Walking as an Intervention for Older Adults With Dementia Within the Community
Introduction regular program of walking has been well established as a low-impact way for older adults to regain and maintain their physical fitness. Because UK law stipulates that older adults with dementia be provided the best care possible and because resources are scarce by definition, it just makes good sense to use such cost-effective walking regimens for groups of older adults suffering from dementia using a community-based approach. Today, older adults (defined for the purposes of this study as people aged 65 years and over) represent 16 per cent of the population of the United Kingdom (male 4,186,561/female 5,549,195) (2008 estimate) (United Kingdom, 2008). The incidence of mild dementia in older adults has ranged from less than 3 per cent to more than 50 per cent (Maj & Sartorious, 2002). In this regard, Kane and Houston-Vega (2004) place the estimate for mild dementia at about 15 per cent, but note that the incidence of severe dementia increases to 20 per cent for persons older than age 80 years. According to Maj and Sartorius, various definitions have been advanced for dementia, but they sum up the condition as, "Dementia is a disorder of the brain. 'Dementia' originally meant 'out of one's mind,' from the Latin de (out of) and mens (mind)" (p. 2). A more precise definition of dementia offered by Hill and his colleagues (2002) states that, "Dementia has three major components: (a) impairment in more than one cognitive domain, (b) impairment that represents a deterioration of functioning, and - impairment that is progressive and irreversible (p. 89).
Outline of the Intervention
While every individual will have unique needs and abilities, it is possible to formulate a general outline of a walking regimen intervention for older adults. According to Ebersole and Hess (1998), when carefully supervised, walking for short periods can be effective in reducing pain and increasing walking capacity for older adults. While there are a number of other health-related benefits related to such programs, older adults suffering from dementia stand to benefit in particular because of the camaraderie as well as the exercise that accrues to older walkers. In this regard, Ebersole and Hess emphasize that, "The value of walking may be in morale and weight control as well as weight bearing and movement" (p. 398). In fact, outdoor walking regimens have been recommended as a standard intervention for all nursing home residents who are ambulatory, even if canes and walkers are required for their participation (Ebersole & Hess). These authors also provide some useful guidance concerning how to manage such a walking program in a wide range of community-based settings. According to Ebersole and Hess, "In urban settings where traffic and crime may present special problems, internal courtyards may be created or special routes selected for elements of safety. It might also be possible to transport groups to more pleasant settings for walking" (p. 424).
Although these authors recommend that the group should be accompanied by the clinician or other staff members depending on their level of need and abilities, in some cases, individual older adults may be encouraged to walk in pairs or small groups without such staff accompaniment (Ebersole & Hess). Furthermore, family members and other visitors can also be solicited to take older adults for walks outside of a community-based facility. The level of supervision required for various group members would require an individual - and ongoing - assessment, but older adults with mild dementia appear to be capable of remaining oriented to space, time and environmental situations to the extent that such alternatives would be viable.
Some other tips provided by Ebersole and Hess for ensuring safe and pleasurable walking experiences for older adults with or without dementia include (a) reducing environmental hazards, (b) keeping an individual moving about to increase endurance and function, and - identifying persons most at risk of falling as methods that can be used to avoid accidents and falls and to maintain mobility among older adults.
The monetary costs - and the potential relative benefits to be gained - that are associated with such walking regimens for older adults with dementia would involve consideration of the above environmental and individual factors, as well as what other community-based resources are available to assist in the administration and execution of such a program. Local business sponsors in the community could be solicited to help offset any out-of-pocket expenses, and could even provide useful accouterments for such an initiative in the form of jackets for each group participant with the business name and logo on the back. It is important to keep in mind, though, that occupational therapists in the UK have a fundamental responsibility to all clients to ensure that they understand the potential benefits and dangers associated with any such walking regimen intervention. In this regard, the 2005 College of Occupational Therapist Code of Ethics and Professional Conduct clearly states that, "Any intervention that is likely to cause pain or distress shall first be explained to the client. Every effort shall be made to ensure that the client understands the nature, purpose and likely effect of the intervention before it is undertaken" (p. 2.4.1). Given the diminished cognitive abilities of many dementia sufferers, though, such understanding is considered to be relative in certain circumstances and is left up to local practice guidelines (note to section 2.1).
Importance of Intervention to Occupational Therapy
Occupational therapists are well qualified and situated in many communities to develop, implement and administer a group walking regimen. To the extent that these clinicians are able to improve the level of physical fitness among older adults suffering from dementia and improve their emotional well-being and morale in the process is the extent to which the impact of dementia on the community will be mitigated. In this regard, Maj and Sartorious emphasize that, "The impact of dementia on individuals, families and communities has been profound, and this will continue until dementia can not only be effectively treated, but prevented" (p. 2). In the meantime, walking regimens appear to represent a cost-effective approach to providing these older adults with the exercise, camaraderie and improved physical well being that go hand in hand with such programs.
Potential Aims of the Intervention
As noted above, dementia remains an irreversible condition, but it is possible to maintain existing faculties to the maximum extent possible by providing these senior citizens with as many opportunities for interaction with others as possible, and by ensuring they receive as much exercise as they are capable of in the process. The potential aims of the above-described intervention would be related to the individual practitioner's assessment of the needs of the community, what specific needs are most prevalent within a given group of older adults suffering from dementia, and what environmental and cultural factors must be taken into account to ensure a safe and pleasurable walking experience for all participants. Other potential aims of the intervention would include raising community awareness of the incidence and consequences of dementia on UK society, and to develop a community-based network of resources that these older adults and their families can use to provide an improved quality of life for dementia sufferers in the future. Indeed, such resources may already exist yet not be coordinated in any substantive fashion. For instance, according to Kane and Houston-Vega, "Multiple services are available for elders with dementia and their caregivers. Services may include medical care, day care, mental health care, institutionalization, meals-on-wheels, home health care, case management, physical therapy, and respite care. Many private and public agencies are involved in service delivery. Branches of the Alzheimer's Association, which provide a vast array of information and services to elders, caregivers, and the community at large, are prominent in most areas of the country" (p. 286).
Critique of the Evidence
The sources consulted for this study included relevant peer-reviewed journal articles and scholarly texts concerning dementia, walking regimens and community-based interventions. Databases consulted included EBSCO/Medline and Questia, as well as both public and university libraries. In addition, governmental sources were consulted to identify relevant demographic data concerning the number of older adults (defined for the purposes of this study as individual aged 65 years or older) living in the United Kingdom today.
The research showed that when formulating a walking regimen for older adults with dementia, the individual level of dementia involved should follow the World Health Organization's Clinical Descriptions and Diagnostic Guidelines for Mental and Behavioural Disorders criteria for dementia that state that each of the following conditions must be present for a diagnosis of dementia, but which also indicate there are different levels of capabilities involved in initial and later stages of the condition:
decline in memory to the extent that it interferes with everyday activities, or makes independent living difficult or impossible;
decline in thinking, planning and organizing day-to-day things, again to the above extent;
Initially, preserved awareness of the environment, including orientation in space and time;
decline in emotional control…