The Implementation, Actual Use and User Experience of an Online
Home Exercise Program That Fits the Needs of Older Adults with
Mild Cognitive Impairments
M. G. H. Dekker-van Weering
1
, S. Jansen-Kosterink
1
and M. Tabak
1,2
1
Roessingh Research and Development, eHealth Cluster, 7500 AH Enschede, The Netherlands
2
University of Twente, Faculty of Electrical Engineering, Mathematics and Computer Science,
Telemedicine Group, Enschede, The Netherlands
Keywords: e-Health, Exercise, Mild Cognitive Impairment, Older Adults, Implementation, User Experience.
Abstract: As the population ages, the number of people in our communities suffering with mild cognitive impairment
(MCI) will increase. Individuals with MCI may benefit from e-health interventions for exercise promotion,
but there is a need for such an e-health program that fits the needs of older adults with MCI. The objective
of this study was to evaluate the implementation, actual use and user-experience of a home-based exercise
program developed for older adults with MCI. Questionnaires were filled in about the implementation
strategy, actual use and user-experience (usefulness, usability and satisfaction). Fifty-seven older adults and
eight formal caregivers participated in the study. Mean duration of the sessions was 18 minutes (+/-15). The
user-experience of the older adults was higher than that of the formal caregivers. Formal caregivers mainly
offered the program at the home care organization, but some older adults indicated that they were willing to
try it at home. In conclusion, the online exercise program is feasible and potentially beneficial for older
adults when taking into account the e-health literacy of older adults and attitude towards e-health of formal
caregivers in the implementation strategy.
1 INTRODUCTION
As the population ages, the number of people in our
communities suffering with mild cognitive
impairment (MCI) will increase (Alexander et al.,
2015). Older adults with MCI have higher risks for
decreased physical function (Marquis et al., 2002),
increased chronic physical illness and increased
levels of affective disturbance (Lopez et al., 2003),
and increased mortality (Bennett et al., 2002). This
will not only affect the quality of life of people with
MCI, but will also increase the burden on family
caregivers, community care, and residential care
services. The support of independent living in the
older adult population is important to preserve
quality of life for as long as possible.
Due to the socioeconomic challenges to the
healthcare systems, there is an urgent need for cost-
effective support programs to increase the
independent living of older adults with MCI (Prince
et al., 2016). New e-health technologies are expected
to contribute to providing this support. In this
context, several studies highlight the potential of e-
health programs, due to the increasing availability of
internet access and the benefit of flexibility,
facilitated accessibility, and personalization of these
programs (Bujnowska-Fedak and Priogowicz, 2014,
McKechnie et al., 2014). As most older adults with
MCI reside in the community, an intervention
designed for the home setting is especially
advantageous.
Individuals with MCI may particularly benefit
from e-health interventions for exercise and health
promotion. There is promising evidence that
exercise programs can improve the ability to
perform activities of daily living in people with
dementia (Forbes et al., 2015). A meta-analysis of
randomized controlled trials by Heyn et al., (2004)
reported beneficial effects of physical activity on
physical fitness and cognitive function in adults with
cognitive impairment.
To date, most research on e-health interventions
to promote exercise and physical activity has
excluded older adults with cognitive impairments
(Savitch, 2006). There are only few published e-
Weering, M., Jansen-Kosterink, S. and Tabak, M.
The Implementation, Actual Use and User Experience of an Online Home Exercise Program That Fits the Needs of Older Adults with Mild Cognitive Impairments.
DOI: 10.5220/0007696801890196
In Proceedings of the 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2019), pages 189-196
ISBN: 978-989-758-368-1
Copyright
c
2019 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
189
health studies specifically targeting people with
cognitive impairment, such as MCI. These adults are
thought to be unable to successfully complete the
programs and assessments due to their limited use of
everyday technology, such as mobile phones or
computers (Malinowsky et al., 2017). Older adults
do have more difficulty engaging with the internet
for health care (Czaja et al., 2008), which has been
partly attributed to poor website design, complex
navigation requirements, and a lack of internet
training (Czaja et al., 2013), factors that are
secondary to cognitive decline and which should be
addressed in the development of e-health for older
adults with MCI.
As such, there is a need for an e-health program
that fits the needs of older adults with MCI in
promoting physical exercise. For this, we developed
a home-based exercise program for older adults with
MCI starting from an evidence-based home exercise
program developed for pre-frail older adults
(Dekker-van Weering et al., 2017). We used a
participatory design to adapt the program to the
needs of older adults with MCI (Dekker- van
Weering et al., 2016). In this paper, we evaluate the
implementation strategy, actual use and user
experience of this program for older adults with
MCI and their formal caregivers. This is in
agreement with previous studies, which emphasized
the need to conduct early evaluation studies such as
“proof-of-principle-studies” to improve the use of e-
health by older adults before the realization of
studies on a larger scale (Makai et al., 2014).
2 METHODS
We conducted a qualitative evaluation study,
between April 2016 and October 2017. The Medical
Research Ethics Committee (MREC) Twente
declared that this study does not meet the criteria
necessary for an assessment by an accredited MREC
according to Dutch law. All participants provided
informed consent prior to participation in the study.
2.1 Participants and Setting
Participants recruited for this study were older adults
and formal caregivers from Trivium Meulenbelt
Zorg (TMZ). TMZ is a healthcare organization in
the Netherlands for older adults with cognitive
and/or physical impairments. TMZ has nursing
homes, homes for elderly and home care. Inclusion
criteria for older adults were: 1) receiving home care
of TMZ; 2) having cognitive impairment or
dementia; 3) living independently at home. Seven
locations from TMZ were invited to participate in
this study.
To recruit participants, the first author organized
workshops to inform informal caregivers about the
exercise program and asked them if they and the
person they cared for were willing to participate.
The formal caregivers were also informed about the
inclusion criteria and based on that they asked their
older adults to participate in this study.
2.2 The Intervention
The intervention was initially developed for pre-frail
older adults in the PERSSILAA project (Dekker-
van Weering et al., 2017). To make the program fit
the needs of older adults with MCI, we organized a
workshop with caregivers to define the adaptations
needed to make it usable for older adults with
cognitive impairments (Dekker- van Weering et al.,
2016). The main adaptations made were:
- a maximum of 20 minutes of training instead
of 30 minutes, due to decreased concentration
capacities of this target population
- minimize the text and click options in the
program, to increase ease of use
- exclude options for older adults to give feedback
about the exercises
- an additional level with only sitting exercises, to
accommodate for physically frail older adults
The intervention is a technology-supported exercise
program, which older adults can perform on their
own in their home setting. The contents of the
exercise program was based on the Otago Exercise
Programme (Robertson et al., 2001) which is an
individually tailored fall prevention program with
muscle strengthening and balance-training exercises.
The exercises are functional and closely related to
daily activities and are categorized in three
categories: balance, strength, and flexibility. Each
training session starts with a warming-up and ends
with a cooling down. In the training session, older
adults perform exercises in each category (balance,
strength, and flexibility). The program consists of 17
exercises each time, which enables training for a
maximum of 20 minutes. Video and spoken and
written instruction guide the older adults through the
exercise. Through a secure login, participants log in
to a web portal to access the program.
The program progresses in five levels. These
levels can be selected and adapted by the formal
caregivers. Exercises are randomly and
automatically chosen by the program according to
the corresponding difficulty level. The first step-in
ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health
190
level of the program consists of light and easy
exercises, which can be performed when sitting in
order to accommodate for sedentary older adults.
Progression of difficulty in levels elapsed in
agreement with the older adult. Older adults were
not obliged to finish all levels during the program.
Older adults could see their progress in the training
module, which tells them at what level they are
training, which week and which session. After each
training session, they get an overview of the
exercises performed.
2.3 Implementation Strategy
From the start, formal caregivers indicated in the
workshops that they felt insecure about providing
the technology to older adults at home without any
professional support. They suggested to provide the
program in their care setting at first, preferably in a
group and once the older adults are familiar with the
technology, they could continue using it at home.
Other formal caregivers thought that there would be
some exceptions and some older adults might be
able to use is at home instantly. To meet these initial
thoughts, formal caregivers were free in how to offer
the program to older adults. There were three
options, which were explained to them:
1) Offer at TMZ location to a group of older adults
with MCI; program is provided by a formal
caregiver
2) Offer at TMZ location, older adults with MCI
can train on his/her own;
3) Offer to the older adults with MCI at home,
individually.
2.4 Procedure
All formal caregivers were instructed about the
program and its content. They received accounts to
log in to the webportal to access the program.
Formal caregivers were free in how to offer the
program to their older adults. Formal caregivers
were instructed to use the online exercise program
for a minimum of four weeks and at least once a
week.
2.5 Outcome Measures
All older adults received paper-based questionnaires
about demographics, living situation, everyday use
of technology and cognitive functioning before the
start of the study (T0) and after the end of the study
(T1) about the implementation and user experience.
All formal caregivers received paper-based
questionnaires about demographics and everyday
use of technology at T0 and about the
implementation and user experience at T1.
2.5.1 Demographic Variables
We collected demographic variables including age,
sex, work status and cognitive functioning at
baseline by means of a questionnaire as well as data
about the use of internet and everyday use of
technology of the participants. Cognitive functioning
was measured with the Mini Mental State Exam
(MMSE) (Kurlowicz and Wallace 1999). The range
of MMSE score is from 0 (highest cognitive
impairment) to 30 (not cognitive impaired) (Murden
et al., 1991). A score between 19 and 23 is used to
specify MCI (Tombaugh and
McIntyre 1992).
2.5.2 Implementation
At the end of the study, a questionnaire was
provided to the older adults with MCI and their
formal caregivers. Formal caregivers were asked
which of the three implementation strategies they
had used and whether they thought the older adults
were able to use the program themselves at home
and potential barriers for independent use at home.
Older adults with MCI were asked in a
questionnaire whether they felt able to use the
program at home and if not, barriers for using the
program in the home setting.
2.5.3 Actual Use
We used log data to analyze the actual use of the
intervention. Actual use will be reported as duration
and frequency of use and the level achieved by the
users.
2.5.4 User Experience
To assess the experience of the user with the
technology we will assess the constructs; perceived
usefulness, usability, satisfaction, intention to use
and willingness to pay.
The perceived usefulness was assessed at the
end of the study by means of a questionnaire. The
perceived usefulness for older adults was assessed
on a 5-point Likert-type scale via the items:
- How useful do you think the exercise program
was” (1=very useful to 5=not useful at all)
- “I think that the online exercise program
improved my physical health and well-being”
(1=strongly agree to 5=not agree at all)
The Implementation, Actual Use and User Experience of an Online Home Exercise Program That Fits the Needs of Older Adults with Mild
Cognitive Impairments
191
The perceived usefulness of formal caregivers
was assessed on a 5-point Likert-type scale via the
items:
- How useful do you think the exercise program
was” (1=very useful to 5=not useful at all)
- “To what extent did the exercise program
improve your quality of work?” (1=a lot to 5=not
at all)
In addition, participants were asked to name the
advantages and disadvantages they experienced in
using the exercise program.
Usability perceived by formal caregivers was
measured with the System Usability Scale (SUS).
The SUS is a short ten-item questionnaire to
investigate the ease of use of the program (Brooke
1996). Rating of the SUS is from one (totally
disagree) to five (totally agree) and the range is a
score from 0 to 100. A score higher than 68 is
considered as good usability, a score of 85 or higher
as excellent usability and a score of 90 or
higherindicates best imaginable. A score of 50 or
lower is considered as poor or unacceptable usability
(Bangor et al., 2009).
Based on the problems we experienced at T0
with older adults filling in the questionnaire, we
decided to decrease the cognitive burden of the older
adults. For older adults, we selected two items from
the SUS:
- I thought the program is easy to use (SUS item
03)
- I would imagine that most people would learn to
use this program very quickly (SUS item 07)
To assess the satisfaction, all participants were
asked to rate the intervention on a scale from 1-10
and they were asked whether they would like to
continue using the intervention in the future
(intention to use). Formal caregivers were also
asked whether they would recommend the program
to other colleagues. In addition, older adults were
asked whether they were willing to pay for the
intervention to continue using it.
2.6 Data Analysis
IBM’s Statistical Package for the Social Sciences
(SPSS, 23) was used for the statistical analyses.
Demographic variables and everyday use of
technology were calculated as frequencies
(percentage) and means (+/-SD). For evaluating the
actual use of the intervention (duration, frequency,
levels), log data were used. Means, standard
deviations and frequencies were calculated for user
experience measures to highlight the most important
aspects.
3 RESULTS
3.1 Participant Characteristics
In total, 101 older adults and 8 formal caregivers
participated in this study. Forty-four older adults
dropped out before the start of the intervention. The
reasons for dropping out were: the hospitalization
(n=6), passed away (n=9); out of care (n=7), transfer
to another location (n=3), didn’t want to participate
anymore (n=4), didn’t like the program (n=2), being
too busy (n=1), or not having enough digital skills
(n=1) (missing reasons n=11).
Table 1 shows demographic variables and
everyday use of technology of the participants. The
mean age of the older adults was 80.2 (+/-10.8)
years and most of the older adults were female and
lived alone. Mean MMSE score was 24.1 (+/-5.9),
indicating MCI. The everyday technology use was
very low in this population, with more than half of
the older adults not having a computer, tablet or
smartphone at home. In addition, more than half of
the older adults didn’t have internet at home. The
formal caregivers were all female and all of them
had a laptop/ computer with internet at home.
Table 1: Participant characteristics and everyday
technology use.
Variable
Older adults with
MCI (n=57)
Formal
caregivers
(n=8)
Mean age in years (sd) 80.2 (10.8) 42.6 (14.5)
Gender, n (%)
Male 13 (23) 0
Female 43 (75) 8
Retired, n (%)
Yes 49 (86) 0
N
o 7 (12) 8
Living situation (n)
I live with spouse/partne
r
17
I live with family 5
I live alone 34
MMSE, mean (SD) 24.1 (5.9)
Use of everyday
technology at home (n)
Computer/laptop yes/no 21/ 35 (missing 1) 8/0
Tablet yes/no 9/ 40 (missing 8) 5/3
Smartphone yes/no 3/ 46 (missing 8) 5/3
Access to internet at
home, yes/ no (n)
15/34 (missing 8) 8/0
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3.2 Implementation Strategy
The online exercise program was used at seven
locations of TMZ in Twente, the Netherlands. All of
the formal caregivers used the program in a group at
the location (see figure 1) with 4-8 older adults
participating in each session. Groups started the
intervention incrementally. Six of the seven formal
caregivers indicated that their older adults wouldn’t
be able to use the program at home, because of lack
of a computer (n=2), fall risk (n=1), more burden on
the informal caregiver (n=1) and/or lack of
motivation (n=1). One formal caregiver indicated
that some older adults might be able to use the
program at home with proper support of a partner at
home to help the older adult starting and using the
program.
Figure 1: Group exercising at TMZ.
Only one of formal caregivers provided the
program to older adults at home and she provided
the program to eight older adults. Nine older adults
indicated they would have been able to use the
program at home, but weren’t offered to by their
formal caregiver. The other older adults indicated
that they would not have been able to use the
program at home for different reasons: lack of
technologies (n=14); lack of digital skills (n=4); not
offered by formal caregivers to be used at home
(n=3); too scared to use it alone (n=2); cognitive
impairments (n=2); physical impairments (n=1);
lack of motivation (n=1); vision problems (n=1); not
able to read (n=1).
3.3 Actual Use
The program was used at the different locations 125
times in total, with a mean duration of 18 minutes
(+/-15). Formal caregivers selected only level 1 for
exercising. In the home setting, the program has
been used 32 times with a mean duration of 15
minutes.
3.4 User Experience
A lot of data of the older adults for the user
experience questionnaires were missing, due to
concentration problems, not understanding the
questions, not willing to fill in the questionnaires
and/or not remembering the program. All formal
caregivers filled in the questionnaire.
Table 2: Advantages and disadvantages perceived by older
adults.
Advantages N Disadvantages n
Exercising together /
social interaction
33
Not enough
variation in the
program
14
Physical improvements
notice
d
23 Program too long 3
Program enables to
exercise more often
12
Unclarity of
exercises
3
Good structure in the
program
5
Technical failure o
f
program
2
Being able to exercise at
home
1 Program too easy 1
Gives some variation in
the day
1 Exercises too heavy 1
Table 3: Advantages and disadvantages perceived by
formal caregivers.
Advantages n Disadvantages n
Exercising with a group/
social interaction
4
Not enough
variation in the
program
6
Program enables to
exercise more often
3
Program suffered
from technical
Problems
2
Creating new ideas for
exercising
1
Older adults are too
good for the
Program
1
Program creates
something to talk abou
t
1
Exercises were
t
oo long
1
3.4.1 Perceived Usefulness
Both formal caregivers (n=6) and older adults
(n=46) perceived the program as useful. Twelve of
the older adults’ ratings (28%) indicated
improvement in perceived physical health and
emotional well-being, twenty older adults (47%)
indicated this as neutral and 11 older adults (26%)
didn’t indicate improvements. Most of the formal
caregivers (n=5) indicated that the program didn’t
improve their quality of work, one formal caregiver
indicated that it improved a lot and two answered
neutral.
Different advantages and disadvantages were
mentioned about the program (see table 2 and 3).
Table 2 shows that both older adults and formal
caregivers liked the possibility to exercise together,
The Implementation, Actual Use and User Experience of an Online Home Exercise Program That Fits the Needs of Older Adults with Mild
Cognitive Impairments
193
making it more fun. One older adult wrote:
“Exercising is important at our age. Exercising
together motivates and is fun, doing it alone is
unpleasant”. Many older adults indicated physical
improvements because of exercising with the
program. For example, one older adult wrote: “The
exercises loosened my leg muscles and I felt better at
night”.
The main disadvantage mentioned by both older
adults and formal caregivers was insufficient
variation in the program. One quote that was heard a
lot was “we often had the same exercises; more
variation would be more motivating”.
3.4.2 Usability
The mean SUS score of the formal caregivers was
65.4 (+/- 12.5), indicating that the usability was
“ok”. For older adults answering the questions, most
of them thought the program was easy to use (23 of
the 29) and imagined that most people would learn
to use it quickly (11 of the 18).
3.4.3 Satisfaction
Formal caregivers rated the system on average with
a 6.0 (+/-1.4). Older adults rated the system with a
7.4 (+/-0.8). Considering the intention to use, 20 of
the 46 older adults (43%) indicated that they would
like to continue using the program after the end of
the project and eight of those older adults (17%)
would be willing to pay for the program. Twelve
older adults (26%) indicated that they didn’t want to
continue using the program.
Two of the eight formal caregivers were willing
to continue using the program after the project had
ended and three of the eight formal caregivers
recommend the program to other caregivers.
4 CONCLUSIONS
This study evaluated the implementation, actual use
and user experience of a home-based exercise
program for older adults with MCI.
We developed a program for exercising at home,
with three implementation strategies considered
beforehand. The implementation strategy that was
used the most was the one offering the program in a
group setting by a formal caregiver at the location of
TMZ. As such, the majority of the older adults
didn’t use the program by themselves and many
indicated that they would not have been able to use
it because of lack of technologies and/or digital
skills. This study shows that every day use of
technology is still an issue in older adults with MCI.
Computer literacy is a major barrier in other studies
as well where e-health is being used independently
by older people (Lee and Coughlin 2015). Despite
the many potentials of e-health in this group, this
will hamper the implementation in the future. This
calls for e-health literacy interventions aiming at
improving older adults' ability to access and use e-
health applications (Korda and Itani, 2013). E-health
literacy refers to the “set of skills and knowledge that
are essential for productive interactions with
technology-based health tools” (Chan et al., 2011).
We recommend focusing on this e-health literacy in
the implementation of the exercise program by the
older adults and formal caregivers to enable older
adults to make better use of the program in the
future.
All formal caregivers started with offering the
intervention in a group setting at location. However,
the initial goal of this strategy of making older adults
familiar with the technology at the location where
after they would be offered the program at home,
was not realized. In addition, only one caregiver felt
secure in providing the intervention to older adults at
home, despite the fact that some of the older adults
indicated that they would have been willing to try
the program at home. Formal caregivers only offered
level 1 (exercises in sit) to the older adults, resulting
in low variety in exercises and demotivation of older
adults. This indicates that caregivers are still careful
in what to provide to their older adults. Caregivers
might be afraid to let go of control and this desire to
maintain their control is seen in other studies as well
as a barrier in e-health implementation (Grünloh et
al., 2018). This indicates that formal caregivers need
some support when implementing e-health to change
their attitude towards using and providing it to older
adults with cognitive impairments. There is still a
need to educate formal caregivers to assess users’
capacities, preferences, and motivation for using e-
health (Kenigsberg et al., 2016).
Older adults were positive about the program.
They thought the program would be easy to use, that
they would be able to learn to use it quickly and a
high amount of older adults would be willing to
continue using the service (43%). They indicated
several advantages, with physical improvements and
exercising together being the most important ones.
This social component is important to take into
account, as this is seen as major facilitator for
exercising in older adults (Resnick et al., 2002). To
date, the program doesn’t facilitate any social
features, but this might be an important
ICT4AWE 2019 - 5th International Conference on Information and Communication Technologies for Ageing Well and e-Health
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improvement point to integrate in the home-based
program. This might stimulate the older adults to use
the program in the home setting as well.
Unfortunately, the user experience was less positive
for formal caregivers, despite several advantages
mentioned. This usefulness was mainly perceived
for the older adult and not for themselves as a
caregiver. This was also reflected in the answer that
the program didn’t improve their quality of work.
Despite the participatory design of the program, still
a few adaptations need to be made in order for the
program being accepted in the future by both older
adults with MCI and their formal caregivers. It is
important to increase the user experience of formal
caregivers, because they play a key and pivotal role
in the initiation and maintenance of exercise
behaviour among the older population (Schutzer et
al., 2004).
As internet technologies become further
integrated into the lives of people across the
lifespan, it seems likely that online training will not
only become more accessible, but also more
desirable, for older adults. The results of the current
study suggest that this type of training approach is a
useful supplement in the current care for older adults
with MCI. The online exercise intervention is
feasible and potentially beneficial for older adults
with MCI when taken into account the e-health
literacy of older adults in the implementation
strategy and further adapting the program according
to the results of this study.
4.1 Limitations
One of the limitations of the study was that older
adults with low level of digital skills were
overrepresented. As such, the program could not be
used in the home setting as much as we had hoped.
In the future, it might be helpful to include informal
caregivers as well in order to help the older adult
with MCI with the use of the program at home. In
addition, there were many missing values in the
questionnaire due to cognitive impairments of the
older adults. This has limited the evaluation. In
many cases, older adults couldn’t remember the
program. In addition, this target group probably had
difficulty in reading or perceiving information, and
this could explain part of the not-so-positive scores
in the usability assessment. This sensory
accessibility could have played an important role
and more attention should be payed to the type and
amount of questions asked to decrease the burden of
the older adult with MCI and the timing of the
evaluation.
4.2 Future Work
Further development of the program is necessary for
older adults with MCI to be able to use it and to
increase the user experience of the formal
caregivers. It seems helpful to develop an e-health
literacy module in the implementation strategy, for
both older adults and formal caregivers. Future
research should focus on changing the attitudes of
formal caregivers towards using e-health in the care
of older adults with MCI and motivate them to offer
it in the home setting.
ACKNOWLEDGEMENTS
The authors would like to thank Trivium Meulenbelt
Zorg in the Netherlands for their participation in the
project. This work was partly funded by the H2020
program (PHC-20-2014) within the IN LIFE project
(grant no. 643442).
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