Long-Term Care in Motion (LTCMo): A Guidebook

Abstract

The main goal of this guidebook is to provide information on the intervention program and the implementation procedure of the Long-Term Care in Motion (LTCMo) project (being part of the innovAge project), with the intention to facilitate replicating the program in nursing homes or other long-term care institutions.

Full text

Long-Term Care in Motion (LTCMo)
A Guidebook
Authors:
Carl-Philipp Jansen
a,b
, Katrin Claßen
b
, Eva-Luisa Schnabel
b
,
Mona Diegelmann
b
, Klaus Hauer
a,b
& Hans-Werner Wahl
b
a
Department of Geriatric Research, Agaplesion Bethanien Hospital, Geriatric Center
at Heidelberg University, Rohrbacher Str. 149, 69126 Heidelberg
b
Institute of Psychology, Department of Psychological Aging Research, Heidelberg
University, Bergheimer Str. 20, 69115 Heidelberg
© 2015, Carl-Philipp Jansen, Katrin Claßen, Eva-Luisa Schnabel, Mona Diegelmann,
Klaus Hauer, & Hans-Werner Wahl

Address for Correspondence:
Carl-Philipp Jansen
Department of Psychological Ageing Research
Institute of Psychology, Heidelberg University
Bergheimer Str. 20
D-69115 Heidelberg, Germany
carl-philipp.jansen@psychologie.uni-heidelberg.de
All rights reserved. No part of this book may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, without the prior written
permission from the authors. All images are subject to copyright.

i
Information About the Authors
Carl-Philipp Jansen, MA, is currently working as research assistant and doctoral
student at the Department of Psychological Ageing Research at Heidelberg
University, Germany, as well as at the Department of Geriatric Research,
AGAPLESION Bethanien Hospital, Heidelberg, Germany. He received his Master’s
Degree in Sports Science in 2012 at Karlsruhe Institute of Technology. Since then his
major field of work has been the linkage between physical activity and exercise in
geriatric populations. His research activities include exercise training programs for
older adults, particularly nursing home residents, with focus on the promotion of
activity behavior as well as the rehabilitation of motor and cognitive function; the
association of physical activity with dementia; and the assessment of physical activity
from different perspectives using technical sensor-based assessment tools or
automated activity monitoring and life-space assessment.
Dr. Katrin Claßen has worked as a research assistant at the Department of
Psychological Ageing Research at the Institute of Psychology at Heidelberg
University, Germany. She received a Diploma in psychology (2007) as well as a
doctorate degree (2012) at the Heidelberg University. Her research activities include
the understanding of the influence of psychological factors regarding technology
acceptance in old age as well as the impact of the introduction and use of assistive
technologies in in-patient and out-patient settings. She received the Südwestmetall
Award and the Cäcilia-Schwarz Award for Innovations in Elderly Care of the German
Association for Public and Private Welfare e. V. in 2013. In March 2015, she
completed an advanced vocational training in cognitive behavioral therapy at
Heidelberg University and is currently working as a therapist.
Eva-Luisa Schnabel, MSc, is a research assistant at the Department of
Psychological Ageing Research at the Institute of Psychology at Heidelberg
University, Germany. She received her Master’s Degree in Psychology in 2014 at the
University of Bamberg. Her research interests include pain, cognitive functioning,
subjective health and subjective age in older adults.
Mona Diegelmann, MSc, is a research assistant (funded by the Cusanuswerk) at the
Department of Psychological Ageing Research at the Institute of Psychology at

ii
Heidelberg University, Germany. She received her Master’s Degree in Psychology in
2014 at Heidelberg University. Her research activities include time-to-death-related
development of depressive symptoms as well as depressive symptoms and activity in
nursing home residents.
Klaus Hauer is associate professor at the medical faculty of Heidelberg University
and director of the research department at the Bethanien-Hospital/ Geriatric Centre at
Heidelberg. He received his PhD in sport science in 1995 and an advanced
equivalent of a medical PhD (Habilitation) in 2005 at the University of Heidelberg. His
research focuses on rehabilitation of motor and cognitive function, development and
evaluation of assessment methods, and ambient assisted living. He is author of more
than 120 scientific publications and reviewer in international peer review journals. His
scientific work has been awarded with a number of highly renowned research prizes,
among those the Cochrane award for methodological development, Wilhelm Woort
award of applied ageing research, award for brain research in Geriatrics, and
Damper research award for prevention and rehabilitation.
Hans-Werner Wahl is professor of psychological aging research at the Institute of
Psychology of Heidelberg University, Germany. He received his Ph.D. in psychology
from the Free University of Berlin in 1989. His research activities include the
understanding of the role of physical-technological environments for ageing well,
adaptational processes in the context of age-related chronic functional loss,
processes of awareness of ageing in a lifespan perspective, and intervention
research. He is the author or editor of 20 books and more than 200 scholarly journal
articles and chapters related to the study of adult development and aging. He is co-
editor-in-chief of the European Journal of Ageing and a member of the editorial board
of The Gerontologist. He is also a fellow of the Gerontological Society of America
(GSA) and has received the 2008 Social Gerontology Award and the 2009 M. Powell
Lawton Award of the GSA. He has also been a fellow of the Marsilius-Kolleg of
Heidelberg University.

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CT: Competence Training
HLE: Healthy Life Expectancy
LTCMo: Long-Term Care in Motion
NH: Nursing Home
NHR: Nursing Home Resident(s)
PA: Physical Activity
QA: Quality Assessment
This work has been part of the project “INNOVAGE - Social Innovations Promoting
Active and Healthy Ageing” and its subproject, “Long-Term Care in Motion” (LTCMo),
funded by the European Commission (Health-F3-2012-306058). We thank the
European Commission for their support. The content of the guidebook does not
represent the opinion of the European Community and the Community is not
responsible for incidental use.
We would also like to thank the residents and staff of the nursing homes in which we
are able to conduct this study, particularly their directors, Michael Thomas and Sonja
Wendel, as well as Kurt Hofmann, Ina Lebeda, Wolfgang Merkel, and Birgit Webster.
We would also like to thank Dr. Nana Notthoff for valuable discussions while
developing the staff component of the program..

iv
Structure of this Guidebook ........................................................................ 1
Theoretical and Empirical Background ....................................................... 2
Main Goals of LTCMo ................................................................................. 4
Setting the Stage ........................................................................................ 6
Evaluation and Sustainability of LTCMo ................................................... 11
Intervention Approach ............................................................................... 13
The Exercise Approach for Residents ....................................................... 14
Group Training ...................................................................................................... 16
Specific Individual Training .................................................................................... 23
Serious Games Approach ..................................................................................... 24
Competence Training for Staff .................................................................. 26
Theoretical and Empirical Background .................................................................. 26
Requirements and Aims of the Communication Training ...................................... 27
Organizational Aspects ......................................................................................... 29
General Description of CT Contents ...................................................................... 29
Specific Contents of Sessions ............................................................................... 31
A
NNEX
Exercise Catalogue and Guidelines .......................................................... 34
Static Balance Training ......................................................................................... 35
Dynamic Balance and Step Training ..................................................................... 38
Dynamic Balance and Gait Training ...................................................................... 40
Functional Strength Training ................................................................................. 43
Seated Exercises .................................................................................................. 45
Safety Measures & Safeguarding Positions .............................................. 47
Tool for the Evaluation of Existing Activities .............................................. 49
Training Group Assignment of Residents ................................................. 50

v
References ............................................................................................... 52
Project-Related Publications ..................................................................... 53
Disclaimer: ................................................................................................ 54

1
The main goal of this guidebook is to provide information on the intervention program
and the implementation procedure of the Long-Term Care in Motion (LTCMo) Project,
with the intention to make the replication of this program as easy as possible. In the
beginning, we provide a short background on the importance of physical activity (PA)
promotion in the nursing home (NH) ecology. This is followed by a comprehensive
outline of the main goals of the program and a description of useful principles that
can be employed when planning and preparing a project in institutional long-term
care settings. This part especially deals with implementation issues and gives useful
suggestions in this regard.
As a central part of this guidebook, the intervention components that were deployed
in LTCMo are explained and described in detail, with a clear focus on practical issues
of the program.
In the Annex, we provide an exercise catalogue with an exemplary compilation of
useful exercises and fundamental didactical principles, supplemented by a
description and explanation of safety measures and safeguarding positions.
Moreover, we provide tools that can be used to evaluate already existing activity
programs in the nursing home setting and to assign participants to the appropriate
exercise training.
In general, this guidebook is addressed at nursing home personnel, i.e. directors or
care managers, social care personnel, activity coordinators, nurses and therapists or
any other professions who are involved in activities with nursing home residents
(NHR) and who are interested in implementing this program. It may also be of
interest to organizations (e.g., senior organizations) engaged in improving the lives of
older people. That said, those being involved in policy issues related to aging may
also find helpful information.
Finally, we hope that the guidebook may also stimulate new PA related intervention
research in the context of NH settings and we are highly interested in interactions
with professionals or research groups who plan to replicate this program.
Structure of this Guidebook

2
Although home care is the predominant care setting in Europe (Rodrigues et al.,
2012), the number of dependent older persons living in long-term care institutions
such as NHs is expected to remain high in Europe (European Commission
[Directorate-General for Economic and Financial Affairs and Economic Policy
Committee (Ageing Working Group)] 2009). Due to the often discussed demographic
change, the number of older people in need of help has been rising in the past
decade. As is well-known, the majority of the current NH population is beyond the
age of 80 years and characterized by high rates of multi-morbidity, frailty, mobility
impairment, severe cognitive deficits, behavioral disturbances and depression. In
terms of day-to-day behavior, an essential feature of NHR is their very low PA,
compared to community-dwelling older adults in advanced old age. Such lack of PA
is to be seen as an important marker of physical impairment. At the same time, an
increase in PA represents an essential pathway to improve quality of life and to
enhance cognitive and social functioning of old and very old individuals. That said
empirical evidence supports rather large positive effects of PA on a range of
important endpoints such as cardio-vascular fitness, gait and balance, fall reduction,
cognitive function, and well-being in the general older population (Potter et al., 2011).
PA training has also revealed sizable positive effects in terms of physical and
functional ability related endpoints in those with dementia-related disorders (Hauer et
al., 2006), if efficiently tailored in its application format to the remaining competencies
of this specific group. There is also evidence that PA training can unfold positive
effects in NHR, such as improved physical function and increased social involvement
(Horn et al., 2012). Aside from positive outcomes for NHR, fostering a physically
active lifestyle in the institution may go along with benefits for the institution (e.g., a
more active social life and an enhanced portfolio of activities for residents that can be
seen as an incentive that might also serve to increase the NH’s reputation). By now,
numerous exercise programs have been developed for NHR and similar populations.
A comprehensive overview is provided by Horn et al. (2012), in which authors
distinguish between recommendable and not recommendable programs.
In the existing research, PA has mainly been addressed as a means to improve
physical function rather than as primary outcome by itself (see our systematic review
by Jansen et al., 2015). In addition to making interventional use of the PA pathway as
Theoretical and Empirical Background

3
means for prevention and enhancement of quality of life of NHR, we are aiming to go
one step further by enhancing PA itself. In this way, NHR may in the long run benefit
even more from an intervention that not only enhances PA due to its mere
implementation, but also from a change in PA behavior due to newly established
competencies. However, there are not only individual factors that determine PA
behavior. It is also determined by the environment and institutional realities, which in
case of NHR include NH staff, predetermined daily schedules and restrictive
architectural aspects, among others. With this in mind, solely concentrating on the
individual level seems short-sighted, as activity behavior is not only based on
individual barriers or motivators. Until now the number of more specific and at the
same time comprehensive intervention approaches taking into account these
characteristics of this specific population is very little. Herein we present a multi-
component intervention approach that is based on individually tailored physical
exercise training for NHR combined with motivational competence training for staff. It
was implemented within the course of the project “Long-Term Care in Motion”
(LTCMo) in two NHs in Heidelberg, Germany. LTCMo is a subproject of the
interdisciplinary research project “INNOVAGE − Social Innovations Promoting Active
and Healthy Ageing” (Health-F3-2012-306058
1
) funded by the European
Commission’s Seventh Framework Program.
The primary aim of LTCMo is to present a social innovation with the potential to
promote PA among NHR in order to prevent a further decline or even elicit an
improvement in motor and cognitive function, and thereby improve the living
conditions and quality of life in NHR in line with the main concept of INNOVAGE
(active and healthy ageing). However, the mission of INNOVAGE is not only to create
a social innovation, but also to spread the newly created and proven concepts. This
guidebook was developed with the intention to address relevant stakeholders and
users. It highlights the potential of PA as well as its barriers, which can hinder a
successful implementation of the intervention program, but also strategies to
overcome them. Furthermore, we provide a detailed description of the
multidimensional training program to make an implementation as easy as possible.
The guidebook is based on previous research findings and experiences made during
the implementation of the intervention program. For further information on the
1
http://www.innovage.group.shef.ac.uk/

4
scientific background and empirical outcomes of the project, please see our already
published works:
• Systematic Review summarizing previous findings regarding interventions and
their effect on PA in NH settings: Jansen, Claßen, Wahl, & Hauer, 2015
• Study Protocol describing the research design and methodological aspects of
the LTCMo project: Jansen, Claßen, Hauer, Diegelmann, & Wahl, 2014.
Additional scientific papers are planned and will be published during the final
phase and in the aftermath.
• A number of manuscripts describing the project and outcomes are currently in
preparation and will be published soon.
The aim of LTCMo was to develop, empirically evaluate and disseminate a socially
innovative and sustainable intervention in the NH ecology by means of a
multidimensional intervention program (resident and staff oriented) with the potential
to promote PA behavior in NHR. It is very important to note that unlike in most other
intervention driven studies and programs in long-term care LTCMo addresses
physical activity decidedly in terms of behavior.
Looking at the institution ‘nursing home’ as a ‘natural lab’, the approach was sought
to address this ‘natural lab’ from several different angles that would add up to
achieving this overall goal of enhancing nursing home residents’ physically active
behavior. In particular, a controlled intervention was to be exerted at two levels of
long-term care institutions: on the side of the main end-users, the nursing home
residents, and on the side of nursing home staff. In order to modify physically active
behavior, multiple factors such as health and psycho-social status, motor and
cognitive function as well as motivational resources that have to be considered due to
their large effects on physically active behavior. The decision to exert an exercise-
based intervention approach in combination with competence training for staff
members was based on several leading considerations.
First, the program can be implemented in a controlled group environment, which not
only fosters motor function and skills but also contains social aspects, helping to
establish close social contacts in-between participants and between participants and
group supervisors. Through close contact to all participants, supervisors are able to
Main Goals of LTCMo

5
not only improve motor function by means of exercise, but to also activate
motivational and psycho-social resources of participants that are important
determinants of activity behavior. For example through the improvement or even
recovery of the most important key motor functions (sit-to-stand transfer, standing,
walking), self-efficacy and a feeling of self-determination may be enhanced, resulting
in more active behavior. In addition, constant groups in ‘safe’ surroundings help
achieving high adherence rates, especially if tailored to end-user needs.
Secondly, the group approach allows including a broad range of participants when it
comes to motor and cognitive abilities. These can be assorted into homogenous
groups, which helps to prevent under- or overexertion of residents and to keep
motivation on a high level.
Thirdly, by motivating residents to be more physically active, staff is able to enable
residents to use their potential and their competencies optimally. Based on own
observations, the main potential of this approach lies in the recurrent close bonds
between nursing staff and nursing home residents. Nursing staff is expected to have
strong influence on residents’ behavior. Therefore, changing staff members’
interactional behavior with residents is hoped to increase the awareness of residents’
health and motion behavior, self-efficacy, control beliefs, self-regulation, and
autonomy, as empirical evidence name these as crucial factors for being physically
active.
Fourthly, through offering a virtual, game-based exercise training (‘serious game’)
targeted at motor-cognitive tasks, residents who are not appealed by “standard”
exercise forms are addressed.
A unique feature of the approach was that the explicitly end-user oriented approach
came at the same time, at the research and methodology level, with an extensive and
innovative technical assessment of physical activity, life-space and motor
performance as well as subjective interview- and proxy-based questionnaires on
psycho-social outcomes were completed (study protocol by Jansen et al., 2014). To
our knowledge, this represented the first combination of a cutting-edge research
methodology and a resident- as well as staff-oriented intervention approach in a long-
term care setting.

6
The implementation of social innovations and programs such as LTCMo is
challenged by a series of barriers, particularly in the NH context. NHs represent
highly structured institutions with a large number of well-established routines and
practical constraints, which are often not obvious for an external person. Such
constraints and routines may follow a rationale which may deviate or even contradict
research interests or implementation of programs. Actors in such an institution, e.g.,
residents, staff or management, also may have diverging interests. As the success of
a project such as LTCMo heavily depends on acceptance by institutional members,
setting specific routines and interests will have to be taken into account. Acceptance
and support are not granted and will have to be merited. As a general
recommendation, respect for the setting and actors should be mandatory. In case of
scientific studies, team members may therefore rather behave as guests—and not as
intruders—in any given situation. Time and resources invested for those issues may
pay off when the project is implemented. The following implementation principles
might facilitate the acceptance of the main actors and the intended intervention
program in a NH setting. Some of the principles are of general importance; some are
specific recommendations for scientific staff or other external personnel.


 Principle I: Inform the whole system in consideration of the hierarchical
structures (top-down-regulated approach)
Detailed information on the planned activities and a continuous update is an
important prerequisite of any project. The information process may not only be used
for delivering news but also to get in contact with the persons in the institution. As
within the formal hierarchy of an institution, information processes, targets and types
of deliverance should be tailored to the addressees. Leading management, staff,
relatives, legal representatives and residents represent different target groups
requesting different ways of communication. Regarding all target groups, essential
factors for motivation are the valuation of individual opinions, the clarification of the
project aims and the positive impact on resident and staff level as well as a skilled
way to establish the first contact.
Setting the Stage

7
Step 1: Leading management
As a first step, the leading management should be informed about the project to
achieve a supportive relationship and a formal “go”. Major target of this step is to
clarify concerns and convince the management of the importance of being physically
active in a NH and the positive effects which can be achieved even in such a
vulnerable population. As with other target groups, it is always helpful to take the
perspective of professionals in institutions as a starting point. Major pros may be
represented by quality management or advertising/publicity/sales promotion issues.
Cons may touch concerns about use of additional (labor-) resources and the
acceptance of residents and staff. Information should be delivered step by step using
different approaches. Formal and less formal talks accompanied by a clear study
description will help to get support. Hierarchies with the management will have to be
respected with the leading persons to be informed first. The support of the leading
persons and their willingness to cooperate is crucial for any further steps.
Step 2: Staff team
Once the management promotes the project, staff should be informed and involved
as their support of the program is essential for its successful implementation.
However, convincing the staff team that the intervention program is worth
implementing can be challenging due to specific workplace characteristics (e.g., lack
of time, inconvenient shift times, heavy workload and the need for emotional labor)
and a series of doubts regarding the effort and the impact of the program.
Firstly, a lack of specific knowledge and insecurity on how to support PA related
behavior represent crucial limitations for the implementation of such innovative
models. Due to functional, physical or cognitive losses in NHR, staff may doubt that a
considerable increase in residents᾽ PA is possible and feasible in principal terms
without taking too many risks. As a typical consequence, a dependency-supportive
interaction style with residents that again strengthens residents᾽ sedentary behavior
has been reported in previous NH related literature (Baltes & Wahl, 1992). Due to the
key role of NH staff to trigger or hinder activity-related behavior, LTCMo aims to
convince and enable staff members to use specific ways of communication and PA-
supportive behavior.
Secondly, some staff members may have concerns about additional workload and
may fear critical evaluation of their individual work. Most colleagues working in the

8
institution will not have any training or insight in scientific or implementation work,
which may mystify or devaluate project proceedings. Furthermore, there might be
skepticism against external persons who do not work in the same institution and take
a more theoretical perspective. Comprehensive information about project plans,
limitations, and goals may help to set straight critical considerations. Referencing the
complete restriction to forward any information concerning residents and staff to
management or the public as requested by ethical boards for project proceedings will
help to clear out concerns related to employment law or ethical issues. It may also be
helpful to address the potential positive consequences of the project on staff level,
including everyday issues such as less care support for residents in case of a
successful improvement in motor key functions as targeted in the project. Because of
the overwhelming impact of persons working in the institution and their close contact
to the target group, staff training is a major intervention approach in this training
concept. Daily shift changes or other personnel gatherings may be an adequate
organizational opportunity to inform staff. At a given and suitable time, a formal
general information meeting including staff and management should also be held. To
establish a more personal, informal access it may prove sensible to be present at the
site for a longer period of time and to be available for less formal requests. It may be
even possible to establish a familiar relationship with staff as well as residents. A
promising way to reach a solid relationship is to play an active part in the daily care
work, e.g., by doing a short-term internship. An added value is to get to know the
daily routine of staff and residents as well.
Step 3: Residents and their relatives
It proved sensible to address residents as potential participants personally in a
motivating and emphatic manner to take care of their specific questions, needs, and
preferences. It is also advisable to inform relatives or legal representatives about the
program and its purposes.


 Principle II: Learn about and evaluate existing activities within the institution
Before implementing the intervention components described in this guidebook, the
setting should be prepared and analyzed carefully and thoroughly. In each facility,
some forms of activity groups, therapy classes or any other programs, circles, etc.
are already installed. Some of them may be very useful or even very close in scope
and execution to what is presented herein. So before modifying the weekly schedule,

9
all activities, be it single or group activities, should be analyzed and checked for
usefulness and their potential to be modified according to the LTCMo components. A
systematic evaluation should include quantitative (e.g., frequency, duration, weekday,
time of day, number of instructors and participants, sequence) and qualitative (e.g.,
concept, content, aim, adaption to target group, instructors’ qualification) criteria.
Activities that are similar to the intervention that is planned to be installed may either
be cancelled during study course or used as expansion of the intervention if the
personnel situation allows parallel activities.
A major problem for scientific or any other external projects in real life institutions is
that the institutions have established roles and routines, which may be interrupted or
altered by the project. The sustainability of successful project standards might be
endangered when a project ends and study resources as well as well-trained study
personnel are no longer available. To develop a sustainable intervention strategy
tailored to the institutional setting and its residents, it is therefore mandatory to start
with a description and evaluation of the existing activities in such a highly structured
environment (see Annex). Four major considerations will lead the process:
Respect established and successful structures and work of staff
It has to be kept in mind that external projects have their own conditions and aims,
which may not be identical with institutional requests. It is a simple fact that studies
are limited in time in which project activities interfere with the daily routine of the
institution. A first important step is to explore specific NH routines like everyday care,
meal and activity schedules. A short-term internship for external project collaborators
(as mentioned above) may offer comprehensive insight and help to get involved.
Many of the established structures have their history and have been developed for
good reason. A useful routine, interrupted by a study project, may only be restored
with substantial effort. Modifications of established processes and activities may lead
to a negative personal feeling (e.g., to be insufficient) or the anticipation of additional
workload and stress by institutional activity coordinators. Resistance is expectable
when the need for any change is not clear or information about the frame conditions
is insufficiently communicated. The critical assessment of proceedings in non-
scientific settings requires evaluation of the organizational (objective workplace
characteristics, daily routines and existing programs) as well as the individual

10
(perceived job demands and resident-staff-interaction, work-related attitudes)
situation within the institution.
Learn about the background of existing activities
Established activities within institutional settings have their own history and
conditions, which may not be obvious at first from an external or scientific point of
view. Partly those activities are triggered by strictly content-related criteria (e.g.
improvement of quality of life or activity promotion). Partly also formal criteria (such
as quality assessment; QA), a lack or abundance of space/equipment/media, as well
as education and training or individual preferences of staff and residents who
participate determine the activities. For a successful implementation of project
standards it is useful to consider all those different perspectives and address those
which may support study targets or sustainability of project standards when the
project runs out. The residents’ perspective might be extremely helpful in getting an
impression of preferences, needs and routines of the main target population of the
project.
Evaluate activities with respect to the project aims
Due to the highly structured character of the NH environment, there is only limited
space for additional activities as planned in study projects or activation programs. In
order to prevent overload or distress of residents and staff, it is necessary to identify
optimal periods for project sessions and avoid overlap of programs. Therefore,
existing activities should be systematically evaluated using quantitative (e.g.,
frequency, duration, weekday, time of day, number of instructors and participants,
sequence) and qualitative (e.g., concept, content, aim, adaption to target group,
instructors’ qualification) criteria. Activities that are similar to the intervention that is
planned to be installed may either be cancelled during the implementation or used as
expansion of the intervention if the personnel situation allows parallel activities.
Try to integrate project standards in established activities and identify active
protagonists
The systematic summary of existing activities will help to integrate project standards
into the established system. In case of external projects, it can be used to identify
eligible persons who may be interested and willing to implement and sustain the

11
project activities. In this case, responsible institution members might be integrated at
an early stage and successively incorporated under regular supervision of the
program leaders (expertise of psychologists, sports scientists or other specialists) to
ensure sustainability of training components. The supervision should be kept up until
the end of the project to reach an appropriate continuation and ensure sustainability
of the program. At this stage, a guidebook including training components and a
detailed description of exercises is very helpful in facilitating training implementation
through nursing home staff. The management of the institution should be integrated
into this process in order to encourage committed staff to become active protagonists
of ongoing activities. It might be helpful to use the management perspective to
balance requested additional resources for such implementation with added value for
institutions (e.g. marketing/ QA).
In case of external projects, a long-term implementation of the program should be
envisaged, so that participants can profit from the intervention during the project and
also beyond. In LTCMo, an important issue was the sustainable implementation of
the program into daily NH routine. Several steps were taken to achieve this goal.
During the intervention phase of the study, social care assistants who worked in the
NHs took part in the exercise groups and the individual trainings on a regular basis.
In this way they were able to learn about the main principles of the program, to learn
basics on group leadership and instruction, to gain basic knowledge of exercise
science, and to develop an adequate repertoire of exercises. In both facilities,
management and staff were convinced of the positive effects and the additional value
of the program. After the end of the intervention phase, the program was seamlessly
continued by these staff members, under regular assistance and supervision of
LTCMo staff until they were able to conduct the program in an appropriate and
effective way without needing support. In both NH facilities, this required a
rearrangement of the weekly activity schedule which was only taken into
consideration due to the likewise extraordinary resonance of NHR, nursing staff and
NH management. As a consequence, both NHs that participated in the study
implemented the exercise program into their care and activity routine. Several groups
are taking place twice weekly with up to eight residents in each group. In one of the
Evaluation and Sustainability of LTCMo

12
NHs, the staff training became an inherent part of the internal training schedule.
Unfortunately, the competence training was not completed in the second NH.
Reasons for that may be that in this NH, LTCMo staff was not able to establish a
more personal relationship to nursing staff, e.g. by doing a short-term internship on
care level (as described above). In both facilities, research staff of LTCMo is still
providing regular support in the execution of the program when necessary.
As part of sustainability measures, it is an important aim for LTCMo to make our
approach accessible and also reproducible for institutions and nursing home
personnel. Therefore, the physical exercise training and the CT training courses for
NH staff will be offered as a two-day training course via AGAPLESION Academy, a
well-established care and health educational institution in Heidelberg with nation-
wide outreach, to allow the implementation of LTCMo into the care routine of
interested nursing homes.
Although our study has faced several methodological challenges (e.g., rather small
sample size; non-randomized controlled trial), we believe that our approach has the
potential to contribute to the enhancement of NHR’s quality of life and at the same
time stimulate further PA-related research with vulnerable populations at large.
The data analysis is currently underway - preliminary evidence already shows that
positive effects on motor performance and physically active behavior were achieved.

13
The program LTCMo has been conceptualized for use within long-term care
institutions. The physical exercise training is targeted at residents of such institutions;
the competence training has been developed for nursing and social assistance staff.
In general, all residents and staff members can participate in the program,
irrespective of cognitive and motor impairment. Specific requirements and exclusion
criteria are delineated below. The key components of the program are illustrated in
Figure 1. Residents receive either physical training in homogeneous exercise groups
or in an individual one-to-one training form if group assignment is not possible due to
sever motor impairment or distinct behavioral problems. For residents who are
interested in new forms of exercise, or residents who are not appealed by “standard”
exercise forms, a serious games training can be implemented in the NH. Each of the
training approaches is described in detail below.
On staff side, a competence training aiming to support physically active behavior of
residents is implemented. It consists of theoretical input as well as practical
exercises. It also provides a platform to discuss particular cases.
Figure 1. Illustration of the intervention components.
Intervention Approach

14
The physical training relies on the existing evidence of successful PA intervention in
multi-morbid, frail, older persons with and without cognitive impairment (Hauer et al.,
2001; Hauer et al., 2012; Schwenk, Zieschang, Oster, & Hauer, 2010) and is at the
same time specifically tailored to the needs of the target population of physically and
cognitively impaired NHRs. Thus, its bottom line is a rigorous focus on functional and
strength exercises and the improvement of key motor qualifications balance, walking
and sit-to-stand transfers that are necessary for mobility, autonomy and motion
security. Additionally, the intervention pursues the goal to improve psycho-social
outcomes such as social participation, self-efficacy, depression, and quality of life. In
addition to influencing external factors and barriers as mentioned in previous
chapters of this report, training improvements in motor, psychological, and cognitive
status are hypothesized to increase activity behavior as these factors have been
identified to be high impact predictors of physical activity.
A major goal of the project was to include as many participants as possible,
requesting a tailored approach for sub-groups with specific demands for each group.
Therefore, the physical training is specifically designed for each target group of NHR,
characterized by old age, advanced frailty, multi-morbidity, and motor as well as
cognitive impairment and behavioral aberrations. Despite these serious restrictions
and deficits, such characteristics do not preclude participation in general and
individual potentials differ a lot. Therefore, the physical intervention includes multiple
exercise approaches with the aim to offer a comprehensive exercise repertoire, which
can be adapted to the special individual needs and limitations of residents (see Table
1). When grouping residents, motor function as well as problematic behavioral
symptoms should be taken into consideration. In the Annex a classification tool that
was developed for this purpose is attached. We defined three different approaches
regarding the group exercise training; each with different group allocation criteria.
The first group training approach was intended for ambulatory participants with
advanced motor function, in which exercises show higher intensity and complexity
due to advanced physical and cognitive function of the participants. A second
approach was implemented for residents who at least were able to stand and showed
only mild to moderate cognitive impairment without serious behavioral symptoms.
The Exercise Approach for Residents

15
For residents with severe cognitive impairment in combination with behavioral
symptoms of dementia a third exercise group training was installed, as successfully
shown in code-secured living units in LTCMo. This sub-division of training
approaches allows for the inclusion of as many residents as possible.
However, severe cognitive and motor impairment represents an exclusion criterion
for the serious games approach, as successful participation requires the motor
ability to complete stepping tasks without support as well as cognitive functioning in
terms of task-performance based on visual stimuli and thus may lead to frustration in
case of overexertion.
Residents with advanced postural deficits / motor impairment or severe behavioral
problems due to cognitive impairment are not included in exercise group sessions but
eligible for specific, individually tailored training, which is based on exercises
used in the group training and adapted to the individual abilities of the participants in
an individualized, one-to-one training situation. Residents with aggression-related
behavior problems were excluded from participation.
Table 1 gives an overview of the different exercise approach components.
Table 1. Physical Exercise Training Approaches
Training
approach Group Description Frequency Group size
Supervised
group training I Residents need to be able to
communicate verbally, to walk with
or without support, and to have no
behavioral symptoms that impede
group participation
45 minutes;
twice a week 4-8 residents
Supervised
group training II Residents need to be able to
communicate verbally, to stand
up, and to have no behavioral
symptoms that impede group
participation.
45 minutes;
twice a week 4-8 residents
Supervised
group training III This training is specifically for
residents of code-secured living
units with severe cognitive
impairment, showing pronounced
behavioral and psychological
symptoms of dementia.
45 minutes;
twice a week 4-8 residents
Specific
individual
training
This training is for residents with
severe motor impairment or
cognitive impairment in
30 minutes;
twice a week 1 resident

16
combination with severe
behavioral problems. Participants
should at least be able to stand
with close supervision and support
and show no highly aggressive
behavior.
Serious game Residents without or mild cognitive
impairment; able to stand and step
without aid.
15 minutes
playing time per
participant
3-4 residents; 1
person plays at
a time
In the following, participant characteristics, aims, and training components of the
three different group training approaches are described. In addition, special
requirements for group trainings in code-secured living units are highlighted.
It is important to note that in LTCMo improving motor function is a means to an end -
the aim is not just to improve motor function but to enable residents to be more
physically active. Improving or even recovering the most important key motor
functions (sit-to-stand transfer, standing, walking), self-efficacy and a feeling of self-
determination may be enhanced, resulting in more active behavior .In addition,
through close contact to all participants, supervisors are able to not only improve
motor function by means of exercise, but to also activate motivational and psycho-
social resources of participants that are important determinants of activity behavior.
With this in mind, the table below refers to practical goals of the exercise groups
regarding improvements in motor function.
Supervised Group Training I
Participant
Characteristics Ability to walk without aid; to stand up independently and sit down
without any support; to walk longer distances without help.
Aims Physical activity promotion in terms of number and duration of active
episodes; improvement of walking performance, dynamic postural
control, and sit-to-stand/sit-to-walk transfers.
Training
Components Functional strength training: Sit-to-stand transfer training without using
the arms.
Dynamic balance and gait training: Different standing positions;
improvement of stability and duration of standing posture; different
walking exercises (e.g., narrow vs. wide distance between feet; slow
Group Training

17
vs. fast walking; uneven floor surfaces).
Supervised Group Training II
Participant
Characteristics Unstable walking with aid; standing up and sitting down without
personal assistance is possible.
Aims Physical activity promotion in terms of higher frequencies of standing
and enabling participants to walk short distances. Improvement of static
and dynamic balance (i.e., stable standing); improvement of sit-to-stand
transfer. In the further course of the training: support of stable walking,
walking security, and a homogeneous walking pattern (then: transition
into Group I).
Training
Components Support of stable standing without aid by exercising in different
standing positions and at different levels of difficulty.
Sit-to-stand training: trying to stand up and stand still; in the long run,
transition to sit-to-walk training
Gait training: In the beginning, improvement of gait performance with
support; gait episodes without aid if this seems possible; prolongation
of the duration of walking episodes under supervision and improvement
of a homogeneous walking pattern.
Supervised Group Training III
Participant
Characteristics Participants show pronounced cognitive impairment accompanied by
severe behavioral problems. Participants should be ambulatory and
able to stand up with little or no support. In LTCMO, this group was
implemented in a code-secured living unit.
Aims Improvement of static and dynamic balance (i.e., stable standing);
improvement of sit-to-stand transfer. Support of stable walking, walking
security, and a homogeneous walking pattern.
In this special group, aberrant motor behavior or wandering behavior
was frequently observed. Therefore, it is another aim to divert this kind
of ‘unwanted’ active behavior to meaningful activities and exercising
activities.
Training
Components Functional strength training: Sit-to-stand transfer training without using
the arms.
Dynamic balance and gait training: Different standing positions;
improvement of stability and duration of standing posture; different
walking exercises (e.g., narrow vs. wide distance between feet; slow
vs. fast walking; uneven floor surfaces)
Focus on social aspect of group training: exercising together by
execution of clearly constructed and meaningful tasks.

18
Special
Requirements Depending on the severity of cognitive impairment, group organization
may require adaptations. In LTCMo, instead of a double chair circle,
residents were seated side by side in direction of a hallway which was
used for exercises. Then, residents were attended to one after another
from left to right. When the last participant in the line was done (right)
with his round, the first in line (left) started with the next exercise.
Residents were seated close to each other so that social contact and
conversations were facilitated. In addition, this organization form was
found to be easier to understand for the participants than the double
chair circle.
Code-secured living units are typically built barrier-free. This allows an
“open” group setting in which participants are able to leave and come
back anytime in case keeping them in the group is not possible.
However, this also means that non-participating residents may enter
the exercise area every now and then. Therefore, it is helpful to have
additional personnel who can address these external visitors without
disturbance of other participants.
Personnel Requirements: Communication and Appearance
The group exercise sessions should be led by a qualified person who is familiar with
the special requirement of the population (e.g., physical therapist, sports scientist,
nursing staff, social assistants or other qualified personnel) and, depending on group
size, at least one assistant to provide highest possible safety for participants. During
the implementation phase, staff members should also become familiar with
communication strategies to ensure suitable training conditions and encourage PA-
related behavior (see Table 2). This includes factors related to verbal instructions
(clear instructions, loud voice, positive wording, etc.) but just as much non-verbal
instructions (demonstration, tactile support, facial expression, etc.) that help the
participants to understand what they are supposed to do. Especially in groups of
residents with behavioral and psychological symptoms of dementia (BPSD; Finkel et
al., 1996), further dementia-specific strategies are necessary to allow organization
and implementation of exercise groups, e.g., measures of person-centered care
(Brooker, 2004) and validation techniques (Feil, 1993), which are based on emphatic
attitude, respect and appreciation of each individual without judgement. In this
regard, it is very important to give particular attention to the individual as well as the
group as a whole, and to create a positive social environment to enable the person
with dementia to experience relative well-being while exercising.

19
Establishing a stable personal relationship with participants is a key element for
adherence and motivation. Therefore, it is advisable not to exchange personnel
during the program if possible. Personal conversations are of high importance in this
context. An instructor should be able to show interest in the needs and feelings of the
participants and find time for personal conversation, e.g., while bringing participants
to the training room. In this way, the instructor can gather information regarding
physical and mental condition, which may also be important to consider when
conducting the training. Especially aspects which can be strong barriers to physically
active behavior, such as apathy, depressive symptoms or a lack of self-efficacy, are
easier to recognize and to address when a personal relationship is established.
Regarding his appearance, the instructor has to be able to attract attention and to act
as a strong motivator with self-assurance, as participants need clear and definite
instructions and motivation. Possible insecurities of instructors inevitably lead to
insecurities on the side of participants. Therefore, it is most important to prepare each
exercise session in advance and maintain a clear and constant structure.

20
Table 2. Overview of Communication Strategies and Approaches (Brooker, 2004;
Feil, 1993; Oddy, 2011; Schwenk, Oster, & Hauer, 2008)
Verbal instructions
• Attract participants’ attention (e.g., by calling the name) and give attention
• Speak slowly, calmly, loud and clear
• Practice active listening
• Give short and clear instructions
• Repeat your request if necessary and be patient
• Use positive wording (e.g., “Please stay seated” instead of “Don’t stand up”)
• Link movements with associations (e.g., ‘Stand like frozen’)
• If there are two or more assistants, decide who should speak
• Chose a proper position (ideally face to face)
• Signalize the simplicity of the task (e.g., “Just move to the marked line”)
• Try goal-based instructions if you assume the person could possibly manage the
task
Non-verbal instructions
• Demonstrate exercises (“mirroring”)
• Give tactile support (e.g., for correction of movements)
• Give rhythmic support (e.g., “and back… and forth…”)
• Be attentive to participants’ non-verbal reactions (e.g., facial expression, body
movements)
• Monitor and control your own non-verbal behavior (e.g., facial expression, tone of
voice)
Person-centered approach and validation techniques
• Emphatic attitude
• Respect and appreciation of each individual
• No judgement of individual behavior
• Give particular attention to the individual but also the group as a whole
• Create a positive social environment
• Promote well-being while exercising
Organizational Aspects of the Group Training
The exercise groups should be conducted in 45-minute sessions at least twice a
week in small groups of four to eight residents, ideally always in the same room to
create familiar surroundings. The level of difficulty should be increased with caution.
In the beginning, simple exercises should be conducted and frequently repeated in
order to enable residents to perform basic motor tasks such as standing up and
stepping. To further motivate participants, constant but appropriate positive feedback
should be given. When basic motor functions are stable, participants can progress to
advanced levels of exercise, i.e., complexity and challenge of tasks can be

21
increased. The complexity and intensity of exercises has to be individually adapted to
the performance level and the training progress of the participants. In any case,
exercises are not supposed to cause overexertion or pain. If so, the exercise has to
be interrupted or reduced in intensity/duration. For participants which show overt
symptoms of exertion or fatigue, the responsible physician must be consulted in
advance (and during the program, in case of adverse events). It is important to keep
in mind that self-report abilities may be
limited in cognitive impaired people.
Persons’ non-verbal reactions (e.g., facial
expressions, vocalization) therefore have to
be observed carefully.
As exercise training inevitably increases risk
exposure, safety aspects are of particular
importance. A ratio of four participants to
one supervisor or assistant should be given.
In addition to the personnel itself, the compliance to certain organizational aspects
(see also guidelines in Table 3) helps to ensure safety, e.g. by using a double chair
circle (see Figure 2), which allows participants to hold on to a chair and sit down
whenever necessary. In addition to its safety aspects, the double chair circle allows
for internal differentiation, which means that each participant is able to train in a
group and according to his/her individual performance level (e.g., with/without holding
on to a chair) at the same time. Further information on safety measures are
described in the exercise catalogue.
Special organizational aspects of group trainings in code-secured areas are
delineated under ‘Special Requirements’ of Group III above.
Figure 2. Double chair circle.

22
Table 3. Overview of Organizational Aspects and Training Guidelines: Group Training
Organizational aspects and training guidelines
• Always use the same room for the training (ideally a familiar area)
• Keep constant and simple organizational forms (e.g., same instructor; same groups)
• Arrange groups as homogenous as possible with respect to motor and cognitive
function
• A maximum of eight participants should not be exceeded
• Individual differentiation should be made possible
• Training should be conducted in small groups under the supervision of at least two
trained instructors
• Be attentive to postural instability and risk of falls
• Adapt the training to the individual status
• Training equipment should guarantee highest possible safety
Training instruction
• Use simple structured exercises
• Increase level of difficulty with caution
• Frequently repeat exercises
• Give positive feedback to reinforce motivation
• Use dementia-specific communication strategies (if necessary)
Spatial and Equipment Requirements
The implementation of the physical exercise training requires an adequate room with
enough space for a double-chair circle for eight residents. Usually spatial conditions
are poor in NHs. Still, if some options are available, some issues should be
considered.
The room should be neither too small nor too big so that participants do not feel
confined or lost and it should allow a certain amount of privacy without external
disruptions or interfering activity. Too many people leaving or entering the room as
well as people passing by might be a distraction for participants. The interior of the
room should be bright and inviting to provide a harmonic atmosphere. It is important
that the room can be heated and ventilated if necessary. A very important issue is the
floor coating. The floor should not be slippery or uneven. Handrails on the walls might
be helpful but they are not mandatory. As the training ideally is conducted within the
premises of the NH, a quick connection to nursing staff in case of emergency can be
expected. To prevent longer interruptions of the training, a near bathroom is very
convenient.

23
Further spatial requirement for groups in code-secured areas are delineated under
‘Special Requirements’ of Group III above.
In addition to the spatial requirements, the following materials should be available to
allow for diverse and functionally effective exercise compilation (see Figure 3):
• Two stable chairs (ideally with side
armrests) have to be available for
each participant in order to build a
double chair circle.
• Balls (e.g., exercise balls or
foam balls)
• Balance pads (e.g., Airex® or Terra
Sensa®)
• Porcupine balls
• Step stools
• Ropes
Specific Individual Training
The specific individual training was developed for those residents who show distinct
motor and functional impairment and/or severe behavioral problems that would result
in unacceptable disturbance of group activities. The exercises are similar to those
used for group training. One major pro of individual training is that the individual
supervision allows perfect fit to the personal needs of an individual. Individual
problems and deficits can be addressed in a more detailed manner. However, this
form of training is very personnel-intensive and requires an instructor who is able to
do the training without help of an assistant in a one-on-one situation.
Specific Individual Training
Participant
Characteristics Residents show severe motor impairment and or cognitive impairment
in combination with severe behavioral problems, but without
aggression-related behavioral problems. Independent standing is not
possible and requires constant help of at least one supervisor. Explore,
whether re-learning or improving standing is possible.
Aims Support of dynamic sitting; relearning of sit-to-stand transfer; advance
to Group I.
Figure 3
. Useful materials to be used in
exercise training.

24
Training
Components In the beginning main focus on seated strength and mobilization
exercises: strengthening of leg muscles (leg extension) to enable sit-to-
stand transfers. In the course of the training, conduct standing
exercises with support if possible. For ambulatory residents who are
eligible for individual training due to behavioral problems, the training
components have to be adapted to the functional abilities. Based on the
description of Group I and II, the training components can be adjusted
to each individual.
Serious Games Approach
In general, physical training is based on repetitive and standardized training tasks,
which guarantee effectiveness, but will possibly fail to attract all participants. An
alternative mode to motivate persons to be physically active is a serious games
approach, in which motivational aspects are driven by a game setting, and
effectiveness is supported by a “serious”, evidence-based exercise task. In this
supervised cognitive-motor training, the motor task is based on a progressive
functional task (stepping/dynamic postural control), the cognitive task targets different
cognitive sub-performances such as divided attention, temporo-spatial orientation,
reaction time, and executive performances (Pichierri et al., 2012; Schoene et al.,
2014; Sherrington et al., 2008).
Serious Games Training
Participant
Characteristics Participants are able to stand and step independently and are not or
mildly cognitively impaired.
Aims The game based training addresses both motor and cognitive
performances. The stepping task focuses on dynamic postural control
(important for motor key features such as standing or walking); the
cognitive task relates to cognitive sub-performances (such as temporal-
spatial orientation, executive functions).
Training
Components Supervised cognitive-motor training. Participants have to execute steps
(forward, backward, right or left) on a dance plate as indicated on a
computer or TV screen.
Due to the execution of major motor-cognitive tasks that are relevant for the target
group, such Serious Games are expected to induce more meaningful improvements
than simple virtual gaming consoles (e.g., Nintendo Wii or Sony PlayStation). Another
important feature of this type of Serious Game is immediate referral to stored

25
previous performance and respective feedback of progress and goal achievement
during ‘play’, meaning a direct motivational support. Difficulty can be individually
adapted as the program depends on previous individual performance in each level to
prevent overtaxing of users. The standardized program has been adjusted to the
performance level of frail older adults with and without cognitive impairment in pilot
testing prior to the intervention.
The Serious Game used in LTCMo was the “Dividat Step Plate”. For further
information, please visit http://www.dividat.ch.

26
The main aim of the competence training is to enable staff members to use specific
ways of communication in order to motivate residents to be more physically active.
We aim to increase the awareness of residents’ health and motion behavior, self-
efficacy, control beliefs, self-regulation, and autonomy, as empirical evidence name
these as crucial factors for being physically active. The resulting change in staff
members’ interactional behavior is hoped to enable residents to use their potential
and their competencies optimally.
Theoretical and Empirical Background
The primary aim of the competence training (CT) is to implement and enhance PA-
encouraging staff behavior. The CT was developed for the target group of nursing
staff and nursing assistants, care supervisors, and activity coordinators and it is
based on three theoretical traditions:
(1) Health psychology approaches applied to old age; (2) self-regulation and co-
regulation approaches related to aging; and (3) life-span motivational models (see
also Table 4).
Regarding health psychology the training builds on motivational theories (e.g. Self-
Determination Theory by Deci & Ryan, 1985) which address the question why
someone does or does not behave in a certain way. The framework of Motivational
Interviewing or work on the Positivity Bias, for example, name ways to practically
influence motivational components of behavior. Self-regulation Approaches (e.g.,
Social Cognitive Theory by Bandura, 1977) assume that persons can achieve their
goals despite certain barriers (e.g., age-related functional impairments), as they
selectively influence their actions, emotions, cognitions, or intentions, for instance.
Co-Regulation Approaches address the question how certain ways of interacting and
communicating (e.g., baby talk) may influence vulnerable persons’ autonomy. The
knowledge on clinical action is highly relevant in this context. Life-span motivational
models (e.g., Socio-Emotional Selectivity Theory by Carstensen, 1991) assume a
goal-focused, mainly conscious, and functionally adaptive process of selection and
active arrangement of the social context that aims at an age-adequate re-
Competence Training for Staff

27
arrangement of the social context as well as at a (re-) activation of social resources in
order to maintain well-being.
Though a large body of research identified factors promoting as well as factors
preventing PA, research lacks findings concerning this matter in older persons,
especially in the NH context. Regarding motivators and barriers of PA, factors like
social support, self-efficacy, individual choice options, perceived security, regular
performance feedback, or positive reward have been named. Furthermore,
individually adjusted interventions including personal activity goals and the provision
of information on local offers have been considered relevant. Regarding the special
role of persons with dementia, it is relevant to enable them to get in touch with others,
to give them the sense that they contribute something relevant, as well as to provide
them the chance of reminiscence. The use of specific communication strategies
(patients’ education, self-monitoring, goal setting, verbal encouragement) is very
important to motivate this target group.
Requirements and Aims of the Communication Training
Based on the theoretical and empirical foundations, the change in staff members’
communicational and interactional behavior is meant to promote the following
components on the part of the residents (see Table 4).

28
Table 4.
Key Variables, Staff
Requirements
, and Intervention Contents
Key Variables
Staff Requirements
Intervention Contents
Health psychology and
motivational
approaches
Au
tonomy
provide and grant residents
leeway in decision-making,
offer opportunities to try
behavior
empathy, positive regard,
value-free conversation
(Rogers); the problem of the
corruption effect; Motivational
Interviewing
Health benefit
sufficient knowledge on
chances and risks; convey an
optimistic view to residents
age-related attitudes and
stereotypes
Self-regulation and co-regulation approaches,
knowledge on clinical action
Self
-
efficacy
beliefs appreciate residents‘
competences, emphasize
their confidence, encourage,
consider fears
techniques to express positive,
self-worth enhancing
statements
Control beliefs
support residents in
attributing success to their
own competences, failures to
external sources; encourage
residents to try again
role of control beliefs;
techniques to express positive
statements
Self
-
regulatory
competences support residents to
recognize and to use
chances of selection,
optimization, and
compensation
develop chances of selection,
optimization, and
compensation
Consideri
ng
individual
preferences
know residents‘ individual
preferences and needs and
respect these
techniques to explore needs
Life span
approaches
Social support,
social
exchange
involve residents in social
interactions to promote their
activity;
give residents the feeling of
being important and needed
positive attitude towards PA;
develop opportunities to
connect PA with social
interactions (e.g., involve
residents in housework); safety
concerns

29
Organizational Aspects
The competence training is offered to nursing staff and is integrated into their regular
in-house training schedule to facilitate participation and to reach higher adherence
rates. The training comprises twelve sessions: eight 1-hour-sessions including
theoretical as well as practical contents and four 30-minutes-sessions serving as
case discussions and feedback-loops. Each session is offered twice a week to
facilitate staff attendance. To encourage motivation, compensatory time off or
financial compensation for participants may be helpful. The 12-session training can
be repeated regularly, e.g. every three or four months. In this way, new staff
members are instructed and staff who already attended the training may use it as
“refresher”.
In order to establish an internal quality management, the program can be adapted
the actual situation or new developments within the institution. Therefore, after each
session staff members may fill out a short evaluation form. This instrument provides
information on the following: interest in session content, structure and pace of
session, comprehensibility and practical relevance of contents, learning effect,
evaluation of practical exercises, response to personal matters, atmosphere,
experienced fun during session, intention to attend next session, general evaluation,
and possibility to provide additional comments. At the end of the 12-week training a
more extensive evaluation may be conducted. In addition to the contents listed above
it addresses consequences of the training and experiences with the practical use of
newly acquired skills.
General Description of CT Contents
The CT consists of 12 weekly in-house-training sessions with two major parts (see
also Table 5):
• Eight introducing sessions of 60 minutes containing especially theoretical
aspects.
• Four intervision sessions of 30 minutes including case-oriented discussions
and feedback-loops.

30
Because time limitations are a critical factor in the NH workplace, every session
should be offered at least twice a week. Furthermore, extrinsic motivators like
compensatory time off or financial reward are required to promote attendance.
Table 5. Contents of the CT for Staff Members
Session Content
1
Practical and theoretical aspects; discussions
Introduction and overview over training program
2 Importance of PA in (old) age: theoretical input and
joint discussion
3 Change of behavior: theoretical input and joint
discussion
4 The role of age stereotypes in caring routines:
theoretical input and joint discussion
5 Communication strategies I: Theoretical input and
practical exercises
6 Communication strategies II: Theoretical input and
practical exercises
7 Communication strategies III: Theoretical input and
practical exercises
8 Feedback on practical application of communication
strategies in caring routines and development of
respective solutions
Intervision
Case discussion and
development of respective solutions
9-12

31
Concerning the theoretical meta-perspective, the first modules (2-4) are based on
health psychology as well as motivational approaches. Modules 5-8 mainly contain
components from the self-regulation, co-regulation approaches and the agency of the
knowledge on clinical action as well as life span approaches. “Applying methods” will
majorly convey techniques of person-centered counseling according to Rogers as
well as by Motivational Interviewing.
In the following, the sessions of CT will be described in more detail. Each session
starts with a brief feedback on the previous session, followed bya discussion of
unsolved issues if needed and ends with a short summary and outlook.
Specific Contents of Sessions
Session 1: Introduction
In the first session, staff members get an overview of the frame conditions and the
contents of the intervention program. They are informed about the project’s mission,
the innovative methods and the research staff involved. Furthermore, the potential
positive consequences for residents as well as staff are highlighted.
The contents of the sessions to come are shortly addressed, an outlook is given and
upcoming questions and doubts are discussed.
Session 2: Importance of PA in (old) age
In this session, staff members learn about the importance of PA in old age and in
NHR in particular. The session starts with a joint reflection on personal reasons for
being physically active or not before discussing pros and cons for being physically
active in old age. Empirical data on demographic statistics as well as age stereotypes
are presented with regard to PA and positive consequences of PA for older adults
with and without cognitive impairment are addressed. Participants are informed about
dementia-related changes in basic motor functions (e.g., gait disorders, limitation in
sit-to-walk-transfer, risks of falling) and dementia-specific intervention techniques
(e.g., specific communication strategies, individually tailored exercises).
Session 3: Change of behavior
This session is about change of PA-related behavior and potential challenges in this
regard. After discussing individual experiences considering behavior change, the

32
difficulty to break behavioral habits (e.g., smoking, alcohol consumption) is illustrated.
Information on the phases of behavior change is provided (pre-contemplation,
contemplation, preparation, action, maintenance) and each phase is discussed with
regard to PA in NHR (e.g., which factors keep NHR in a rather inactive status). Ways
to overcome potential barriers are discussed jointly afterwards.
Session 4: The role of age stereotypes in caring routines
In this session, the role of age stereotypes in caring routines is discussed with regard
to fostering the independency of NHR. Information about age stereotypes, gains,
losses and risks associated with older age as well as the impact of subjective age
(how old someone feels) are provided. Socially predominant age stereotypes are
described and the resulting consequences are critically examined. For this purpose,
video sequences are shown illustrating in an exemplary way, how different types of
staff behavior can influence dependent vs. independent lifestyle of NHR. In a
subsequent discussion, strategies promoting autonomy of NHR are worked out
together.
Session 5-8: Communication strategies I-III
These sessions aim at PA-encouraging staff-resident interactions. Staff members get
information about how to structure conversations actively. Techniques such as active
listening, clear communication, paraphrasing, expressing contents personally and
using meta-communication are presented in this regard. Special attention is drawn to
dementia-specific communication techniques as well as to challenging conversation
situations (e.g., dealing with anger, sadness, aggression, personal attacks). Offering
practical exercises (e.g., role plays) staff members get extensive practice
opportunities. Practical experiences with the new techniques made during the daily
nursing care are discussed in the following session.
Session 9-12: Case discussion and development of respective solutions
The intervision sessions offer an opportunity to jointly discuss challenging single
cases and develop respective solutions together. Furthermore, the practical
application of the newly learned communication and interaction strategies are
reviewed, and strategies for upcoming challenges are developed

33
A
NNEX
Exercise Catalogue and Guidelines
Safety Measures & Safeguarding Positions
Tool for the Evaluation of Existing Activities
Training Group Assignment of Residents

34
This catalogue contains an exemplary compilation of exercises that are specifically
suitable for use in nursing home residents. It mainly comprises a progressive
functional and strength training as well as dual task exercises. By now there is a
rather large amount of training programs that are based on similar exercises and
principles. An extensive overview of interventions useful in the nursing home setting,
including recommendations of particularly useful programs is given by Horn et al.,
2012, e.g. HIFE - High Intensity Functional Exercise Program (Littbrand et al.), SimA-
P (Oswald et al., 2007), MIA (Sportbund Bielefeld, 2009), or Strength- and Functional
Training for Older People with Dementia (Schwenk et al., 2008).
In the following, the exercises will be assigned to the main motor skills that are
trained with the exercise, although most exercises address multiple motor skills.
Training is performed in static as well as dynamic standing positions and, depending
on individual functional abilities, during walking. In the exercise catalogue basic
exercises are described that can be adapted and varied in multiple ways. The
exercises are implemented following three didactical principles:
• from low to high intensity
• from known to unknown tasks
• from simple to complex exercises.
With each exercise, we also describe alternatives and more complex variations of
each exercise that can be used to further aggravate the exercises. In this way,
exercises have constant high impacts and thus stronger effects on motor function. In
general, exercise can always be developed further. Creativity is completely
unrestrained as long as the exercises are functional, effective and safe.
Exercise Catalogue and Guidelines

35
Static Balance Training
B1: Side by Side Stance
Both feet are placed parallel in an
upright stance, touching each other.
This position should be held with as
little movement as possible, as long as
possible but no longer than 30s. If the
person can hold this position with
support, this can be done without
support, under close supervision.
Alternative: High level performance:
both eyes closed during exercise.
B2: Semi-Tandem Stance
This exercise builds up on B1 and
poses higher demands on participants’
balance due to the more complex
location of the body’s center of gravity.
The starting position is similar to B1.
Then, one foot is shifted to the front for
about ten to 15 cm. The execution of
this task is similar to B1.
B3: Tandem Stance
Just as B2, the Tandem Stance further
increases the complexity of the
standing task. Starting position is as in
B1 and B2. Then, on foot is placed
straight in front of the other foot. The
execution of the exercise is as in B1
and B2.
Alternative: All three exercises can be
performed on e.g. balance pads (B1a)
or porcupine balls (B1b) to further
increase complexity.
B1
B3
B1a
B2

36
B4: Leg pendulum
The exercise requires the participant to
stand straight on one leg, while the
other leg is swung to the front and
back like a pendulum. Initially, the
person may hold on to a chair placed
alongside the participant. The better a
person can manage the task, the less
aid should be used. After 30 seconds,
the legs can be switched.
Alternative: The standing foot can be
placed on an uneven underground
(balance pad, porcupine ball, etc.)
which increases the complexity of the
task.
B5: Catching a ball
The person is standing straight and
has a hand-sized ball in one or both
hands. Depending on the experience
with this exercise, the standing position
can be varied (see B1 to B3).
B1b
B4
B5
B1a

37
The person throws the ball up in front
of his/her face and catches it with both
hands. As this exercise requires the
use of both hands, direct contact with a
supervisor is mandatory to ensure
highest possible safety. To increase
complexity, the task can be done with
one handed throws and catches,
different stances, and with different
balls (exercise ball vs. tennis ball). By
adding a complex motor-cognitive task
such as throwing and catching a ball,
keeping one’s balance is made more
difficult.
Alternative: This exercise can be
performed as a partner exercise. Two
or more persons are standing opposite
to each other. For safety reasons,
chairs can be placed behind and in
front of the persons, in case they want
to hold on to a chair. Then, the ball is
thrown back and forth between the
persons with one hand (if holding on to
a chair; B5.1) or both hands (if
standing freely; B5.2). Different balls or
balloons (B5.3) can used to vary the
exercise task.
B5.1
B5.2
B5.3

38
Dynamic Balance and Step Training
D1/D2: Lunges
In an upright stance, the person holds
on to a chair in front with both hands.
Then, a lunge to the side (S1) or to the
front (S2) is performed. Lunges to the
left and right can be performed either
alternately or one side after the other;
lunges to the front should be
performed alternately with each side.
The step has to be performed
recognizably; the foot has to be lifted
up in a distinct manner.
Alternative: To increase difficulty, the
person can grab the chair with one
hand (see Figure D1) or perform the
exercise without support.
D3: Lunges with porcupine balls/
balance pads
To combine the stepping task with an
aggravated balance task, porcupine
balls and balance pads can be used.
The starting point is the same as in S1.
Porcupine balls or balance pads are
placed in front of the person. The steps
then have to be executed on the
materials. The person can either hold
on to a chair or be held with hands by
the instructor. This exercise requires
the ability to stand safe and a certain
amount of strength, experience, and
security of the instructor.
D2
D1

39
Alternative: To further aggravate the
task, the participant can start already
standing on two porcupine balls. In this
way, a balance training of rather high
intensity can be incorporated in the
stepping task. Two modes are
possible:
• Three balls; standing on two parallel
balls and stepping on the ball in front;
• Four balls: from side-by-side on the
two back balls (D3.1) through
stepping forth (D3.2) to side-by-side
on the two frontal balls (D3.3); and
back again.
D3
D3.3 D3.2 D3.1

40
Dynamic Balance and Gait Training
G1: The stalker
The person has to walk with distinct
and excessive knee lifts. Each step
should be performed in a slow and
deliberate manner. The supervisor has
to walk close by and, if necessary, the
person can hold on to the supervisor’s
hand until s/he is capable of walking
independently. The length of the
walking path can be adapted according
to individual skills.
Alternative: This task can be performed
under different conditions which
increase difficulty and complexity: with
eyes closed; back-wards; with different
stepping patterns or paces.
G2: Walk the line
A slip-resistant rope is placed straight
on the floor. The task is to balance on
the rope with each step at least
touching the rope. Ideally, the whole
foot is placed on the rope with each
step. The better this task is performed,
the less support should be provided.
Alternative: To increase complexity,
the rope can be lain in a wavy line; the
task can be executed with eyes closed;
steps can be performed as in G1; a
ball can be included as in B5.
G1
G2

41
G3: Multi-task walk
Walking a distance is linked with
certain motor-cognitive tasks, for
example throwing and catching a ball
(G3.1); solving tasks such as math
problems; enumerating names, cities,
animals, spelling words, or else. Close
supervision is mandatory as cognitive
tasks while walking increase the
intensity and at the same time raise the
risk of adverse events such as falls.
G4: Obstacle course
Many different materials can be used
for the construction of an obstacle
course that can be adapted according
to individual preferences or deficits.
The course should be adapted
regarding obstacles length. Due to the
higher complexity and intensity,
obstacle courses should be shorter
than the normal walking exercises.
Such courses present an excellent way
to train several motor skills simul-
taneously. In the following, different
forms of obstacle courses are
presented. In all of them, very close
supervision and aid are mandatory as
these are the most challenging
exercises in a sample of NHR.
G4.1: Shaky ground walk
This course can be used to initiate
obstacle courses in general. Terra
Sensa® mats are very useful just as
Airex® mats or any other balance pad.
However, these are required to be slip-
resistant. Otherwise, the risk of falls is
very high.
G4.2: Balance mix
Balance pads can be combined with
several other obstacles, such as ropes
(G.4.2a) and porcupine balls (G4.2b). It
is important to mind the distance
between the obstacles, which should
be adapted to the step length of each
individual.
G3.1 G4.1

42
There are many options to combine
materials, and no combination is
inappropriate or false. It is possible to
adapt the courses according to the
training goals and/or participants’
preferences to ensure efficiency, fun
and enjoyment while doing the
exercises.
G5: Get up and walk
Starting from a chair in a seated
position, the person has to stand up
and walk a certain distance turn
around after passing an obstacle. In
order to train balance as much as
possible, this task should be executed
in a very slow fashion.
Alternative: The exercise can be done
as fast and quick as possible; while
talking to the supervisor; with or
without aid.
G6: Get up, walk and step
The execution of this exercise is similar
to G5, with one exception: the person
stops in front of the porcupine ball and
performs alternating steps on the ball
with the right and left foot, then returns
to the chair.
Alternative: The person can stand on
the ball with one foot and hold the
position for ten seconds; then uses the
other foot. The person walks back to
the chair backwards.
G4.2a
G4.2b
G5

43
Functional Strength Training
S1: Push the button
While standing, the person has to
stand on a ball with one foot and push
down the ball as hard as possible –
then hold the pressure for about ten
seconds (depending on the exhaustion
of the individual). Balls with air outlet
are particularly suitable as the fill up
with air again once pressure is
released. After ten rounds, the foot is
switched.
Alternative: Instead of switching after
ten rounds, the task can be performed
alternately with the left and right foot to
lay more focus on the stepping task.
S2: Uplifting
The person is standing behind a chair
and holding on to it. Then, ten to 15
calf-raises are performed. Depending
on the individual strength of the
participant, these can be done single-
legged or with both legs and/or hands-
free.
It has to be made sure that the person
does not push her/himself up with help
of the arms. This is also important for
safety reasons as the chair may be
torn down.
S3: Step up
The person has to step on a tread and
down again. As many rounds as
possible should be executed, but no
more than 15 per leg. It can be done
either one leg at a time or alternating
with the right and left leg. If available,
treads of different heights can be used,
starting with the lowest for those with
weak motor skills and highest for
advanced stair climbing skills. For
safety reasons, the supervisor should
always stand close to the person.
S1
S2

44
S4: Chair rises
This exercise is intended to a) streng-
then the lower extremity muscular
system and b) train a proper chair rise
technique in order to enable persons to
stand up independently. Therefore, the
chair rise task can be separated into
three major parts that have to be
performed five to twelve times:
S4.1: Slide to the front edge of the
chair with feet positioned in shoulder
width, directly below or slightly behind
the knees.
S4.2: Lean forward until the shoulders
are at the height of the knees.
S3
S3
S4.1
S4.2

45
S4.3: Stand up, if possible without
momentum and use of hands.
Alternative: To increase the intensity of
the task, balance pads can be put
under the feet. If done so, an elevation
of the sitting surface may be
necessary. The slower the task is
performed, the higher the intensity.
Another aggravation of the task would
be not to put down the rear on the
sitting surface but to rise again once it
is slightly touched.
Seated Exercises
Many of the exercises above can be
adapted to the needs and require-
ments of persons who are not able to
stand up or walk. There are also some
more exercises that are especially for
wheel-chair bound residents. They can
be used for exercise groups as well as
in individual single training as
implemented in the project LTCMo.
W1: Riding a bike
The person is sitting on a (wheel)chair
and leaning backwards. Then, both
legs are lifted in the air and moved as
in cycling. One round should last ten to
30 seconds, depending on individual
muscular endurance.
Alternative: The cycling can be done
backwards; each cycle can be
performed in a very slow manner;
cycles can have a small or large
diameter.
W2: Leg extensions
The person is seated on a chair and
leaning backwards. A ball is clamped
between both feet; the feet are slightly
S4.3
W1

46
above ground. Then, both legs are
extended ten to 15 times with the ball
still being clamped between feet.
The ball can be left out if a person is
unable to keep it between feet.
W3: Knee raise
The person is seated nearer to the
front edge of a chair; the back is kept
straight; both feet are placed straight
on the ground. Then, one leg is lifted
straight up and held at the highest
possible point for about two seconds.
Legs are switched after each
repetition.
Alternative: Both legs can be lifted at
the same time; a ball can be clamped
between both feet while the exercise is
performed (W3.1).
W4: Push the button – seated
Seated position as in W3. A ball is
placed under one foot and pushed
down as hard as possible. Pressure
should be held for about ten seconds
(depending on the exhaustion of the
individual). Soft balls or balls with air
outlet are preferred; after ten rounds,
the foot is switched.
Alternative: Instead of switching after
ten rounds, the task can be performed
alternately with the left and right foot.
W5: Kicking it
Two or more persons are seated facing
each other and kicking one or two balls
to and fro; both feet should be used.
Alternative: Smaller (tennis ball) or
bigger (soccer ball) balls can be used;
the ball can be kicked back
immediately or stopped in between.
W2
W3.1
W4

47
Participants’ safety is one of the most
important issues when it comes to
exercise training with frail older people.
Therefore, we present the most
important safety measures and
precautions as well as safeguarding
positions during exercises.
The double chair circle has already
been mentioned. It is the most effective
way to provide safety and prevent falls,
especially in larger exercise groups. A
proper double chair circle provides one
chair within reach in front of a person
and one in the back, close enough to
sit down immediately without having to
take a step backwards (SF1/SF2).
The better the motor function of a
person gets, the less aid should be
provided. However, safety has to be
kept at the highest possible level
throughout the training course. The
balance between two somewhat
opposing interests, safety and exercise
effectiveness, has to be kept at all
times. There are several ways to
facilitate or aggravate an exercise for a
person. Whether this is necessary or
useful is always an individual decision
that depends on the ability and
experience of the instructor and the
motivation and attitude of the
exercising person. In the following,
safety measures and safeguarding
positions are presented from easy to
difficult (meaning that the exercise
becomes more complex and intense).
The easiest way to provide safety is to
use the double chair circle with
additional aid of the instructor. In this
way, the participant can hold on to a
chair and the instructor can provide
additional aid and help performing the
task. This is especially useful for
participants who feel unsafe or have
severe motor deficits.
If an instructor is sure that s/he can
handle the task, the chair in front of the
participant can be left out. Instead, the
Safety Measures & Safeguarding Positions
SF1
SF2

48
instructor can stand in front of and hold
the person by both hands (SF3).
To make the exercise more difficult for
the participant, the instructor may take
away one hand and place it on the
shoulder. Still, the participant can hold
on to the instructors’ other hand (SF4).
If the instructor is sure that a person is
able to do the exercise on his/her own,
both hands can be placed near the
shoulder or waist of the participant, so
that the instructor can intervene
immediately if necessary (SF5).
The closer the instructor stands to the
person, the easier it is to intervene in a
safe and uncomplicated manner.
The positions above can be used in
almost all exercises. However, when
walking, the instructor should walk
alongside the participant and have one
arm around shoulder or waist and one
hand free to hold on to if necessary
(e.g., see exercise G2).
SF3
SF4
SF5

49
Date & duration: Rater/Observer:
Unit: e.g. 1st floor unit
Activity:  word of the day  sitting-dance
 morning round  evening round
 calisthenics  painting / creativity group
 Wii-training  fall prevention
 Other: ___________________
Participants (Residents): overall: N=___
wheelchair users: N=___
walker-rollator users: N=___
Participants (Staff): N= (including trainers, interns, legal guardians, etc.)
Profession of trainer:  social care  nurse  honorary post  other: ____________
Short description of activities: - main goal of activity:
- performed activities:
- amount of physical activity involved:
- intensity of activities:
- cognitive:
- physical:
- motivation of participants:
Potential use for project: Grade  A  of strong use; similar aims; only small
modifications required (if necessary)
 B  medium to high potential; slightly different
aims; may be useful if modified
 C  low potential; different aims; hardly any
activity involved
 D no potential; totally different aims; no
activity involved
Modifications necessary:
Tool for the Evaluation of Existing Activities

50
Ability to stand without personal assistance
No Yes Ambulatory
No Yes
• Characteristics/Criteria: Residents show severe motor impairment and or
cognitive impairment in combination with severe behavioral problems.
Independent standing is not possible and requires constant help of at least one
supervisor. Explore, whether re-learning or improving standing is possible.
• Aims: Support of dynamic sitting; relearning of sit-to-stand transfer; advance to
Group II or III.
• Training Components: In the beginning main focus on seated strength and
mobilization exercises: strengthening of leg muscles (leg extension) to enable sit-
to-stand transfers. In the course of the training, conduct standing exercises with
support if possible.
• Characteristics: Ability to walk without aid; to stand up independently and sit
down without any support; to walk longer distances without help.
• Aims: Physical activity promotion in terms of number and duration of active
episodes; improvement of walking performance, dynamic postural control, and sit-
to-stand/sit-to-walk transfers.
• Training Components:
o Functional strength training: Sit-to-stand transfer training without using the
arms.
o Dynamic balance and gait training: Different standing positions; improvement
of stability and duration of standing posture; different walking exercises (e.g.,
narrow vs. wide distance between feet; slow vs. fast walking; uneven floor
surfaces)
• Characteristics: Unstable walking with aid; standing up and sitting down without
personal assistance is possible.
• Aims: Physical activity promotion in terms of higher frequencies of standing and
enabling participants to walk short distances. Improvement of static and dynamic
balance (i.e., stable standing); improvement of sit-to-stand transfer. In the further
course of the training: support of stable walking, walking security, and a
homogeneous walking pattern (then: transition into Group I).
• Training Components:
Training Group Assignment of Residents
Severe behavioral problems/code
-
secured
No/Bedridden
Ability
to sit
Group II Group I
Individual Tr.
Not possible
Group Assignment:
Group II
Individual Training
Yes
Yes No
Group I
Group III Serious Game

51
o Support of stable standing without aid by exercising in different standing
positions and at different levels of difficulty.
o Sit-to-stand training: trying to stand up and stand still; in the long run, transition
to sit-to-walk training
o Gait training: In the beginning, improvement of gait performance with support;
gait episodes without aid if this seems possible; prolongation of the duration of
walking episodes under supervision and improvement of a homogeneous
walking pattern.
• Characteristics: Participants show pronounced cognitive impairment
accompanied by severe behavioral problems. Participants should be ambulatory
and able to stand up with little or no support. In LTCMO, this group was
implemented in a code-secured living unit.
• Aims: Improvement of static and dynamic balance (i.e., stable standing);
improvement of sit-to-stand transfer. Support of stable walking, walking security,
and a homogeneous walking pattern.
• Training Components:
o Functional strength training: Sit-to-stand transfer training without using the
arms.
o Dynamic balance and gait training: Different standing positions; improvement
of stability and duration of standing posture; different walking exercises (e.g.,
narrow vs. wide distance between feet; slow vs. fast walking; uneven floor
surfaces)
o Focus on social aspect of group training: exercising together by execution of
clearly constructed and meaningful tasks.
• Special Requirements: Depending on the severity of cognitive impairment,
group organization may require adaptations. In L TCMo, instead of a double chair
circle, residents were seated side by side in direction of the hallway which was
used for exercises. Then, residents were attended to one after another. When the
last participant in the line was done with his round, the first in line started again. In
this way, residents were seated close to each other so that social contact and
conversations were facilitated. In addition, this organization form was found to be
easier to understand for the participants than the double chair circle.
• Characteristics: Participants are able to stand and step independently and whot
are not or mildly cognitively impaired.
• Aims: Improvement of motor-cognitive function and dynamic postural control.
• Training Components: A supervised cognitive-motor training. Participants have
to execute steps (forward, backward, right or left) on a dance plate as indicated
on a computer or TV screen.
Group III
Serious Game

52
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Project-Related Publications

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Disclaimer:
All contents of this Guidebook have been thoroughly reviewed before publication.
Nevertheless, it may be the case that mistakes and wrong information are still part of
the book. Given that this book offers guidelines, no less but also no more, we do not
take any responsibility for events that may occur as part of a training based on this
book. For example, all success depends on highly qualified instructors with large
experience in working with older adults, particularly physically and mentally frail older
adults.
We thank Mrs. Gerlinde Scholz and Mr. Harald Rehn from Maria von
Graimberg Haus, Heidelberg (Germany) for being our photo models!