The need to increase physical activity in individuals with dementia is well established. Reduced activity compounds the lifestyle restrictions frequently experienced by this group; they are vulnerable to physical and functional decline, which can lead to reduced autonomy and participation in activities of daily living (Blankevoort et al., 2010). Physical disability complicates the care provided and increases the risk of institutionalization and early death (Regan, Katona, Walker, & Livingston, 2005). Increased activity mitigates some of the negative physical aspects associated with dementia, such as risk of falls and fractures, loss of muscle tone, and compromised cardiovascular function (Rolland et al., 2007). Exercise has also been found to improve activities of daily living function and sleep and reduce the behavioral and psychological symptoms of dementia (Thuné-Boyle, Iliffe, Cerga-Pashoja, Lowery, & Warner, 2012; Winchester et al., 2013). The Watermemories Swimming Club (WSC) was designed to be a meaningful daytime activity that increased physical activity, improved health, and enhanced social and affective outcomes in individuals with dementia.
There is very little literature addressing the benefits of a water-based exercise program for individuals with dementia. Anecdotal reports of swimming for people with dementia attested to the physical and psychological benefits already described above, plus a number of other positive outcomes (Brierley, 2007; Smith, 2002). These included increased verbal responses, singing, smiling, clapping, alertness, playfulness, social interaction, relaxation, reduced tension, and improved appetite. Additionally, residential aged care facility (RACF) staff enjoyed the activity as well—even attending in their own time—becoming closer to the people they cared for, being more person-centered in their care, and reporting a sense of achievement.
The purpose of the WSC was to try something different: rekindle positive memories of swimming in people with dementia who had enjoyed water activity, such as swimming, throughout their lives and get them involved again in swimming activities. Swimming is enjoyed at the beach, in a river, or at a swimming pool, usually with several other people doing the same thing. There is nothing about dementia that precludes participation in this healthy, fun, relaxing, and social activity. Swimming is non-weight bearing, so it is ideal for those with arthritis. In addition, water can be used for resistance to enhance muscle strength for those experiencing reduced capacity in activities of daily living (Sato, Kaneda, Wakabayashi, & Nomura, 2009).
We started this primarily pleasure-based swimming club for people with dementia using a local municipal pool. The swimming was supported by an evidence-based, aquatic exercise program specifically developed for people with dementia.
WSC Expert Reference Group
An expert reference group was established because, to our knowledge, a program with a dementia-specific, evidence-based aquatic exercise protocol had not been described in the literature. We wanted to be sure we had thought about and planned solutions for all the predictable issues involved. The expert reference group consisted of two clinical nurses (M.-A.M.), two nurse academics (C.N., E.B.), a recreational therapist, two exercise physiologists (T.H.), a neuropsychologist, a psychogeriatrician, and the project manager (K.C.). The role of this group was to contribute their knowledge and experience and consult with other stakeholders including family caregivers, individuals with dementia, and RACF staff and volunteers. The reference group was also available to troubleshoot any problems or perceived barriers.
Criteria for swimming club membership included: memory loss or a diagnosis of dementia, independently mobile (including use of a walking aid), medical clearance from the RACF or the individual’s medical practitioner, and a past or current interest in swimming. Continence was not an inclusion criterion, as suitable incontinence devices were sourced for pool use. Membership was open to individuals who resided at home or in a RACF.
Information flyers detailing the program and listing expected benefits were sent out to family caregivers and interested aged care providers. Families, in particular, required information and opportunities to ask questions and relay any concerns prior to agreeing to their family member’s participation in the club. Providing the family and resident with the opportunity to observe a club session was found to encourage participation. Time was taken to explain the benefits and safety features of the program to inquiring medical practitioners.
Accredited swimming and/or aqua aerobics instructors were employed to deliver the WSC, as these people are comfortable with the aquatic environment. Instructors had an interest, experience, and certifications in working with older adults and special populations (including those with mental and physical disabilities). The WSC program benefited from instructors who were passionate, motivational, encouraging, and supportive of club members.
A WSC coordinator or coordinating team is essential to ensure the club runs smoothly. Tasks include participant recruitment, communicating with family caregivers and medical practitioners, managing volunteers, organizing transportation, liaising with pool staff and the WSC instructor, and ensuring other staff are able to assist with resident preparation. An activities coordinator or recreational therapist is probably best placed to assume this role, and consideration could be given to a volunteer coordinator.
Volunteers are an important feature of the WSC to allow people with dementia to extend their social networks and have greater community engagement. Further, it minimizes the costs of the club (i.e., no paid staff time), resulting in greater long-term sustainability. Volunteers from the RACFs (staff, family, and community members) were recruited because of their interest and experience with people with dementia, and volunteers from local adult swimming clubs were recruited because of their comfort and experience in the aquatic environment. Volunteers are needed to assist the adults with dementia in the changing rooms, so staff, family members, and those with previous dementia-related care experience may be most suitable. Ideally, volunteers sign up on a roster and are not required to attend every session. It is important to invest time in setting up a strong volunteer network and being familiar with the organization’s policies and procedures regarding volunteers. Some RACFs may require police checks or security clearances for potential volunteers working with vulnerable older adults.
The volunteers, interested aged care staff, and the swimming instructors underwent a 2-hour orientation and training session, with topics including physical activity and the older adult, understanding dementia, how to interact with a person with dementia, and the WSC exercise program. These sessions were conducted by an RN and an exercise physiologist. It is important to deal with misconceptions concerning the benefits of exercise and frail older adults. Common misconceptions include viewing physical deterioration as an inevitable part of the aging process and perceiving exercise for frail older adults as unsafe. However, frail older adults can benefit from physical exercise, and exercise need not be strenuous to achieve benefits. Aged care staff need to be reminded that, although there is a significant time cost in setting up and running a WSC, there will be long-term positive outcomes as residents’ functional abilities are maintained or even improved.
Integral to the WSC was the development of a dementia-specific, evidence-based, aquatic exercise program to specifically address the physical, psychological, and social needs of people with dementia. This was undertaken by an exercise physiologist in consultation with other dementia experts. The involvement of the exercise physiologist ensured that the benefits of the swimming activity were maximized with tailored exercises for strength, endurance, flexibility, balance, and relaxation. The risk of causing harm or injury is considerably lessened when an exercise activity is based on best practice and safety issues are given full consideration.
In the pilot program, 45-minute classes were conducted twice weekly over a period of 12 weeks. Each class consisted of five to seven adults with dementia, and each member had his or her own volunteer assisting in the water, a 1:1 ratio. A period of free swimming was provided at the end of the session. A municipal pool was used, as the opportunity for adults with dementia to socialize and be part of their community is another essential component of the WSC.
The aquatic exercise program is pictorially detailed in a manual and available on DVD (Neville & Henwood, 2013). Examples of information sheets and promotional flyers are also available from the corresponding author.
WSC Aquatic Facilities And Equipment
A delegation from the expert reference group visited local swimming pools to determine the most suitable location. A purpose-built rehabilitation hospital pool was considered, but despite its many excellent features—indoor, heated, consistent depth, ramp access, hand bars—it did not have the community-oriented ambience important for social participation. Two hydrotherapy pools were also available; however, the club’s exercise physiologist was concerned these pools may be too hot given the aerobic component of the program. If members become too hot they may experience adverse effects such as dehydration and skin problems. The local municipal pool was the other option considered. It was indoor, heated, had a graduated “beach-style” access that made it easy for people to walk into, a kiosk area where members could relax with a drink or snack, and life guards on duty. Access issues should be considered when identifying a suitable facility. An accessible facility will have a ramp entrance and a drop-off space close by. A beach-style access, ramp, or hoist to assist frail older adults in entering the pool is an essential requirement.
The pool manager was excited to work with the club to accommodate its special needs and, after negotiating a suitable time, agreed to set aside a specific area that provided enough room for the group and the program instructor. The instructor worked both in the water and at pool side; however, some members found it difficult to look up at the instructor if he or she worked out of the water by the edge of the pool. The pool water was approximately 3 feet deep, with the option to move into deeper water (approximately mid-chest height) for resistance activities involving arm motions. A range of flotation devices were also obtained in case they were required. Pool noodles and flotation belts worked well, increasing member confidence and assisting with balance and mobility without inhibiting natural movement and ability to complete the WSC program.
Our experience with the WSC has provided many worthwhile insights into implementing a successful evidence-based aquatic exercise club. Careful attention is required in the selection of an aquatic facility (Table). Time taken to set up functional internal structures within the aged care facility will support and sustain the program. If a dedicated coordinator is not available, a staff committee is more effective than burdening a single staff member. Information sessions are key to ensuring staff, family, and medical practitioners are supportive. If the aged care facility does not have a volunteer service, it is worth considering developing one. Having a roster of volunteers ensures that no one is overly burdened and that there will always be enough helpers in the pool. An accredited swimming or aqua aerobics instructor with training in special populations is recommended.
Table: Checklist For Selecting An Appropriate Aquatic Facility
So far, we have not been able to predict who will or will not do well with this activity. Therefore, it is recommended that each member be assessed individually and on each day of WSC attendance. A potential barrier is not allowing enough time to prepare the member prior to them attending the WSC. This is usually related to staff shortages. Additionally, the member’s current health status, weather conditions, and the length of travel time must be taken into consideration when planning this activity. Some facilitators identified from the perspective of adults with dementia were that they enjoyed the physical and social aspects of the WSC, it was something different to look forward to, it made them feel good about themselves, and it engendered a sense of achievement. Staff and volunteers reported that some members returned with a sense of calm, more confidence, less behavioral and psychological symptoms, and had a reduced number of falls. They appreciated seeing members enjoy themselves and being able to interact with them in a different environment from the RACFs.
Implications for Nurses
Potential WSC members should be assessed by an RN, medical practitioner, or allied health professional regarding their medical and psychological suitability to join the club. The RN should monitor the participants’ health and functional ability across the course of the program and advise on a session-by-session basis whether a participant had medical clearance to participate. Further, the RN can advise on the level of supervision required for club members at the pool. Specifically, do participants require more than one volunteer to support them in the water? Do any club members require clinical supervision while participating, and, if so, what level (e.g., attendance by an RN, enrolled nurse, or certified nursing assistant)? The RN will also need to liaise with family and medical practitioners and answer any concerns these groups have regarding the person with dementia’s participation in the WSC. Finally, the RN has a key role in educating family, volunteers, and other staff in the benefits of physical activity for older adults and safety issues related to physical activity.
The WSC has been a challenging but exciting and fun undertaking for a number of reasons. The structure of the club requires a committee so the best options to overcoming barriers can be determined by people with relevant expertise. It uses resources that are commonly available in most communities such as swimming pools, instructors, and volunteers. An evidence-based, dementia-specific aquatic exercise protocol was developed. This protocol and other important information for establishing a club was produced as a manual so other dementia care providers can replicate the process or adapt it to suit their local conditions with certainty that it uses best practice and is safe and effective. The WSC can be easily incorporated in existing activity programs (e.g., walking groups, dancing, gardening) and is an ideal option for people who may not be able to participate in other programs due to physical limitations. The benefits of swimming such as increased strength, lung capacity, balance, agility, and elevated mood may make it easier to pursue previously enjoyed activities or new activities. This club links people with dementia with the broader community by utilizing public/private swimming pools and volunteers from community organizations. Family and friends can easily join in, as it is an activity that can be enjoyed together. The club has been able to rekindle many happy memories of swimming in people with dementia and get them involved in swimming again, with positive changes for their quality of life.
- Blankevoort, C.G., van Heuvelen, M.J., Boersma, F., Luning, H., de Jong, J. & Scherder, E.J. (2010). Review of effects of physical activity on strength, balance, mobility and ADL performance in elderly subjects with dementia. Dementia and Geriatric Cognitive Disorders, 30, 392–402. doi:10.1159/000321357 [CrossRef]
- Brierley, J. (2007, April1). Splash party. Long-Term Living Magazine. Retrieved from http://www.ltlmagazine.com/article/splash-party
- Neville, C. & Henwood, T. (2013). The Watermemories Swimming Club: Program manual and DVD. Ipswich, Australia: University of Queensland, Ipswich.
- Regan, C., Katona, C., Walker, Z. & Livingston, G. (2005). Relationship of exercise and other risk factors to depression of Alzheimer’s disease: The LASER-AD study. International Journal of Geriatric Psychiatry, 20, 261–268. doi:10.1002/gps.1278 [CrossRef]
- Rolland, Y., Pillard, F., Klapouszczak, A., Reynish, E., Thomas, D., Andrieu, S. & Vellas, B. (2007). Exercise program for nursing home residents with Alzheimer’s disease: A one-year randomized, controlled trial. Journal of the American Geriatrics Society, 55, 158–165. doi:10.1111/j.1532-5415.2007.01035.x [CrossRef]
- Sato, D., Kaneda, K., Wakabayashi, H. & Nomura, T. (2009). Comparison of 2-year effects of once and twice weekly water exercise on activities of daily living ability of community dwelling frail elderly. Archives of Gerontology and Geriatrics, 49, 123–128. doi:10.1016/j.archger.2008.05.011 [CrossRef]
- Smith, P. (2002). Coming along swimmingly. Nursing Times, 98(32), 28–29.
- Thuné-Boyle, I.C., Iliffe, S., Cerga-Pashoja, A., Lowery, D. & Warner, J. (2012). The effect of exercise on behavioral and psychological symptoms of dementia: Towards a research agenda. International Psychogeriatrics, 24, 1046–1057. doi:10.1017/S1041610211002365 [CrossRef]
- Winchester, J., Dick, M.B., Gillen, D., Reed, B., Miller, B., Tinklenberg, J. & Cotman, C.W. (2013). Walking stabilizes cognitive functioning in Alzheimer’s disease (AD) across one year. Archives of Gerontology and Geriatrics, 56, 96–103. doi:10.1016/j.archger.2012.06.016 [CrossRef]
Checklist For Selecting An Appropriate Aquatic Facility
|□ Disability access to aquatic facility|
|□ Disability access to pool (e.g., graduated “beach-style” access, ramp, hoist); ladders and stairs not recommended|
|□ Heated pool (although not a hydrotherapy pool)|
|□ Indoor pool is desirable; an outdoor pool is an option but sun exposure and temperature must be considered|
|□ Depth of 3 feet to mid-chest height; mid-chest height will allow better water resistance for some of the arm exercises|
|□ Exercise area is a consistent depth (flat surface, not sloping)|
|□ Exercise area is large enough to accommodate both club members and volunteers|
|□ Aquatic facility can provide a sectioned-off area in the pool for the club|
|□ If the instructor stands by the side of the pool, he or she can be easily observed by those in the pool|
|□ Aquatic facility has a quiet time for the program. (Members may be distracted or distressed if there is too much noise and too many people.)|
|□ Flotation devices are available; if not, can you provide your own?|
|□ On-duty lifeguard|
|□ Kiosk with tables and chairs|
|□ Adequate seating for those observing|
|□ Adequate changing room area|
|□ Does the aquatic facility require volunteers to have any additional training (e.g., cardiopulmonary resuscitation certification)?|