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

, S. Jansen-Kosterink

and M. Tabak

1,2

Roessingh Research and Development, eHealth Cluster, 7500 AH Enschede, The Netherlands

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

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

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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

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

higher indicates 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

o 7 (12) 8

Living situation (n)

I live with spouse/partne

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

Not enough

variation in the

program

Physical improvements

notice

23 Program too long 3

Program enables to

exercise more often

Unclarity of

exercises

Good structure in the

program

Technical failure o

program

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

Not enough

variation in the

program

Program enables to

exercise more often

Program suffered

from technical

Problems

Creating new ideas for

exercising

Older adults are too

good for the

Program

Program creates

something to talk abou

Exercises were

oo long

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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