Effect of Lively Later Life Programme(3LP) on Quality of Life amongst Older People in Institutions

Available online at www.sciencedirect.com

ScienceDirect Procedia - Social and Behavioral Sciences 202 (2015) 252 – 262

ASEAN-Turkey ASLI (Annual Serial Landmark International) Conference on Quality of Life 2014, ABRA International Conference on Quality of Life, AQoL2014, 26-28 December 2014, Istanbul, Turkey

Effect of Lively Later Life Programme(3LP) on Quality of Life amongst Older People in Institutions Akehsan Dahlana*, Syamsul Anwar Sultan Ibrahimb a

Occupational Performance and Behaviour Measurement Group (RIG), Occupational Therapy Department, Faculty of Health Sciences / CORE b Huminities and Quality of Life, Universiti Teknologi MARA, Kampus Puncak Alam, 42300 Selangor, Malaysia

Abstract

Older people in an institution live in a sedentary lifestyle. They loss their autonomy, seldom engage in activities and did not have a meaningful social relationship. These issues lead to decreased in quality of life (QoL). The aim of this randomised trial is to determine the effectiveness of a lifestyle redesign programme, i.e. the Lively Later Life Programme (3LP) on QoL. Eighty-two older people who fit the inclusion criteria were randomly assign to the 3LP group and the control group. At the end of six months, there is a significant change in physical, psychological and social domains of QoL. © 2015The TheAuthors. Authors.Published Elsevier © 2015 Published byby Elsevier Ltd.Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers) and cE-Bs (Centre Peer-review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers) and cE-Bs (Centre for Environment-Behaviour Studies, Faculty of Architecture, Planning & Surveying, UniversitiTeknologi MARA, Malaysia for Environment-Behaviour Studies, Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. Keywords: Older people; occupational activities; lifestyle; quality of life

1. Introduction There is an increased in number of older people in Malaysia as a result of the declining of birth rates and longer life expectancy. The modernisation of the society increased participation of women in the work force has changed the traditional role of women who was once perceived as a carer for their older parents. Subsequently, there are an increasing numbers of older people who are seeking formal care from private or public elderly institutions. Previous studies shows that older people who live in the institution live in a sedentary lifestyle, seldom engage in

* Corresponding author. Tel.: +03-32584380; fax: +03-32584599. E-mail address:[email protected]

1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers) and cE-Bs (Centre for Environment-Behaviour Studies, Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. doi:10.1016/j.sbspro.2015.08.229

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individualised, meaningful and valued activities, such as recreational, leisure, work, instrumental activities of daily living or educational related activities (Haslam, 2008; O’Sullivan & Hocking, 2006; Dahlan& Ibrahim, 2014; Almeida &Rui, 2014). They spend a high proportion of their daily life being inactive, alone or immobile (Ice, 2002), spend many hours in bed and frequently taking a nap during the day (Gordon &Gladman, 2010; Neikrug&Ancoli-Israel, 2010). Ice (2002) investigated the daily life of older people in a nursing home found that the resident spend 56% of their time doing nothing. The majority of them spent their time in their room, sitting alone, not doing anything and contemplating the past. Chung (2004) found institutionalised older people spent 90% of their time engaged in passive activities. The older people stated that ‘… every day is the same’ (Chuang and Abbey 2009: p.1644), and they felt ‘[the] time stands still’ (Cook and Stanley (2009: p. 397). Although they have a positive attitude towards physical activities, the opportunity to engage in the activities seldom occurs (Almeida &Rui, 2014). In addition, activities organised by the institutions is often infrequent, insignificant to the older people, conducted by a non-professional, for ‘passing time’ and often aimed for socialisation or to establish relationship (Kolanowski&Litaker, 2006). Furthermore, the relationship between residents in institutions is seldom a meaningful type of relationship. It is often for adjustment (Chuang & Abbey, 2009) a compromised relationship to ensure harmony (Lee, 2010), infrequent, non-intimate and a fragile type of relationship (Kolanowski&Litaker, 2006; Spilsbury, et al., 2011). The relationships with staff are often formal in manner as a result of the forced routine or the daily tasks imposed on the staff (van Beek&Gerritsen, 2010; Ryvicker, 2011; Spilsbury, et al., 2011). Spending time on an assigned job is perceived to be more important than being with the residents who subsequently leaves the resident alone and doing nothing. Visits from family members and friends often declines over time (Fukahori, et al., 2007; Cheng et al. 2010) and there are elderly people who sever links with their children as a result of feeling abandoned (Cheng, 2009). In addition to the lack of engagement in meaningful activities and lack of meaningful social relationship, they also experiencing institutionalised syndrome as a results of erosion in personal autonomy, lack of internal locus of control, loss of personal space, loss of meaning and sense of belonging in life (Choi, et al., 2008; Custers, et.al., 2012). Subsequently, there are many older residents who feel powerless, depressed, low self-efficacy, low self-esteem and decreased general well-being (Choi, et al., 2008; Boyce, et al., 2012), which subsequently affected their quality of life (QoL)( Luleici, et al., 2008; Hedberg, et al., 2010). There are various health programmes that have been conducted to prevent the deteriorations identified, for example, programmes that redesign a lifestyle through re-engagement in individualised, meaningful, valued and self-directed activities. However, such programmes have only been conducted in developed countries and were designed for older people who live in community settings (Mountain et al. 2008; Frandin, et.al, 2013). There is no substantial work exploring the applicability and the effectiveness of such programmes for institutionalised older people with different of culture sets, values and beliefs, such as in Malaysia. Hence, the aim of this study is to evaluate the effect of a program that modify older people lifestyle in institutions through a lifestyle redesign programme known as The Lively Later Life Programme (3LP). 2. Methodology 2.1. Settings and participants The study was conducted in a public funded elderly institution in Malaysia that houses elderly people, 60 years old and above. The aims of the home are to provide daily basic needs, care and support. 2.2. Sampling and randomisation A Pre-test-Post-test parallel experimental study design with a control group was chosen to investigate the effect of 3LP on QoL. To be included in this study, the participants had to meet the following criteria (I) aged 60 years or older; (II) independent in basic self-care skills; (III) able to speak in either in Bahasa (the local language) or English, (IV) have scores of 22 or above in the translated version of the Mini-Mental State Examination (MMSE) (Folstein et

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al., 1975); (V) have scores below seven in the translated version Geriatric Depression Scale (GDS) (Yesavage et al., 1983). Based on the a priori method of G*Power calculation analysis a sample size of 368 is needed to test hypothesis at 0.05 level (2-tailed) which will give a power equivalent of 80% in detecting a population effect size of 0.3 or greater. However, it was found that the there are 82 elderly people who fitted the inclusion criteria and were willing to participate in the study. Subsequently, the power calculation was modified based on the sample available, and a compromise power analysis (Buchner et al. 1996) was conducted to provide a pragmatic solution to the sample size problem. The result of the compromise power analysis indicated that base on the effect size of medium (.5), beta/alpha ratio is 1, the significant value p is increased to .295 with power of 0.65 (65%). All of the participants who were willing to participate in the programme and fit into the inclusion criteria were listed. Each of the participants was given a random numerical identification or unique identifier from number 01 to number 82, and their names were erased from the lists. This will provide concealment, thus avoiding selection bias (Morrow, 2008). The unique identifier was computed by random allocation software (Saghaei, 2004) to generate random numbers for two groups (experimental groups and control groups). In addition, single blinding was integrated into the study to minimise interpretation bias (Johnston and Case-Smith, 2009). The post-test was conducted by independent researchers who were blinded to the aim, theoretical framework, participation allocation and to the nature of the 3LP. Although a double blind is desirable in the experimental study, however it is not feasible to be conducted in this study as a result of the nature of the intervention (Johnson and Case-Smith, 2009). 2.3. Research instruments Data regarding QoL was collected using the brief version of World Health Organisation Quality of Life (WHOQOL-Bref) that was developed by World Health Organisation Group (The WHOQOL Group, 1995). The questionnaire is cross-culturally accepted and was translated into 19 different languages. It covers 4 main domains and contains 24 facets of QoL, i.e. physical health (7 facets), psychological (6 facets), social relationship (3 facets) and environment (8 facets) (The WHOQOL group, 1995). It has five points Likert type of scale and the range of scores is 25 to 125 with high scores indicated greater QoL. It is a valid and reliable measure of the QoL of elderly people as it has a psychometric property of Cronbach’s alpha at 0.935, and the correlation between facets is significant at p<0.01. A translated version (English to Malay) was used for this study (Hasanah et al., 2003). The researcher conducted Pre-experimental evaluation; whilst post-experiment evaluation was conducted by independent assessors who are not related to the intervention. 2.4. Ethics The study was approved by the Research Ethics Committee of UniversitiTeknologi MARA. In addition, the study was approved Department of Social Welfare in Malaysia. All participants were explained the aim and objectives of the study and informed consent were obtained and collected from all of the participants. 2.5. Intervention- the Lively Later Life Programme (3LP) Participants in the control group received programme conducted by the staff of the institution. The programme is an ad-hoc programme, comprising mainly of recreational and social types of activities aimed at occupying the residents’ time. Participants in the experimental group received lifestyle redesign programme (i.e. the 3LP) for six months conducted by occupational therapists. The programme was inspired by a successful lifestyles re-design programme; the Lifestyle Matters programme (Mountain et al., 2008). The 3LP used and applied various theories in ageing, theory in occupational therapy, research, health promotion and education and involves engagement in various individualised, meaningful and valued activities such as recreational, leisure, social related activities, education and work related activities. Each participant in the experimental group received 2 hours of group sessions and one hour individual sessions before and during participated in the programme. The group sessions consisted of eight inter-related themes that focused on the

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importance and benefits of engagement in activities from a health perspective, whilst the individual sessions focused on issues related to engagement in the selected activities. The model of the programme is shown in Figure 1.

3LP Core Content.

Method of delivery

x Activity analysis and

reflection. x Activity and health x Physical activities and

health x Cognitive activities

and health. x Social activities and

health. x Personal activities and

health. x Exploration x Reflection and

Synthesis

Changes in pattern

Health Outcomes

x Ability to do more x Individual and Group

approach.

meaningful and individualised activities

x Didactic instruction x Improve physiological, x Experiential learning

x Self Exploration

psychological and psychosocial functions.

x ‘story telling’

x

Improved quality of life

x Ability to plan, x Exchange ideas with

peer (discussion and sharing experiences) x Motivational

organized time x Improve knowledge in

benefits of Activities and managing health.

components x Autonomy and assert

individuality

Fig. 1.3LP Programme Model.

2.6. Data analysis Data was analysed using SPSS Version 12. The Mann-Whitney U test was conducted to determine compatibility between the experimental and control group pre-test scores on the demographic variables and the WHOQoL-Bref. Wilcoxon Signed Rank test was used to accept or reject the null hypothesis. An alpha level of 0.5 was used to determine whether there was any significant difference between the pre-test and post-test values. Acceptance or rejection of the hypothesis were based on a 95% confidence interval (CI) (p<0.05). In addition, standard mean differences based on Cohen’s effect size were used to determine the strength of the effect. Pre-post effect sizes were calculated as standardised response mean (= mean change scores divided by the standard deviation of the change score) and classified as minimum (<0.2), small (0.2-0.49), medium (0.50 – 0.79) and large (≥ 0.80) (Cohen, 1988). 3. Results The total numbers of residents who participated to the study was 82 (Figure 2). The Mann-Whitney U test revealed no statistical significant differences between experimental group and control group (p > 0.05) on demographic variables and pre-test scores of the WHOQoL-Bref (Table 1).

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Total residents in the institution (225 residents)

Enrolment

Not included due to: x In the secure ward ) (n=41) x D ependent in AD L (due to musculoskeletal problems, severely weak, others ) (n=18) x C hronic sensory deficit (vision and hearing) (n=16) x C hronic medical conditions (C R ) (n=5) x O thers e.g. language (n=11) T O T A L = 91 elderly people.

134 residents Not meeting the inclusion criteria x MM S E < 22 = 15 elderly people. x G D S below 7 = 12 elderly people. x B oth = 9 elderly people. T O T A L = 36 elderly people

Analysis (Post Intervention)

Analysis (Pre Intervention)

Allocation

98 residents x D eclined to participate ( n = 16 elderly people)

R andomized (n=82 partic ipants)

Allocated to 3LP G roup. (Analysed n = 46)

Allocated to In-house programme (Analysed n = 36)

Analysed (n=42) x E xcluded in the study (died) n = 4

Analysed (n=32) x E xcluded in the study (died) n = 2

Fig. 2.Participant recruitment and randomisation. ADL= activities of daily living; CR=cardio-respiratory; MMSE=Mini-Mental State Examination, GDS=General depression Scale.

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Akehsan Dahlan et al. / Procedia - Social and Behavioral Sciences 202 (2015) 252 – 262 Table 1.Socio-demographic characteristics of the participants. Variables / Group

Experiment

Control

N (%)

N (%)

Male

28 (60.9)

28 (77.8)

Female

18 (39.1)

8(22.2)

Total

46 (100)

36(100)

60 to 75 years old

25 (54.3)

20 (55.6)

above 75 years old

21 (45.7)

16 (44.4)

Median age (IQR) :

74.0(68.25-80.0)

74.50(67.25-80.0)

Malay

33 (71.7)

23 (63.9)

Chinese

9 (19.6)

11 (30.6)

Indian

4 (8.7)

1 (2.8)

Others

-

1 (2.8)

never go to school

18 (39.1)

18 (50.0)

up to standard six

25 (54.3)

12 (33.3)

Lower certificate

3 (6.5)

2 (5.6)

Others

0

4 (11.1)

1 to 36 months

41 (89.1)

29 (80.6)

37 to 72 months

4 (8.7)

5 (13.9)

73 to 180 months

1 (2.2)

181 to 144 months

0

1 (2.8)

145 to 180 months

0

1 (2.8)

Duration median (IQR)

26.0 (13.50-45.25)

32.0 (12.25-58.75)

1

12 (26.1)

9 (25.0)

2

16(34.8)

13 (36.1)

3

12 (26.1)

10 (27.8)

6 (13.0)

6 (11.1)

(u)

Z scores

p-value

688.0

-1.62

0.11

782.0

-0.43

0.66

774.0

-0.62

0.54

801.0

-0.28

0.78

774.0

-0.51

0.61

826.0

-0.20

0.98

755.0

-0.61

Gender

Age

Race

School qualification

Duration in institution

Number of health problem no health problem

WHOQoL – Bref Domain 1: Physical Health Median (IQR)

13.10 (12.0-14.4)

13.40 (12.0-14.3)

0.54

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Domain 2 : Psychological Median (IQR)

763.5

-0.61

12.00 (11.0-14.7)

790.5

-0.36

12.80 (11.0-14.0)

12.00 (11.1-14.0)

797.0

-0.29

51.44 (48.1-55.9)

51.50 (45.7-54.5)

731.0

-0.91

13.80 (11.3-14.0)

13.40 (11.3-13.2)

12.00 (11.7-16.0)

0.54

Domain 3: Social relationship Median (IQR) Domain 4: Environment Median (IQR) Total scores WHOQOLBref Median (IQR)

0.72 0.77

0.37

N = number of participants, IQR = Inter quartile range, WHOQOL-Bref = Brief version of World Health Organisation Quality of Life,

After six months of the intervention, 76 participants completed the 3LP programmes. The post-test results indicated that there are statistically significant differences for participants in the experimental group. There is an increase in median scores for WHOQoL-Bref in all domains and increment in median differences with medium to large effect size as shown in Table 2. There was little difference between the pre-test and post-test scores for the control group. Participating in 3LP significantly increased perceptions of QoL and all domains in the WHOQOLBref scale with highest changes is in the physical domain, followed by psychological domain of WHOQOL-Bref. Table 2. Overall result of the study measures. Baseline

After six months

Median (IQR)

Median (IQR)

Exp. Group

13.34 (12.00-14.23)

Control Group

12.57 (12.00-14.29)

WHOQoL – Bref Domain

Z score

p value

14.87 (14.29-16.14)

-5.08

0.02

0.58

12.57 (12.00-13.86)

-0.04

0.97

0.00

d

Domain 1: Physical health

Domain 2: Psychological health Exp. Group

12.66 (11.33-14.00)

14.00 (13.33-15.33)

-4.04

0.03

0.46

Control Group

12.00 (11.33-13.17)

12.00 (10.67-12.67)

-1.23

0.22

0.14

Domain 3: Social relationship Exp. Group

12.00 (11.67-16.00)

16.00 (14.00-16.33)

-3.71

0.02

0.43

Control Group

12.00 (11.00-14.67)

12.00 (10.50-14.17)

-1.12

0.26

0.13

Exp. Group

12.75 (11.00-14.00)

13.24 (121.50-14.50)

-2.47

0.05

0.28

Control Group

12.00 (11.13-14.00)

12.00 (11.50-13.50)

-1.09

0.28

0.13

Exp. Group

51.44 (48.07-55.91)

58.45 (55.57-60.76)

-4.98

0.02

0.57

Control Group

51.50 (45.75-54.51)

49.73 (45.29-53.69)

-1.13

0.26

0.26

Domain 4: Environment

Total scores

IQR = interquartile range, d = effect size, WHOQoL-Bref = Brief version of World Health Organisation Quality of Life, Exp = Experimental group. Differences assessed by Wilcoxon Signed Rank Test; Effect size was calculated using the formula r=z/√n

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4. Discussion Post-intervention results indicated that there are statistical significant changes in all domains in WHOQOL-Bref – physical health, psychological, social relationship and environment domains with small to large effect size. The scores are comparable with the norms of an international elderly people (Skevington et al. 2004; Hawthorne, et al , 2006) and elderly people in the community in Taiwan and Turkey (Hwang et al. 2003) but slightly lower than elderly people in Australia (Ikin et al. 2009). An increased in the physical domain in WHOQoL is postulated to have been contributed from engagement in activities that requires physical movement. These activities contributed to increasing in musculoskeletal functions, such as strength, endurance, balance and coordination. For example, physical related activities such as walking and gardening require a certain degree of muscular skeletal involvement such as lifting, carrying, stooping, crouching and kneeling. Previous RCT’s and longitudinal studies indicate that engagement in physical related activities such as gardening and walking improved physical related functions such as muscular strength, balance and range of movement (Resnick et al. 2009; Egan and Mantes, 2010; Frandin, et, al, 2013), increased physical function and fitness (Luleici, et al., 2008; Shin et al. 2009; Lee, Lee and Woo, 2010, Frandin, et, al, 2013). The second largest effect of the 3LP is towards the psychological domain in WHOQOL-Bref (medium effect, r = 0.46, median increment from 12.66 to 14.00). Questions in this domain inquire about the experience of enjoyment and meaning of life, ability to concentrate, satisfaction towards self and frequency of having negative feelings. Experience of enjoyment in life was obtained through engagement with varieties of meaningful activities such as recreational activities like movies, indoor and outdoor activities, cooking session, shopping at the mall, etc. Opportunity to engage in meaningful activities as planned in 3LP provides a sense of enjoyment. Previous studies show that engagement in activities facilitates positive affect, such as feelings of happiness (Elavsky et al. 2005; Meeks, et al., 2007), fun and contentment with life (Harmer and Orrell, 2008; Pereira and Stagnitti, 2008) and reduction in depression (Resnick et al. 2008; Shin et al. 2009; Cheng, et al., 2012) and improved quality of life (Guallar-Castillón, 2014). Changes in psycho-social domain in WHOQoL is postulated due to opportunity given to the participants to reengage relationships with children, connecting with community outside the institution and establishing relationship with other participants in the group sessions and people in the community. This could offer an explanation for the medium effects of the intervention within the social relationship domain in WHOQOL-Bref. It is speculated that the benefits of changes in physiological, psycho-social and psychological functions are interrelated; in which one benefit could facilitate enhancement in other benefits. For example, changes in musculoskeletal function (i.e.; increased walking endurance) could provide enhancement in psychological function (i.e.; feeling happy, increased self-esteem and having future direction in life) and the changes in musculoskeletal function could also encourage participants to engage in occupation outside the institute (which will facilitate benefits associated with psychosocial function). The 3LP that was centralised on engagement in individualised, meaningful and valued activities was successful in improving QoL for participants in the experimental group. This finding was supported by the theory of engagement in activities in occupational therapy professions. Theory in occupational therapy indicates that engagement in individualised, meaningful, self-directed and valued activities facilitates changes in physical, psychological and psycho-social functions; (Egan and Mantes, 2010; Lee et al., 2010, Frandin, et, al. 2013), increased positive affect (Meek at al., 2007), increased social network, which eventually improved QoL and life satisfaction (Tse, 2010). Statistical significant changes in QoL scores could also be mediated by the unique characteristics of the core content of the 3LP. The 3LP provides opportunities for the participants to engage in activities that are individualised and meaningful activities to them. Individualised activities motivates participation and facilitate quality of life (Vriendt, et.al., 2014) and more responsiveness to institutionalised older people (Cohen-Mansfield, et al., 2010; Kolanowski & Buettner, 2008), increased adherence (Findoff, Wyman & Gross, 2009), reduced anxiety in relation to participation (Sung, Chang & Lee, 2010), enables the development of feelings of proficiency and success (Holthe, et al., 2007). Furthermore, based on systematic review, it is found that individualised intervention is more effective than ‘blanket’ programmes or control programme (Richards et al., 2007; Suhonen, et al., 2008).

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Another characteristic of individualised activity in 3LP is that the activity conducted are interesting and challenging, yet not exceeding participants physical capacity, related to previous roles in life, self-identity and belong to regular pattern of life as life prior relocation to the institution. For example, gardening, craft, cooking, indoor and outdoor activities. Engagement in activities related to life roles facilitate sense of well-being (Harmer & Orrell, 2008; McKenna, Broome & Liddle, 2007; Frandin, et.al, 2013) and provide sense of connection between past and present (la Cour, et al., 2005). Previous literature shows that there are internal and external barriers towards engagement in activities, such as physical limitations, lack of facilities, environmental barriers and lack of supports (Li, et al., 2010; Anderiesen, et.al., 2014). All these barriers were addressed during 3LP; which enables participants to successfully engaged in individualised, meaningful and valued activities. Furthermore, 3LP integrated motivation components to the programme, which encourage participants to adhere to the activities throughout the period of the study. Eliminating barriers to engagement and provide motivation facilitates enhancement in self-efficacy and confidence through reduction in stress (Shin et al., 2009) which eventually facilitate success in engagement in individualised, meaningful and valued activities. One of the limitations of the study is its limited sample size. Based on previous methods of a sample calculation, the sample size of 368 is needed to obtain a power equivalent of 80% with effect size of 0.3 or greater. Further studies that enrol a greater number of participants are, therefore, warranted to provide stronger and conclusive evidence regarding the effectiveness of the 3LP in facilitating enhancement in QoL. Another limitation is related to living arrangement in the institution. Participants in this study are living in a communal environment. This may raise an issue and threat to internal validity through contamination, thus favouring to accept the null hypothesis (Howe et al., 2007, Keogh-Brown et al., 2007). To avoid ‘contamination’, participants in the experimental group were asked not to discuss anything pertaining to 3LP to other participants. However, Galbraith (2007) stressed researcher should less concern about bias from contamination if the differences in study measures were found between group that provide evidence to rejecting the null hypothesis. 5. Conclusion Our results indicated that 3LP, a lifestyle redesign programme which is similar with lifestyle redesign programme that were conducted for community-dwelling older people in Western countries facilitate improvement in QoL. Therefore, we suggest that lifestyle redesign programme which focus on active engagement or re-engagement in meaningful, individualised, self directed and valued activities should be a part of rehabilitation programme for older people in institutions. Further research that explore the applicability of the programme in smaller setting and for older people in community could be conducted to elaborate further the effect of 3LP on QoL amongst older people in Malaysia. Acknowledgments The authors wish to thank Faculty of Health Sciences, University Teknologi MARA (UiTM) and Research Management Institute (RMI), UiTM and the Department of Social Welfare for permission to conduct the study and to all participants in the study. This research was funded by Fundamental Research Grant (FRGS), Fasa 1/2012 (600-RMI/FRGS 5/3 (70/2012). References Almeida, P., Rui, N. (2014). Physical Activity - the Attitude of the Institutionalised Elderly. Journal of Physical Education and Sport, 14(1), 12 -15. Aderiesen, H., Scherder, E.J.A., Goossens, R.H.M., Sonneveld, M.H. (2013). A systematic review – physical activity in dementia: The influence of the nursing home environment. Applied Ergonomics, 45(6), 1678-1686. Bergland, A and Kirkevold, M (2007). The significant of peer relationships to thriving in nursing homes. Journal of Clinical Nursing. 17(10), 1295 – 1302

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