Exercise as it relates to Disease/Does the inclusion of physical activity within nursing homes, increase self-efficacy for those with dementia?
This is a critique of the article “Increase self-efficacy: the experience of high-intensity exercise of nursing home residents with dementia” by Cecilie Fromholt Olsen, Elisabeth Wiken Telenius, Knut Engedal and Astrid Bergland.
What is the background to this research?
Dementia is a syndrome that causes deterioration in memory, thinking, behaviour and physical ability in people. It is a major source of morbidity and mortality that affects up to 50 million people worldwide. Research designed to discover strategies and to delay the onset and progression of dementia is ongoing. The most effective preventative strategy would result in improved quality of life, prolonged life expectancy and financial savings for sufferers. 
Physical activity is an important element in overall health promotion, it has well-known benefits for many chronic diseases including osteoporosis, stroke and diabetes. There is little evidence that suggests physical activity may delay cognitive loss and physical impairment. In clinical settings, beneficial effects of physical fitness intervention on memory and other aspects of psychological conditions has been documented in elderly people, although inconsistently. 
This study evaluates the association between regular High-Intensity Functional Exercise program (HIFE) and dementia patients within a nursing home. The study implies that the overall outcome will increase the self-eficiacy of patients, therefore, delaying further cognitive dysfunction.
Where is the research from?
The following article was written by four persons:
- Cecilie Fromholt Olsen- A previous student and now an employee at the Oslo Metropolitan University, in the Department of Physiotherapy. Has so far completed five research studies, based on the topics, of mind, health care and the impact of exercise on these areas.
- Elisabeth Wilken Telenius- Is a Norwegian National Advisory Unit on Ageing and Health Care. She has completed nine studies, which mainly focus on, different forms of exercise affecting patients with dementia and improving mental health within nursing homes. 
- Knut Engedal- Is a current employee at Oslo University Hospital in the Department of Geriatric Medicine and previous Professor in Psychogeriatric Medicine. He has completed hundreds of studies focusing on Alzheimer patients within nursing homes and how this can be improved.Is also working on eleven projects, that have a focus on improving the knowledge, attitude and exercise of Alzheimer's within nursing homes in India. 
- Astrid Bergland- Affiliated with Oslo Metropolitan University, has completed a few study as well 
These researchers, are highly regarded for their work on exercise science and its effects on chronic disorders in special reference to individuals who are placed in healthcare and are diagnosed with dementia.
This study was published on the BioMed Central (BMC). A webpage, that allows for individuals to have access to quality peer-review journals specifically within the interest of biology and medicine.
BMC has a strong focus on the innovation of better support for the community, whilst ensuring the reliability and validity of the research that is published.
What kind of research was this?
The research conducted was a randomised, controlled clinical trial of the High-Intensity Functional Exercise Program (HIFE), within a nursing home in Norway. All patients participated in the exercise program and completed a semi-structured survey, for this qualitative study. Randomised, controlled clinical trials are effective for examining safety and efficacy to answer, patient-related questions  and the use of the semi-structured interviews, allows for the researchers to gather, the main attitude, experience and themes within the study. Overall, effective methods and proven methods have been utilised for this study. 
What did the research involve?
The main criteria for this study was that the patients had to have a mild to moderate dementia diagnosis. 12 participants volunteered for the study, however, only eight were interviewed as the study reached capacity.
Using the HIFE program,each session consisted of:
- Five minute warm-up sessions
- Two strengthening exercises with 12 repetitions each
- Two balance exercises (throwing balls, stepping over obstacles and reaching for objects)
All exercises targeted the lower body. The duration of each session was 50-60 minutes, three times a week, for 10 weeks.
After the completion of the exercise program, participants were asked a series of open-ended questions, to gather common attitudes, experiences and themes, throughout the group.
Detailed results were recorded for all patients every week.
- Robust methodology utilised to ensure reliability and viability of outcomes
- Research based on the point of view of dementia patients, rather than from the family and carers 
- Length of study, was long and sufficient enough to make the results reliable and valid
- Small sample size;may not be representative of the larger nursing home community
- All participants were Norwegian, though all have dementia in common, certain traits and behaviours, may differ from other cultures and nationalities. 
- Semi-structured interviews provide a generalisation of common themes. This could potentially narrow down the themes, attitudes and experiences, to find the root of the cause.
What were the basic results?
The study found the following key results:
- Participants reported positive experiences with the exercise, finding the HIFE exercises, challenging, but, fun. Reportedly, patients preferred to fel exhausted after being physically active, rather than from lack of activity. Patients felt that the exercises being performed were relevant and meaningful to everyday activities. 
- Participants felt a sense of acknowledgment, invested-in and noticed, providing a sense of value. They also thoroughly enjoyed the level of interacting with other patients, through exercise, rather than, sitting and talking.
- Physical activity should be encouraged, as a voluntary activity, twice a week. 
This positive experience, of feeling achievement, is a powerful source of self-efficacy according to Bandura ],therefore, supporting the purpose of this study.
What conclusions can we take from this research?
Overall, the following study provides enough evidence, that the HIFE program, had a positive effect, on the self-efficacy of this group of patients. In most nursing homes, there is a general perception in the community that there is a lack of concern, for physical activity with the patients, though, these relative results, suggest otherwise. Healthcare professionals need to be made aware, of the positive results and further promote physical activity within, nursing homes.
Physical activity can be beneficial for patients that are diagnosed with dementia, however, to get more insight into the mechanism underlying the effects of physical activity, we need more high-quality studies . Though, for the time being, carers and family, can encourage them to perform physical activities such as walking or stretching, for at least 20 minutes, into their routine. This can be proven to be a source of motivation for patients and help maintain an active physical regime.
Further information/ resources
For more information on Dementia and importance of physical activities or even ways to incorporate exercise into fun activities for the nursing home patients. Links have been attached below.
- WHO Dementia : https://www.who.int/news-room/fact-sheets/detail/dementia
- Carers Perspective of Dementia: https://www.caregiver.org/caregivers-guide-understanding-dementia-behaviors
- Importance of Physical Activity: https://www.dementia.org.au/files/NSW/documents/AANSW_DiscussionPaper11.pdf
- 12 Ideas for Exercise and Physical activity: https://dailycaring.com/12-ideas-for-exercise-and-physical-activities-for-seniors-with-dementia/
- Increased self-efficacy: the experience of high-intensity exercise of nursing home residents with dementia – a qualitative study, Cecilie Fromholt Olsen1, Elisabeth Wiken Telenius2, Knut Engedal3 and Astrid Bergland1*, 2015, website: https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-015-1041-7
- WHO, Dementia,2019, website https://www.who.int/news-room/fact-sheets/detail/dementia
- Physical Activity and Risk of Cognitive Impairment and Dementia in Elderly Persons, Danielle Laurin, MSc; René Verreault, MD, PhD; Joan Lindsay, PhD; et a, 2001, journal article, website: https://jamanetwork.com/journals/jamaneurology/fullarticle/778849
- Exercise Is Associated with Reduced Risk for Incident Dementia among Persons 65 Years of Age and Older, Eric B. Larson, MD, MPH; Li Wang, MS; James D. Bowen, MD; Wayne C. McCormick, MD, MPH; Linda Teri, PhD; Paul Crane, MD, MPH; Walter Kukull, PhD, 2006, website: https://annals.org/aim/fullarticle/719427
- Research Gate, website:https://www.researchgate.net/profile/Cecilie_Olsen3
- BioMedCentral, 2019, website:https://www.biomedcentral.com
- HIFE Program, Nina Lindelöf, Håkan Littbrand,Erik Rosendahl,Nina Lindelöf,2011, website: https://www.hifeprogram.se/media/1017/engelsk-version-2014-28-nov.pdf
- Randomized Controlled Trials, Maria Kabisch, Dipl.-Biomath.,1 Christian Ruckes, Dipl.-Math.,1 Monika Seibert-Grafe, Dr. med.,1 and Maria Blettner, Prof. Dr. rer. nat.,2011, website:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196997/
- Qualitative methods in research on healthcare quality, C Pope, P van Royen, R Baker, 2002, journal article, website:https://qualitysafety.bmj.com/content/qhc/11/2/148.full.pdf
- Self-Efficacy, Albert Bandura, 1998, journal article, website:https://s3.amazonaws.com/academia.edu.documents/32507115/Self_Efficacy.pdf?response-content-disposition=inline%3B%20filename%3DSelf-Efficacy_I._Sources_of_Self-Efficac.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20190918%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190918T123324Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=fbc78657870133fc75d2486e5811a7fac3abd01f34a04a75935ea7ef80a9b074
- Research Exploring Physical Activity in Care Homes (REACH): study protocol for a randomised controlled trial, Anne Forster,corresponding author1 Jennifer Airlie,1,2 Karen Birch,2 Robert Cicero,3 Bonnie Cundill,3 Alison Ellwood,4 Mary Godfrey,1 Liz Graham,3 John Green,4 Claire Hulme,5 Rebecca Lawton,6 Vicki McLellan,3 Nicola McMaster,4 Amanda Farrin, 2017, journal article, website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395795/
- Review of Effects of Physical Activity on Strength, Balance, Mobility and ADL Performance in Elderly Subjects with Dementia,Christiaan G. Blankevoorta Marieke J.G. van Heuvelena Froukje Boersmab Helga Luninga Jeltsje de Jongc Erik J.A. Scherdera, d, 2010,journal article, website: https://www.karger.com/Article/PDF/321357