Effects of the MEP on ADL performance
The primary aim of this paper was to investigate the influence of a 16-week multimodal exercise program on ADL performance in IWD. We did not observe any significant time-group effects (η
p2: 0.004–0.019) of the 16-week MEP on ADL performance in IWD. Therefore, we could not confirm our hypothesis that participants of the MEP improved their ADL performance compared to the CG. Previous studies that investigated the effects of PE on ADL performance in IWD living in nursing homes yielded heterogeneous results. While some studies did not find any significant effects (Henskens, Nauta, Drost, & Scherder,
2018; Lamb et al.,
2018), others found a slowed deterioration of ADL compared to a control group (Bürge et al.,
2017; Littbrand, Lundin-Olsson, Gustafson, & Rosendahl,
2009; Rolland et al.,
2007; Toots et al.,
2016) or positive effects of PE on ADL performance (Bossers et al.,
2016). Nevertheless, all these studies differed in terms of sample characteristics, setting, intervention period and intervention content, hampering a comparison and a critical handling with these findings is thus recommended (Forbes et al.,
2015). Studies that yielded positive effects had longer intervention periods, higher training frequency, smaller groups or one-to-one sessions, and/or an adaption of intensity of exercise content during the intervention. We could not reach our aim to increase intensity throughout the intervention, which may be a main reason for our non-significant results. Moreover, even though two training sessions are recommended for nursing home residents (de Souto Barreto et al.,
2016), this was feasible for our sample but might not have been sufficient. Furthermore, the baseline differences in walking-aid use were not further addressed within our analysis, but may have influenced the intensity adaption throughout our intervention period. Instructing a group in which some IWD use walking aids and others do not may have complicated the implementation of intensity adaptions, especially with regard to ensuring the safety of the participants. These mentioned challenges underline the difficulty to adapt exercise intensities in a highly heterogeneous sample.
Another reason for our non-significant results may be the high variability of ADL performance that was also reported in a previous study (Bürge et al.,
2017). Moreover, even though the BI, E‑ADL and PPT‑7 were used in other studies with IWD before, it must be noted that they may not be specific enough to detect subtle changes in ADL performance in IWD. The sensitivity of the BI and its objectivity in assessing ADL performance of IWD living in nursing homes must be seen critical (Yi et al.,
2020). Nevertheless, we decided to use the BI as a proxy-based evaluation tool, and to include an external assessment in addition to the performance-based tests as they may have been influenced by daily form or mood of the participants. However, we are aware that the BI may not have captured the effects of our MEP. Moreover, the E‑ADL was rated as too easy for individuals with mild dementia (Luttenberger et al.,
2012). Originally, the PPT‑7 was not developed for IWD and therefore may not be feasible to detect small changes from baseline to post measurement as in our study. Nevertheless, previous longitudinal studies showed that ADL performance of IWD residing in long-term care facilities deteriorates over time (Johansen et al.,
2020). Therefore, a small improvement or even maintenance of ADL performance over time could be a valuable outcome.
Indeed, our explorative responder-analysis revealed between 20.2 and 31.7% positive-responders with regard to ADL performance in the IG. Nevertheless, the majority of the participants did not respond to the MEP (i.e., non‑R, between 50 and 68%). We observed worse motor performance (balance, mobility, and lower limb function) in positive‑R compared to non‑R. These results imply that the intensity of our MEP worked well for individuals with weak baseline performance. From a training science point of view, it is crucial to individually modify intensity of interventions in order to achieve an improvement (Bürge et al.,
2017; Littbrand et al.,
2009; Littbrand, Stenvall, & Rosendahl,
2011). Originally, our MEP was designed to be carried out with increases of intensity of PE to achieve adaptions in participants of the IG. Due to the high heterogeneity of our sample in terms of disease severity, age, and other personal characteristics, we had to intensify our safety efforts and the majority of exercises were carried out while participants were seated. This resulted in lower training stimuli and may be one explanation as to why less performance adaptions might have been achieved. This consideration is supported by the fact that previous research found positive effects of PE on ADL performance when PE was provided in one-to-one guided sessions (Bossers et al.,
2016). Therefore, more person-centered approaches considering individual skills and impairments may be warranted (Prizer & Zimmerman,
2018) and an individualization of instructions depending on the degree of cognitive impairment may be also useful. These factors underline the need for individualized MEPs tailored to the specific needs of an IWD in order to impact physical performance and cognitive function. Indeed, the concept of individualized medicine which has already become popular in prevention and treatment of Alzheimer’s disease (Hampel et al.,
2017) is also transferable to the design and conduct of individualized exercise programs for IWD (Müllers et al.,
2019). Of note, the feasibility of individualized exercise programs for IWD in nursing homes has to be discussed, as time available for PE programs in geriatric care settings is often limited. Organizational and structural aspects from both nursing homes and health care systems could support and facilitate the implementation of PE interventions in nursing homes (e.g., by engaging volunteers) (de Souto Barreto et al.,
2016). While previous studies have shown the cost-effectiveness of PE interventions for IWD in community settings (Nickel, Barth, & Kolominsky-Rabas,
2018), the evaluation of costs and personal resources in nursing homes is lacking to date. One may only speculate that individualized PE interventions may require more personal resources at first, but save financial and personal resources in the long-term if they are effective. Mobile health applications may therefore be an effective and efficient possible solution in the implementation of individualized exercise programs in IWD (Barisch-Fritz et al.,
2020). In detail, they may represent an easy to administer tool that could support nursing home staff, while conducting PE interventions with information on exercises, training plans, possible risk factors or required training material. Furthermore, mobile health applications offer the opportunity to individually adapt PE programs for example by integrating data-based or artificial intelligence algorithms (Helbostad et al.,
2017). Of note, the monitoring of exercise intensity may be a further advantage of mobile health applications. Previous research used and recommended a combination of heart-rate monitoring and rating of perceived exertion (Sanders et al.,
2020), but this was mainly done by research assistants and may be too time-consuming for nursing home staff. For a feasible and applicable monitoring of exercise intensity in IWD, a protocol of exercise repetitions or exercise time, as well as externally rated exertion by nursing home staff could be implemented in a mobile health application. Despite all these advantages and possibilities of mobile health interventions, studies examining their usability and feasibility of in nursing homes are sparse (Barisch-Fritz et al.,
2020).
Our MEP was originally designed to primarily improve cognitive function and motor performance (Barisch-Fritz et al.,
2021; Trautwein et al.,
2020), and to address ADL performance indirectly. PE interventions which include ADL-specific tasks and take into account the complex requirements of ADL performance could be more effective. Therefore, we investigated the underlying mechanisms of ADL performance using multiple regression analysis. Explained variance ranged from 2.4% (E-ADL) to 51.4% (PPT-7) with statistically significant coefficients for both cognitive function and motor performance. The small explanation of variance in E‑ADL was expected, as the test contains tasks for upper extremities that were not captured with our assessment battery (Graessel et al.,
2009). Nevertheless, our results may contribute to a deeper understanding of different sub-dimensions of ADL performance. If relevant cognitive and motor functions are carefully selected for the conceptualization of PE interventions, potential transfer effects on ADL performance could be more beneficial (Hagovska & Nagyova,
2017). Our results showed that assessments for balance and mobility explained the variance in the BI. For the performance of the PPT‑7, walking speed, lower limb strength, and memory were additionally important. These results are partly in line with previous studies (Garcia-Pinillos, Cozar-Barba, Munoz-Jimenez, Soto-Hermoso, & Latorre-Roman,
2016; Portegijs, Rantakokko, Viljanen, Sipilä, & Rantanen,
2016). However, beyond cognitive function and motor performance, other factors like having depression or feeling pain during specific tasks of daily life (e.g., sit-to-stand transfers) may influence ADL performance in IWD (Mlinac & Feng,
2016) and should be considered in the conceptualization of PE interventions.
Strengths and limitations
The strengths of our study are the high methodological quality and the large sample size. Furthermore, we implemented a MEP that was based on theoretical considerations and proved to be feasible conducted in a sample of IWD living in nursing homes within a pilot study. In addition, we designed the MEP to be highly suitable in everyday life of nursing homes. Our previously assumed dropout rate was lower than expected which may be an indicator for the acceptability of the MEP in the participating nursing homes. Indeed, after the conclusion of our intervention study, many of the 36 participating nursing homes continued the MEP and we received positive feedback from nursing home staff and participants. Furthermore, nursing staff received special training to continue the MEP following the intervention study. This training included information on how to adapt intensity level during exercise sessions when needed. Another strength of the study was the comprehensive acquisition of ADL performance using one proxy-based questionnaire, and two performance-based assessments.
Nevertheless, our study has some limitations that must be considered when interpreting the results. First, we did not reach the intended sample size of 405 IWD because the number of participants that did not fulfill our inclusion criteria was higher than expected. However, a sensitivity analysis (G*Power 3, Version 3.1.9.2) showed that we were still able to detect small to medium effects. Second, our intervention program was initially designed with adjustments of exercise intensity during the 16-week intervention period. However, due to the high heterogeneity of individual characteristics of our study participants such as age or disease severity, we had to increase our safety efforts and could possibly not achieve an adequate training stimulus for all participants. Moreover, the theoretical recommendation of two training sessions per week (de Souto Barreto et al.,
2016) was only partially feasible within our study. Hence, we strongly recommend including strategies to support adherence as proposed by van der Wardt et al. (
2017). Another factor that may limit our findings is that we did not control for any other interventions that might have taken place during the conduct of our study in the IG no CG. Therefore, we cannot rule out that other social or therapeutic interventions may have biased our results. Another limitation is related to the number of incomplete data sets which reduced the sample size for statistical analysis in the per protocol analysis. Especially the BI as a proxy-based measurement filled in by nursing home staff was less often completed than the other assessments carried out by our study staff. Other reasons for incomplete data sets may be daily form and mood, depressive symptoms, other severe impairments or schedule conflicts. As we did not assess depressive symptoms with an evaluated assessment tool, we were not able to make assumptions about the possible influence of depression on ADL performance. Finally, our study did not include a follow-up assessment or a long-term monitoring of the continuation of the MEP in the participating nursing homes, so we do not have any results about the long-term effects of our intervention.