Changing the focus: Facilitating engagement in physical activity for people living with mild dementia in a local community - A feasibility study

Preparation: In preparation for the intervention, the project team will develop a training program for exercise practitioners in the Frankston / Mornington Peninsula area, Victoria, Australia who are interested in improving their understanding of strategies to support working with people with mild dementia in programs they provide. Training will include in-person opportunities at the start of the intervention period, and online resources will be made available for exercise practitioners who engage with the program. Another round of in-person training opportunities can be arranged mid study depending on the interest of new exercise practitioners who join the program. We encourage exercise practitioners to attend the training program, however, this training is optional (not compulsory for the intervention). This is because in usual practice, exercise practitioners do not have to attend training to do their daily work. If they choose to do the training, they can decide to attend in person or online or do both. The in-person training workshop can cater for up to 30 practitioners per workshop and will be facilitated by two project team members. The in-person training will be conducted at the commencement of project recruitment and a repeated session may occur approximately 6-9 months after project commencement, depending on the interest from new physical activity providers who engage with the program over time. The in-person training workshop will be a once off session, approximately 2-3 hours in duration with a 15 minutes rest break during the workshop. The online training is expected to take approximately 2-3 hours to complete, consisting of all learning modules and further e-resources, open to those interested throughout the study period. An updated Peninsula Health physical activity program directory in the local areas will be promoted through the training program, and be made available to the research staff supporting the decision making about suitable physical activity options in the local area for each participant with dementia, as well as to referrers and providers who request a copy. The shared decision support tool is being developed based on results from a series of three stakeholder co-design panels and interviews incorporating key stakeholders (including people with dementia and their carers, exercise providers, health services managers, and peak organisation representatives) that had the broad aim of informing approaches to optimise uptake and sustained participation in increased physical activity for people with mild dementia. The shared decision support tool notes assessment items (relating to physical performance measures) and questions that may influence physical activity decisions (including previous and current physical activities, health problems impacting physical activity, transport factors, and costs). It will be an A4 page with prompt questions and progresses the users (the health professional, the person with dementia and their carer) through to the stage of identifying one or more preferred physical activity options to follow up with in the local area. Physical activity options will include structured programs such as gym, group exercise or home programs; informal physical activity programs such as a walking program (individual or as a group), and recreational activities that have a physical activity component (eg lawn bowls, golf, dance). First home visit (~2.5 hours). Following recruitment and screening for eligibility criteria, an initial home visit will be organised by the study therapist (a Physiotherapist or Exercise Physiologist) at the home of the person with dementia and their carer. This first home visit will include (1) a consenting process (see details in the section of Ethics and ethical issues-consent and withdrawal) for the person with dementia +/- carers if applicable, (2) assessment of baseline physical performance outcomes; (3) identification of domains of physical performance (based on assessment outcomes) outside of age adjusted normal limits as potential intervention priorities, (4) discussion of physical activities that are likely to address impairments, (5) discussion about physical activities they enjoy, or have previously undertaken, and (6) discussion of physical activity options available locally. A shared-decision support tool (see above) will be used by the study therapist and the person with dementia (and their carer if they have one) to aid the decision making discussion used by the study therapist and the person with dementia and their carer in this home visit. This discussion will also incorporate the setting of physical activity goals. Whatever physical activity options are selected, each individual’s program will aim to: (1) address identified physical impairments; (2) incorporate multimodal (balance, strength and fitness) physical activities personalised to the person, across the week; and (3) progress dosage of physical activity intervention by 10-20% / month from the baseline physical activity level, starting from month 1 (e.g. if doing 30 min/week, initial target=36 min/week) and aiming to progress at each month to reach a minimum 12-month target of greater than or equal to 150 min/week. Progression principles for increasing dosage will be provided to participants/carers and discussed during motivational support calls during the 12 months intervention period. The total time of physical activity participation undertaken each week for new and/or changed physical activities as a result from participation in the study (frequency and duration) will be recorded in a physical activity diary on a weekly basis by the person with mild dementia or their carer. To assist with the discussion of physical activity options available locally, the Peninsula Health physical activity program directory will be utilised, as well as other programs the research team identify. Examples of local physical activity programs that may be discussed include group exercise (e.g. community health centre), Council on The Ageing strength training programs, gym programs, and walking programs. Individually tailored home exercise programs (provided by the study therapist) will also be offered as another option (it is anticipated this option may be selected by approximately 40%), augmented by telehealth options. Second home visit (~45 mins). The study therapist will perform a second home visit for the person with dementia and/or their carer at week 3 of the decision-making session (when the physical activity plan has commenced) to provide motivational support. Third home visit (~1 hour). The study therapist will perform a third home visit for the person with dementia and/or their carer at six months to repeat physical performance outcomes, and discuss participation level, participation barriers and facilitators, and sustained participation in physical activities longer term. Fourth home visit (~1 hour). The study therapist will perform a fourth (and final) home visit for the person with dementia and/or their carer at 12 months to repeat physical performance outcomes, and discuss participation level, participation barriers and facilitators, and maintenance of physical activity longer term. Motivational support (~20 minutes for each phone/video call). After the first home visit, motivational support will be provided by the study therapist through a series of telephone contacts. Seven phone calls (or video-conference) will occur in the months 0-6 of each individual’s intervention (suggested phone schedule at week 2, 6, 9, 12, 16, 20 and 24). Guided by the COM-B framework for behaviour change, the aim is to increase capability (defined as the individual's psychological and physical capacity to engage in the physical activity program by having the necessary knowledge and skills), provide motivation (defined as processes that energize and direct behaviour including goals and decision-making) and capitalise on the opportunity (defined as all the factors that lie outside the individual that make physical activity participation possible) to reinforce exercise behaviour. Each call will focus on discussing the program, challenges, barriers, facilitators, revisiting the goal and troubleshooting for solutions. If indicated, (e.g. health status change) additional home visits or phone calls may be scheduled.