.

Number Gender Age List of diseases the participant suffered from (remark)
1 Female 86 Dementia, Hypertension, Diabetes, Hyperthyroidism
(During walking, the participant is able to walk without the use of assistive devices, but occasionally exhibits unsteady gait. Assistance is required when transitioning from a seated to standing position.)
2 Female 79 Dementia, Hypertension
3 Female 89 Dementia, Hypertension (using assistive devices during walking)
4 Female 77 Dementia, Hypertension, Heart Disease
5 Female 87 Dementia, Hypertension, Neurodegeneration
6 Male 95 Dementia, Hypertension, Heart Disease, Enlarged Prostate, Depression (using a one-handed crutch)
7 Female 84 Dementia, Hypertension, Gout
8 Female 89 Dementia, Hypertension, Diabetes (using assistive devices during walking)
9 Female 69 Dementia, Hypertension, Diabetes, Osteoarthritis, Osteoporosis, Intellectual Disability (using assistive devices during walking)
10 Female 91 Dementia, Hypertension, Diabetes, Hyperlipidemia (using a one-handed crutch)
11 Female 81 Dementia, Hypertension
12 Female 80 Dementia, Hypertension, Depression (using assistive devices during walking)
13 Female 74 Dementia, Heart Disease, Diabetes (using assistive devices during walking)
14 Female 76 Dementia, Hypertension, Stroke (using a one-handed crutch)
15 Female 78 Peripheral artery occlusion (treated), Dementia (using a one-handed crutch)
16 Female 79 Dementia, Hypertension
17 Male 87 Dementia, Hypertension (using a one-handed crutch)
18 Female 82 Dementia, Hypertension
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To ensure anonymity, each participant was assigned a code instead of using their real name, and their participation in the study and data collection was authorized by both the institution and their family. Due to the presence of multiple diseases, each participant required permission from the institution and their family to participate in this study. The current study was approved by the Research Ethics Committee, National Taiwan University (Case number: 202109EM005).

The final sample of 18 participants had a mean age of 82.39 years. The age distribution was as follows: one participant was below 74 years old (69 years old), five participants were aged 75 to 79 years, five participants were aged 80 to 84 years, five participants were aged 85 to 89 years, and two participants were aged 90 years or above. Therefore, individuals aged between 80 and 89 years old comprised 55% of the sample. In addition, 16 participants were female, accounting for 89% of the sample. Finally, all participants included in the study data had moderate or severe dementia.

Design and Procedure

After obtaining consent from all participants (and obtaining institutional and family consent), the researchers held an information session for those who agreed to participate in the study. A 12-week (2 days per week, 1 hr per day) comprehensive exercise training program was implemented starting 2 days after the information session. The content and goals of the program for each week are detailed in Table 2. The comprehensive exercise program was led by a lecturer who holds a master’s degree in sports science and a Ph.D. in adult education, ensuring that the program’s implementation was not only professionally based on sports science but also more suitable for adult learning contexts.

Table 2.

Weekly Schedule of PA Program for Current Research Design.

Week Topic Objectives Supplementary
1 Upper body Stretching exercises Shoulder joint muscle group for upper limb stretching • Take 20 min to do the pre- (post-) test at the first (12th) week.
• It takes about 10 min to complete the subject content of a set of courses, and each course takes about 20 min for step-by-step teaching, about 20 min for the lecturer to lead the practice, and about 10 min for breaks between classes.
• In the weeks of “Review lessons from previous weeks,” the instructor will lead all participants to complete at least one set of lessons in the previous weeks.
• The course content of the current PA program has been recorded as a video and publicly broadcast on the YouTube platform. The reference video materials for each course are listed below:
1. Upper body stretching exercises (https://youtu.be/t0r9BqBVH3A)
2. Lower body stretching exercises (https://youtu.be/9PV0JrqSf0I)
3. Lower extremity strength training (https://youtu.be/vpHWktwQb70)
4. 1 min run (https://youtu.be/IhQkZ3Qvr5c)
5. Water bottle dumbbell (https://youtu.be/QvC47YmyJ7I)
6. Fine motor training for hands (https://youtu.be/Ow8nkiPOGAA)
7. Sports bungee cord (https://www.youtube.com/watch?v=KZ3-nmhS5TQ#t=1m36s)
2 Lower body stretching exercises Relaxing the muscles of the lower limbs
3 Lower extremity strength training Enhance lower extremity muscular strength
4 1 min run Enhance reaction ability and speed ability
5 Review lessons from previous weeks
6 Water bottle dumbbell Enhance upper extremity muscular strength
7 Fine motor training for hands Train the precision of hand movements
8, 9 Review lessons from previous weeks
10, 11 Sports bungee cord Training muscle strength and muscle endurance
12 Review lessons from previous weeks
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Measures

When evaluating physical activity in older adults, clinical practitioners and researchers widely use tests such as gait speed, grip strength, jump test, and walking test (Patrizio et al., 2021). This study aims to improve the basic physical activity function needed for participants’ daily lives, such as moving, carrying objects, and performing simple household chores. Therefore, to better meet the participants’ daily life context, we examined their changes in “6m walk,” “grip strength,” and “range of motion across arm joints” before and after participation in the study. Among them, the 6 m walk was measured in seconds, grip strength was measured separately for the left and right hands in kilograms, and finally, the range of motion of the arm joints was measured in degrees.

Furthermore, the study by Lyons et al. (2015) confirmed the validity of the 6 m walk test in samples of older adults. Additionally, they suggested that excessively long test distances may not be feasible in limited environments, hence opting for shorter courses as they are also effective. Therefore, the current study adopted the 6 m walk as the measurement standard. Furthermore, grip strength in older adults is considered to be strongly associated with cognitive function (Carson, 2018), and arm joint mobility greatly influences the range of motion in older adults (Bains & Askari, 2022). Therefore, these indicators were adopted as measurement variables in the current study.

Data Analysis

The current study involves descriptive statistical analysis and paired-sample t-test analysis. The descriptive statistical analysis will present the mean and standard deviation of participants’ pre-test and post-test scores before participating in the comprehensive PA program. In addition, a paired-sample t-test will be used to examine whether there is a statistically significant difference between participants’ pre-test and post-test scores.

Results

The descriptive statistics and paired-sample t-test results of this study are presented in Table 3. Among them, in the 6 m walking test, the participants’ walking time in the post-test (M = 29.29, SD = 29.79) was significantly shorter than that in the pre-test (M = 32.82, SD = 27.16; t = −3.53, p = .011), indicating an increase in walking speed after participating in the comprehensive PA program. In addition, for the range of motion of the arm joint, the post-test angle was significantly greater than the pre-test angle for both the left hand (t = 21.00, p = .002) and the right hand (t = 13.68, p = .032), indicating an increase in the range of motion of the participants’ arm joints. Finally, there were no statistically significant changes in grip strength for either the left hand (t = 1.36, p = .085) or the right hand (t = 0.67, p = .371) as measured by the grip strength test.

Table 3.

Results of Paired-Sample t-test.

N = 18  Pre-test Post-test
M SD M SD t p-value
6 m Walking Time (s) 32.82 27.16 29.29 29.79 −3.53 .011
Grip strength (left hand) (kg) 10.32 6.44 11.68 5.95 1.36 .085
Grip strength (right hand) (kg) 10.05 5.34 10.71 5.20 0.67 .371
Range of motion across arm joints (left) 48.00 17.05 69.00 15.27 21.00 .002
Range of motion across arm joints (right) 54.74 15.04 68.42 14.53 13.68 .032
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Discussion

Effectiveness of Comprehensive PA Health Promotion Program on Older Patients With Multiple Diseases

The results indicate that the PA program intervention had a significant effect on improving participants’ walking speed and arm joint range of motion, which may be helpful for their daily activities. Firstly, our finding regarding the improvement in walking speed among older adults through the PA program is consistent with previous research (e.g., Falls et al., 2018; Kanwar et al., 2021; Kemoun et al., 2010; Pau et al., 2014). However, previous studies mostly focused on either healthy older adults or older adults with specific diseases, such as Kanwar et al. (2021)’s study, which showed significant effects of the PA program on improving walking speed among healthy older adults, and Kemoun et al. (2010)’s study, which found significant improvement in walking speed among older adults with dementia after participating in a PA program. While few studies have considered whether participants have multiple diseases. However, in the current study, no significant improvement in grip strength was found among participants. Although the mean grip strength score in the post-test was numerically higher than that in the pre-test, it did not pass statistical tests and therefore needs to be interpreted with caution. Finally, due to some limitations, the current study could not discuss each disease separately but still indicates that the PA program may be an effective way to promote the health of this population. Therefore, the current study also provides a program schedule and concise content for future researchers and practitioners to further explore, pointing out a clear direction for future research.

Promoting PA Health Promotion Programs in Long-Term Care Institutions in Rural Areas

Furthermore, the current study participants are all from long-term care facilities in rural areas. Based on past research findings, it can be inferred that there may be some issues with long-term care in rural areas, such as shortages in human resources, inadequate infrastructure, policy issues, and inconvenient transportation (Chuakhamfoo et al., 2020; Radcliff et al., 2022; Zhu & Österle, 2017). In addition, the issues of outflow of the young population and aging population in rural areas may urgently require support for aging-related facilities (Fang et al., 2020). Although the current study cannot provide any analysis of the differences between elderly individuals in urban and rural long-term care facilities Our findings suggest that PA programs may also be effective in rural long-term care. Therefore, the current study suggests that researchers and practitioners focus more resources on promoting the overall health and quality of care of elderly individuals in rural areas. For example, Hsu et al. (2022) designed a portable package for promoting older adults’ health, which allows service providers who are willing to serve rural areas to more easily enter various regions and communities.

Limitations and Conclusion

First, the current study includes some limitations that require careful interpretation of the findings. Firstly, due to the lack of manpower and resources, the current study was not based on a randomized controlled trial (RCT), thus, there was no control group for comparison to determine whether the current PA program is suitable for other study populations, such as the general elderly population. Hence, it is suggested that future research should include a control group in the implementation (such as comparing urban and rural areas or comparing healthy and older adults with multiple comorbidities) to establish that the improvement in participants’ physical health is based on the experimental intervention and not influenced by other potential factors. These potential factors include the person-centered care approach proposed by the authoritative scholar Tom Kitwood, which is currently supported by empirical evidence and emphasizes the use of interactive methods and humanistic ethics, rather than medical interventions in providing care for dementia patients (Kitwood, 1998). In conclusion, it is important to interpret the current research findings cautiously to avoid making erroneous attributions.

Second, the current study only physiological measures were collected, limiting the interpretation of participants’ psychological changes. To obtain more comprehensive empirical results, it is recommended to include psychological variables such as subjective well-being, emotion, or cognition in the measurements.

Last but not least, the current study is limited by the uniqueness of the target population and the challenges encountered in participant recruitment, resulting in a final sample size of only 18 participants. This limitation is crucial to consider in interpreting the statistical analysis results of the current study. Therefore, it is recommended that future research endeavors make every effort to recruit a larger number of participants to enhance statistical power and improve the generalizability of findings.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Research Ethics and Patient Consent: This study was approved by Research Ethics Committee, National Taiwan University with IRB protocol/human subjects approval number 202109EM005.

Data Availability Statement: The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The data are not publicly available due to restrictions their containing information that could compromise the privacy of research participants.

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