Dementia is a neurological syndrome associated with progressive cognitive decline involving difficulties with memory, language, executive function, visuospatial perception, and disorientation, all of which influence the ability to perform activities of daily living (ADL; Alzheimer's Association, 2019). Psychological symptoms (e.g., depression, anxiety) and behavioral symptoms (e.g., agitation, aggression, wandering) are often present in persons with dementia (Alzheimer's Association, 2019), increasing distress and burden for caregivers and often leading to institutionalization (Huang, Liao, & Wang, 2015).
Although pharmacological treatments are commonly prescribed to manage behavioral and psychological symptoms of dementia (BPSD), adverse events (e.g., sedation, dizziness) have led to concerns about the safety of these drugs (Pasqualetti, Tognini, Calsolaro, Polini, & Monzani, 2015). There is growing interest in nonpharmacological interventions for older adults with dementia, such as physical activity (Lee, Park, & Park, 2016), exercise programs (Pedroso et al., 2018), and music therapy (Li et al., 2019).
Physical exercise has often been prescribed for older adults with Alzheimer's disease (AD) and other dementia (Lee et al., 2016; Pedroso et al., 2018). Recent meta-analyses have shown that various types of exercise may contribute to prevention or delay of cognitive decline in older adults with mild cognitive impairment (MCI) or mild dementia (Stephen, Hongisto, Solomon, & Lönnroos, 2017). Several randomized control trials (RCTs; Pitkälä et al., 2013), nonrandomized trial studies (Pedroso et al., 2018), and systematic reviews (Stephen et al., 2017) have demonstrated that physical exercise is effective in reducing behavioral and/or emotional symptoms (Lee et al., 2016) and improving physical or cognitive capability (Stephen et al., 2017). However, older adults with dementia may not be able to participate in rigorous or standing exercise due to problems with balance, cognitive impairment, or fear of falling (James, Boyle, Bennett, & Buchman, 2012). Thus, evidence-based, safe, and effective nonpharmacological treatments are needed for older adults with dementia who cannot perform standing or strenuous exercise (Park et al., 2019).
As a nonpharmacological approach, chair yoga (CY), a movement-based mind–body therapy, refers to yoga practice while sitting in a chair or standing and holding the chair for support (Park, McCaffrey, Newman, Liehr, & Ouslander, 2017). CY includes a combination of physical posture, breathing, and meditation/deep relaxation and is well-suited to older adults with dementia who cannot participate in standing yoga or exercise (Litchke, Hodges, & Reardon, 2012); however, only a few studies (Litchke & Hodges, 2014; Litchke et al., 2012) have shown yoga to be beneficial for persons with AD. Given the physical limitations and risk of falling associated with dementia in older adults, in addition to CY, chair-based exercise (CBE) may be an appropriate strategy for those with dementia. Still, few CBE studies have been conducted with older adults with moderate to severe dementia. One study randomized participants to music-based dance therapy (i.e., CBE) or a control group (Van de Winckel, Feys, De Weerdt, & Dom, 2004). CBE was shown to have positive effects in cognitive functioning on the Mini-Mental State Examination (MMSE; p = 0.001) and visual short-term memory on the Amsterdam Dementia Screening test 6 (Van de Winckel et al., 2004).
Music therapy, a nonpharmacological intervention, has been found to be beneficial in managing BPSD (Ueda, Suzukamo, Sato, & Izumi, 2013; Zhang et al., 2017). However, there is not enough evidence to support beneficial effects of music therapy on cognitive function or physical function (Ueda et al., 2013). Overall, music therapy has been shown to be effective for patients with mild to moderate dementia as it enables them to relax and be rewarded, which alleviates depressive symptoms (Chang et al., 2015). Music therapy has a larger positive effect on patients with mild to moderate dementia than on those with moderate to severe dementia (Chang et al., 2015).
Although emerging evidence demonstrates that nonpharmacological approaches are effective in reducing BPSD (Ueda et al., 2013; Zhang et al., 2017), little is known about the perceptions of family caregivers of persons with dementia who participate in nonpharmacological interventions, particularly CY. Perceptions of older adults with dementia are difficult to assess (Murphy, Jordan, Hunter, Cooney, & Casey, 2015) and the reliability of data provided by them has been challenging (Lloyd, Gatherer, & Kalsy, 2006; Smebye, Kirkevold, & Engedal, 2012). As family caregivers spend the most time with older adults with dementia, it is reasonable to seek their insight (Olsen, Telenius, Engedal, & Bergland, 2015) regarding perceived effects of the interventions in which their family members with dementia participate. Family caregivers are faced with the challenges of assisting with ADL and managing BPSD, which could lead to stress and serious burden on caregivers (Fauth, Femia, & Zarit, 2016). Thus, it is important for family caregivers to seek nonpharmacological interventions for their family members with dementia to manage dementia symptoms. Such interventions can be integrated into the family's treatment plan as developed with health care providers.
The Health Promotion Model (HPM) developed by Pender, Murdaugh, and Parsons (2011) was used to guide the current study. The HPM is one of the most comprehensive models to test factors in health-promoting behaviors (Khodaminasab, Reisi, Vahedparast, Tahmasebi, & Javadzade, 2019). The HPM posits that people are likely to engage in health-promoting behaviors when significant others, such as caregivers or peers, model the behavior, anticipate the promoting behaviors to occur, and provide support or assistance to perform the behavior (Pender et al., 2011). The HPM includes three determinants of health-promoting behavior: (a) individual characteristics and experiences, (b) behavior-specific cognition and affect, and (c) behavioral outcomes (Pender et al., 2011). In the current study, the HPM was modified to identify factors that influence health-promoting behaviors (i.e., starting, adhering to, and completing a 12-week nonpharmacological intervention to alleviate dementia symptoms).
In the current study, three major determinants influenced attendance and completion of the 12-week nonpharmacological intervention (health-promoting behavior). The first determinant of individual characteristics and experiences included two components: (a) personal factors (i.e., dementia, age, inability to participate in standing or rigorous exercise), and (b) prior related behaviors (i.e., no previous participation in a nonpharmacological intervention). The second determinant, behavior-specific cognition and affect, included (c) interpersonal influence (i.e., importance of the family care-giver's support), (d) perceived self-efficacy (i.e., older adult's confidence in participating in a nonpharmacological intervention), and (e) situational influences (i.e., nonpharmacological intervention provided by a community-based day care center). The third determinant included behavioral outcomes: (f) commitment to a plan of action (i.e., enrolled in a nonpharmacological intervention), and (g) health-promoting behavior (i.e., starting, adhering to, and completing a 12-week nonpharmacological intervention to improve cognitive, physical, and emotional function, and sleep; Figure A, available in the online version of this article).
Modified Health Promotion Model for Completing a Nonpharmacological Intervention in Older Adults with Dementia
Older adults with dementia are more likely to engage in health-promoting behaviors when they are confident in their ability to participate in the intervention offered by a community-based day care center and receive the family caregiver's support.
The purpose of the current qualitative study was to explore the perceived effects of three nonpharmacological interventions—CY, participatory music intervention (MI), and CBE—in managing symptoms in older adults with dementia according to the perspectives of family caregivers. In a quantitative study by the current authors (Park et al., 2019), 31 patients with dementia engaged in twice weekly 45-minute sessions of CY, MI, or CBE for 12 weeks (Figure 1). Caregivers did not participate in the interventions. Significant differences in quality of life (QoL; p = 0.010) were observed, with CY and CBE groups experiencing an increase in QoL and the MI group experiencing a decrease in QoL (Park et al., 2019); there were no significant differences in physical or behavioral symptoms. An in-depth understanding of the effects of such interventions can be obtained by exploring the experiences of family caregivers who observed symptoms of dementia in older adults. Thus, specific research questions were posed: (a) Is there improvement in cognitive symptoms in older adults with dementia after attending the nonpharmacological intervention (CY, MI, or CBE) from the perspectives of their family caregivers? (b) Are there any perceived effects of the three nonpharmacological interventions in alleviating physical limitations, emotional distress, and sleep disturbance?
CONSORT flow of participants through the study.
Note. MMSE = Mini Mental State Examination.
Design and Data Collection
A qualitative descriptive design was used. Qualitative data were collected from three focus groups (i.e., CY, MI, and CBE) conducted with family caregivers of older adults with dementia to explore whether caregivers observed changes in participants after the RCT of the impact of the 12-week nonpharmacological interventions.
Inclusion and Exclusion Criteria
Requirements for participation in the CY, CBE, or MI intervention were as follows: (a) diagnosed with major neurocognitive disorder (e.g., AD, dementia with Lewy bodies [DLB], or Parkinson's disease dementia [PDD]); (b) MMSE score ≤24 (Folstein, Folstein, & McHugh, 1975); (c) unable to participate in standing or rigorous exercise due to problems with balance or cognitive impairment; (d) never participated in a nonpharmacological intervention; and (e) if taking dementia medication, stable on the medication(s) for >1 month (Park et al., 2019). To participate in the focus group, caregivers had (a) a family member who had just completed a 12-week CY, CBE, or MI intervention; (b) enough experience to address questions related to his/her role as the major caregiver; and (c) observed the family member's dementia while he/she was participating in the 12-week intervention.
Family caregivers were recruited for the focus group after the 12-week interventions occurred. Nine of 27 caregivers who were invited to the focus groups agreed to attend, but one did not participate due to transportation issues. The 18 remaining caregivers declined for several reasons: conflicting medical appointments for the family member with dementia (n = 8), employment (n = 6), or personal matters (n = 4).
At completion of the interventions and data collection, caregivers whose family member with dementia had completed one of the three interventions were invited to the focus group to share their perspectives on the effects of the interventions. The research assistant (RA) confirmed eligibility of caregivers who agreed to participate. Table 1 describes caregivers' characteristics and care recipients' diagnoses.
Caregiver and Care Recipient Characteristics
Three focus groups were scheduled according to the intervention in which the patient had participated. A generic focus group questionnaire (Table A, available in the online version of this article) was developed. Nine family caregivers agreed to participate in one of the focus groups; however, one caregiver in the CBE group did not attend the focus group session due to her own medical issue. Therefore, a total of eight caregivers participated in the focus groups: CY (n = 3), MI (n = 3), and CBE (n = 2). One of the eight caregivers was not able to attend the scheduled session in the university's clinical trial building due to a transportation issue. Thus, the investigator (H.H.) visited the caregiver's home to interview her using the same guideline that was used in the focus group session. Each session lasted approximately 1.5 hours and was digitally recorded and transcribed.
Open-Ended Questions for the Focus Group
Study procedures were approved by the Florida Atlantic University Institutional Review Board. The RA explained the interview process and described the voluntary nature of participation. Each caregiver signed an informed consent form and was provided a copy of the focus group questions.
Data were analyzed using constant comparative analysis (Marshall & Rossman, 2011) to determine whether the intervention had an impact on participants with dementia. Interview transcripts were reviewed multiple times and compared across two investigators (J.P., H.H.) to identify thematic aspects and measure intercoder reliability (i.e., credibility in qualitative research; Morrow, 2005). NVivo® 12 was used to run word frequencies and identify emerging themes. Yardley's (2000) four principles for assessing validity of qualitative research were applied: sensitivity to context, commitment and rigor, transparency and coherence, impact and importance.
Table 2 presents the demographic characteristics of eight caregivers who participated in focus group sessions or interviews. Regarding the relationship to the family member with dementia, one half of caregivers were daughters. Six self-identified as the primary family caregiver. One was the primary caregiver for two family members (mother and aunt). Seven participants with dementia had been diagnosed with AD and one with DLB (mean MMSE score = 14.7). Caregivers spent a mean of 70.29 (SD = 38.65) hours per week caring for their family member with dementia. Four shared caregiving responsibilities with one or more siblings.
Demographic Characteristics of Caregivers (N = 8)
Themes Derived From Focus Groups
Data were assigned to three themes: (a) Changes in Cognitive Symptoms, (b) Changes in Physical Function, and (c) Changes in Mood, Behavioral Symptoms, and Sleep Disturbance (Table 3).
Themes and Subthemes Developed from Focus Groups
Cognitive Impact. CY, MI, and CBE produced different perceived cognitive effects. CY participants improved in memory and MI and CBE participants improved in communications, engaging in family conversations after the intervention. Three caregivers of participants in the CY intervention acknowledged that the intervention had affected cognitive ability in participants. Some, but not all, reported that the person with dementia remembered some poses practiced in CY sessions. Caregiver F (CY) said:
My mom remembered everything. She remembered the instructor…. My mom was pretty persistent with cognition through the whole thing. Cognitively, it would brighten her up. And my aunt…got used to being in the building. She just would walk right into her seat, assigned seat, and she would know exactly what to do.
All caregivers in the MI group reported that the intervention had stimulated participants, who enjoyed listening to and singing songs. Caregiver A described a change in her mother, who had a lucid conversation after participation:
She's more assertive, and then this—she's just lying in the bed, relaxing, and she's having, like, a phone conversation. And she's aware that she's talking to herself.
Caregiver C talked about her mother's changes in communication related to the music (i.e., MI intervention). Her mother had more conversations with family members after MI and sang the song that she had sung in the group:
When my daughter came, she [mother] seemed to talk a little bit more to her…actually, she played music for her at night. And so, she gets a response from her with music and singing the stuff at night. I think the music really helped. Even when songs come on the radio or television, if she's not watching (and you don't ever know if they're watching), the feet are moving, and to me that's good. That tells me, “Well, you've got it made. Your mom talks, so that's wonderful.”
Caregiver H talked about her family member's cognitive improvement in alertness, attention, and being engaged in casual conversations and in answering questions appropriately after participation in CBE:
Especially on the days that she participated…she was more alert, more engaged, when she would come home in the evening. She would not initiate a conversation, but she would participate in a conversation. She could answer questions, and her answers would be longer than just one or two words. I even found she had a little bit more energy.
Physical Impact. The movement-based interventions (i.e., CY, CBE) produced perceived physical effects. Caregiver H in the CBE group shared that the participant's physical function had changed since the intervention. Her mother felt comfortable in the sessions, which led her to attempt physical movements. However, after the class she lost self-efficacy to continue to practice CBE at home:
I just see it's challenging for her. And I don't think she fully understands. I think she takes a lot of her information based on the cues that she's getting: “Oh, I'm sitting in a wheelchair. I must not be able to walk.” But she felt more comfortable attempting to do certain physical things. She claims she can't walk, can't stand up. However, because she's not doing it, she's weaker. The confidence is gone.
Three caregivers of participants in the CY group reported that their family members had improved in mobility, posture, and balance, all key components in physical function. Caregiver E (CY) said, “She walked better. Her balance seemed to get better.” Caregiver F (CY) said:
My mom, though, the chair yoga definitely helped her posture. And my aunt really enjoyed the—as far as physicality go, it's hard to know with my aunt. But I felt as though her posture and balance were better after. You could tell from going on at 10:00, and coming out quarter to 12, that they were moving better. And this is really what I enjoyed about the chair yoga particularly, towards the end of it was that we had this camaraderie.
Emotional/Mood Impact. Mood changes were reported in CY and CBE. Caregivers of participants in CY reported positive changes in mood. According to Caregiver F, her mother and aunt were motivated to continue to attend the CY sessions:
They were also much brighter. Like, they were looking forward to what they were going to do next. My aunt started getting up earlier…every day, after the study.
Similarly, caregivers of CBE participants noted positive changes in mood. Caregiver H reported a reduction in self-pity during the intervention; however, her mother had a relapse after the intervention (now institutionalized):
She seemed to be much more up-beat and pleasant to be around. She didn't have that “feel sorry for myself ” attitude that she's displaying now. But now she's giving up. At that point, she wasn't giving up. She was feeling good about herself. Initially, the changes were all positive. My mother was very upbeat, very happy, very engaged.
Caregivers perceived that participants gained pride and had a purpose after participating in the intervention.
Caregiver F reported that her participant improved in self-esteem and considered CY to be a mood booster:
It's like, social phobias, or “I'm not good enough,” or very low self-esteem. I think that's the key thing about this commitment that we had, where she felt good about herself. Because she was participating in a class. And so, the image, it's boosting her self-esteem. When you put that forward to people who have no recall, it immediately boosted her mood. And I think the caregivers felt better knowing they were all together. The mood was boosting, and they're contributing to something.
Caregiver H shared a similar observation, reporting that her mother had gained self-confidence during the CBE sessions. She noted that receiving special attention from the research staff led her mother to feel a sense of belonging and improvement in self-esteem:
I think she felt good about herself, because she was participating. When she started, there were things she said she couldn't do. Then near the end, she felt more confident and was starting to do the things that she said she couldn't do. I think there was something fun about being part of the group. So, she was special. People were paying attention to her. So, she felt good about that, about being recognized for being something different.
Changes in Sleep. Two caregivers attributed CBE with helping their family members with dementia to have restful sleep. Caregiver H shared that her mother slept without disturbance or awakening at night:
She didn't get as tired as quickly in the evening. She could stay up until 9:00 or 9:30 at night. [Now] she's drifted back. She got a more restful night's sleep, which is very important. And now, what's happening, and it happened this morning.
Unlike previous qualitative studies of the effects of nonpharmacological interventions in MCI or patients with mild dementia (Cedervall & Åberg, 2010; Hammar, Emami, Engström, & Götell, 2011; Osman, Tischler, & Schneider, 2016), the innovative perspective of the current study was the perceived effects of CY, MI, and CBE in older adults with moderate to severe AD or DLB (mean MMSE score = 14.7), as reported by family caregivers with practical knowledge about what care is best for their family member.
Regarding cognitive function, three interventions showed improvement in different aspects of cognition from the caregiver's standpoints: CY participants improved in memory and MI and CBE participants improved in communication by engaging in family conversations. Findings were generally consistent with previous qualitative studies of exercise or yoga (Brett, Traynor, Stapley, & Meedya, 2018; Litchke & Hodges, 2014); however, the current study provided more articulate descriptions of those aspects of cognition.
Caregivers observed that MI participants responded to musical stimuli, which they had not done before the intervention. MI also improved communication by increasing temporary arousal, stimulating cognitive activity (Van de Winckel et al., 2004), and involving participants in more conversations with family members. Findings are in line with a previous qualitative MI study (Osman et al., 2016) in which MI seemed to have a positive impact on the relationship between older adults with dementia and their caregivers or other family members. MI seems to be an enjoyable topic of conversation as an approach to improve relationships (Osman et al., 2016).
Several mechanisms in the CBE and CY interventions were associated with improvement in physical function. CY participants improved in posture and balance and moved better after the intervention; CBE participants walked and stood with minimal assistance during the intervention. Comfort in the CBE session led to physical movement, which improved physical function. It appeared that the mechanisms that underlie benefits of CY practice for patients with dementia involve simple and repetitive movements that provide a sense of familiarity and attentional components that are inherent in yoga practice (Oken et al., 2006).
Participants were more comfortable and confident in trying new physical movements after attending the intervention sessions. It is possible that participants may have experienced positive social aspects of attending the intervention; participants enjoyed being with others, observing others' accomplishments, and supporting each other. The group experience for older adults with dementia seems to have served as a motivator for adherence (Sondell et al., 2018).
Caregivers reported visible uplifting effects of CY and CBE on participants' mood, including relaxation, as well as increased alertness and interest in surroundings. Mood improvement was not observed by caregivers in the MI group, which differs from previous findings (Li et al., 2019). The positive experience was a sense of participants' achievement associated with the intervention. Caregivers discussed the importance of gaining confidence and purpose to complete the interventions. CY was considered a mood booster, as caregivers reported that participants had increased self-confidence after each session and were committed to attending. The experience of physical activities provided participants with a sense of doing something useful for themselves, which led to a change in their emotional state (Olsen et al., 2015). Caregivers' continuous support and assistance played an important role; they brought older adults with dementia to each intervention session, waited during the session, and participated in a focus group to report changes in the person with dementia after the 12-week intervention.
The current study is in line with findings from related studies. A qualitative study on nursing home residents with dementia indicated that exercise stimulated the body and improved a sense of security and self-esteem through increased secretion of endorphins that improved mood (Olsen et al., 2015). Participation in the exercise program seemed to introduce experience of mastery, which could have had a positive effect on participants' self-esteem (Olsen et al., 2015). Caregivers perceived the interventions to be a positive contrast to participants' previous sedentary life, speculating that this action could have contributed to improved self-efficacy. Although participants were cognitively impaired, they had a purpose and willingness to complete the intervention. They experienced positive benefits from the three interventions, which may have had an impact on their self-efficacy.
The current study has methodological limitations. Although focus group participants may not be comfortable revealing opinions in a group and dominant personalities may steer a group's responses, this did not appear to be an issue in the current study based on review of the transcripts. Caregivers seemed to feel empowered to tell their stories and discuss their perspectives. They listened actively to each other's accounts. Focus groups may be limited in the number of questions that can be posed due to time constraints (Barbour, 2008).
Use of data from caregivers about participants could lead to validity issues; the extent of caregivers' commitment supports the validity of their contributions. All caregivers were female; thus, the authors cannot know whether male caregivers would have reported the same observations and perceptions. Three of eight caregivers did not reside with the older adult with dementia but lived close by and spent a significant number of hours in caregiving; these individuals may not have been able to observe dementia symptoms, such as sleep disturbance, closely. The sample was small but acceptable in qualitative research focused on understanding in a homogeneous group selected for specific knowledge and experience (Silverman, 2011). No caregiver whose family member was diagnosed with PDD participated in a focus group due to medical appointment conflicts; it is possible that findings might have differed if those caregivers had participated.
Implications and Conclusion
Gerontological nurse practitioners and gerontological nurses should consider nonpharmacological treatments as complementary approaches to manage dementia symptoms in specific patients who have adverse effects or drug-to-drug interactions from polypharmacy. Findings indicate that it is important to integrate family caregivers' insight into the treatment plan; participants in the current study described changes in cognitive function and physical and psychological symptoms that could be integrated to provide support about evidence-based practice. For future practice, participants and caregivers are encouraged to attend CY, CBE, and MI sessions together and to practice at home. Caregivers in the current study stated that participants with dementia needed support to continue the exercise after the intervention. These interventions should be implemented and continued in a dementia health center or senior housing facility. Gerontological nurses and nurse practitioners could provide effective strategies and resources to encourage and assist older adults with dementia to engage in such interventions. Future research should focus on such interventions with assistance from caregivers to manage dementia symptoms and compare CY, CBE, or MI practiced with a caregiver against CBE, CY, or MI practiced solely by participants with dementia.
- Alzheimer's Association. (2019). Alzheimer's disease facts and figures. Retrieved from http://www.alz.org/facts
- Barbour, R. (2008).Doing focus groups. Thousands Oak, CA: Sage.
- Brett, L., Traynor, V., Stapley, P. & Meedya, S. (2018). Exercise and dementia in nursing homes: Views of staff and family carers. Journal of Aging and Physical Activity, 26(1), 89–96. https://doi.org/10.1123/japa.2016-0368 PMID: doi:10.1123/japa.2016-0368 [CrossRef]
- Cedervall, Y. & Åberg, A. C. (2010). Physical activity and implications on well-being in mild Alzheimer's disease: A qualitative case study on two men with dementia and their spouses. Physiotherapy Theory and Practice, 26(4), 226–239. https://doi.org/10.3109/09593980903423012 PMID: doi:10.3109/09593980903423012 [CrossRef]20397857
- Chang, Y. S., Chu, H., Yang, C. Y., Tsai, J. C., Chung, M. H., Liao, Y. M. & Chou, K. R. (2015). The efficacy of music therapy for people with dementia: A meta-analysis of randomised controlled trials. Journal of Clinical Nursing, 24(23–24), 3425–3440. https://doi.org/10.1111/jocn.12976 PMID: doi:10.1111/jocn.12976 [CrossRef]26299594
- Fauth, E. B., Femia, E. E. & Zarit, S. H. (2016). Resistiveness to care during assistance with activities of daily living in non-institutionalized persons with dementia: Associations with informal caregivers' stress and well-being. Aging & Mental Health, 20(9), 888–898. https://doi.org/10.1080/13607863.2015.1049114 PMID: doi:10.1080/13607863.2015.1049114 [CrossRef]
- Folstein, M. F., Folstein, S. E. & McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. https://doi.org/10.1016/0022-3956(75)90026-6 PMID: doi:10.1016/0022-3956(75)90026-6 [CrossRef]1202204
- Hammar, L. M., Emami, A., Engström, G. & Götell, E. (2011). Finding the key to communion-caregivers' experience of “music therapeutic caregiving” in dementia care: A qualitative analysis. Dementia (London), 10(1), 98–111. https://doi.org/10.1177/1471301210392994 doi:10.1177/1471301210392994 [CrossRef]
- Huang, S. S., Liao, Y. C. & Wang, W. F. (2015). Association between caregiver depression and individual behavioral and psychological symptoms of dementia in Taiwanese patients. Asia-Pacific Psychiatry, 7(3), 251–259. https://doi.org/10.1111/appy.12175 PMID: doi:10.1111/appy.12175 [CrossRef]25704825
- James, B. D., Boyle, P. A., Bennett, D. A. & Buchman, A. S. (2012). Total daily activity measured with actigraphy and motor function in community-dwelling older persons with and without dementia. Alzheimer Disease and Associated Disorders, 26(3), 238–245. https://doi.org/10.1097/WAD.0b013e31822fc3cb PMID: doi:10.1097/WAD.0b013e31822fc3cb [CrossRef]
- Khodaminasab, A., Reisi, M., Vahedparast, H., Tahmasebi, R. & Javadzade, H. (2019). Utilizing a health-promotion model to predict self-care adherence in patients undergoing coronary angioplasty in Bushehr, Iran. Patient Preference and Adherence, 13, 409–417. https://doi.org/10.2147/PPA.S181755 PMID: doi:10.2147/PPA.S181755 [CrossRef]31040649
- Lee, H. S., Park, S. W. & Park, Y. J. (2016). Effects of physical activity programs on the improvement of dementia symptom: A meta-analysis. Retrieved from https://www.hindawi.com/journals/bmri/2016/2920146/
- Li, H. C., Wang, H. H., Lu, C. Y., Chen, T. B., Lin, Y. H. & Lee, I. (2019). The effect of music therapy on reducing depression in people with dementia: A systematic review and meta-analysis. Geriatric Nursing, 40(5), 1–7. https://doi.org/10.1016/j.gerinurse.2019.03.017 PMID: doi:10.1016/j.gerinurse.2019.03.017 [CrossRef]
- Litchke, L. G. & Hodges, J. S. (2014). The meaning of “now” moments of engagement in yoga for persons with Alzheimer's disease. Therapeutic Recreation Journal, 48, 229–246.
- Litchke, L. G., Hodges, J. S. & Reardon, R. F. (2012). Benefits of chair yoga for persons with mild to severe Alzheimer's disease. Activities, Adaptation and Aging, 36(4), 317–328. https://doi.org/10.1080/01924788.2012.729185
- Lloyd, V., Gatherer, A. & Kalsy, S. (2006). Conducting qualitative interview research with people with expressive language difficulties. Qualitative Health Research, 16(10), 1386–1404. https://doi.org/10.1177/1049732306293846 PMID: doi:10.1177/1049732306293846 [CrossRef]17079800
- Marshall, C. & Rossman, G. B. (2011). Designing qualitative research (5th ed.). Thousand Oaks, CA: Sage.
- Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52(2), 250–260. https://doi.org/10.1037/0022-022.214.171.124 doi:10.1037/0022-0126.96.36.199 [CrossRef]
- Murphy, K., Jordan, F., Hunter, A., Cooney, A. & Casey, D. (2015). Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies. Dementia (London), 14(6), 800–824. https://doi.org/10.1177/1471301213512489 PMID: doi:10.1177/1471301213512489 [CrossRef]
- Oken, B. S., Zajdel, D., Kishiyama, S., Flegal, K., Dehen, C., Haas, M. & Leyva, J. (2006). Randomized, controlled, six-month trial of yoga in healthy seniors: Effects on cognition and quality of life. Alternative Therapies in Health and Medicine, 12(1), 40–47 PMID:16454146
- Olsen, C. F., Telenius, E. W., Engedal, K. & Bergland, A. (2015). Increased self-efficacy: The experience of high-intensity exercise of nursing home residents with dementia: A qualitative study. BMC Health Services Research, 15(1), 379–388. https://doi.org/10.1186/s12913-015-1041-7 PMID: doi:10.1186/s12913-015-1041-7 [CrossRef]
- Osman, S. E., Tischler, V. & Schneider, J. (2016). ‘Singing for the brain’: A qualitative study exploring the health and well-being benefits of singing for people with dementia and their carers. Dementia (London), 15(6), 1326–1339. https://doi.org/10.1177/1471301214556291 PMID: doi:10.1177/1471301214556291 [CrossRef]
- Park, J., McCaffrey, R., Newman, D., Liehr, P. & Ouslander, J. (2017). A pilot randomized controlled trial of the effects of chair yoga among older adults with lower extremity osteoarthritis. Journal of the American Geriatrics Society, 65, 592–597. https://doi.org/10.1111/jgs.14717 PMID: doi:10.1111/jgs.14717 [CrossRef]
- Park, J., Tolea, M., Sherman, D., Rosenfeld, A., Arcay, V., Lopes, Y. & Galvin, J. (2019). Feasibility of conducting nonpharmacological interventions to manage dementia symptoms in community-dwelling older adults: Cluster randomized control trial. American Journal of Alzheimer's Disease and Other Dementias. Advance online publication. https://doi.org/10.1177/1533317519872635
- Pasqualetti, G., Tognini, S., Calsolaro, V., Polini, A. & Monzani, F. (2015). Potential drug-drug interactions in Alzheimer patients with behavioral symptoms. Clinical Interventions in Aging, 10, 1457–1466 PMID:26392756
- Pedroso, R. V., Cancela, J. M., Ayán, C., Stein, A. M., Fuzaro, G., Costa, J. L. R. & Santos-Galduróz, R. F. (2018). Effects of physical exercise on the P300 of elderly with Alzheimer's disease. Journal of Physical Activity & Health, 15(6), 403–410. https://doi.org/10.1123/jpah.2017-0179 PMID: doi:10.1123/jpah.2017-0179 [CrossRef]29542360
- Pender, N. J., Murdaugh, C. L. & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Boston, MA: Pearson.
- Pitkälä, K. H., Pöysti, M. M., Laakkonen, M. L., Tilvis, R. S., Savikko, N., Kautiainen, H. & Strandberg, T. E. (2013). Effects of the Finnish Alzheimer disease exercise trial (FINALEX): A randomized controlled trial. Journal of the American Medical Association: Internal Medicine, 173(10), 894–901 PMID:23589097
- Silverman, D. (2011). Interpreting qualitative data: A guide to the principles of qualitative research. Thousand Oaks, CA: Sage.
- Smebye, K. L., Kirkevold, M. & Engedal, K. (2012). How do persons with dementia participate in decision making related to health and daily care? A multi-case study. BMC Health Services Research, 12(1), 241. https://doi.org/10.1186/1472-6963-12-241 PMID: doi:10.1186/1472-6963-12-241 [CrossRef]22870952
- Sondell, A., Rosendahl, E., Sommar, J. N., Littbrand, H., Lundin-Olsson, L. & Lindelöf, N. (2018). Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes. PLoS One, 13(11), e0206899. https://doi.org/10.1371/journal.pone.0206899 PMID: doi:10.1371/journal.pone.0206899 [CrossRef]30427894
- Stephen, R., Hongisto, K., Solomon, A. & Lönnroos, E. (2017). Physical activity and Alzheimer's disease: A systematic review. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 72(6), 733–739. https://doi.org/10.1093/gerona/glw251 PMID:28049634
- Ueda, T., Suzukamo, Y., Sato, M. & Izumi, S. (2013). Effects of music therapy on behavioral and psychological symptoms of dementia: A systematic review and meta-analysis. Ageing Research Reviews, 12(2), 628–641. https://doi.org/10.1016/j.arr.2013.02.003 PMID: doi:10.1016/j.arr.2013.02.003 [CrossRef]23511664
- Van de Winckel, A., Feys, H., De Weerdt, W. & Dom, R. (2004). Cognitive and behavioural effects of music-based exercises in patients with dementia. Clinical Rehabilitation, 18(3), 253–260. https://doi.org/10.1191/0269215504cr750oa PMID: doi:10.1191/0269215504cr750oa [CrossRef]15137556
- Yardley, L. (2000). Dilemmas in qualitative health research. Psychology & Health, 15(2), 215–228. https://doi.org/10.1080/08870440008400302 doi:10.1080/08870440008400302 [CrossRef]
- Zhang, Y., Cai, J., An, L., Hui, F., Ren, T., Ma, H. & Zhao, Q. (2017). Does music therapy enhance behavioral and cognitive function in elderly dementia patients? A systematic review and meta-analysis. Ageing Research Reviews, 35, 1–11. https://doi.org/10.1016/j.arr.2016.12.003 PMID: doi:10.1016/j.arr.2016.12.003 [CrossRef]
Caregiver and Care Recipient Characteristics
|Caregiver||Age/Race||Length of Caregiving (years)||Relationship to Care Recipient (Age)||Care Recipient Diagnosis||Intervention Group|
|A||62/Non-Hispanic White||1.5||Mother (92)||Alzheimer's disease||MI|
|B||60/Non-Hispanic White||1||Brother (62)||Alzheimer's disease||MI|
|C||73/Hispanic||10||Mother (91)||Alzheimer's disease||CY|
|D||81/Non-Hispanic White||5||Husband (84)||Alzheimer's disease||MI|
|E||74/African American||0.5||Sister (76)||Alzheimer's disease||CY|
|F||54/Non-Hispanic White||2.5 (mother) 2 (aunt)||Mother (91), aunt (88)||Alzheimer's disease (mother), dementia with Lewy bodies (aunt)||CY|
|G||78/Non-Hispanic White||3||Husband (81)||Alzheimer's disease||CBE|
|H||65/Non-Hispanic White||1||Mother (93)||Alzheimer's disease||CBE|
Demographic Characteristics of Caregivers (N = 8)
|Mean age (SD) (range)||69 (9.2) (54 to 81)|
| Female||8 (100)|
| Non-Hispanic White||6 (75)|
| African American||1 (12.5)|
| Hispanic/Latino||1 (12.5)|
| Single/never married||4 (50)|
| Married||3 (37.5)|
| Divorced||1 (12.5)|
|Relationship to family member|
| Daughter||4 (50)|
| Spouse||2 (25)|
| Sister||1 (12.5)|
| Brother||1 (12.5)|
| No||2 (25)|
| Yes||6 (75)|
|Living with family member(s) with dementia|
| Yesa||5 (62.5)|
| Nob||3 (37.5)|
|Sharing caregiving responsibilities with sibling(s), if having sibling(s)|
| Yes||4 (80)|
| No||1 (20)|
|Sharing caregiving responsibilities with child(ren), if having child(ren)|
| Yes||1 (50)|
| No||1 (50)|
Themes and Subthemes Developed from Focus Groups
|Changes in Cognitive Symptoms|
CY improved memory
MI and CBE improved communication, with participants engaging in family conversations after the intervention
CBE contributed to cognitive improvement in alertness, attention, and being more engaged in casual conversations and answering questions appropriately
|Changes in Physical Function|
CBE improved physical function
CY improved mobility, posture, and balance, all key components in physical function
Comfort in the CBE session led to physical movement, which improved physical function
|Changes in Mood, Behavioral Symptoms, and Sleep Disturbance|
Mood changes were identified in CY and CBE
After CBE intervention, participants gained pride and self-confidence and had a purpose
Participants slept without disturbance or night awakening during CBE intervention
The group experience served as a motivator for adherence
Open-Ended Questions for the Focus Group
|We have completed our 12-week chair yoga (chair exercise or music intervention). Now, we would like to know more about how this chair yoga (chair-based exercise or music intervention) helped your family member or helped you to manage your family member's symptoms. Your responses will help us to improve the program and to plan future research studies.
How would you describe the dementia that your loved one suffers from?
While your family member was participating (or after he or she had participated) in the chair yoga (or chair exercise program or music intervention), what did you notice about your loved one in terms of dementia symptoms?
If you described any changes in symptoms in your family member since participating in the intervention), why do you think these changes happened? If you saw no changes, why do you think that there were no changes after the program?