The Impact of Regular Outdoor Walks on Depression in Individuals with Early Dementia and Informal Caregiver Stress: A Pilot Study

This master's research project investigated the effects of joint outdoor walks on caregiver stress and depression in individuals with dementia. According to Watt and colleagues (2021), nearly half of all individuals diagnosed with dementia will experience depressive symptoms, while 16% of the dementia population have been diagnosed with major depressive disorder. Caregivers of individuals with dementia also experience high levels of stress and burden, with at least 60% of dementia caregivers reporting high levels of stress (Pinquart, 2019). The study, Exercise Programs for People with Dementia, supports the idea that physical exercise can be a non-pharmacological intervention to alleviate depression in individuals with dementia and reduce caregiver stress (Forbes, 2015). There is limited research on how physical activity interventions can reduce caregiver stress levels, and no studies have explored the benefits of dyad outdoor walks for lowering both the depression levels in individuals living with dementia as well as their caregivers stress. The target population for this study is community- dwelling older adults with early-stage dementia and their informal caregiver. There were 3 participating dyads recruited. The Cornell Scale for Depression in Dementia (See Appendix A) and the Perceived Stress Scale (See Appendix B) were both self-administered by participants before and after the intervention period. This research study suggests that there is still much research needed in this area of caregiver stress, depression in dementia, and participating in regular physical exercise.

1 The Impact of Regular Outdoor Walks on Depression in Individuals with Early Dementia and Informal Caregiver Stress: A Pilot Study by Erianne Stewart The University of Utah, College of Nursing, Gerontology Interdisciplinary Program Master’s Project Aug 5, 2023 Supervisory Committee Dr. Nanci McLeskey Dr. Kara Dassel Dr. Gail Towsley 2 The Impact of Regular Outdoor Walks on Depression in Individuals with Early Dementia and Informal Caregiver Stress: A Pilot Study Executive Summary This master’s research project investigated the effects of joint outdoor walks on caregiver stress and depression in individuals with dementia. According to Watt and colleagues (2021), nearly half of all individuals diagnosed with dementia will experience depressive symptoms, while 16% of the dementia population have been diagnosed with major depressive disorder. Caregivers of individuals with dementia also experience high levels of stress and burden, with at least 60% of dementia caregivers reporting high levels of stress (Pinquart, 2019). The study, Exercise Programs for People with Dementia, supports the idea that physical exercise can be a non-pharmacological intervention to alleviate depression in individuals with dementia and reduce caregiver stress (Forbes, 2015). There is limited research on how physical activity interventions can reduce caregiver stress levels, and no studies have explored the benefits of dyad outdoor walks for lowering both the depression levels in individuals living with dementia as well as their caregivers stress. The target population for this study is communitydwelling older adults with early-stage dementia and their informal caregiver. There were 3 participating dyads recruited. The Cornell Scale for Depression in Dementia (See Appendix A) and the Perceived Stress Scale (See Appendix B) were both self-administered by participants before and after the intervention period. This research study suggests that there is still much research needed in this area of caregiver stress, depression in dementia, and participating in regular physical exercise. 3 Background and Significance Introduction It is estimated that 50 million people have dementia worldwide. Additionally, there are nearly 10 million new diagnoses every year (World Health Organization, 2017), a number expected to increase to nearly 131 million by 2050 (Sampaio, 2021). Dementia is “a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is a disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment” (World Health Organization, 2016). Dementia consists of three stages—mild, moderate, and severe. Also known as early, mid, and late-stages. Prevalence of Depression in Dementia “Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depressive disorder or clinical depression, it affects how you feel, think and behave and can lead to a variety of emotional and physical problems” (“Depression (Major Depressive Disorder)”, 2022). According to Watt and colleagues (2021), nearly half of all individuals diagnosed with dementia will experience depressive symptoms without a formal diagnosis, while 16% of the dementia population at large have been specifically diagnosed with a major depressive disorder. Depression in older adults may be difficult to recognize when it’s compared to depression in younger adults. For older adults, sadness may not be their main symptom. Instead, it could be a feeling of numbness or loss of interest in their usual activities or 4 hobbies (“Depression and Older Adults”, 2021) Depressive symptoms may result in the following behaviors: persistent sad, anxious, or “empty” mood, hopelessness, irritability, restlessness, aggression, agitation, inability to sleep, decreased energy, refusing to eat, tearfulness, weight loss, withdrawing from others, and thoughts of suicide or death. (“Depression and Dementia”, 2021, and “Depression and Older Adults”, 2021). These symptoms cause adverse health outcomes, including lower quality of life, functional decline, and a higher risk of death. This in turn adds increased distress, burden, and depression in caregivers (Watt et al., 2021). Historical Interventions for Depression in Dementia Historically, the first line of defense against depression and other behavioral and psychosocial symptoms in dementia (BPSD) has been pharmacological interventions (Hsu et al.,2017), however, these drugs pose several side-effects such as impaired day-time wakefulness, increased risk of metabolic syndrome, cardiovascular events, and overall mortality (Sink et al., 2005, Hsu et al., 2017) that could be avoided if non-pharmacological interventions were utilized. As such, non-pharmacological interventions are gradually becoming accepted and considered to be an appropriate “first-line” treatment (Hsu et al.,2017). Physical exercise is one such non-pharmacological intervention that has been studied for its potential to alleviate depression in individuals with dementia (Forbes et. al, 2015). However, there is minimal research on the topic of outdoor walks reducing depression in individuals living with dementia. In the few studies found, these were the outcomes 1) no change was noticed in depressive symptoms (Potter et al., 2011, and Hernandez et al., 2015), and 2) one study found convincing 5 evidence that walking can reduce depression in individuals living with dementia (Brett et al., 2016). Due to insufficient research in this area, and the sparse studies conducted which report conflicting data, further research is necessary. Prevalence of Caregiver Stress Discussing individuals with dementia, especially with depression cannot be fully addressed without also acknowledging their family caregivers and the hurdles many of them face daily. Almost two-thirds of people with dementia live at home and receive support from family (Saxl, 2014). That suggests that nearly 31 million family members are supporting someone with dementia. Because family caregivers bear the primary burden of caring for someone living with dementia, it is critical to also explore the effects of physical activity interventions on caregiver stress (Farran, 2016). This is especially important given that at least 60% of dementia caregivers experience high levels of stress and burden (Pinquart, 2019). Garcia-Ptacek and fellow researchers (2019), reiterate how difficult caregiving is, and how the needs of the care recipient evolve over time which in turn changes the relationship between the caregiver and the recipient. As a result, it is crucial the caregiver finds strategies that will help their overall health during their caregiving journey. It is estimated that caregivers spend an average of 64 months as a caregiver (de Labra C. et al., 2015). This is 64 months of them postponing their health and well-being. It is unfortunate that some caregivers often refuse or withdraw from interventions targeted at them, and little research even exists on caregiver participation in research focused on their physical activity (Garcia-Ptacek et al., 2019). 6 Benefits of Walking for Stress and Depression Forbes (2015) reports that outdoor walks may be particularly beneficial for reducing caregiver stress. And while there is only limited research available on the topic, increasing a caregiver’s physical activity is a possible intervention in helping them with their overall health (Farran, 2016). This same study also mentioned that there have been many research studies that have provided substantial evidence that active people experience 30% less distress, 45% lower depressive symptoms, and 30% higher odds of experiencing enhanced well-being than inactive people. Although these statistics didn’t necessarily focus on caregivers specifically, we can hypothesize that increasing physical exercise in caregivers would produce some of the same benefits. Unfortunately, few studies have been conducted to increase caregiver physical activity (Farran et al., 2016). Of the studies that have been conducted they noted that physical activity interventions are feasible, they showed improved caregiver self-efficacy and physical activity, decreased psychological distress, and improved caregiver energy expenditure, stressinduced blood pressure reactivity and sleep (King A. et al., 2022). The Gap in Research There is a significant gap in research in regard to joint dyad studies on the effects physical exercise, and particularly outdoor walks, can provide for both individuals living with dementia and their primary caregiver. In a research study by Brett et al. (2016) found benefits in participants (individuals with dementia) when there was a caregiver or therapist supervising their physical activity. However, the caregiver or therapist was not participating in the study 7 with the individual who had dementia. As a result, no benefits were noted for the caregiver or therapist. Again, little research is out there on dyad studies focused on this topic. Research Purpose and Objectives The purpose of this master's research project is to investigate the effects of joint outdoor walks on caregiver stress and depression in individuals with dementia. Given the prevalence of depressive symptoms in individuals with dementia and the high levels of stress experienced by their caregivers, this study aims to explore whether joint physical activity interventions can serve as a non-pharmacological approach to alleviate depression in individuals with dementia and reduce stress levels in their informal caregivers. Study Objectives: 1) To assess the level of depression in individuals with early-stage dementia before and after participating in joint outdoor walks. 2) To measure the perceived stress levels of informal caregivers of individuals with earlystage dementia before and after engaging in joint outdoor walks. 3) To determine the potential benefits of joint outdoor walks as a non-pharmacological intervention for reducing depression levels in individuals with dementia. 4) To investigate the effectiveness of joint outdoor walks in lowering stress levels among informal caregivers of individuals with dementia. 8 5) To contribute to the existing body of knowledge on physical activity interventions for individuals with dementia by exploring the specific benefits of joint dyad outdoor walks for both individuals with dementia and their caregivers. 6) To offer recommendations and implications for future research and the development of targeted interventions aimed at improving the mental health outcomes of individuals with dementia and their caregivers. Hypothesis Informal caregivers who walk outdoors regularly with an individual living with dementia will experience less stress over the 4-week intervention period. Individuals with dementia who walk outdoors regularly with their informal caregivers will experience less depressive symptoms over the 4-week intervention period. Research Questions Do individuals with dementia who walk outdoors daily with their informal caregivers experience lower levels of depression than when they do not? Do informal caregivers who care for someone with dementia experience lower levels of stress when walking outdoors daily compared to when they do not? Does the informal caregiver’s level of perceived stress increase when they regularly walk outdoors with their loved ones with dementia? 9 Methods Proposal and Approval The principal investigator (PI) of this required master’s project research study is a Gerontology Master’s student. As a result, an oversight committee was chosen from within the University of Utah’s Gerontology Interdisciplinary Program. After reviewing the research study proposal and completing the colloquium presentation, the committee approved the study. Submission to the University of Utah’s Institutional Review Board (IRB) was later approved as exempt. Participants This study involved dyads, or two individuals maintaining a sociologically significant relationship. Evidence suggests that when caregivers and clients are treated as a dyad, the outcomes for both individuals improve (Collins et. al, 2011). The target population for this study was community-dwelling older adults with early-stage dementia and their informal caregiver that met certain criteria. This criterion included an informal caregiver that was caring for the individual with dementia for more than 20 hours per week. Both individuals were physically capable to ambulate on their own, and both the individual with dementia and their caregiver consented to participate. Both the caregiver and individual with dementia were Englishspeaking. Recruiting To recruit participants for this study the PI designed an informative and compelling flier (See Appendix C) to distribute to 3-4 adult day facilities in Utah and Southern California. These 10 flyers were directed at caregivers and were readily available for them to receive upon the dropoff or pick-up of their care recipient. Before dropping the fliers off at these day facilities, the PI met the director or manager of the facility. Mody and colleagues (2008) discusses the importance of developing relationships with faculty and staff and with key providers of community services such as adult day cares. These relationships could help facilitate recruitment in order to recruit more individuals, network, and make connections for future endeavors. The second recruiting strategy was to reach caregivers through social media, specifically Instagram. The PI utilized an Instagram page with activity ideas for those living with dementia that has over 4,500 followers, and so the research study flier (See appendix C) was shared with them, as well as like-minded creators to share on their page and with their followers. The main goal was to let caregivers know they would be helping further research and their participation would be valuable to the community of dementia caregivers and the individuals living with dementia. The recruitment flier contained the specifications for the participants who will be included in the study. Those specifications meant the individuals who participated in the study must be—community-dwelling, have early-stage dementia, be able to walk on their own or with some assistance, and the caregiver must be their primary informal caregiver meaning that this is not a paid position and were willing to participate in the study. Enrollment As potential participants reached out regarding the study flier, they were asked a few screening questions to ensure they would qualify for the study. These questions included, “can 11 both you and your care recipient walk for at least 15 minutes at a time?”, “what stage of dementia is your care recipient in, and can they consent to participate in this study?”, and “are you the primary caregiver for the individual living with dementia?”. The PI also shared the consent email (See Appendix F) to ensure the participants understood what the expectations were and allowed them to ask any questions they had regarding the research study. The individual with dementia consented to participate through their informal caregiver. Informed Consent After sending the informed consent email (see Appendix F) the participants knew that by submitting the pre-intervention questionnaire and both pre-surveys they were consenting to participate in the study. This consent without documentation process was exempt from the IRB. There was minimal risk to participants and the IRB didn’t require any additional documentation that needed further approval. Included in the informed consent email was a detailed overview of what the research study involved, information on the perceived risks and benefits of participating in the study, explanation of voluntary participation, no cost from the participants, and at the end of the research study each dyad received a $50 gift card for their time. Data Management Completed survey data and questionnaires were de-identified and stored on a password protected computer. A master copy of the participant’s names was kept in a separate file. All identifying data was destroyed upon the completion of the project. 12 Materials The outdoor walking intervention was done within the community, so the participants didn’t need any physical equipment or access to a facility. All documents (Pre-intervention questionnaire, Walking Log, Cornell Scale for Depression in Dementia, and Perceived Stress Scale) were received through email, and the participants were told that if they had any questions or concerns during the intervention period, they were able to reach out to the PI who would be an available resource throughout the entire study. Below is an explanation and breakdown of each document (evidence-based surveys, and documents created by the PI) used for this research study. Pre-Intervention Questionnaire The Pre-Intervention Questionnaire (See Appendix D) is a 10 question survey the caregiver was asked to fill out prior to starting the walking intervention. This survey examined the caregiver age, gender, race, relationship to care recipient, and hours of care they gave a week. It also gave us an idea of their current walking situation both with and without the individual living with dementia. Lastly, it showed how they perceived walks and what walks could do for their stress and overall well-being. Walking Log The walking log (See Appendix E) was created by the PI for the caregivers to simply put a check on the days they walked 15 minutes or more. The goal was simplicity so as to not add more stress or confusion to their daily routine. 13 The Perceived Stress Scale The Perceived Stress Scale (Cohen et al., 1983) (See Appendix A) is a stress assessment that was developed in 1983 originally. It helped us to better understand how different situations affect our feelings and perceived stress. All responses to this assessment were considered from the previous month before taking the assessment. It is a 10-question assessment that has a 0–4-point scale. 0=Never, 1=Almost Never, 2=Sometimes, 3=Fairly Often, 4=Very Often. Scores can range from 0-40 with higher scores indicating higher perceived stress. Scores ranging from 0-13 are considered lower stress. 14-26 are considered moderate stress. 27-40 are considered high perceived stress. This scale was used for caregivers in assessing their stress levels pre and post study. The Cornell Scale for Depression in Dementia The Cornell Scale for Depression in Dementia (Alexopolous et al., 1988) (See Appendix B) is a screening tool to determine the level of depression in individuals living with dementia. It uses a scoring system of a= unable to evaluate, 0= absent, 1=mild or intermittent, 2=severe. From the scale it mentions, ratings should be based on symptoms and signs occurring during the week prior to the interview. No score should be given if symptoms result from physical disability or illness. Caregivers administered this test to their care recipient with dementia. Both scales (The Perceived Stress Scale and the Cornell Scale for Depression in Dementia) were chosen over others for their ease of use, quick to complete, and ability to conduct without help from the research team. The factor that was considered in choosing scales for this research was to not add more stress to the caregivers during the study. All three (Perceived Stress Scale, Cornell Scale for Depression in Dementia, and the Pre-intervention 14 Questionnaire) of these tools should take no longer than 45 minutes to complete, and they are to be administered by the caregiver. Study Timeline Table 1. Study Timeline May 2023 Recruiting/consent period June 2023 Pre-survey, Intervention period, Post Survey July 2023 Collect, analyze, document data Aug 2023 Final Defense May was the beginning of the recruiting process. The PI visited 1 adult day facility and 1 senior center in Utah and reached out to 2 more by telephone or email in California. After meeting with these managers and explaining the research study to them the PI requested that the recruitment flier (See Appendix C) be available for their clients and their informal caregivers. Lastly, social media was utilized to send the flier to informal dementia caregivers through social media posts and stories and sharing with other dementia educators to share with their community. In late May/early June after consenting to participate in the study they received the PreIntervention Questionnaire (Appendix D), the 2 surveys Perceived Stress Scale and the Cornell Scale for Depression in Dementia (Appendix A and B), and the walking log (Appendix E) to complete before beginning the intervention in June. 15 At the beginning of July after the 4-week trial period, the PI sent out the surveys again to complete, and submit the walking log and journal. All the data from these pre and post surveys were then analyzed and synthesized into the research paper. Procedure Instead of a randomized controlled trial design, this study was done as a quasiexperimental design as a one-group pretest-posttest. Each caregiver completed a pre- and postintervention survey, the Perceived Stress Scale (See Appendix A) for caregivers and The Cornell Scale for Depression in Dementia (See Appendix B) for the individuals living with dementia. These were used to document their perceived level of depression and perceived level of stress before and after the 4-week walking intervention. The informal caregiver also took the preintervention questionnaire (See Appendix D) and recorded the frequency of outdoor walks each week on the walking log (See Appendix E). In the text Approaches to Social Research it is mentioned that the ultimate goal of measurement is to specify simply and clearly observable referents of the terms contained in the hypothesis. However, the terms must first be considered before getting to that point. As a result, the entire measurement process moves from the abstract to the concrete (Singleton, 2017). Ultimately, the goal was to measure the individual with dementia’s level of depression and the caregiver’s level of stress both before and after the outdoor walking intervention. This was to test the effectiveness of the 4-week outdoor walking intervention to determine if their stress and depression was in fact lowered because of the joint outdoor walks. 16 Results Participants The goal was to recruit a total of 3-5 dyads for this research study, and a total of 3 dyads were recruited. 2 other informal caregivers showed interest, but injuries that happened just before they consented did not allow them to follow through with the study. Each of the 3 dyads were recruited through social media as they saw the recruitment flier and messaged the PI for additional information. As they each went through the screening questions over direct message and qualified, they were sent the Informed Consent email (See Appendix F) to participate by email. The participants understood that by submitting their pre-intervention questionnaire and survey that they consented to participate, and as a result it secured their spot in the research study. Participant Flow After each participating dyad consented for their participation in this research study they were contacted weekly by email or text message, depending on their preference, as a reminder and to check-in and see how they were doing with their walks. The PI also sent simple motivational messages and tips like, how to stay hydrated on hot summer days to help them continue to have a positive experience. After completing and returning their post-surveys, each participating dyad received a $50 gift card by email. Pre-Intervention Survey Table 2. Pre-Intervention Survey Pre-Survey Questions for Caregivers Age Gender #1 40-50 Female #2 40-50 Female #3 50-60 Female 17 Race Hispanic White Relationship Child Child Hours caring per week 40+ 40+ Walk without PLWD (Scale of N/A - 7) 5 2 Walk with PLWD (Scale of N/A - 7) 5 1 Perceived importance of walking (Scale of N/A - 5) 5 5 Perceived ability to decrease stress by walking (Scale of N/A - 5) 5 5 Enjoy walks? (Yes or No) Y Y *(See Appendix D for more details) *PLWD=Person living with dementia White Child 40+ N/A 1 4 5 Y Table 2 shows the responses of the participants from their Pre-Questionnaire Survey (See Appendix D). All three caregivers were women between the age of 40-60. All three were caregivers for their mother living with dementia and spent more than 40 hours a week as their primary caregiver. Caregiver 1 engaged in five walks per week, both with and without her care recipient, prior to the research study. Caregiver 2 walked two days a week on average without her mother, and one day a week with her mother. Caregiver 3 never went on walks without her mother, and only walked with her mother one day a week on average. Caregiver 1 and 2 noted a five, or a strong belief, on their perception of how important walks are to their overall wellbeing. Caregiver 3 noted a four. All 3 caregivers strongly believed that walks would decrease stress. Lastly, all three participants shared they enjoyed walks. Walking Log Summary The results of the participants' consistency of walking the required 3 times a week for 15 minutes for 4 weeks were as follows. Caregiver 1 walked twice the first week, three times the second week, four times the third week, and one time the fourth week. Caregiver 2 walked 18 three times the first week, three times the second week, two times the third week, and two times the fourth week. Caregiver 3 walked three times each of the 4 weeks. Statistical Analysis As mentioned previously, this was a quasi-experimental design study with a one group pre-test posttest. Analyzed in the tables below is everyone’s score on the Perceived Stress Scale for the caregivers and the Cornell Scale for Depression in Dementia for the care recipients both before and after the 4-week walking intervention. The group’s mean score was also analyzed to show overall changes in their perceived stress and depression levels. Perceived Stress Scale Results As seen in Table 3, Caregivers 1 and 2 were in the low stress category, and caregiver 3 is in the moderate stress range. However, when looking at the group the mean score between the three participants is 13.67. This overall group score is still in the low stress range. After the 4-week study the mean remains the same at 13.67 which was still in the low stress category. Although the mean remained the same, there were individual changes within the specific survey questions that would be important to discuss below. 19 Table 3. Perceived Stress Scale Question 1 “How often have you been upset because of something that happened unexpectedly?” Caregiver 1 noted in their pre-survey that she ‘sometimes’ felt this, and in her post survey noted she ‘fairly often’ felt this. Numerically this would be a 50% increase in feeling more upset because of unexpected situations. Caregiver 2 noted no change at ‘Never’ feeling this way. Caregiver 3 noted feeling ‘Fairly Often’ upset in the beginning and then in her post survey marking ‘Almost Never’, so she experienced a 66% decrease in this category. As a group they showed lower levels of being upset from unexpected situations by 20%. 20 Question 2 “How often have you felt that you were unable to control the important things in life?” Caregiver 1 noted no change at ‘Sometimes’ feeling this way. Caregiver 2 noted no change at ‘Almost Never’. Caregiver 3 noted a change from ‘Almost Never’ to ‘Sometimes’ on her pre and post survey. Numerically this is a decrease in feeling able to control the important things of life by 100% for caregiver 3. As a group they reported being 25% less able to control the important things in their lives at the completion of the study. Question 3 “How often have you felt nervous or stressed?” None of the participants experienced any change in this category. However, each caregiver started at different baselines. Caregiver 1 noted feeling ‘Almost Never’ stressed or nervous. Caregiver 2 noted feeling ‘Never’ stressed or nervous. Caregiver 3 noted feeling ‘Sometimes’ stressed or nervous. Question 4 Questions 4, 5, 7, and 8 each appear with an asterisk in the table above. Simply put, these questions change from a negative form of the question in the pre-test, to a positive form in the post test. This provides a check on the applicant and helps uphold the integrity of the test. For this reason, the results in the table above include the numeric responses consistent with the scoring on the Perceived Stress Scale as opposed to simply the participants response. Question 4: “How often have you felt confident about your ability to handle your personal problems?” Caregiver 1 reported feeling “Fairly Often” in both tests, showing no change. Caregiver 2 noted at the beginning of the study ‘Sometimes’ and ‘Very Often’ at the end. According to the PPS score, this shows a 50% decrease in stress levels. Caregiver 3 marked 21 ‘Fairly Often’ in the initial report and “Sometimes” at the end. Overall, leaving no change in PSS score at the group level. Question 5 “How often have you felt that things were going your way?”. Caregiver 1 stayed the same at ‘Sometimes’. Caregiver 2 stayed the same at ‘Fairly Often’. And Caregiver 3 remained the same at ‘Sometimes’, resulting in no change at both the caregiver and group level. Question 6 “How often have you found that you could not cope with all the things you had to do?” Caregiver 1 remained constant at ‘Never’. Caregiver 2 remained constant at ‘Almost Never’. Caregiver 3 dropped from ‘Sometimes’ to ‘Almost Never’ or a 50% decrease in stress, or 33% decrease when measured as a group. Question 7 “How often have you been able to control irritations in your life?”. Both Caregiver 1 and Caregiver 2 initially reported “Fairly Often” initially, and “Very Often” in their Post tests, both showing a 100% decrease in stress; while Caretaker 3 reported “Sometimes” in the pre-test and “Never” in their post-test, resulting in a 100% increase in stress. As a group, they showed no change in stress levels from start to finish. Question 8 “How often have you felt that you were on top of things?” In response to this question, each caretaker reported no change with Caretaker 1 reporting “Almost Never” to both tests, and Caretaker 2 & 3 reporting “Sometimes” to both tests. 22 Question 9 “How often have you been angered because of things that happened that were out of your control?” Caregiver 1 dropped from ‘Sometimes’ to ‘Almost never’, a 50% decrease. Caregiver 2 increased from ‘Never’ to ‘Almost Never’. Caregiver 3 decreased from ‘Sometimes’ to ‘Almost Never’, again a 50% decrease like Caregiver 1. Question 10 “How often have you felt difficulties piling up so high that you could not overcome them?” Caregivers 1 and 2 went from ‘Never’ to ‘Almost Never’. Caregiver 3 dropped from ‘Sometimes’ to ‘Almost Never’, a 50% decrease. Perceived Stress Scale Group Results Summary Looking at the group’s pre and posttests, we observed several areas that showed a significant improvement following the walking intervention. The group showed a 20% decrease in participants feeling upset “because of something that happened unexpectedly” and also showed a 33% decrease in participants finding that they “...could not cope with all the things [they] had to do”. The areas where the group showed an increase in stress over the course of the study included: “How often have [they] felt that [they] were unable to control the important things in life”, with an increase of 25%; in addition to a 50% increase in stress in “How often have [they] felt difficulties piling up so high that [they] could not overcome them”. The following areas showed no change throughout the walking intervention: feeling nervous or stressed, confidence in their ability to handle personal problems, feeling like they were on top of things, their ability to control the irritations of life, angered because of things 23 that happened that were out of their control, how often things were going their way in life, and confidence in handling their personal problems. Cornell Scale for Depression in Dementia Results Table 4 below will show the results from the care recipients pre and post surveys with the Cornell Scale for Depression in Dementia. 24 Table 4. Cornell Scale for Depression in Dementia 25 Care Recipient 1 would be considered in the major depressive episode category scoring a 20 prior to the walking intervention. Care recipients 2 and 3 showed very low signs of depressive episodes, with respective scores of 5 and 8. When looking at the results of the group as a whole on the pre-test, the mean score was 11. However, that number jumped slightly to 11.66 on the post-test surveys. This is still in the possible major depressive episode category. Interestingly, only one care recipient increased their overall depression score on the postsurvey. More in depth results follow. The Mood-related Signs This category includes 4 questions that when combined at the group level show no change throughout the study. However, question 1 “Anxiety-anxious expression, ruminations, worrying” showed a 50% decrease in anxiety/worrying by Care Recipient 1, and no change for Care Recipient 2 and 3. Regarding Question 2, “Sadness- sad expression, sad voice, tearfulness”, Care Recipient 1 experienced a 50% improvement, while Care Recipient 2 saw no change, and Care Recipient 3 went from being “absent” of such feelings to having “mild or intermittent” feelings of Sadness. Question 3, “Lack of reactivity to pleasant events” saw an overall increase from being “absent” in all three Care Recipients to “mild” in Care Recipient 1 and Care Recipient 3, with Care Recipient 2 seeing no change. Question 4, “Irritability- easily annoyed, short-tempered” saw no change from Care Recipient 1 and 2 but did see an increase from Care Recipient 3 from such feelings being “absent” to “mild or intermittent”. 26 Behavioral Disturbances This category contains 4 questions, showing an overall increase in points on the CSDD scale in 2 of the 4 questions. Question 1, “Agitation-restlessness, handwringing, hair pulling” saw no change at both the group level and the individual level with Care Recipient 1 showing “Severe” levels, and Care Recipient 1 and 2 being “absent” of such. Question 2, “Retardation- slow movements, slow speech, slow reactions” overall saw a slight increase in 1 of the 3 Care Recipients. For example, the results showed an increase from “absent” to “mild or intermittent” in Care Recipient 1, while Care Recipient 2 & 3 saw no change from such signs being “absent”. Question 3, “Multiple physical complaints” similarly saw a slight increase as a group from 2 to 4, with no change from Care Recipient’s 1 & 2 at “mild or intermittent” and a jump from Care Recipient 3 from being “absent” to “Severe”. Question 4, “Loss of interest- less involved in usual activities”, overall saw no change at the group level. This was also the case for Care Recipient 1; however, Care Recipient 2 did see an increase from “absent” to “mild or intermittent”, while Care Recipient 3 saw a decrease from “mild or intermittent” to “absent”. Physical Signs This category contains 3 questions and showed no overall change at the group level; but did experience changes by at least on Care Recipient for each question. Question 1, “Appetite loss - eating less than usual”, saw a slight total increase as the corresponding Caregiver’s noticed a change from “absent” to “mild or intermittent” for Care 27 Recipient’s 1 & 3, while Care Recipient 2 experienced a decrease of “mild or intermittent” Appetite loss to being “absent”. Question 2, “Weight loss - score 2 if greater than 5lbs in a month”, saw an overall decrease at the group level from a total score of 1 to 0 at the group level. The change came from Care Recipient 2 showing “mild or intermittent” during the pre-test and showing “absent” at the post test. The other two Care Recipients saw no change as their caregivers saw an “absen[ce]” of weight loss at both stages. Question 3, “Lack of energy - fatigues easily, unable to sustain activities” saw no change at the group level. However, Care Recipient 2 saw a decrease in energy while Care Recipient 3 experienced an increased energy level, and Care Recipient 1 saw no change at all. Cyclic Functions This category contains 3 questions with results showing an increase on 2 of the 3 questions. Question 1, “Diurnal variation of mood - symptoms worse in the morning”, each Care Recipient showed “absent” at pre-test, with no change for Care Recipient 2 & 3, but an increase to “mild or intermittent for Care Recipient 1. Question 2, “Difficulty falling to sleep - later than usual for this individual” produced multiple changes. For Care Recipient 1, they experienced an increase from “absent” to “mild or intermittent” and Care Recipient 2 also saw an increase from “mild or intermittent” to “Severe”, while Care Recipient 3 saw a decrease from “mild or intermittent” to “absent.” 28 Question 3, “Multiple awakenings during sleep saw no change at the group level. Care Recipient 1 experienced no change, while Care Recipient 2 saw an increase (1 to 2) and Care Recipient 3 saw a decrease from 1 to 0. Question 4, “Early-morning awakenings - earlier than usual for this individual”, saw no change overall but saw a 2 to 1 decrease for Care Recipient 1, an increase of 0 to 1 from Care Recipient 2 and no change for Care Recipient 3, staying a 1 (mild or intermittent) for both pre and posttests. Ideational Disturbances This category contains 4 questions, with an overall decrease of 75% at the group level. Question 1, “Suicide - feels life is not worth living, has suicidal wishes or makes suicide attempt”. Care Recipients saw no change with all experiencing “absent” in this regard. Question 2, “Poor self-esteem, self-blame, self-deprecation, feelings of failure”, saw no change with Care Recipient 1 maintaining “Severe” and Care Recipient’s 2 & 3 maintaining “absent”. Question 3, “Pessimism- anticipation of the worst” saw a decrease of 66.6% at the group level with Care Recipient 1 seeing a 50% improvement, no change from Care Recipient 2, and a drop from “mild or intermittent” to “absent” for Care Recipient 3. Question 4, “Mood - congruent delusions - delusions of poverty, illness or loss” saw a decrease of 50% at the group level. Care Recipient 1 went from “Severe” to “mild or intermittent” while Care Recipient’s 2 & 3 remained unchanged at “absent”. 29 Summary Dyad 1 There could have been some level of progression in the care recipient’s dementia making them overall less communicative and interactive, which helps the caregiver feel less stress on daily care and activities, although more stressed as it pertains to their perception of their ability to improve or affect their care recipient’s life and potentially cross over into their view of themselves and what they can control own life. This is why they may feel all the “piling up” of life as described in the questionnaire. Dyad 2 There is a good chance the walks were helping caregiver 2 because they felt more confident in their ability to handle their problems and the irritations of their life. While it appears, there is a conflicting response regarding how they are able to control their life but also not be able to control their surroundings, it makes more sense as we learn that their care recipient has been having trouble falling to sleep, waking up multiple times at night, and even waking up earlier than usual. If the care recipient hasn’t been on walks before it is not unreasonable to assume they are experiencing soreness from those walks, which could be indicated by their loss of interest in being involved with usual activities. Dyad 3 The results are very interesting. It would be informative to interview this care recipient to better understand her physical complaints, irritability, and disinterest in pleasant events. Each of these could be caused from additional physical activity or pain caused from walking, while at the same time improving sleep due to exhaustion and more energy from improved 30 sleep. Meanwhile, for the caregiver, walking seemed to have helped them handle the things that come up in life whether that is coping or dealing with unexpected occurrences. However, they may feel a sense of confusion and lack of control as a result of their loved one having increased pain despite these other obvious benefits. Discussion The purpose of this research study was to test the impact regular outdoor walks had on the level of depression in individuals with dementia, and their caregiver’s level of perceived stress. The hypothesis included 1) Informal caregivers who walk outdoors regularly with someone living with dementia will experience less stress, and 2) Individuals with dementia who walk outdoors with their informal caregivers regularly will experience fewer depressive symptoms. Below are the key findings and interpretations from this research study. The results from this 4-week walking intervention testing the impact outdoor walks have on caregivers' stress levels and individuals living with dementia’s level of perceived depression show that the caregiver’s level of perceived stress remained the same over the 4-week walking intervention. The level of perceived depression in individuals with dementia slightly increased over the 4-week period. However, it should be noted that only one care recipient, care recipient 2, increased their overall depression score during the research study. Care recipient 1 stayed the same at 20 which is a definitive major depressive episode, and care recipient 3 slightly decreased in her overall depression level from a 8 to a 7, which is below a possible major depressive episode. Below will be discussed each of the 3 dyad’s possible interpretations from their results. 31 Dyad 1 (Caregiver 1 and Care recipient 1) Caregiver 1. As we take a deeper look into each dyad’s experience, we can note several changes. Caregiver 1 and Care recipient 1 both were walking regularly before the study. In the caregiver’s pre-intervention questionnaire, she answered that they were walking 5 times a week together, and 5 times a week without her mother. This could have contributed to the fact that neither of their scores changed over the course of the 4-week study. It would also be interesting to conduct an interview with this dyad to investigate further into Care Recipient 1’s perceived depression levels. Since she was walking already prior to this study it would be interesting to find out if her depression was even worse months before and that is why they started to walk. At the very least, it would be interesting to find out why they began walking regularly together. Caregiver 1 started out at a 13 on the PSS scale, and they ended at a 13 after their posttest. Overall, it shows that they have a lower level of stress and no major changes across the board. She did see improvements in how she was angered because of how things happened out of her control. As well as how often they were able to control irritations in life. However, they did see an increase in stress when it came to how often they felt difficulties were piling up so high that they could not overcome them. As well as how often they had been upset because of something that had happened unexpectedly. Care recipient 1 when it came to mood-related signs, specifically saw a decrease in anxiety and sadness, no change in irritability, and a slight improvement in lack of reactivity to pleasant events. Behavioral disturbance saw an overall increase, specifically in retardation and appetite loss. Physical signs saw an overall slight increase with more of an appetite than before 32 the study. Cyclic function saw an overall increased diurnal variation in the morning, difficulty falling to sleep. But an improvement in waking up later. Ideational disturbances there was an improvement specifically in pessimism and mood congruent delusions. Dyad 2 (Caregiver 2 and Care Recipient 2) Caregiver 2 had mentioned that she is a sandwich caregiver, meaning she is not only taking care of her mother but also her children at home. This factor could have caused an increased level of stress throughout the study that the other caregivers did not face. She was only walking 2 times a week on average without her mother, and 1 time a week with her. However, she did mark a 5 on her perceived importance of walking and perceived ability to decrease stress by walking. So, although she was not participating in regular walks both by herself or with her mother, she did recognize the importance of them for her overall health and stress levels. Caregiver 2 started out at a 9 on the PSS pretest and with the same score in the post test. However, there was improvement in how often they felt confident in their ability to handle personal problems in addition to how often they were able to control irritations in life. However, they saw an increase in anger because of things that happened out of their control and how often they felt difficulties were piling up so high that they could not overcome them. Care Recipient 2 started out at a 5 on the Cornell Scale for Depression in Dementia and ended at an 8. So, related to depression there was a slight increase. They did see physical signs of improvement with an improved appetite and lack of weight maintenance. They did see a loss of interest in being involved with usual activities. They did see a lack of energy, difficulty falling to sleep at night, multiple awakenings at night, and waking up earlier than usual. 33 Dyad 3 (Caregiver 3 and Care Recipient 3) Caregiver 3 was in the older age category (50-60) than the other two participating caregivers (40-60). She was not walking at all by herself before the study, and only noted 1 walk on average a week with her mother. However, she, like caregiver 2, recognized the importance of walking on her overall health by marking a 4 out of 5 on the scale, and a 5 out of 5 on the recognition of the importance of what walks could do for her stress levels. She also began walking 3 times a week during the study, so she did double her average number of walks per week. Overall, there was no change in the PSS score between the pre and posttest. However, there were improvements and declines in certain areas. The improvements were feeling less upset because something happened unexpectedly, they also saw improvement in their ability to cope with all the things they had to do, and felt they were able to handle more things piling up. Some of the declines included how often they felt in control of their life, in their confidence, improvement in their ability to handle personal problems, and ability to control irritations in life. Care Recipient 3 saw a decrease from 8 to 7 on the Cornell Scale for Depression in Dementia. They had a decrease in their level of sadness, more interest in being involved in activities, more energy, improved ability to fall to sleep, less awakening during sleep, and less pessimism. There was an increase in physical complaints, less of an appetite, more irritability and less reactivity to pleasant events. 34 Barriers Moving Forward There are a few perceived barriers to conducting this type of research study in the future. The first is being able to recruit caregivers who will participate in this type of study who are not already regularly walking on their own, and who do not enjoy walking or physical exercise. It may also be difficult to recruit participants who are on the higher end of perceived stress because they may not want to add more to their daily routine. Another barrier is that it is hard to differentiate the outside factors of depression and stress. These could include injury, sickness, stress from a job, death of a loved one, diet, sleeping patterns, etc. Because it is a field-study there are many things that could be going on in an individual’s life that the other participants in the research group are not experiencing. This could provide unfair or biased results. Lastly, having consistent walking environments for all participants could be challenging. Weather can be a barrier in being able to go on outdoors walks, and especially with an individual with dementia. If some participants have bad weather, they may not be able to participate as consistently as a participant who has great weather conditions. All these barriers should be considered when planning future research studies on this or similar topics. Limitations The study design discussed previously has several limitations. First, the lack of a control group makes it difficult to attribute any observed changes in the post-intervention survey solely to the outdoor walk intervention, as other factors could also contribute. The number of participants was very low with only 3 participating dyads. If there was a larger group, the results could be drastically different. The study may be affected by some degree of bias, as participants 35 who are more inclined to engage in outdoor walks or have a positive attitude towards them may be more likely to take part in the study. Individuals who are not as physically active, or do not enjoy walking may not want to participate. With this research being a field study, we encountered certain limitations that could occur like environmental factors contributing to not being able to walk outdoors, forgetting to walk, physical injuries, or just not wanting to participate. The length of the study is longitudinal of 4-weeks, there could possibly be other factors that contribute to the level of depression with the individual with dementia and the level of stress in the caregiver. Lastly, this study is only focused on individuals who can ambulate on their own. It would be interesting to consider if the individual with dementia was wheelchair bound if the stress levels of the caregiver would change as a result of having to push them on their walk. Recommendations for Moving Forward For future research, it would be suggested that these barriers and limitations are considered and addressed/implemented as the research teams deem necessary. It would also be suggested to only test caregivers who are already experiencing high levels of stress in their daily life and individuals with dementia who have major depressive symptoms, and are not currently walking, but would like to/find it important. This will give a more accurate representation of the impact regular outdoor walks play on their overall stress and depression levels. It may also be beneficial to conduct the research as both a quantitative and qualitative study so we can understand the responses from the participants under a different light. Much research is still needed in this area of caregiving and dementia care. Caregivers need as much support as possible, and conducting research in order to help understand their needs is crucial. 36 As discussed previously, the studies that have been conducted by other researchers (Sampaio et al., 2021, Watts et al., 2021, Farran, 2017) on depression in individuals with dementia have shown some positive outcomes by participating in physical exercise, particularly a better quality of life and less neuropsychiatric symptoms (Sampaio et al., 2021). Although not all care recipients in this dyad research study had their overall level of depression attenuate, all participants did see improvements in one area or another on the Cornell Scale for Depression in Dementia. Additionally, in future research if the suggestions for future research are implemented more benefits and improvements could be seen in both the individual with dementia as well as their informal caregiver. Conclusion The purpose of this research study was to test the impact joint outdoor walks have on an individual with dementia’s level of depression and a caregiver’s level of stress. Overall, according to the scales used throughout this study, the levels of depression in the individuals living with dementia did increase slightly, and the stress levels in the group of caregivers remained constant throughout the 4-week outdoor walking intervention. These findings add to the limited research on the topics of caregiver stress, depression in dementia, and the impact outdoor walks has on both groups, while continuing to point to the need for additional research and narrowing of scope. Together we can help make a meaningful difference in the lives of caregivers and individuals living with dementia. 37 References Alexopoulos, G. S., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23(3), 271–284. https://doi.org/10.1016/0006-3223(88)90038-8 Brett, L., Traynor, V. and Stapley, P. (2016), “Effects of physical exercise on health and wellbeing of individuals living with dementia in nursing homes: a systematic review”, JAMDA Vol.17, pp.104-116. Collins, L. G., & Swartz, K. (2011). Caregiver care. American Family Physician, 83(11), 1309– 1317. Cohen, S., Kamarck, T., and Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386-396. “Depression and Dementia.” Alzheimer's Society, 7 Dec. 2021, https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/depressiondementia. “Depression (Major Depressive Disorder).” Mayo Clinic, 14 Oct. 2022, www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007. “Depression and Older Adults.” National Institute on Aging, 7 July 2021, www.nia.nih.gov/health/depression-and-older- 38 adults#:~:text=Depression%20in%20older%20adults%20may,lack%20of%20interest%20in %20activities. De Labra C, Millan-Calenti JC, Bujan A, Nunez-Naveira L, Jensen AM, Peersen MC, Mojs E, Samborski W, Maseda A. Predictors of caregiving satisfaction in informal caregivers of people with dementia. Arch Gerontol Geriatr 2015; 60:380-8. Farran, Carol, et al. “Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial.” AIMS Medical Science, vol. 3, no. 1, 24 Nov. 2017, pp. 15–31., https://doi.org/10.3934/medsci.2016.1.15. Forbes, Dorothy, et al. Exercise Programs for People with Dementia, 15 Apr. 2015, https://www.cochrane.org/CD006489/DEMENTIA_exercise-programs-for-people-withdementia. Garcia‐Ptacek, Sara, et al. “The Caregiving Phenomenon and Caregiver Participation in Dementia.” Scandinavian Journal of Caring Sciences, vol. 33, no. 2, 2018, pp. 255–265., https://doi.org/10.1111/scs.12627. Hernández, S.S., Sandreschi, P.F., da Silva, F.C., Arancibia, B.A., da Silva, R., Gutierres, P.J. and Andrade, A. (2015), “What are the benefits of exercise for Alzheimer’s disease? A systematic review of the past 10 years”, J of Aging and Phys Act. Vol. 23 No.4, pp. 65968. 39 Hsu, Ting-Jung, et al. “Predictors of Non-Pharmacological Intervention Effect on Cognitive Function and Behavioral and Psychological Symptoms of Older People with Dementia.” Geriatrics & Gerontology International, vol. 17, 2017, pp. 28–35., https://doi.org/10.1111/ggi.13037. J. Farran, Carol, et al. “Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial.” AIMS Medical Science, vol. 3, no. 1, 24 Nov. 2017, pp. 15–31., https://doi.org/10.3934/medsci.2016.1.15. King A, Baumann K, O’Sullivan P, et al. Effects of moderate-intensity exercise on physiological, behavioral, and emotional responses to family caregiving: A randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2022; 57:M26-36. Mody, L., Miller, D. K., McGloin, J. M., Freeman, M., Marcantonio, E. R., Magaziner, J., & Studenski, S. (2008). Recruitment and retention of older adults in aging research. Journal of the American Geriatrics Society, 56, 2340–2348. doi:10.1111/j.15325415.2008.02015.x Pinquart, M., & Sörensen, S. (2019). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 74(8), 1299-1310. https://doi.org/10.1093/geronb/gby064 40 Sampaio, A., et al. “Physical Exercise for Individuals with Dementia: Potential Benefits Perceived by Formal Caregivers - BMC Geriatrics.” BioMed Central, BioMed Central, 6 Jan. 2021, https://doi.org/10.1186/s12877-020-01938-5. Potter, R., Ellard, D., Rees, K. and Thorogood, M. (2011), “A systematic review of the effects of physical activity on physical functioning, quality of life and depression in older people with dementia”, Int J Geriatr Psychiatry Vol. 26, pp. 1000-1011 Saxl, S. (2014). Mit Demenz zu Hause leben: Möglichkeiten der ambulanten Versorgung für Menschen mit Demenz. Retrieved from https://www.deutsche‐alzheimer.de/unser‐ service/archiv‐alzheimer‐info/mit‐demenz‐zu‐hause‐leben‐moeglichkeiten‐der‐ ambulanten‐versorgung‐fuer‐menschen‐mit‐demenz.html Singleton, R. A., & Straits, B. C. (2017). Approaches to Social Research (6th ed.). Oxford University Press Academic US. https://online.vitalsource.com/books/9780190635114 Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 2005; 293: 596–608. Watt, Jennifer A, et al. “Comparative Efficacy of Interventions for Reducing Symptoms of Depression in People with Dementia: Systematic Review and Network MetaAnalysis.” BMJ, 2021, https://doi.org/10.1136/bmj.n532. World Health Organization (2017). Dementia: Fact Sheet. Retrieved from http://www.who.int.mediacentre/factsheets/fs362/en/ World Health Organization (2016). International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version: Chapter V Mental and Behavioral 41 Disorders. Retrieved from http://apps.who.int/classifications/icd10/browse/2016/en#/F00-F09 42 Appendix A 43 Appendix A (cont.) 44 Appendix B 45 Appendix B 46 Appendix C 47 Appendix D 48 Appendix E 49 Appendix F 50 Evidence Tables Citation Information (Title, year, Author, source) Title: Exercise Programs for people with Dementia (Review) Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Study Questions: Type of Study: Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) 1067 Results: Limitations to Database participants in the review: searches located 17 trials that a total of 5241 Do exercise included Literature Enough studies articles; they programs for individuals Review were used to screened the older people with dementia study the abstracts and with dementia and Study effects of titles of 542 of improve their caregivers. Design: exercise on these for cognition, inclusion. 69 Year: Most ADL’s, activities of articles were 2015 participants 17 cognition, and daily living, retrieved and neuropsychiatr randomized needed to be depression. rated by 2 ic symptoms, Authors: 65+ and controlled However, reviewers. 18 depression, Forbes D, diagnosed trials only one trial articles met the and mortality? Forbes SC, having was included criteria. Two of Blake CM, dementia to analyze the the articles Do exercise reported on Thiessen EJ, programs for Strength of using effects of different Forbes S accepted Evidence: neuropsychiatr older people outcomes of the criteria such ic symptoms with dementia same trial, so 17 In a 9 trial have an Source: as the and caregiver trials were study with indirect impact Cochrane Diagnostic burden, included. 409 on family Database and statistical The summary participants caregivers’ of manual of suggests that there was burden, exercise may help Generalizabilit Systematic quality of life mental very improve people Reviews disorders. y: substantial and mortality? with dementia’s Participants heterogeneit ability to perform y which was were Authors note Purpose of ADL’s. One trial mostly recruited from that more the Study: also suggested unexplainable nursing research is that a caregiver’s and so they homes, needed in this Analyzes level of burden rated the several trials may be lightened graduated topic, but quality low. In on the impact if they observe residential evidence may 6 trials with of exercise on the individual care, suggest that 289 people with with dementia participants, psychiatric dementia. 51 it was the same. Low quality. facilities, day care centers, homes for the elderly, and lastly their own home settings. participate in an exercise program. Conclusions: No clear evidence of benefit for cognitive function, neuropsychiatric symptoms, and depression. exercise can be beneficial. 52 Citation Information (Title, year, Author, source) Title: Physical Exercise for individuals with dementia: potential benefits perceived by formal caregivers. Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Purpose of the Study: Type of Study: Multi center Quasiexperimental nonrandomized study To analyze the effects of an exercise intervention on functional Study capacity, Design: behavioral, 9 nursing and homes Year: psychological accepted to 2021 symptoms in participate in the study. dementia Blinded Authors: and quality assessors did of life of the A. Sampaio, I. institutionali assessment Marqueszed older and data Aleixo, A. collection. 4 adults with Seabra. J. nursing dementia, Mota, and J. homes were perceived by Carvalho the exercise their group for 6 caregivers. Source: months and BMC Geriatrics Singapore Medical Journal Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) 9 formal caregivers in a supervising position, from 9 different nursing homes aged 28-47 years old accepted to participate. These individuals had daily interaction with the IWD Conclusions: Limitations to the review: Small sample size. Lack of randomization for group assignments. Overall results show that after the exercise intervention, the people with dementia who were in the exercise group were capable of preserving the functional capacity, quality of life, 64 and institutionalize neuropsychiatri d older adults c symptoms from both thus genders aged contributing to 65-93 years a lower load of old, clinically diagnosed with distress for the dementia, had caregivers. not participated in while 5 regular exercise nursing in the past 6 homes did months, all not diagnosed by participate in their physician an exercise and were in a program. mild or moderate stage. Generalizabilit y: Exercise programs should be incorporated into nursing homes to help with QoL in IwD. 53 Citation Information (Title, year, Author, source) Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Title: Study Type of Dementia Questions: Study: and Multicenter physical , pragmatic, activity trial Purpose of investigator of the Study: masked, moderate randomized to high To test the control intensity effects of a trial. exercise moderate to training for high Study people with intensity Design: dementia: aerobic and randomized randomized strength control trial. control trial exercise 329 training individuals Year: program for with 2018 individuals dementia with were Authors: dementia. assigned to the exercise Sarah E group and Lamb, et. al Source: BMJ 165 were assigned to the usual care. Random allocation was 2:1 in favor of the exercise group. Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) People with dementia were eligible if they had a clinically confirmed diagnosis of dementia in accordance with the DSMIV and the sMMSE of greater than 10, were able to sit in a chair and walk 10 feet without assistance and lived in the community either alone or with others. Results: The results showed that there were greater cognitive impairments in the exercise group after the 6-month trial. Clinical relevance is uncertain. Limitations to the review: They excluded people with acute, unstable physical or terminal illness that would make participation in the program unsafe. Conclusions: A moderate to high intensity aerobic and strength exercise training program does not slow cognitive impairment in people with mild to moderate dementia. The exercise program improved physical fitness but there were no other noticeable improvements in other clinical outcomes. Generalizabilit y: Future trials should explore other forms of exercise. 54 Citation Information (Title, year, Author, source) Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) 55 Title: Study Type of The Questions: Study: effectivenes Literature s of physical Review exercise Purpose of intervention the Study: Study s in the Design: managemen To search 5 data t of out research bases were neuropsychi articles that searched. atric show RCT’s were symptoms in physical sought out dementia exercise that applied patients: a interventions to physical systematic of activity review neuropsychia interventio tric ns with Year: symptoms in specific 2022 dementia characterist patients. ics in Authors: patients Komanthi with Kouloutbani dementia et al. or MCI, studied the Source: effect of Internationa exercise on l the NPS and Psychogeriat compared rics this with the control group that had no exercise program. Search criteria were based on the PICOS method. From 512 Limitations to articles, 13 were the review: included in this review. 1925 Possibly participants. publication Results showed Institutionaliz bias. They only that repetitive ed or nonused aerobic exercise institutionalize 3-5 times a week published had a positive d patients articles. effect on NPS, with MCI or whereas other dementia. In many of the multidimensional studies NPS interventions Comparison of with other types were not the exercise primary of exercises did not to be as group vs the outcomes effective. standard which could Strength training have affected treatment programs have group. the results. shown to reduce depression Generalizabilit symptoms and y: behavioral problems in dementia Nonpatients with pharmacologic mobility al problems. Conclusions: No clear evidence that exercise programs are effective in the NPS treatment. interventions such as exercise should be prioritized for the treatment of NPS. 56 Citation Information (Title, year, Author, source) Title: The caregiving phenomeno n and caregiver participatio n in dementia Year: 2019 Authors: Sara GarciaPtacek, Beth Dahlrup, Ann-Katrin Edlund, Helle Wijk, Maria Eriksdotter Source: Scandinavia n Journal of Caring Sciences Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Study Questions: Type of Study: Purpose of the Study: To determine how caregivers can participate in the care of individuals with dementia. Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) Literature Conclusions: Limitations to search where the review: PubMed was Caregiving is a Literature used difficult task. They only used Review PubMed as the searching for Several care search engine. the terms systems are Study “Caregiver working to Others are Design: available that AND improve could provide participation patient Search AND participation in more feedback terms on caregiver dementia” care. This is included research. with 311 hits, difficult with caregiver, “Caregiver dementia participatio AND support patients, so n, AND caregiver dementia, dementia” participation is support, with 5731 more feasible. scales, hits, Little research Sweden. “Caregiver exists on this AND scales caregiver Articles that AND participation. came up dementia” More research were 921 hits, is needed to examined to “Caregiver determine how identify AND scale this should research AND dementia look. groups AND Sweden” focused on 39 articles. this caregiving. 57 Citation Information (Title, year, Author, source) Purpose Study Design (Study Questions or hypothesis) (Type of study strength of evidence) Description of the Sample Results (The finding of the study) Implications (Limitations, generalizability) 58 Title: Impact of an Individualiz ed Physical Activity Interventio n on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomize d Controlled Trial Year: 2016 Authors: Carol J. Farran & colleagues Source: AIMS Med Sci Study Questions: Purpose of the Study: Type of Study: Randomized Controlled Trial Study This study Design: examined secondary This benefits of secondary an analysis individualize used data d physical from an RCT activity that tested intervention the on effectivenes improving s of the dementia Enhancing family Physical caregivers’ Activity subjective Intervention burden. in Depressive comparison symptoms to the and positive Caregiver affect. Skill Building group. 211 caregivers were randomly assigned to one of the two study arms. Family Conclusions: caregiver of a “Results person with support earlier possibly AD or studies that related indicated that dementia who stressed family resided at caregivers home. were able to Older than 30. increase their physical English activity as well speaking. Provided as improve more than 10 their positive hours of care emotional per week. outlook” Not admitting their loved one Second, “this into a facility study demonstrated in the next 6 the feasibility months. of Engaged in implementing less than 60 an min of physical individualized activity per flexible week physical activity intervention that combined both physical activity and caregiving related issues and following caregivers for 12 months.” Limitations to the review: Level of physical activity was self-reported Generalizabilit y: Results may not be generalized to other caregivers populations