International Psychogeriatrics: page 1 of 11 © International Psychogeriatric Association 2017

doi:10.1017/S104161021700028X

Aquatic exercise for residential aged care adults with

dementia: benefits and barriers to participation
...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Timothy Henwood,1,2,3 Christine Neville,1 Chantelle Baguley1 and Elizabeth Beattie4

1
School of Nursing and Midwifery, The University of Queensland, Brisbane, Qld, Australia
2
Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia
3
AgeFIT Solutions, Brisbane, Qld, Australia
4
School of Nursing, Queensland University of Technology, Brisbane, Qld, Australia

ABSTRACT

Background: Pilot work by our group has demonstrated that aquatic exercise has valuable functional and
psychosocial benefits for adults living in the residential aged care setting with dementia. The aim of the
currents study was to advance this work by delivering the Watermemories Swimming Club aquatic exercise
program to a more representative population of older, institutionalized adults with dementia.
Methods: The benefits of 12 weeks of twice weekly participation in the Watermemories Swimming Club
aquatic exercise program were assessed among an exercise and usual care control group of residential aged
care adults with advanced dementia. A battery of physical and psychosocial measures were collected before
and after the intervention period, and program implementation was also investigated.
Results: Seven residential aged care facilities of 24 approached, agreed to participate and 56 residents were
purposefully allocated to exercise or control. Twenty-three participants per group were included in the final
analysis. Both groups experienced decreases in skeletal muscle index and lean mass (p < 0.001), but exercise
stifled losses in muscle strength and transition into sarcopenic. Behavioral and psychological symptoms of
dementia and activities of daily living approached significance (p = 0.06) with positive trends observed across
other psychosocial measures.
Conclusions: This study demonstrates the value of exercise participation, and specifically aquatic exercise
in comparison to usual care for older, institutionalized adults with advanced dementia. However, it also
highlights a number of barriers to participation. To overcome these barriers and ensure opportunity to
residents increased provider and sector support is required.

Key words: dementia, residential aged care, aquatic exercise, functional performance psychological well-being

Internationally, an increased prevalence of de- 65.7 million people by 2030, present expendit-
mentia will bring with it significant financial and ure may increase greater than 85% worldwide
carer implications. In Australia, the prevalence of (Alzheimer’s Disease International 2010). Demen-
dementia is projected to almost double in the tia was the third leading cause of death (6% of all
next two decades and then almost double again deaths) in Australia in 2010, but recorded as an
by 2050. With this will come a 364% increase underlying or addition cause in 14% of all deaths
in health and residential aged care expenditure in the same year. In addition, for those over 65
between 2003 and 2033, with the dementia years of age, dementia is reported as the second
prevalence rate having the second greatest impact leading cause of overall disease burden and the
behind diabetes (Goss, 2008). Alzheimer’s Disease leading cause of total disability burden (AIHW,
International reported that in 2010 US$604 billion 2012). Given the growing prevalence, burden and
was directed to dementia care and treatment, health cost implications, significant breakthroughs
but with diagnoses projected to increase to in dementia are needed that will reduce incidence
and improve outcomes for adults with this disease
(Alzheimer’s Disease International, 2010).
Correspondence should be addressed to: Dr Timothy Henwood, The University of Exercise and physical activity as a treatment
Queensland, Brisbane Qld 4305, Australia. Phone: +61 7 424078209. Email:
[email protected]. Received 27 Sep 2016; revision requested 7 Nov 2016;
and/or preventative measure has received growing
revised version received 6 Feb 2017; accepted 12 Feb 2017. attention. A number of studies have demonstrated

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 2 T. Henwood et al.

that increased levels of physical activity are the challenges of research in residential aged care
associated to reduced incidents in dementia adults with moderate to severe dementia, learnings
development (Laurin et al., 2001; Barnes et al., gained during the pilot study were employed
2007), suggesting that physical activity may play to design a larger investigation. Specifically, the
a key role in prevention. As for all people, aim of this project was to establish the benefits
evidence is also strong that with exercise a person of the Watermemories Swimming Club program
with dementia can improve their aerobic, muscle among residential aged care adults with advanced
strength, and physical performance capacity (Heyn dementia. Within this, our objectives included
et al., 2004; Littbrand et al., 2011). While evidence the evaluation of the physical and psychological
is mixed over the ability of exercise to slow benefits associated to program participation, as well
and/or stifle cognitive decline in people with as the feasibility and barriers to program delivery.
dementia (Littbrand et al., 2011), a growing body
of research supports that exercise can reduce
behavioral fluctuations and agitation, and improve Method
sleeping patterns, with the potential to reduce
the need for psychotropic medications (Miranda- Design and recruitment
Castillo et al., 2010; Neville et al., 2014). However, The study was a controlled trial of residential aged
in residential aged care, the setting in which the care adults with moderate to severe dementia, con-
greatest prevalence of dementia is present, more ducted between February and December of 2013.
work is needed to detail the benefits of exercise Residential aged care facilities within Brisbane,
as well as the optimal method of prescription the Gold Coast and Toowoomba, Queensland,
(Littbrand et al., 2011). Australia, were approached with an opportunity
Pilot work by our group has demonstrated that to participate in the Watermemories Swimming
among adults with dementia in the residential Club program. In recruiting facilities to this study,
aged care setting, aquatic exercise is a feasible contact was made with facility service managers,
modality of activity with small but important the reputation of the program leveraged, the
benefits (Neville et al., 2014; Henwood et al., study explained in detail and it was established
2015b). The Watermemories Swimming Club the facility had sufficient residents meeting the
program was initially designed due to the older inclusion criteria.
Australians familiarity to swimming, and in line Facilities that agreed to participate were pur-
with anecdotal evidence that aquatic exercise poseful selected to the Watermemories Swimming
has important benefits for adults with dementia Club exercise or usual care control group based on
(Neville et al., 2013; Smith, 2003). When trialed, (i) discussion with the facility about their capacity
our pilot work revealed improvements in the to transport participants to the pool for program
behavioral and psychological symptoms among attendance, (ii) whether they had staff availability
people with dementia as well as in grip strength to support participants during program attendance,
and some physical performance measures (Neville and (iii) if they could supply other necessary
et al., 2014; Henwood et al., 2015b). Recognition resources including adult’s incontinence swimwear
of the programs value was significant from the and dressing gowns for participants to wear after
regional aged care communities where the pilot leaving the water. In addition, facilities were
occurred and, following the pilot, the program matched by the organization running them (N = 3)
was implemented locally using council, aged care to ensure similar practices and missions. To support
providers, and local business support. Nationally participation, research funds were allocated to pay
and internationally, the program sparked broad an instructor to deliver the program, the cost of
interest, with the research team receiving a number entry to the pool for participants and for in-pool
of requests for more information and for the support equipment (pool noodles and floatation
program training manual (Neville and Henwood, vests). A case-by-case discussion was entered into
2013), an outcome of which was the team being with the facility in the exercise group about funding
invited to present the pilot as a keynote symposium support for taxiing participants to and from the
during the 2012 World Congress on Active Ageing pool and the incontinence swimwear.
in Glasgow (Neville et al., 2012). Participant recruitment was based on the
However, while feasibility was supported, during individual facilities’ Service Manager approval of
the pilot dropout rates, measure reliability and re- residents meeting the eligibility criteria. Inclusion
cruitment were all identified as factors that needed criteria for the study were a past history of
greater attention for successful program delivery swimming, residing in a residential aged care
(Henwood et al., 2015b), as well as investigation facility (low or high care), with a diagnosis of
among a larger representative group. Conscious of dementia, able to walk a minimum of 10 m

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 Aquatic exercise for people with dementia 3

self-ambulating or with a walking cane or wheelie 30 kilometer (km) catchment area of the aquatic
walker, and able to gain substitute decision maker center where delivery would occur, five could
consent. Residents were excluded if they had an not be re-contacted after multiple telephone calls
unstable or terminal illness, were wheel chair or bed and emails, four could not get ethical approval,
bound, had dangerous or unpredictable behaviors, two were not interested, three had no eligible
had a pacemaker, and were taking medications participants (either only mild dementia or had
contradictory to exercise. Written informed proxy dementia but were immobile), six had staff/resource
consent was obtained for all participants. This issues and were not in a position to provide support
included consultation with the participant’s sub- for the project, and three were interested, but
stitute decision maker, and them signing the were not able to obtain family consent for their
consent form directly or giving verbal assent for eligible residents. One facility was recruited within
the facility Service Manager to sign the form in the original catchment area. To ensure a control
their absence. Prior to involvement, participant group for the recruited facility, a regional facility
required a medical fitness clearance from both (Gold Coast, Australia) operating within the same
their facility and their General Medical Practitioner organization was recruited into the study. To build
(GP). If participants were unable to obtain a participant numbers, facilities in the regional town
medical clearance for exercise from their GP or if of Toowoomba (Australia) were approached to
they decided they no longer wanted to participate participate. The strong program reputation gained
in the intervention following baseline assessment, during the pilot delivery ensured that of the
they were allocated into usual care group. five facilities approached in Toowoomba, all were
The study received ethical approval through recruited into the study.
the University of Queensland Human Research
Ethics Committee and was registered on the
Australian New Zealand Clinical Trials Registry Intervention
(12613000503729). Participants who received usual care engaged in
their normal facility activities for a 12-week period.
Participants Participants allocated to the Watermemories Swim-
ming Club exercise group travelled by taxi to a
Fifty-six residents from seven facilities in Brisbane
heated, municipal swimming pool, twice-weekly for
(one facility; N = 16), Gold Coast (one facility;
12 weeks. Each exercise session, 45 minutes in
N = 9), and Toowoomba (five facilities; N = 31)
duration, was delivered in the middle of the day,
were recruited into the study. Of these, 29 were
outside busy pool times and school holidays. A
allocated to the exercise group. Among facilities,
trained swimming instructor delivered the program
four were members of Bupa Aged Care, two of
from the side of the pool. Each session had a
Freedom Aged Care, and one of St Vincent’s
maximum of ten participants. In-pool support
Health Services. Ten participants were lost to
for participants was provided in a 1:1 or 1:2
follow-up due to reasons unrelated to the research.
arrangement by facility staff or nursing students
These were; one participant had passed away, one
recruited from a local university as part of the
was immobile and bedridden following a stroke,
practical component of their nursing degree. In
one was in hospital for an indefinite period, one
addition to in-pool assistance, participants used
was too agitated to complete the assessments, two
the pool lane rope, pool side, and pool floatation
refused to participate, and four participants were
devices to maintain their balance. Participants were
absent from the facility due to family outings.
encouraged to follow the guidance of the instructor
The final sample consisted of 18 men and 28
but at all times monitored for fatigue and told to
women. Twenty-seven participants had a dementia
rest if and when needed. Session attendance was
assessment using the Psychogeriatric Assessment
recorded, and inclusion compliance set at attending
Scales (PAS) (Jorm et al., 1995), with a group
≥ 40% of all sessions.
mean of 12.4 ± 4.1. Remaining participants had
The Watermemories Swimming Club inter-
an assessment of moderate to severe dementia by
vention program was designed by an exercise
the Functional Assessment Staging of Alzheimer’s
physiologist with experience in program delivery
Disease (FAST) (Reisberg, 1988) questionnaire.
for very old adults with physical and cognitive
disease, in consultation with an aquatic exercise
Design modification and justification specialist and dementia experts. The program has
Initially planned as a randomized controlled achieved delivery feasibility and been shown safe
trial, this design required modification based on and beneficial for the target cohort (Neville et al.,
a low facility participation rate. In brief, of 2014; Henwood et al., 2015b). A manual has
the 24 facilities initially approached within the been produced detailing program delivery and

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 4 T. Henwood et al.

Table 1. Summary of measures collected during the study and their purpose
p u r po s e
.........................................................................................................................................................................................................................................................................................................................

PHYSICAL MEASURES
Height (cm) Height, body mass index (BMI), sarcopenia
Weight (kg) Weight, BMI, sarcopenia
Bioelectrical impendence analysis (Janssen et al., 2000) Body fat, muscle mass, sarcopenia
Short Physical Performance Battery (Guralnik et al., 1994) Functional capacity summary score, individuals measures
informed: lower body strength, static balance, mobility,
sarcopenia
Grip strength (Cruz-Jentoft et al., 2010) Hand grip and total body strength, sarcopenia
BOOMER (Haines et al., 2007) Static and dynamic balance, agility
Activities of daily living scale (Katz et al., 1963) Six core activities of daily living
PSYCHOSOCIAL MEASURES
Revised Memory and Behavioral Problem Checklist (Teri Behavioral and psychological symptoms of dementia
et al., 1992)
Psychological well-being in cognitively impaired persons Affect, behaviors, and social interactions
(Burgener et al., 1992)
Cornell scale for depression in dementia (Alexopoulos Depression
et al., 1988)
Geriatric anxiety inventory (Pachana et al., 2007) Anxiety

considerations (Neville and Henwood, 2013). The Facility records were consulted to provide demo-
program targets resistance, balance, flexibility, and graphic and cognitive impairment information.
aerobic activities, and includes a warm up and Data collected included date of birth, ethnic
cool down. Exercises include walking, marching background, level of education, marital status,
and weight transfer, and lower- and upper-body primary occupation, level of care based on the
resistance activities. In brief, the program is Australian Age Care Funding Instrument, falls
structured as follows: a short warm up of water history, length of stay in the facility, medical
walking and toe raises, followed by 10 minutes conditions and medications. Dependent on which
of combined aerobic and balance exercises (high tool the facility used, cognitive status was based
knee marching and butt kicks, tightrope walking, on either the PAS or the FAST questionnaire.
and weight transfer balance), then 15 minutes of All measures collected by the research team are
upper- and lower-body resistance exercise (water presented in Table 1.
squats, chest, and back arm swings through the Prior to physical and functional performance
water), and finished with stretching. Following each assessment, participants were familiarized to the
session, the program has a time allowance of up task and offered verbal encouragement and physical
to 10 minutes for free swimming so participants support to ensure their safety throughout. Height
can engage in playing or relaxing. Exercises can and weight were measured by stadiometer (Charder
be tapered to cater for the group and individual’s Electronic Co, Ltd., Taichung Hesin, Taiwan) and
capacity. Initially, groups undertook a two-week electronic scale (SECA Medical Scales and Meas-
conditioning phase, during which the total work uring Systems, Birmingham, UK), respectively,
load was reduced to approximately half and the using standardized methods. Body composition
rest periods increased. Following the conditioning was measured by Bioelectrical Impedance Analysis
phase, participants continue for ten weeks using the (BIA) (Maltron 906, Maltron International Ltd.,
full program. Program delivery was accompanied Rayleigh, UK). Participants lay supine during
by music and participants were encouraged to work the test. Skeletal muscle mass (SMM) (kg) was
at a moderate intensity. calculated from the validated equation:

 
Measures SMM = [((height cm2 /BIA resistance ())
Physical and functional performance, behavioral × 0.401) + (gender × 3.825) + (age (years)
and psychological data were collected for each
participant at their facility before and after the ×−0.071)] + 5.102 (Janssen et al ., 2000).
12-week study period. Data were collected using
the same team and equipment at each facility Then divided by the individual’s height squared to
by degree qualified health workers using tools calculate the skeletal muscle index (SMI) (kg/m2 )
validated for use among older adults with dementia. (Cruz-Jentoft et al., 2010).

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 Aquatic exercise for people with dementia 5

The Jamar dynamometer (Sammons Preston strength > 30 and > 20 kg for men and women,
Roylan, Bolingbrook, USA) was used to measure respectively, and low muscle performance as a gait
hand grip muscle strength (kg). Participants were speed of > 0.8 m/sec (Cruz-Jentoft et al., 2010).
instructed to squeeze the dynamometer as hard as Ability to perform activities of daily living was
they could while seated, keeping their elbow at their assessed with the Activities of Daily Living Scale
side and flexed at 90° (Cruz-Jentoft et al., 2010). (Katz et al., 1963). In brief, staff reported on
Both hands were measured. the participant’s ability to perform six activities;
Two standardized physical performance bathing, dressing, toileting, transferring, contin-
batteries were used to measure performance- ence, and feeding, with each activity scored as
related balance and functional capacity. The “0” = can be performed independently, “1” =
Balance Outcome Measure for Elder Rehabilitation needs some assistance, or “2” = needs total
(BOOMER) uses a step test (number of steps), assistance or cannot do the activity. Frequency
timed up and go (TUG) (sec), functional reach of behavioral and psychological symptoms of
(cm) and static standing test (sec) to measure dementia (BPSD) and reaction of staff to BPSD
agility, dynamic, and static balance (Haines was recorded using the Revised Memory and
et al., 2007). The Short Physical Performance Behavioural Problem Checklist (RMBPC) (Teri
Battery (SPPB) uses a standing balance (sec), et al., 1992). Changes in affect, behavior, and social
2.4-m walk (m/sec) and repeated chair rise test interaction were measured with the 11 items Psy-
(sec) to assess functional well-being and mobility chological Well-Being in Cognitively Impaired Per-
among older adults (Guralnik et al., 1994). Each sons (Burgener et al., 1992). The 19-item Cornell
test can be analyzed separately or combined Scale for Depression in Dementia (Alexopoulos
to provide an overall summary score, ranging et al., 1988) was used to rate signs and symptoms of
from poor performance to high performance major depression, and anxiety was measured using
(0–12, respectively). Measures were collected the 20-item Geriatric Anxiety Inventory (Pachana
in triplicate and the best outcome was used in et al., 2007). For all questionnaire tools, a high
analyses. Competency to complete measures was numerical outcome was indicative of a negative
assessed on a case-by-case basis. Specifically, when result.
an individual was unable to complete a measure or
performed the measure with significant variation
Statistical analysis
from the protocol, they were given opportunity
for two more attempts before that measure was Data were analyzed using IBM SPSS Statistics
terminated and skipped. For the Repeated Chair Version 21 (IBM Corporation, New York, USA).
Stand and TUG participants were consistently Descriptive and frequency analysis were conducted
reminded of the protocol, but the larger percentage dependent on the variable status, continuous
failed to perform the task as requested. Data or categorical. Between group analysis was by
for these measures have been included and independent sample t-test for continuous data and
coupled with data outlining the variation from the Pearson’s Chi-squared test (χ 2 ) for categorical
protocol. data at baseline. Post-intervention cohort analysis
In this cohort test–retest Interclass Correlations was by repeated measures analysis of covariance
Coefficients (ICC) established by our group (ANCOVA) adjusted for baseline differences (Age,
previously are anthropometric measures ≥ 0.925; % body fat, SPPB summary score and TUG). For
grip strength ≥ 0.956; the BOOMER: step test small sample or non-parametric repeated measure
0.797, TUG 0.940, functional reach 0.586, and outcomes, the Wilcoxon Signed Rank Test (for
static standing 0.905; and the SPPB: standing pre–post comparisons) was used. Percent change
balance 0.394, 2.4-m walk 0.719, and repeated was calculated on individual data, effect size was
chair rise 0.548. calculated from the Wilcoxon test statistic and the
Sarcopenic status was assessed according to the strength assumption based on Cohen interpretation
European Working Group on Sarcopenia in Older (Cohen, 1988). All tests were two-tailed and an α
People (EWGSOP). A diagnosis of sarcopenia of 0.05 was required for significance.
requires the presence of both low muscle mass and
low muscle function (muscle strength or physical
performance). In this study, (a) muscle mass was Results
by SMI, (b) muscle strength by hand grip strength,
and (c) physical performance by 2.4 m habitual Participants
walking speed. The cut-off point to define low Ten participants were lost to follow-up, but no
muscle mass are ≥ 2 standard deviations below the difference found between completer and non-
norm of a young healthy population, low muscle completers. The final group (N = 46) were

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 6 T. Henwood et al.

Table 2. Baseline group and between group characteristic, anthropometric, muscle strength, and physical
performance data
t ota l g ro u p e x e rc i s e co n t ro l p
.........................................................................................................................................................................................................................................................................................................................

N N
Age (yrs) 82.4 ± 6.6 23 80.5 ± 6.9 23 84.3 ± 5.9 0.048
Sex (N) – Male∗ 18 9 9 1.000
Marital status (N) ∗
– Single 3 2 1
– Married 12 7 5
– Divorced 22 3 2
– Widowed 42 10 12 0.812
Primary language spoken (N) ∗ – English 43 23 20 0.360
Level of care (N) – high∗ 37 20 17 0.265
Duration in care (days) 459.2 ± 458.1 23 466.5 ± 533.1 23 451.9 ± 381.0 0.915
Falls in the last six months (N) 1.7 ± 4.7 20 7.7 ± 2.8 22 1.7 ± 5.9 0.985
Sarcopenic (N)∗ 5 22 4 22 1 0.154
Percent body fat 27.4 ± 11.9 22 30.9 ± 10.3 22 23.9 ± 12.6 0.049
Body mass index (kg/m2 ) 26.4 ± 5.2 23 26.9 ± 5.9 23 25.8 ± 4.5 0.466
Skeletal mass index (kg/m2 ) 10.3 ± 3.2 22 9.7 ± 3.4 22 11.0 ± 3.0 0.209
Lean mass (kg) 47.8 ± 10.7 22 47.7 ± 11.2 22 47.9 ± 10.5 0.942
Grip strength (kg) 18.8 ± 7.7 22 17.8 ± 7.8 23 19.8 ± 7.7 0.398
Grip strength-left (kg) 16.9 ± 6.8 22 6.4 ± 6.7 23 17.9 ± 6.9 0.477
Short physical performance battery
Standing balance (sec) 18.6 ± 8.4 21 16.6 ± 8.0 21 20.6 ± 8.5 0.124
Chair stand (sec) 21.4 ± 8.6 19 24.9 ± 7.4 23 18.6 ± 8.6 0.016
Chair stand assistance (N)∗
– No assistance 30 13 17
– Used arms/incomplete stand 10 5 5
– Added assistance again 2 1 1 0.926
Walking speed (m/sec) 0.66 ± 0.26 23 0.59 ± 0.25 23 0.73 ± 0.25 0.058
Summary score 6.0 ± 3.0 23 4.9 ± 2.4 23 7.2 ± 3.2 0.009
BOOMER
Step test – R (N) 8.0 ± 4.0 18 7.0 ± 3.1 23 8.8 ± 3.1 0.155
Step test – L (N) 8.1 ± 4.1 18 7.4 ± 3.2 22 8.6 ± 4.4 0.405
Timed up and go (sec) 26.3 ± 23.9 23 33.7 ± 30.2 23 18.9 ± 11.9 0.033
Timed up and go assistance (N)∗
– No assistance 40 18 22
– Used arms to stand or assisted walking 4 3 1
– Used arms to stand and assisted walking 2 2 0 0.183
Functional reach (cm) 18.3 ± 8.9 20 16.4 ± 9.0 22 20.1 ± 8.8 0.186
Static standing (sec) 74.2 ± 27.2 22 78.2 ± 23.7 23 70.3 ± 30.1 0.332

Abbreviations: yrs – years; N – number; kg/m2 – kilogram/meter2 ; kg – kilograms; sec – seconds; cm – centimeters.
Values are mean ± standard deviation.
p – Exercise versus control by independent t-test, except variables denoted with a ∗ which are by Pearson’s chi-squared test.

82.4 ± 6.6 years of age with a BMI of 26.4 ± 5.2 slower in completing the TUG and the repeated
kg/m2 and body fat of 27.4 ± 11.9%. Participants chair stands task, and had a lower SPPB summary
had been in residential aged care for 459.2 ± 458.2 score (p ≤ 0.048). Cohort and group characteristics
days (Range 0–2079 days), and presented with at baseline are presented in Table 2. The exercise
below normal physical performance and muscle group attended 63.2% ± 26.8% of all sessions,
strength (walking speed 0.66 ± 0.25 m/sec; SPPB with greater attendance from Brisbane (87.5% ±
summary score 6.0 ± 3.0; muscle strength 18.8 12.8%) than from Toowoomba (44.6% ± 18.1%)
± 7.7 kg). Five of the group were sarcopenic. (χ 2 = 20.287, df = 13, p = 0.088).
However, 37 and 34 individuals had below Post-intervention analysis revealed a significant
normal muscle strength and physical performance, Group × Time interaction for BMI, SMI, and
respectively. At baseline, the exercise group (N = lean mass (p ≤ 0.007). Within-group investigations
23) were younger, had a high percent body fat, were revealed a decrease in SMI and lean mass for

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 Aquatic exercise for people with dementia 7

Table 3. Post-intervention anthropometric, physical, and functional performance measures and change in
adults with dementia living in residential aged care facilities
effect
n e x e rc i s e % change n co n t ro l % change p size
.........................................................................................................................................................................................................................................................................................................................

Fat mass (%) 22 36.7 ± 8.1 30.8 ± 57.5 22 35.5 ± 8.2 138.8 ± 302.4 0.433 0.015
BMI (kg/m2 ) 22 27.7 ± 5.5 2.2 ± 10.6 23 26.2 ± 4.7 2.1 ± 10.8 0.007 0.162
Skeletal mass index (kg/m2 ) 22 7.6 ± 1.8 − 24.3 ± 16.1 22 7.1 ± 1.9 − 33.1 ± 18.9 0.002 0.220
Lean mass (kg) 22 43.1 ± 9.3 − 7.5 ± 10.3 22 41.3 ± 9.5 − 14.28 ± 9.42 0.001 0.278
Grip strength – right (kg) 20 18.2 ± 8.1 7.7 ± 24.0 23 16.9 ± 8.1 − 15.1 ± 23.8 0.017 0.137
Grip strength – left (kg) 20 16.9 ± 7.7 3.9 ± 23.6 21 16.8 ± 6.6 − 11.2 ± 18.8 0.003 0.218
Seniors physical performance battery (SPPB)
Standing bal (sec) 19 17.1 ± 8.1 9.3 ± 38.1 20 21.0 ± 6.7 13.8 ± 53.2 0.084 0.083
Chair stands (sec) 17 24.9 ± 12.2 − 1.7 ± 24.1 23 18.3 ± 10.7 1.5 ± 33.5 0.034 0.119
2.4-m walk (m/sec) 21 0.58 ± 0.25 − 9.3 ± 30.4 23 0.71 ± 0.27 − 8.1 ± 26.5 0.255 0.032
Summary score 21 5.3 ± 2.6 12.4 ± 35.2 23 7.1 ± 3.1 4.01 ± 34.63 0.009 0.149
BOOMER
Step test (R) 16 8.5 ± 4.4 30.0 ± 65.77 19 9.9 ± 4.5 12.9 ± 39.1 0.818 0.002
Step test (L) 16 8.3 ± 4.5 20.3 ± 65.3 18 10.1 ± 4.7 23.4 ± 50.6 0.635 0.008
Timed up and go (sec) 20 23.4 ± 10.6 − 8.1 ± 41.2 23 18.5 ± 12.2 0.6 ± 25.7 0.396 0.019
Functional reach (cm) 19 17.2 ± 7.0 8.4 ± 48.1 16 24.2 ± 7.0 30.3 ± 61.5 0.003 0.248
Static standing (sec) 20 75.9 ± 28.5 39.9 ± 158.3 20 80.6 ± 25.5 25.5 ± 84.3 0.086 0.080

Data are by analysis of covariance adjusted for age and the SPPB Summary score.
Abbreviations: yrs – years; N – number; kg/m2 – kilogram/meter2 ; kg – kilograms; sec – seconds; cm – centimeters
Values are mean ± standard deviation.

both groups (p < 0.001), but no statistical change to BPSD, psychological well-being, anxiety, and
in BMI. Grip strength achieved a Group × depression (p > 0.05).
Time interaction (p ≤ 0.017), influenced by
the significant within-group decrease among the
control group (p ≤ 0.026). For measures of physical
Discussion
performance and balance, a significant Group ×
Time interaction was found for the SPPB summary Results from this study support the benefits of
score, chair stand, and functional reach task (p ≤ participation in the Watermemories Swimming
0.034). However, a within-group analysis revealed Club when compared to usual care for resid-
no static difference in post-intervention scores. All ential aged care adults with advanced dementia.
post-intervention data are presented in Table 3. Exercise participation reduced the transition into
Sarcopenia prevalence increased in both groups. sarcopenia, and, while not significant, did lead to
Specifically, at baseline, the exercise and control positive trends for balance, physical performance
groups had four and one participant, respectively (as measured by the SPPB Summary Score),
with a diagnosis of sarcopenia. In contrast, at and grip strength. In addition, with exercise
follow-up frequency data revealed in the exercise participants experienced positive trends across
group six participant had a diagnosis of sarcopenia BSPD’s, activities of daily living, psychological
(p = 0.038), while the control group increased well-being, anxiety, and depression, as well as staff
substantially with nine diagnoses (p = 0.002) (χ 2 = burden to BSPD’s being reduced. Given that a
10.800, df = 2, p = 0.005). diagnosis of dementia contributes to increased costs
In relation to the behavioral and psycholo- of care, distress and burden for carers, and severe
gical measures, RMBPC between group analysis disruption of social networks and institutional
revealed baseline to post change approached environments (Dewing, 2010; Miranda-Castillo
significance (p = 0.06; effect size 0.07) (exercise et al., 2010), and that the prevalence and
group −3.8 ± 4.8 vs. usual care −0.9 ± 5.8). progression of dementia poses a significant problem
Similarly, for activities of daily living baseline to for healthcare expenditure and utilization (Goss,
post change between group analysis approached 2008), these outcomes are positive in contrast to
significance (p = 0.06; effect size 0.07). These the current models of care. Nevertheless, a number
data are presented in Figure 1. Positive but non- of barrier encountered in the delivery of this study
significant trends were observed for staff reaction suggest there is significant work to do before

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 8 T. Henwood et al.

Figure 1. (Colour online) Revised Memory Behavioral Problems Checklist (RMBPC) and activities of daily living (ADL) pre to post-
intervention scores for the exercise and control group.

exercise participation becomes more available to pilot work showed physical benefit coupled with
the institutionalized dementia population. psychological benefit from the Watermemories
Swimming Club program (Neville et al., 2014;
Benefits of participation Henwood et al., 2015b). The current study further
When compared to the usual care controls, supports the value of exercise participation as
participant in the Watermemories Swimming Club having psychosocial benefits (Teri et al., 2003;
experienced gains in a number of variables linked Williams and Tappen, 2007). Given the side-
to capacity in activities of daily living. While it is effects of psychotropic medications, exercise to
disappointing there was not a greater demonstra- treat the behavior and agitation symptoms common
tion of statistical significance, this is not uncommon with dementia would appear a significantly more
in this setting or among this cohort. Littbrand desirable alternative (Thune-Boyle et al., 2012). In
et al. (2011) reported only three of eight studies contrast, the implication of participation to physical
returned significant between group difference post well-being are more mixed, with some studies
exercise, and were unable themselves to show reporting the potential for gains becoming smaller
significant between groups following three months with the increasing progression of the disease (Heyn
of high-intensity, supported exercise. This lack of et al., 2004; Conradsson et al., 2013). Nevertheless,
change might be related to a number of factors our study support that something is better than
including inter-cohort performance variability and nothing for a cohort known to experience an
attendance, as well as the significant delivery accelerated downturn in well-being, with exercise
challenges encountered in undertaking this type of participants leading to some small gains and a
research. These difficulties were echoed by Brett greater resistance to other physical losses such
et al. (2016) in their recent systematic review of as the muscle mass (Hancock et al., 2006). For
the value of exercise among dementia residents in the control group, the loss of muscle mass and
the aged care setting, who concluded that where grip strength was the driver of the large change
evidence was positive, methodological rigor needed in sarcopenia prevalence, which is suggestive of
improving, and a number of barriers needed to be an increased risk of mortality, depression, and
overcome. increasing disability (Cruz-Jentoft et al., 2010).
These challenges aside, as both a preventative While small, the benefits of participation were
and treatment participation in physical activity and treasured by our Brisbane facility who self-
exercise regimes is building a strong reputation as funded an on-going delivery of the program after
an intervention of value for people with dementia the study had finished and were awarded an
(Barnes et al., 2007, Neville et al., 2013). In Australian Government Aged Care Best Practice
support, Alzheimer’s Australia New South Wales Award based on a reduction in the group’s
have most recently released a discussion paper falls and emotional disturbances, and increase
encouraging adults with any level of dementia in positive interactions (Australian Government,
to become involved (Alzheimer’s Australia NSW, 2014).
2014). Within this document, significance evid-
ence is presented alongside numerous personal Barriers to delivery
testimonials about the importance and breath The challenge of research delivery in the aged
of benefit from involvement. From our group, care setting has been widely acknowledged, with

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 Aquatic exercise for people with dementia 9

individual and review publications raising sampling Conclusion

issues that include recruitment, drop-out, and
attendance (Ouslander et al., 2011; Tilden et al., Physical inactivity is a significant issue with
2013). The list of challenges is complicated further deleterious health impacts for older adults with
when the participants have moderate to severe dementia (Scherder et al., 2010). Our study shows
dementia (Littbrand et al., 2011; Burge et al., participation in the Watermemories Swimming
2012). Facility recruitment proved a significant Club program brings a number of positive physical
challenge to this project with 24 facilities within a and psychosocial benefits. While many of the
30-km distance of the delivery site approached, and benefits occurred as positive trends, in contrast to
only one agreeing to participate. This demonstrates an accelerating decline in health, our program is
that even with the program’s reputation and proven a valuable alternative to usual care. In addition,
benefit, and a commitment of financial support, this study also reiterates the difficulties of doing
under-resourcing, and under-staffing, a product research in the setting and among this population.
of financial strain in the sector, are a significant We identified facility resources and engagement are
preventative to participation (Tilden et al., 2013). among the greatest challenge in successful delivery,
These barriers were most pertinent among the but that these can be overcome when the facilities
not-for-profit facilities and were echoed by the and their staff are invested in the well-being of the
ethics committees of the organizations approached resident even if the program in question is delivered
(Henwood et al., 2015a). off-site. As a practical learning of this investigation,
A further barrier to participants directly benefit- we are adamant the incorporation of structured
ing was the disparity between attendances. While exercise programs into daily activities for this older
our other facilities did not demonstrate a high level vulnerable population is a better practice alternative
of investment, our Brisbane facility were proactive than the current model of care, but for programs to
about preparing and delivering participants to succeed aged care providers need to embrace the
the pool, and supported staff helping with the opportunity and support their staff and residents in
project. In turn, Brisbane had almost double the participation.
attendance rate (87.5% ± 12.8% vs. 44.6% ±
18.1%, respectively), which, as a product of dose
related gains, may have increased the benefits Conflict of interest
of participants from this facility and therefore,
their willingness to continue with the program. None.
Definitely, personal testimonials from this facility
spoke to the better behavior and well-being of
participating clients. Description of authors’ roles
Timothy Henwood and Christine Neville formu-
lated the research question, designed and carried
Limitations out the study, and proofed the paper. Chantelle
The challenges associated with recruitment in this Baguley was the research assistant on the project,
setting and cohort are not uncommon; however, and lead recruitment and coordinated trainings
they do imply more work is needed to be conclusive and assessment. Elizabeth Beattie assisted with the
about the value of the Watermemories Swimming design of the study and proofed the paper.
Club for this population. Worth considering is that
in this setting, structured exercise programs are
resources and staff demanding, and this demand Acknowledgments
is leading to a lack of engagement, despite the
benefits to residents. The implications of this are The research was funded by an Alzheimer’s
far reaching, and will potentially lead to bias and Australia Dementia Research Foundation Project
unrepresentative research work (Henwood et al., Grants. The trial was registered on the Australian
2015a). A further consideration for the current New Zealand Clinical Trials Registry (ANZCTR):
study was the reductions in skeletal muscle and 12613000503729. The authors acknowledge the
lean mass in the presence of regular exercise. While support of the residents, staff, families, and
more often positive gains are found (Fiatarone volunteers of Bupa Aged Care, Freedom Aged
et al., 1990), previous work has shown that Care, and St Vincent’s Health Services aged
nutritional insufficient in the presence of exercise care facility Lourdes. In addition, we would like
can reduce muscle growth (Fiatarone et al., 1994). to acknowledge Alzheimer’s Australia for their
Diet was not controlled for in the present study. research support.

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 10 T. Henwood et al.

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