Perceptions About Dyadic Physical Activity Intervention for Rural-Dwelling People With Cognitive Impairment

Abstract

Background/Objectives:

Rural populations face an elevated risk of Alzheimer’s disease and related dementias partially attributed to modifiable risk factors such as physical inactivity. The study gathered key community partners’ perspectives about (a) feasibility of implementing the telerehabilitation physical activity behavioral (TPAB) intervention, a virtual program aimed at increasing daily stepping with sensor-based monitoring, and (b) necessary adaptions for implementation for rural-dwelling people with cognitive impairment and care partners (dyads).

Methods:

Eleven rural-dwelling individuals (three medical providers, four older adults, and four care partners of individuals with mild cognitive impairment) in Nebraska were recruited for a focus group via fliers and word of mouth. The person-based approach was used to gain the perspectives of participants during a 1-hr group discussion regarding six dimensions of feasibility. Session transcriptions were analyzed using thematic analysis.

Results:

Participants highlighted the need to improve physical activity in the community and supported care partners receiving TPAB alongside individuals with mild cognitive impairment. Suggested modifications to TPAB included, establishing a local champion, integrating local resources, involving primary care providers, setting recruitment deadlines, using participant testimonies for recruitment, and emphasizing program individualization.

Conclusion:

Overall, participants perceived TPAB was practical, feasible, and necessary for rural-dwelling participants with cognitive impairment and their care partners; however, several adaptations and the creation of the Cognitive Impairment Rural Community—TPAB are required to optimize rural implementation.

Significance/Implications:

There is an identified need for the TPAB intervention with outlined redesign approaches to facilitate intervention development and rural implementation.

Rural populations face a two-fold higher risk of Alzheimer’s disease and related dementias (ADRDs) mortality (Baranowski et al., 2018), the sixth leading cause of death in the United States (Alzheimer’s Association, 2016), compared with metropolitan populations due to disparities in health services access, income, and education (Mattos et al., 2017; Prince et al., 2013). With aging, cognitive decline and physical and functional decline are most feared (Mol et al., 2007; Molden & Maxfield, 2017). Interventions aimed at delaying progressive cognitive decline during the early stages (i.e., mild cognitive impairment [MCI]/early-stage ADRD) can maintain or improve cognition (Oberlin et al., 2022; Schwartz et al., 2019) and result in substantial cost savings. Slowing the progression from MCI to advanced ADRD by 5 years is estimated to save $500,000 in societal costs per patient (Ton et al., 2017; Zissimopoulos et al., 2015).

Even with the new monoclonal antibody treatment (van Dyck et al., 2023), healthy behavior support continues to be a key element of care and risk reduction (Sabbagh et al., 2022). Modifiable risk factors for dementia, including physical activity, remain a key target for prevention (Nianogo et al., 2022). Increasing physical activity to meet activity guidelines (i.e., 150 min of moderate physical activity per week or 75 min of vigorous activity per week) can improve mobility, cognition, and quality of life in individuals with MCI/early-stage dementia (Song et al., 2018) and reduce the risk of further cognitive decline by 35%–45% (Hamer & Chida, 2009; Livingston et al., 2017; Sofi et al., 2011). Physical activity may also support functional health and independence (Morris et al., 2017). Additionally, improving physical activity can reduce caregiver burden (Kim et al., 2023; Law & Kwok, 2019), and enhance physical and mental well-being (Borges-Machado et al., 2023; Kim et al., 2023).

Health disparity research tells us rural adults engage in different physical activity (Althoff et al., 2017; Aronson & Oman, 2004; Meit et al., 2014; Trivedi et al., 2015; Wilcox et al., 2000), and eating patterns (Befort et al., 2012; Trivedi et al., 2015), live in a structurally different environment (Althoff et al., 2017; Braveman, 2006; Trivedi et al., 2015), and face unique challenges including exercise facility access (Aronson & Oman, 2004; Erwin et al., 2010; Trivedi et al., 2015), access and utilization of healthcare services (Bolin et al., 2015; Erwin et al., 2010; Meit et al., 2014; Murimi & Harpel, 2010), access to healthy food (Befort et al., 2012; Trivedi et al., 2015), lower social support (Murimi & Harpel, 2010; Wilcox et al., 2000), and higher rates of chronic disease (Befort et al., 2012; Meit et al., 2014) and obesity (Befort et al., 2012; Meit et al., 2014; Trivedi et al., 2015; Wilcox et al., 2000) than their urban counterparts. Like any structurally inequitable health challenge, interventions to support and increase physical activity for people with cognitive impairment (i.e., MCI/early-stage dementia) living in rural areas must accommodate the unique needs of the population. For rural-dwelling older adults with cognitive impairment (i.e., MCI/early-stage dementia), proven home-based interventions need to be fully redesigned for individuals with cognitive impairment who face additional challenges (e.g., remembering how to perform exercises correctly; Logsdon et al., 2009; Tak et al., 2012). The telerehabilitation physical activity behavioral (TPAB) intervention (Christiansen et al., 2024) may be an ideal approach to enhance daily physical activity in individuals with MCI/early-stage ADRD and care partners. The TPAB is remotely delivered and incorporates seven behavior change techniques—(a) self-monitoring of behavior, (b) action planning, (c) graded tasks, (d) restructuring the physical environment, (e) restructuring the social environment, (f) problem-solving, and (g) prompts and cues—and is accompanied with an electronic workbook detailing the intervention and tables to record goals throughout the intervention. These techniques incorporate the social cognitive theory (Carey et al., 2019) concepts of problem-solving (Nickerson & Shade, 2021), action planning (Park et al., 2019), and motivational interviewing techniques (Schwartz et al., 2019) that individually have improved physical activity in individuals with MCI/early-stage ADRD living in urban areas (Hobson et al., 2019; Nickerson & Shade, 2021; Park et al., 2019; Schwartz et al., 2019).

TPAB’s remote delivery modality holds potential to improve daily stepping for individuals who must contend with disparities in access to health services due to distance or transportation challenges such as those living in rural and frontier areas. Telehealth has been shown to be a feasible and acceptable approach to deliver care and provide greater access to care options to older adults in rural areas (Batsis, DiMilia, et al., 2019; Batsis, Naslund, et al., 2019). Telehealth is also a way to remotely address physical inactivity—a prevalent issue and a modifiable risk factor of ADRD (Di Marco et al., 2014; Kivipelto et al., 2018; Nickerson & Shade, 2021; Vancampfort et al., 2018). In individuals with MCI/early-stage ADRD, increased physical activity is related to greater cognitive performance (Chang, 2020; De la Rosa et al., 2020; Nickerson & Shade, 2021; Petersen et al., 2018; Song et al., 2018; Wang et al., 2021), functional performance (Morris et al., 2017), and slower progression of ADRD pathology (Rabin et al., 2019).

However, TPAB has not been adapted to meet the specific needs of memory loss of rural-dwelling individuals with ADRD that impact the intervention’s physical activity goal setting and follow through components and the inclusion of a care partner for dyadic delivery. The substantial impact of care partners (e.g., spouse, child, and friend) on the outcomes of individuals with cognitive impairment is commonly underestimated and unrecognized. Care partners of individuals with cognitive impairment play a crucial role in the daily routines of individuals with ADRD. Having a care partner has been shown to greatly impact physical health (Holt-Lunstad et al., 2017; Stadler et al., 2012) and behavior change (Berli et al., 2018). Additionally, approaching physical activity from a dyadic perspective (e.g., patient and care partner team) has been suggested as a strategy to maximize health behavior change effectiveness in individuals with cognitive impairment (Burton et al., 1997; Liffiton et al., 2012; Vidoni et al., 2016).

Current health behavior change research largely focuses on metropolitan areas while neglecting rural areas (Branger et al., 2016; Porter et al., 2021; Werts et al., 2023). Research is also lacking on how to remotely promote daily steps in individuals with ADRD and care partner dyads, which is pertinent for those living in rural areas. These factors, along with the disparities in health service access, income, and education rural populations face compared with their metropolitan counterparts (Mattos et al., 2017; Prince et al., 2013) suggest that changes need to be made to the TPAB to best implement it in rural communities.

This study focuses on recommendations to redesign and adapt the TPAB as a dyadic physical activity intervention for rural areas. The purpose of this study was to gather key community partners’ perspectives regarding the TPAB and assess (a) the feasibility of implementing the intervention and (b) determine necessary adaptions in preparation for creating the Cognitive Impairment (CI) Rural Community—TPAB and eventual implementation in rural communities. Seeking input from key partners in the community enhances implementation planning and can foster the sustainable impact of community-based interventions (Essery et al., 2021).

Methods

All study procedures were determined exempt by the Creighton University Institutional Review Board (CU: 2003634–01). Exemption was determined based on data being acquired from adults with no cognitive impairment (self-report) via interviews and all data being deidentified (Category #2 Exemption). Verbal assent was acquired from all focus group participants immediately prior to the focus group discussion.

Focus group discussions were conducted in a rural Nebraska community. Rurality was defined using the U.S. Department of Agriculture Economic Research Service’s Rural-Urban Continuum Codes (Codes, 2014). These codes classify nonmetropolitan areas by their degree of urbanization and location relative to metropolitan areas. These classifications are further divided into six categories based on population size. The focus group discussions were held in a community classified as a nonmetropolitan area with an urban population of 2,500–19,999 people that is not adjacent to a metropolitan area.

A person-based approach was used to evaluate the feasibility and necessary adaptations for the TPAB intervention (Kalmar et al., 2008; Morrison et al., 2018; Yardley et al., 2015). The person-based approach uses a qualitative approach to gain the perspective of individuals who will use or be involved with the intervention. The person-based approach has previously been implemented with medical providers (Arden et al., 2021), care partners (Dale et al., 2018), and older adults (Essery et al., 2021; Lawrence et al., 2019).

Participants

Eleven adults (≥19 years of age) were recruited for 1 month by flier distribution in local primary care clinics and word of mouth in the community. To be considered for enrollment, potential participants needed to self-report having no cognitive impairment and belong to one of the three focus group categories (a) currently practicing medical providers (e.g., physicians, physician assistants, physical therapists, and nurses), (b) community-dwelling older adults (≥65 years of age), or (c) care partners of individuals with mild cognitive impairment. No participants that expressed interest in the study refused to participate. All focus group discussions were held in conference rooms in the community with only research team members and focus group members present. The Nebraska rural-raised focus group leader (R.M.H.) established a connection over the phone with each participant individually to confirm the focus group time/date and to identify the importance of rural health embedded within the study purpose.

Focus Group Discussions

Three 1-hr focus groups were conducted: (a) currently practicing rural medical providers, (b) community-dwelling older adults, and (c) care partners of individuals with mild cognitive impairment. No repeat interviews were carried out. Before the focus group discussion, each participant was provided a copy of the physical activity behavioral intervention workbook. This workbook detailed the use of technology (i.e., Fitbit app for monitoring daily steps and Zoom for intervention sessions), goal setting and action planning documentation, a weekly intervention session outline, and weekly charts for prospective participants to track progress across the 12-week intervention.

At the start of each focus group discussion, a short presentation was delivered by the focus group leader (R.M.H.) to provide additional details on TPAB. Community was defined geographically as the town and surrounding area highlighting the importance of individuals dwelling and interacting in close proximity to each other. The focus group leader was a female with a clinical doctorate in physical therapy (i.e., DPT) and a research doctorate (i.e., PhD) with expertise in older adult rehabilitation and physical activity promotion. Following the presentation, six dimensions were explored during each focus group discussion to comprehensively gain the perspectives of the participants. The six dimensions used to determine the intervention’s feasibility were demand, implementation, practicality, acceptability, adaptation, and integration (Table 1; Bowen et al., 2009). Participants were guided by the focus group questions (Table 1) but not confined to only these areas, allowing for reflection and adaptation recommendations spanning several areas (e.g., program length, delivery, components, and activity goals). During the sessions, a research team member took analytic memos and initially identified the main ideas and themes suggested by the focus group members. Each focus group discussion was audio recorded using a digital voice recorder.

Table 1.

Focus Group Discussion Feasibility Dimensions and Questions

Feasibility dimension	Definition	Focus group discussion questions
Demand	Identifying and meeting the perceived need to improve the health and well-being of individuals with MCI, care partners, and the individuals they may impact in the community.	How is physical activity important to this community? Is there a need to improve physical activity in this community?
Implementation	How the intervention could be fully executed within the community by examining the identification of prospective patients with MCI and care partners, carrying out the study protocol (remote testing sessions and intervention delivery), and notifying the community of the study results.	Could this study be successful in this community with its current structure? If not, what needs to be changed? How could we best identify dyads that would be eligible for the study? What would be helpful to motivate dyads to stay in the intervention the full 12 weeks? What technology barriers do you foresee?
Practicality	The perceived costs (i.e., time and money) of the intervention study.	Is the amount of participant time to be in the study and reimbursement seem feasible? Why or why not?
Acceptability	The appropriateness and perceived subjective satisfaction of the community with the intervention.	How well received would this study be in the community?
Adaptation	The necessary modification(s) to accommodate the project implementation in the community.	What needs to be changed to make this study project and intervention better for this community?
Integration	The evaluation of postintervention skills to maintain and/or improve physical activity after enrollment in the study has been completed.	How will participating in this study positively impact this community? How can we prolong the positive impact of this study on the community?

Note. MCI = mild cognitive impairment.

Data Processing and Analysis

A research team member (B.R.M.) transcribed the audio recordings while removing personal identifying information. Finalized transcriptions were imported to the qualitative data analysis software (ATLAS.ti Scientific Software Development GmbH, version 5.21.1). Transcriptions were not returned to participants for review. Thematic analysis with consensus coding was used to identify common themes across the transcripts (Braun & Clarke, 2006). A combination of deductive and inductive analysis was used. The deductive approach was used to initially develop a code book according to the six feasibility dimensions. The transcripts were initially coded according to the developed code book, and then, an inductive approach was used to identify new codes/categories being added/collapsed as additional transcripts were reviewed. Consensus coding approaches were applied with independent coding of transcripts by two research team members (R.M.H. and B.R.M.) and regular meetings to discuss and resolve differences in the application of codes. Trustworthiness in the data collection and analysis followed the key principles of credibility, confirmability, dependability, and transferability (Lincoln & Guba, 1985). Credibility was enhanced by triangulation of information from transcripts, written notes, and consensus coding noted above. Confirmability was evident from thorough documentation of analytical decisions and transcript interpretation by the first author (Saldaña, 2021). Dependability and transferability of the study findings to other contexts was enhanced by review and discussion with community members outside of the study team or participant pool. Categories of concepts and common themes were extracted, and example quotes were generated during the analysis process. Participants were not contacted to provide feedback on the findings. Data saturation was reached when no new information was generated from additional interviews.

Results

There Is a Demand to Improve Physical Activity in Rural Communities

Participants identified that there is a need and desire in the community to improve physical activity: “I think there’s always a need to improve physical activity. I think we have set people that are very into it and you’re always gonna have some that could benefit from more. So, I think programs like this would be great to maybe try to get more people involved.” Participants highlighted how the demand is supported by the establishment of a YMCA, and two major parks, with walking paths in this small rural community. Participants highlighted the gap in knowing physical activity is important with limitations in performing physical activity, “It’s important, but how many actually do it is different.” The care partners’ focus group also highlighted the importance and demand for the dyadic design of the intervention: “I really like the idea of partnering with your care partner that you’ve got some accountability with.” Another confirmed that: “Doing it [TPAB] with a person that they trust and somebody that they care about. I think that makes a big difference.”

Implementation Is Possible With Problem-Solving Unique Barriers

For intervention recruitment and adherence, participants in the care partner and community-dwelling focus groups highlighted how word of mouth (e.g., in social groups and local testimonies) and support from the primary care providers would strongly encourage individuals to participate. Participants in the medical providers’ focus group discussed how they thought the program was important and feasible to promote for study recruitment: “We would really like them [patients with cognitive impairment] to continue to do physical activity after discharge … this [program] is a good segway to keep active for more long term.” Additionally, medical providers mentioned it would be helpful to flag in the medical chart that individuals are in this program for follow-up during routine appointments.

For intervention implementation, participants highlighted the resources in the community to enhance the intervention implementation: “the auditorium and museum allow a lot of people to come and walk.” Several participants mentioned resources to facilitate intervention delivery, such as the use of Wi-Fi at several local locations if participants did not have Wi-Fi in their homes, and a local champion to problem-solve technology issues: “People could come to the library, Senior Center, or the community college for Wi-Fi access to do the program.” Barriers to implementation included individuals with MCI/early-stage ADRD that may not have a care partner and would not be eligible to enroll in the study. To reduce dropout during the program, all participants recommended self-reflection on benefits, maximizing physical activity enjoyable, and establishing a local champion to provide additional encouragement.

Barriers to study implementation included privacy surrounding a MCI/early-stage ADRD diagnosis. One care partner asserted, “It always seems like dementia and Alzheimer’s are such a taboo subject and people don’t want to talk about or think about it. I feel there’s a lot of self-denial and family denial.” Care partners mentioned reduced encouragement to leave the home and be active following the COVID-19 pandemic, “Some are afraid to leave home and are stuck in that mindset of it’s just easier to stay home now because they did it for three years.” Across all participants, the seasonal effects on physical activity were viewed as a barrier (i.e., less activity in winter months compared with spring/summer).

The Program Is Practical Considering the Time Commitment and Reimbursement

All participants thought the time commitment to be in the program and the reimbursement ($30 gift card per person at the beginning and end of participation), including getting a Fitbit wearable tracker, was very reasonable and motivating: “And Fitbit you know that’s big deal. I think you give people that and that is a huge motivator. They gave me this deal I better use it.” Additionally, participants thought the program could be sustained once the project period was over, given the use of personally owned technology to track physical activity (i.e., smartwatches and cell-phone) and leveraging social connections in the community for motivation to be physically active.

The Rural Community Is Accepting of the Program Especially if Recommended by Their Medical Provider

Most participants agreed that the intervention would be readily accepted in the community especially if their medical provider encouraged it. One care partner explained: “I think it would be accepted very well if they just hear it from their provider, or their physical therapist, or their kid. Their kids or spouse can get on them for doing this but if they’re hearing it from a lot of different people in general, they’re more apt to do it.” Medical providers commented that some eligible individuals with MCI/early-stage ADRD may be embarrassed of having cognitive impairment that would negatively impact acceptability in the community.

Several Adaptations Are Needed for Optimal Implementation

Across the focus group discussions, several modifications were identified to enhance implementation. Examples of modifications for feasibility of recruitment and adherence included: (a) establishing a local champion/facilitator to reinforce the remotely delivered intervention concepts: “Finding a champion that could meet with them [study participants] face to face I think would be a big benefit in a rural area,” (b) having deadlines for recruitment windows to motivate interested individuals to be enrolled: “I think having time deadlines motivates people who otherwise procrastinate,” (c) using community members that have gone through the program to share their feedback and recruit other members: “Showing evidence of positive outcomes from people in the community would help get buy in,” (d) have a part of the program focused on current participants inviting others to join for enhanced social support for the study recruitment: “I could see where a couple of women are doing this together and they’re talking to their friends and then the group grows to eight women walking. I mean that’s just how a small town is, so different than a big city,” (e) primary care provider communicating support and encouragement for the study: “I feel like if the program is encouraged by providers it will take encouragement from your research team because you know older patients are always trying to please them [medical providers],” (f) emphasizing how the program is tailored for each participant to enhance recruitment: “Modification for each person is important because some levels of exercise may be possible for some people but impossible for others,” and (g) understanding and incorporating local resources during the intervention: “Using resources like the Y that already encourages a lot of people to be active whether the weather is good or bad would be great to include with the program.”

Rural Communities Have Unique Strengths to Integrate, Raise Awareness, and Sustain Programming

Participants across all focus groups shared that having a program like this draws attention to the importance of cognitive health and physical activity to enhance the lives of members of the rural community beyond those specifically involved in the program. All focus groups mentioned sustainability may be easier in small communities due to greater connectedness. For example, a community-dwelling older adult explained, “If three days a week three couples meet at the Y, or somewhere to walk, there is power in the group and network. There’s more peer pressure and wanting to succeed and a sense of community. I think if you can exercise and have a purpose in it that’s really where you want to be.” Additionally, it gives individuals with MCI/early-stage ADRD something positive to do, “In the mild stages of cognitive impairment they feel like there’s just so much that they can’t do about the situation. This is something they can do and is encouraging.” Participants also expanded on the possible benefits to health, such as sleep quality, emotional health, and weight loss. Medical providers additionally suggested the intervention was critical to reduce the risk progression of cognitive impairment and for additional health benefits (i.e., lower risk of comorbidities, anxiety, and depression).

Discussion

The perspectives of the focus groups support that TPAB can be feasible for implementation in rural areas, contingent upon the adaptations and creation of the CI Rural Community–TPAB. Overall, the focus group discussions favored the inclusion of a care partner in the intervention delivery and the need to increase physical activity to reduce cognitive and functional decline in the community. However, there were several adaptations (i.e., establishing a local champion, using recruitment windows to enhance study enrollment, adding community members to the recruitment team, program endorsement by primary care providers, and program individualization) recommended to enhance implementation.

The focus groups suggested that implementing a 12-week remotely delivered intervention to improve daily stepping of individuals with ADRD and care partners would be feasible. The remote delivery of the intervention was positively received by the focus groups. Remote delivery of a physical activity intervention to rural areas has been successful in other work as well. For example, a small telehealth-delivered exercise program (4 weeks aerobic exercise program) delivered to two Rural and Remote Memory Clinic patients and caregiver dyads in Saskatchewan, Canada was found to have high attendance and acceptability (Dal Bello-Haas et al., 2014). A 12-week aerobic exercise telerehabilitation program in persons with subjective cognitive decline (not dyads) living in rural northern Minnesota determined preliminary feasibility of intervention implementation with noted 0% dropout rate, 85% adherence to the exercise protocol during each session, and cost saving of nearly half of the cost per person compared with in-person training (remote training: $1,001, in-person training: $1,860; Salisbury et al., 2023).

Many of the modifications recommended by our focus group participants are evidence-based techniques that have improved the implementation of other physical activity interventions. A review of 38 physical activity/exercise interventions including home-based walking lifestyle interventions (Carroll et al., 2011) determined successful recruitment and retention strategies, specifically in primary care and community settings for underserved populations. The primary modification brought up by the focus groups was the establishment of a local champion/liaison/facilitator to overcome the distance barrier between the research team and participants. Establishing a local champion not only helps create relationships within the community, but also offers someone who can assist with recruitment, and foster sustainable change (Taylor-Piliae & Froelicher, 2007). Having the local champion trained in the intervention purpose and techniques creates a bridge from the study staff to the community, allowing the research team to monthly discuss issues and problem-solving strategies (Carroll et al., 2011) to optimize the delivery of the intervention, study recruitment, and to reduce study attrition. The focus groups also identified the need to incorporate local resources. Many of the studies reviewed (Carroll et al., 2011) took place in community recreation centers, churches, primary care clinics, fitness clubs, or schools and using these spaces exhibited increased retention due to the familiarity and easy access of the settings to the participants (Taylor-Piliae & Froelicher, 2007).

The focus groups also recommended primary care providers communicating support and encouragement of the study. The primary care providers were identified as key, trusted members of the community who can influence recruitment efforts. The use of respected community leaders to appeal to participants is a proven technique used to enhance recruitment (Carroll et al., 2011; Taylor-Piliae & Froelicher, 2007). Further, primary care providers are a trusted source for underserved and underrepresented populations, as they often care for entire families (Carroll et al., 2011). Primary care providers could be the local champion if willing to commit to monthly contact and discussion with the research team.

Additionally, the focus group discussions highlighted the benefit of emphasizing TPAB’s structure to allow personalization and individual modifications. Tailoring programs to fit individual needs (physically, mentally, and culturally) and providing personalization enhance research recruitment and retention (Carroll et al., 2011; Taylor-Piliae & Froelicher, 2007). Along with individualization, the timing of recruitment and creating recruitment windows/deadlines was recommended by our focus groups. Properly timing the start of the intervention is a technique that has appeared to increase retention (Taylor-Piliae & Froelicher, 2007). The last modification mentioned by the focus groups was using people who have gone through the intervention to share feedback and recruit other people. Social networking and word-of-mouth were pinpointed as efficient and effective forms of recruitment in numerous studies (Carroll et al., 2011). The similarities between the modifications generated in the focus group discussions and the successful techniques identified in the study (Carroll et al., 2011) are promising; however, more research is necessary in these areas as there is a limited number of dyadic rural interventions. A future study making the modifications suggested by the focus groups would help address this issue.

Issues not directly addressed by the focus groups, but which likely need further development based on similar physical activity programs in the context of dementia, include specialized motivational strategies and messaging, safety, and structured support. Prior physical activity and behavioral support interventions such as the Reducing Disability in Alzheimer’s Disease (Menne et al., 2014; Perales-Puchalt et al., 2021; Teri et al., 2003) have relied on dyadic caregiver support and in-person assistance. Included in the Reducing Disability in Alzheimer’s Disease is pragmatic consideration for adapting the home environment for safe physical activity and for using physical activity as structured time to support the interpersonal interactions of the person with dementia and care partner, for example, treating exercise time together as a routine, healthy, dependable, and structured time in which a care partner does not need to create additional activities for the person they care for. Additionally, our team will need to consider barriers not raised by the focus groups, such as reduced internet connectivity/cellular reception, that may a greater barrier for some rural regions compared with others. Lastly, the caregiver’s time demands to participate in the program may be a barrier.

The fully remote delivery of TPAB provides additional opportunity to reach individuals in rural and frontier communities, beyond some of the in-person support limitations of interventions such as Reducing Disability in Alzheimer’s Disease. This project focused on the perspectives of the care partners of people living with MCI. In the next project phase, the focus groups will include the voices of the people living with MCI to maximize each dyad members voices and finally will progress to looking at people with MCI and care partners voices together in a third phase. Data will be compiled, and an advisory board formed to adapt the CI Rural Community–TPAB, addressing the needs of care partners and understanding the perspectives of individuals with MCI to support safe in-home and community exercise and monitor improvements.

Conclusions

In conclusion, the focus group participants perceived the TPAB was practical, feasible, and necessary for rural-dwelling participants; however, adaptations and the creation of the CI Rural Community—TPAB is required for future implementation in rural communities. The modifications suggested have been successful in other physical activity and exercise studies. Ideally, the recommended adaptations should be incorporated into the intervention design through collaborative input with rural community partners. Overall, remotely delivered physical activity interventions to rural-dwelling individuals with cognitive impairment and their care partners should strategize ways to connect with the community during the program (e.g., local champion/facilitator) to address demands with a implementable approach.

Key Points.

• Rural-dwelling participants identified a community need to increase physical activity of individuals with cognitive impairment and care partners.

• Adaptations were recommended to redesign the intervention and enhance rural implementation.