BACKGROUND & AIMS: Evidence suggests that targeted exercise is important for people living with dementia. The aim of this review was to collect and synthesize evidence on the known barriers and facilitators to adherence to walking group exercise of older people living with dementia in the community. METHODS: We have searched appropriate electronic databases between January 1990 until September 2019, in any language. Additionally, we searched trial registries (clinicaltrial.gov and WHO ICTRP) for ongoing studies. We included all study designs. Studies were excluded when participants were either healthy older people or people suffering from dementia but living in residential care. Narrative synthesis was used. FINDINGS: 10 papers met the inclusion criteria. The narrative analysis focused on barriers, facilitators, and adherence. All studies reported on barriers and facilitators. Barriers included: bio-medical reasons (including mental wellbeing and physical ability); relationship dynamics; and socio-economic reasons and environmental issues. Facilitators included: bio-medical benefits & benefits related to physical ability; staff, group relationship dynamics and social aspect of walking group; environmental issues and individual tailoring; and participants perceptions about the walks & the program. Most studies did not provide data about adherence or attendance; where reported, adherence ranged from 47 to 89%. CONCLUSIONS: This systematic review of literature has highlighted known barriers and facilitators to adherence to walking groups type of exercise for people living with dementia in community. Carers' willingness to engage, their circumstances, perspectives and previous experiences of exercise seem to play a key role in facilitating adherence but there is little research that explores these. Also, the design, location and organisation of walking groups facilitate adherence. This reflects the need for such activities to be part of a wider 'program of care', tailored to the needs of the individual, flexible and convenient. Knowledgeable and well-trained instructors or healthcare professionals are recommended as group exercise leaders.

Faculty of Physical Education and Sport Charles University Prague Czech Republic

Faculty of Wellbeing Education and Language Studies The Open University Milton Keynes MK7 6AA UK

Institute for Health Research University of Bedfordshire Bedford UK

See more in PubMed

Woodcock J, Franco OH, Orsini N, Roberts I. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol. 2011;40(1):121–138. PubMed

Olanrewaju O, Kelly S, Cowan A, Brayne C, Lafortune L. Physical activity in community dwelling older people: a systematic review of reviews of interventions and context. PLoS One. 2016;11:12. PubMed PMC

Perri MG, Anton SD, Durning PE, Ketterson TU, Sydeman SJ, Berlant NE, Kanasky WF, Jr, Newton RL, Jr, Limacher MC, Martin AD. Adherence to exercise prescriptions: effects of prescribing moderate versus higher levels of intensity and frequency. Health Psychol. 2002;21:452–458. PubMed

Cedervall Y, Torres S, Aberg AC. Maintaining well-being and selfhood through physical activity: experiences of people with mild Alzheimer’s disease. Ageing Ment Health. 2015;19(8):679–688. PubMed

McDuff J, Phinney A. Walking with meaning: subjective experiences of physical activity in dementia. Glob Qual Nurs Res. 2015. 10.1177/2333393615605116. PubMed PMC

Duggan S, Blackman T, Martyr A, Van Schaik P. The impact of early dementia on outdoor life: a ‘shrinking world’? Dementia. 2008;7(2):191–204.

Cook M. Forests as places of mental well-being for people with dementia. Forestry Commission Research note: UK; 2015.

Mapes N, Milton S, Nicholls V, Williamson T. Is it Nice outside? - consulting people living with dementia and carers about engaging with the natural environment. Natural England Commissioned Reports: UK; 2016.

Gage H, Cheynel J, Williams P, Mitchell K, Stinton C, Katz J, Holland C, Sheehan B. Service utilization and family support of people with dementia: a cohort study in England. Int J Geriatr Psychiatry. 2014;30(2):166–177. PubMed

Phinney A, Chaudhury H, O’Connor D. Doing as much as I can do: the meaning of activity for persons with dementia. Aging Ment Health. 2007;11:384–393. PubMed

Gibson G, Chalfont GE, Clarke PD, Torrington JM, Sixsmith AJ. Housing and connection to nature for people with dementia: findings from the INDEPENDENT project. J Hous Elder. 2007;21:55–72.

Mapes N, Hine R. Research project: living with dementia and connecting with nature—looking back and stepping forwards (exploring the benefits of green exercise with people living with dementia) 2011.

Olsson A, Lampic C, Skovdahl K, Engström M. Persons with early-stage dementia reflect on being outdoors: a repeated interview study. Aging Ment Health. 2013;17:793–800. PubMed

Who is considered a carer? NHS England. https://www.england.nhs.uk/commissioning/comm-carers/carers. Accessed 13 July 2020.

Chong TW, Doyle CJ, Cyarto EV, Cox KL, Ellis KA, Ames D, Lautenschlager NT. Physical activity program preferences and perspectives of older adults with and without cognitive impairment. Asia Pac Psychiatry. 2012;6:179–190. PubMed

Meads C, Exley J. A systematic review of group walking in physically healthy people to promote physical activity. Int J Technol Assess Health Care. 2018;34(1):27–37. PubMed

Kassavou A, Turner A, French DP. Do interventions to promote walking in groups increase physical activity? A meta-analysis. Int J Behav Nutr Phys Act. 2013;10(18); doi: 10.1186/1479-5868-10-18. PubMed PMC

Van der Wardt V, Hancox J, Gondek D, Logan P, das Nair R, Pollock K, Harwood R. Adherence support strategies for exercise interventions in people with mild cognitive impairment and dementia: a systematic review. Prev Med Rep. 2017;7:38–45. PubMed PMC

Coleman RJ, Kokolakakis T, Ramchandani G. Walking for health attendance study. Natural England Commissioned Reports: UK; 2011.

Foster C, Cavill N. Expert testimony – the effectiveness of physical activity promotion interventions. Report submitted to NICE CVD PDG Committee. London: NICE; 2009.

Evangelista LS, Dracup K, Erickson V, et al. Validity of pedometers for measuring exercise adherence in heart failure patients. J Card Fail. 2005;11(5):366–371. PubMed

Findorff M, Wyman J, Gross C. Predictors of long-term exercise adherence in a community-based sample of older women. J Women's Health. 2009;18(11):1769–1776. PubMed PMC

Osuka Y, Jung S, Kim T, Okubo Y, Kim E, Tanaka K. Does attending an exercise class with a spouse improve long-term exercise adherence among people aged 65 years and older: a 6 month prospective follow up study. BMC Geriatr. 2017. 10.1186/s12877-017-0554-9. PubMed PMC

Vseteckova J, Deepak-Gopinat M, Borgstrom E, Holland C, Draper J, Pappas Y, McKeown E, Dadova K, Gray S. Barriers and facilitators to adherence to group exercise in institutionalised older people living with dementia: a systematic review. Eur Rev Aging Phys Act. 2018;15(11). PubMed PMC

Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12. PubMed PMC

Rodgers M, Sowden A, Petticrew M, Arai L, Roberts H, Britten N, Popay J. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews. Evaluation. 2009;15:47–71.

Pope C, Mays N, Popay J. Synthesising qualitative and quantitative health evidence: a guide to methods. New York: McGraw-Hill Education; 2007.

Kyaw BM, Saxena N, Posadzki P, Vseteckova J, Nikolaou CK, George PP, Divakar U, Masiello I, Kononowicz AA, Zary N, Tudor Car L. Virtual reality for health professions education: systematic review and meta-analysis by the digital health education collaboration. J Med Internet Res 2019;21(1). PubMed PMC

Boyle S, Vseteckova J, Higgins M. Impact of motivational interviewing by social workers on service users: a systematic review. Res Soc Work Pract. 2018;29(8):863–875.

Popay J, Robers H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews. ESRC Methods Programme. 2006..

Pluye P, Robert E, Cargo M, Bartlett G, O’Cathain A, Griffiths A, et al. Proposal: A mixed methods appraisal tool for systematic mixed studies reviews. 2011. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/page/24607821/FrontPage. Accessed 14 Sept 2020.

Higgins J, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration; 2011. https://handbook-5-1.cochrane.org/. Accessed 1 Nov 2019.

CASP Appraisal Checklists. https://casp-uk.net/casp-tools-checklists/. Accessed 14 Sept 2020.

van Alphen HJM, Hortobagyi T, van Heuvelen MJG. Barriers, motivators and facilitators of physical activity in dementia patients: a systematic review. Arch Gerontol Geriatr. 2016;66:109–118. PubMed

Bantry White E, Montgomery P. Supporting people with dementia to walkabout safely outdoors: development of a structured model of assessment. Health Soc Care Community. 2016;24(4):473–48. PubMed

Phinney A, Kelson E, Baumbusch J, O’Connor D, Purves B. Walking in the neighbourhood: performing social citizenship in dementia. Dementia. 2016;15(3):381–394. PubMed PMC

King DK, Faulkner SA, Hanson BL. The feasibility of adopting an evidence informed tailored exercise program within adult day services: the enhance mobility program. Act Adapt Aging. 2018;42(2):104–23.

Harrison R, Strachan K and Thorburn S. Stirling Dementia Friendly Walking Project Evaluation Report 2017.

Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Br Med J. 2017;358:j4008. PubMed PMC

McLean S, Ismail S, Powel J, et al. Systematic review of community business related approaches to health and social care. Research Institute Report No. 20. The Power to Change Trust. 2019. https://www.powertochange.org.uk/wp-content/uploads/2019/02/Systematic-review-of-CB-approaches-to-Health-Social-Care-V3-FINAL.pdf . Accessed 23 Oct 2019.

Lowery D, Cerga-Pashoja A, Iliffe S, Thune-Boyle I, Griffin M, Lee J, Bailey A, Bhattacharya R, Warner J. The effect of exercise on behavioural and psychological symptoms of dementia: the EVIDEM-E randomised controlled clinical trial. Int J Geriatr Psychiatry. 2014;29(8):819–827. PubMed

McCurry SM, Pike KC, Logsdon RG, Vitiello MV, Larson EB, Teri L. Predictors of short and long- term adherence to a daily walking program in persons with alzheimer’s disease. Am J Alzheimers Dis Other Dement. 2010;25(6):505–512. PubMed PMC

Rantakokko M, Portegijs E, Viljanen A, Iwarsson S, Rantanen T. Task modifications in walking postpone decline in life-space mobility among community-dwelling older people: a 2-year follow-up study. J Gerontol. 2017;72(9):1252–1256. PubMed

Van Uffelen JGZ, Chinapaw MJM, Hopman-Rock M, van Mechelen W. Feasibility and effectiveness of a walking program for community-dwelling older adults with mild cognitive impairment. J Aging Phys Act. 2009;17:389–415. PubMed

Gibson G, Robertson J, Pemble C, Harrison R, Strachan K, Thorburn S. Dementia friendly walking project. Evaluation report. University of Stirling. 2017. https://core.ac.uk/download/pdf/110695591.pdf. Accessed 1 Jul 2019.

Van Uffelen JGZ, Chinapaw MJM, Mechelen W, Hopman-Rock M. Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomized controlled trial. Br J Sports Med. 2008;42:344–351. PubMed

Barnes C, Oliver M, Barton L. Disability studies today. Cambridge: Blackwell publishing; 2002.

Sheehan B, Burton E, Mitchell L. Outdoor wayfinding in dementia. Dementia. 2006;5(2):271–281.

Symonds P. Finding our way: a socio-cultural exploration of Wayfinding as an embodied experience. Unpublished thesis. Cardiff Metropolitan University. 2017. https://s3-eu-west-1.amazonaws.com/paulsymonds/Prom/Dr-PaulSymonds-phd-web.pdf. Accessed 14 Sept 2020.

Forbes D, Forbes S, Morgan DG, Markle-Reid M, Wood J, Culum I. Physical activity programs for persons with dementia. Cochrane Database Syst Rev. 2008. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006489.pub2/epdf/full. Accessed 27 Oct 2019. PubMed DOI

Willis JD, Campbell LF. Exercise psychology. Champaign: Human Kinetics; 1992.

Dishman RK. Advances in exercise adherence. Champaign: Human Kinetics; 1994.

Hancox JE, van der Wardt V, Pollock K, Booth V, Vedhara K, Harwood RH. Factors influencing adherence to home-based strength and balance exercises among older adults with mild cognitive impairment and early dementia: Promoting Activity, Independence and Stability in early dementia. PLoS One. 2019;14(5). PubMed PMC

Heath A, Carey LB, Chong S. Helping carers care: an exploratory study of factors impacting informal family carers and their use of aged care services. J Relig Health. 2018;57:1146–1167. PubMed

Khalil H, Quinn L, van Deursen R, Martin R, Rosser A, Busse M. Adherence to use of a home-based exercise DVD in people with Huntington disease: participants’ perspectives. Phys Ther. 2012;92(1):69–82. PubMed

Puterman E, Weiss J, Lin J, Schlif S, Slusher AL, Johansen KL, Epel ES. Aerobic exercise lengthens telomeres and reduces stress in family caregivers: a randomized controlled trial – Curt-Richter award paper 2018. Psychoneuroendocrinology. 2018;98:245–252. PubMed

Suttanon P, Hill KD, Said CM, Byrne KN, Dodd KJ. Factors influencing commencement and adherence to a home-based balance exercise program for reducing risk of falls: perceptions of people with Alzheimer’s disease and their caregivers. Int Psychogeriatr. 2012;24(7):1172–1182. PubMed

Taylor ME, Lord SR, Brodaty H, Kurrle SE, Hamilton S, Ramsay E, Webster L, Payne NL, Close JCT. A home-based, carer enhanced exercise program improves balance and falls efficacy in community dwelling older people with dementia. Int Psychogeriatr. 2017;29(1):81–91. PubMed

Holthe T, Halvorsrud L, Karterud D, Hoel KA, Lund A. Usability and acceptability of technology for community-dwelling older adults with mild cognitive impairment and dementia: a systematic literature review. Clin Interv Aging. 2018;13:863–886. PubMed PMC

Barnett DW, Barnett A, Nathan A, Van Cauwenberg J, Cerin E. Built environmental correlates of older adults’ total physical activity and walking: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2017;14:103. PubMed PMC

Lamb SE, Sheehan B, Atherton N, Nichols V, Mistry D, Dosanjh S, Slowther AM, Khan I, Petrou S, Lall R. Dementia and physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. Br Med J. 2018;361. PubMed PMC

Courtin E, Nadia J, Mossialos N, Mossialos E. Mapping support policies for informal carers across the European Union. Health Policy. 2015;118(1):84–94. PubMed

Pickard L. The effectiveness and cost-effectiveness of support and services to informal carers of older people. London: Audit Commission; 2004.

Wanless D, Fernandez JL, Poole T, Beesley L, Henwood M, Moscone F. Securing good care for older people. London: PSSRU; 2006.

Garmendia ML, Dangour AD, Albala C, Eguiguren P, Allend E, Uauy R. Adherence to a physical activity intervention among older adults in a post-transitional middle income country: a quantitative and qualitative analysis. J Nutr Health Ageing. 2013;17(5):466–471. PubMed PMC

Vreugdenhil A, Cannell J, Davies A, Razay G. A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: a randomized controlled trial. Scand J Caring Sci. 2012;26:12–19. PubMed

Global action plan on the public health response to dementia 2017-2025. World Health Organization 2017. http://www.who.int/mental_health/neurology/dementia/action_plan_2017_2025/en/. Accessed 10 July 2019.

Patient engagement. Technical Series on Safer Primary Care. World Health Organisation. 2016. https://apps.who.int/iris/bitstream/handle/10665/252269/9789241511629-eng.pdf;jsessionid=69E09763555942A0E0E73E2301FB8937?sequence=1. Accessed 27 Oct 2019.

Ferrer L. Engaging patients, carers and communities for the provision of coordinated/integrated health services: strategies and tools. World Health Organisation 2015. http://www.euro.who.int/__data/assets/pdf_file/0004/290443/Engaging-patients-carers-communities-provision-coordinated-integrated-health-services.pdf?ua=1. Accessed 27 Oct 2019.

Robertson J, Gibson G, Pemble C, Harrison R, Thorburn S. Dementia friendly walking project. Evaluation report. University of Stirling. 2018.https://www.pathsforall.org.uk/mediaLibrary/other/english/dementia-friendly-walking-project-report.pdf. Accessed 27 Oct 2019.

Physical Activity: walking and cycling. National Institute for Health and Care Excellence. 2012. http://www.nice.org.uk/guidance/ph41. Accessed 8 July 2019.

Al-Qahtani AM, Shaikh MAK, Shaikh IA. Exercise as a treatment modality for depression: a narrative review. Alexandria J Med. 2018;54(4):429–435.

McPhee JS, French DP, Jackson D, Nazroo J, Pendleton N, Degens H. Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology. 2016;17(3):567–580. PubMed PMC

Borgstrom E, Deepak Gopinath M, Vseteckova J. Learning in the fourth age: the role of physical activity interventions for people living in long term facilities. Int J Educ Ageing. In press. 2018.

Crizzle AM, Newhouse IJ. Themes associated with exercise adherence in people with Parkinson’s disease: a qualitative study. Occup Ther Health Care. 2012;26(2–3):174–186. PubMed

Grierson LEM, Zelek J, Lam I, Black SE, Carnahan H. Application of a tactile way-finding device to facilitate navigation in persons with dementia. Assist Technol. 2011;23(2):108–115.

Alsawy S, Mansell W, McEvoy P, Tai S. What is good communication for people living with dementia? A mixed-methods systematic review. Int Psychogeriatr. 2017;29(11):1785–1800. PubMed

Brawley EC. Therapeutic gardens for individuals with Alzheimer’s disease. Alzheim Care Q. 2002;3(1):7–11.