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R E S E A R C H Open Access
The impact of group activities and
their content on persons with dementia
attending them
Jiska Cohen-Mansfield
1,2,3
Abstract
Background: Individuals suffering from dementia and residing in nursing homes often feel lonely and bored.
This study examined the engagement and mood of people with dementia in group activities, and how personal
characteristics, such as cognitive function, may impact on an individual’s responses to group activities.
Methods: The study included 102 participants, who took part in group activities while their mood and engagement
levels were observed. Participants were invited to attend 10 different types of group activities, each of which was
offered twice.
Results: Results found improved engagement and mood during group activities as compared to control no-group
times. Significant relationships between the type of activity and ratings of engagement and mood were also found.
Although participants with higher levels of cognitive functioning manifested greater responsiveness to groups,
the pattern of response to different contents did not differ by cognitive function.
Conclusions: This study shows the potential utility of group activities for improving quality of life of persons with
dementia and demonstrates a methodology that can be used for quality improvement to optimize group
contents. Future research should expand the range of contents of group activities in order to enhance the options for
improving mood and engagement of individuals with dementia.
Keywords: Dementia, Group activities, Mood, Cognitive impairment
Background
Persons with dementia residing in nursing homes and
long-term care settings are often not engaged in any
activity [1]. Low levels of engagement and understimulation
are problematic because they can result in boredom
and loneliness that may lead to behavior challenges [1].
A potential way to mitigate these issues is to engage
multiple persons with dementia in group activities.
Group activities can provide individuals with dementia
the opportunity to interact with both staff members
and other residents within a social context while being
engaged in an activity. Therefore, it is important to
understand the impact of group activities on engagement
and the possible related outcomes. The Comprehensive
Process Model of Group Engagement serves as a
conceptual framework to understand engagement of
persons with dementia within group activity settings [2].
This model posits that environmental (e.g., physical and
group environments), stimulus (e.g., content of activities),
and personal attributes (e.g., age, cognitive functioning)
impact on the engagement and affect levels of individuals
taking part in the activity, which can, in turn, influence
behaviors of persons with dementia. In particular, stimulus
attributes, such as the content of a specific group activity,
may differentially impact engagement and may also
interact with other attributes, such as characteristics
of group members.
Based on this model, it is possible that certain activities
may be more engaging than others, depending on the
characteristics of the activities. Some insight comes from a
Correspondence: Jiska@post.tau.ac.il
1
Minerva Center for the Interdisciplinary Study of End of Life, Tel-Aviv
University, P.O.B. 39040, Ramat Aviv, 6139001 Tel-Aviv, Israel
2
Department of Health Promotion, School of Public Health, Sackler Faculty of
Medicine, Tel-Aviv University, P.O.B. 39040, Ramat Aviv, 6139001 Tel-Aviv,
Israel
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cohen-Mansfield Alzheimer's Research & Therapy (2018) 10:37
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small descriptive study of 23 individuals who were
diagnosed with dementia [3]thatcomparedtheengage-
ment level in five different types of group activities—music,
art, exercise, cognitive, and functional household activities.
Active participation levels were highest for the exercise,
music, and art groups. Although this study provides
some insight into certain activities that may be more
engaging, in that exercise, music, and art elicited
higher active participation levels than the cognitive
and household activities, no statistical tests comparing
the activities were reported. The small sample size of
higher functioning persons with dementia (who were
able to give their own consent to the study) and the
limited range of activities also make it challenging to
generalize these results to other settings.
A larger study with 107 participants [4] found that
activity interventions—some of which were completed in
groups—engaged residents 84% of the time overall, with
an average engagement duration of 27 min. Examples of
activities that resulted in engagement 98–99% of the
time included drama, wine/cheese social, garden, and
dancing activities. These results are encouraging because
they demonstrate that persons with dementia are
capable of showing high engagement levels in different
types of activities. However, this study tailored activities
to each individual, which may have contributed to high
engagement levels. Individualization of activities may
not always be feasible in resource-limited facilities, so
there remains a need for research that compares common
group activities (e.g., exercise, reading) that have not
been individualized.
Other studies have examined different outcomes that
may be related to engagement, such as wellbeing and
affect. For example, one study compared levels of
wellbeing of persons with dementia during reminiscence
group therapy, general activities (e.g., crafts and games),
and unstructured time [5]. Wellbeing was observed to
be lower during unstructured time compared to the
activities. Wellbeing was also higher for reminiscence
therapy than for general group activities. The superiority
of activity over unstructured time was also demonstrated
by Phillips et al. [6], who found significantly more
pleasure during a group storytelling than during an
unstructured control condition.
Other studies have also compared two or three group
activities on outcomes other than engagement, but have
not found significant differences in affect between music
and reading activities [7], or in behavior when compar-
ing a music activity versus general recreational activities,
such as puzzle games and cooking [8], or else they
reported inconclusive or unclear results [9]. The limited
evidence, together with different study methodologies,
makes it difficult to conclude which group activities may
have the most promising impact, and how they compare
to unstructured time. The sample sizes of four of these
studies were small (fewer than 50 participants [3,5,7,9]),
with some consisting of relatively higher functioning
persons with dementia who were capable of making
their own responses on questionnaires (e.g., [7]). Such
limitations make it challenging to provide recommen-
dations for group activities that would be generalizable
to a range of persons with dementia. Thus, there is a
need to clarify the impact of group activities in general
(i.e., in comparison to unstructured time) and to elucidate
the impact of different activities on various outcomes.
To address this research gap, this study measured
the engagement and mood of persons with dementia
with various levels of functioning during 10 group ac-
tivities. The first aim was to compare the engagement
level of participants during group activities to a con-
trol condition consisting of unstructured time. The
hypothesis was that group activities would be more
engaging than unstructured time. The second aim
was to assess whether certain activities were more en-
gaging than others. The general hypothesis was that
certain group activities would be more engaging than
others, but the lack of clear findings in the literature
did not lend itself to specific predictions as to which
these activities would be. The third aim was to exam-
ine whether cognitive level, a personal characteristic
of participants, changes the impact of the different
group activities.
Methods
Participants
Persons with dementia were recruited from nine units at
a geriatric residential facility consisting of a nursing home,
a community adult day program, and an independent
living facility. Inclusion criteria included: a diagnosis
of dementia (derived from the medical chart) and
informed consent. The criteria for exclusion were: a
diagnosis of bipolar disorder; a lifelong diagnosis of
schizophrenia; Cognitive Performance Scale (CPS)
[10] score of 1 or lower (higher scores indicate lower
function), because it is believed that people with
higher levels of cognitive function can articulate their
interests and needs most of the time; no dexterity
movement in either hand; cannot be comfortably
seated in a chair or wheelchair, or cannot be moved
to the location of the group therapeutic recreation;
and never spoke any English. This information was
gathered from computerized charts using Minimum
Data Set (MDS) version 2.0 [11,12]. We purposefully
did not exclude potential participants on the level of
cognitive function, as our aim was to examine the
feasibility and outcomes of group activities for per-
sons with all stages of dementia.
Cohen-Mansfield Alzheimer's Research & Therapy (2018) 10:37 Page 2 of 8
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Ethics, consent, and permissions
This study was approved by the Research Ethics Board
(REB) of Baycrest Health Sciences. We contacted the
persons responsible for making decisions for those
meeting inclusion criteria. Of the 217 contacted, 22
refused and informed consent was obtained for 105
study participants.
Procedure
Once consent was obtained for 10–12 eligible participants
for each unit, recruitment was stopped, on the assumption
that 10–12 participants would be an appropriate size
for a group. One participant who enrolled in the
study was subsequently excluded due to the onset of
illness prior to the first session. The analyses reported
in this article were conducted with a final sample size
of 104 study participants. Participants were grouped
into nine units, with each unit having between 10
and 13 participants for whom consent was obtained.
Occasionally, group activities were joined by clients
who were not enrolled in the study and dropped in
on the groups. The total group size ranged from 3 to
17 for the group activity sessions, with a mean of 9.2
(SD = 3.1). In total, 102 participants with consent ac-
tually attended groups, and the following text pertains
to them.
Baseline characteristics were collected from the MDS
and medical charts: age, sex, language, education, marital
status, number of children, mobility, vision, hearing,
speech, number of medications, number of diagnoses,
cognitive functioning (via the CPS), and activities of
daily living (via the Activities of Daily Living Long form;
ADL-Long Form, obtained through the MDS [13]). Over
half of the persons with dementia were female (63.7%),
and the average age was 87.20 years (SD = 8.44, ranging
from 59 to 101 years). Cognitive functioning assessed via
the CPS [10] averaged 3.09 (SD = 1.31; range 2–6; scale,
0=‘Intact’to 6 = ‘Very Severe’). ADL-Long Form [13]
performance averaged 16.9 (SD = 18.98, range 0–28;
scale, 0 = ‘independent’to 28 = ‘total dependence’).
Participants were invited to participate in two sessions
of each of 10 group activities which had been selected
based on therapeutic recreation (TR) staff expertise and
are considered to be common activities in nursing
homes and long-term care settings: exercise; active
physical games, such as bowling or ring toss; reminiscence
poetry; baking; choral singing; creative storytelling;
reading aloud with discussion; brain games/fitness;
holiday discussion; and holiday newsletter activities
(for additional details see [14]). One group activity
was conducted per session, and each group activity
was conducted twice, in random order, so that each
unit completed 20 sessions of group activities. Over
nine units, this resulted in a total of 180 sessions. Each
unit had one TR who led all the group activities for
that unit, with the exception of one unit in which the
group activities were shared amongst two TRs. Each
session lasted approximately 30 min, and all were
conducted in English. The study took place for
approximately 3–4 months on each unit and lasted
7monthsoverall.
The control condition consisted of observations of
study participants during one or two visits in their
residential location during unstructured time (i.e.,
when organized activities were not being conducted).
These 3–5-min observations were scheduled to take
place at a random order with respect to the other
group sessions.
Observations of participants during group activities
were independently made by a trained research assistant,
trained student volunteers, and the TR who had led
the group activity (after its completion). The control
condition sessions were observed by at least one TR
or research staff observer (often both).
Assessments
Outcome measures Observations were collected using
the Group Observational Measurement of Engagement
(GOME) [2] and included outcomes of engagement,
mood, and sleep. These are described in the following.
The construct of engagement was measured by three
variables: ‘engagement’,‘How much of the group was the
participant engaged in the group activity?’, rated on a
scale from 0 = none of the time to 5 = most or all of the
time; active participation, ‘To what extent did the
participant actively participate in the group?’,rated from
0 = not at all to 4 = very much; and attitude towards
the activity (‘most of the time’), ranging from 1 = very
negative to 7 = very positive.
Active participation and attitude were not measured
in the control observations, since most often there was
no particular stimulus or activity to actively participate
with or to have an attitude toward.
Because the term ‘engagement’is used to describe a
group of variables as well as a specific indicator
variable, we will use quotes whenever referring to the
particular observed variable named ‘engagement’and
use the term without quotes when we refer to the
general construct of engagement.
Positive mood was measured through observation, with
ratings ranging from 0 = not at all to 4 = very much.
Sleep and sleepiness was rated on the basis of observa-
tion on a scale ranging from 0 = none of the time to 6 = all
of the time.
More detailed descriptions of the variables represent-
ing engagement, mood, and sleep, together with their
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psychometric properties showing good inter-rater
reliability and validity, are presented in [2,15].
Analytical approach
In order to compare ratings during groups to ratings
for control observations, we aggregated all group
observations across the 20 group experiences of each
of the participants and also aggregated the two control
observations for each participant. Paired ttests were
used to compare engagement, mood, and sleep for
each participant during group observations vs control
observations. Effect size for those paired ttests were
calculated as: (mean
diff
/SD
diff
)×√2
.
To address the second goal, of assessing the relative
impact of the different group activities on participants,
we used a mixed model analysis in order to address the
repeated measures in the data, which included two
observations per participant per group topic done by
two different observers. The mixed model analysis also
enabled us to address the missing data resulting from
uneven participation in the groups, which we will examine
in another paper. In order to reduce the number of models
we examined, we used the average of observations by TR
and by the other observer as the dependent variable. In the
mixed model, we included cognitive function as a covariate,
becausewehavefoundittobethemostimportant
personal variable affecting engagement and mood in this
population [16]. Holiday discussion was used as the
reference group to which other groups were compared.
In order to examine the third goal, determining
whether the relative impact of different group topics
varied by cognitive function, we divided the population
into two groups, those of moderate cognitive impairment
(CPS rating of 2 and 3; n= 55) vs advanced cognitive
impairment (CPS ratings of 4, 5, and 6; n=47).Wethen
conducted the same mixed model analysis described for
the second goal within each subgroup and examined these
results for the two subgroups for ‘engagement’, active
participation, and positive mood. Due to the small group
sizes, we examined effects with p<0.10inthissection.
Results
Group activities vs control condition
Table 1presents the comparison of the group obser-
vations to the control observations, showing that
during group activities participants were more engaged,
displayed a more positive mood, and spent less time
asleep or displaying sleepiness than during the control
observations. This was found regardless of whether
TR staff or research observations were used, although
effect sizes were larger when using TR ratings.
Comparison of group activities
The mixed model analysis found statistically significant
effects for group topic and for cognitive function in each
of the analyses, with p< 0.001 for ' engagement', active
participation, attitude, and positive mood, and p= 0.018
in the comparison of the different group activities on
sleep and sleepiness (Table 2). The much higher values
for Fstatistics associated with cognitive functioning as
compared to group activities suggest that cognitive
function had a greater impact on the outcome variables
than did the differences among group topics. When
comparing the different activities to the reference group
of holiday discussion, games and choral groups resulted
in significantly more ‘engagement’, active participation,
positive attitude, and positive mood, and also in signifi-
cantly less sleepiness; exercise groups resulted in signifi-
cantly more active participation; brain games resulted in
significantly more positive mood; and baking was associated
with significantly more active participation and positive
mood; in contrast, poetry resulted in a worse attitude and
less positive mood, and storytelling resulted in significantly
less ‘engagement’, less active participation, and a less
positive attitude (Table 3). The estimated means of the
dependent variables for the different groups (after control-
ling for cognitive function) are displayed in Fig. 1.The
figure shows that the different dependent variables
tended to fluctuate in a similar manner for the different
activities, with sleep naturally showing the mirror
image of the fluctuations and also manifesting smaller
changes among activities.
Table 1 Comparison of mean engagement, mood, and sleep levels during group activities vs during control observations
Variable Rater Group activity Control tdf p(two-tailed) Effect size
Mean SD Mean SD
'Engagement' TR 3.55 1.41 2.72 1.96 4.84 92 0.000 0.71
Observer 3.73 1.35 3.31 1.7 3.43 96 0.001 0.49
Positive mood TR 2.48 1.07 1.76 1.28 6.04 91 0.000 0.89
Observer 1.52 1.07 1.24 1.29 3.12 96 0.002 0.45
Asleep TR 1.14 1.62 1.87 2.15 −3.87 89 0.000 −0.58
Observer 1.19 1.63 1.48 2.09 −1.94 94 0.056 −0.28
SD standard deviation, df degrees of freedom, TR therapeutic recreation
Cohen-Mansfield Alzheimer's Research & Therapy (2018) 10:37 Page 4 of 8
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The interaction between group topics and
participants’cognitive function
Figure 2displays the means of ‘engagement’, active
participation, and positive mood separately for partici-
pants with moderate cognitive impairment and with
advanced cognitive impairment. As expected, higher
levels were observed for those with moderate cognitive
impairment. However, the trends were similar for both
groups, suggesting that for the activities used in this
study, the difference in responsiveness to the groups is a
matter of magnitude of observable response rather than
responsiveness to different types of groups. This is further
supported by other observations: mean ‘engagement’
scores were highest for both levels of cognitive function in
the games group and second highest for choral, and they
were lowest for storytelling. Active participation was also
highest in games for both levels of cognitive function
and, again, storytelling had the lowest levels of active
participation regardless of cognitive function. For
positive mood, games had the highest ratings, choral
had the second highest, and poetry had the lowest
ratings regardless of level of cognitive functioning.
Discussion
The results provide relatively clear answers for the three
research aims. Group activities were clearly superior to
control time without such groups. Participants’levels of
engagement, mood, and sleep varied with group content.
While persons with higher level of cognitive function
manifested more positive effects in response to the
groups, the relative responses to the various group
contents did not differ by cognitive function.
The superiority of group activities to control obser-
vations concords with Brooker and Duce’s[5]and
Phillips et al.’s[6] findings that wellbeing was higher
during activities than during unstructured time. In
contrast, our findings of differential effects of groups
based on their contents differ from those of some
previous studies [7–9]. This could be due to our use
of a larger range of activities, a larger sample size,
different assessments, or the nature of the activities
as described in the following. However, responses for many
Table 2 Mixed model analyses comparing the impact of different
group activities while controlling for cognitive function
Variable Group topic effect CPS effect
'Engagement' F
9, 1097
= 7.03*** F
1,100
= 87.35***
Active participation F
9, 1097
= 14.55*** F
1, 102
= 87.72***
Attitude F
9, 1108
= 11.50*** F
1, 104
= 63.07***
Positive mood F
9, 1100
= 9.16*** F
1,99
= 66.26***
Sleep F
9,1030
= 2.24* F
1,105
= 48.187***
CPS Cognitive Performance Scale
*p≤0.05, ***p≤0.001
Table 3 Significant comparisons found as compared to holiday discussions (reference group)
Variable Exercise Games Poetry Baking Choral Storytelling Brain games
'Engagement' 0.44;
t
1100
= 3.83***
0.35;
t
1098
= 3.18**
−0.34;
t
1094
=−2.92**
Active participation 0.30;
t
1099
= 2.94**
0.74;
t
1101
= 7.29***
0.23;
t
1099
= 2.17*
0.35;
t
1099
= 3.56***
−0.22;
t
1095
=−2.20*
Attitude 0.38;
t
1113
= 3.96***
−0.27;
t
1109
=−2.82**
0.45;
t
1109
= 4.79***
−0.27;
t
1104
=−2.78**
Positive mood 0.44;
t
1104
= 4.26***
−0.27;
t
1100
=−2.63**
0.30;
t
1101
= 2.81**
0.38;
t
1101
= 3.70***
0.25;
t
1101
= 2.46*
Asleep −0.29;
t
1035
=−2.17**
−0.31;
t
1031
=−2.26*
Cells include effect size and related tstatistic and pvalue
*p≤0.05, **p≤0.01, ***p≤0.001
Fig. 1 Mean impact on different outcomes, after controlling for
cognitive function. Note: different outcome variables are not
comparable, as they involve different scales. Engagement scale,
0 = none of the time to 5 = most or all of the time; active participation,
0 = not at all to 4 = very much; attitude, 1 = very negative to 7 = very
positive; positive mood, 0 = not at all to 4 = very much; sleep scale,
0 = none of the time to 6 = all of the time
Cohen-Mansfield Alzheimer's Research & Therapy (2018) 10:37 Page 5 of 8
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of the group activities in our study did not seem to signifi-
cantly differ from each other, thus also providing partial
agreement with those same studies.
This comparison to previous studies points to a major
strength of this article, in that it uses both a large variety
of activities and multiple outcome measures, which helps
explain some of the negative or inconclusive findings. The
results here clearly show that different activities affect dif-
ferent outcome measures, which supports the use of mul-
tiple outcome measures and the view of engagement as
multidimensional, as specified in the GOME [2].
The most successful group activities were games and
choral singing, whereas the least successful were story-
telling and poetry, with other topics being in between or
having a greater impact on a specific outcome, such as
exercise impacting active participation. This may be
partially due to the observable nature of active participa-
tion in exercise, which is likely greater than in poetry or
reading. There are, however, several caveats that need to
be taken into account in interpreting these findings. The
group activities were conducted on the basis of a pre-
prepared protocol and materials organized in a box, later
labeled ‘activity in a box’[14]. For example, for the
reading activity, booklets with short stories were
prepared with large print and high contrast, as well as
fail-free questions for the TR staff to use with the stories;
for holiday discussions, pictures, CDs, texts, and ques-
tions were prepared. The level of success of a group is a
function of both the specific stimulus presented, such as
songs in the choral group, as well as the particular
choice of exemplars used in the activity, such as old
familiar popular songs. For the less successful contents,
it is possible that the particular activity was too difficult
or inappropriate for the population, but it is also
possible that the specifics were not sufficiently devel-
oped. For example, holiday discussion was prepared for
several holidays, but, given the randomized order of the
group content, groups were sometimes conducted with
this topic at a calendar time that did not correspond
with any of these holidays. This was a barrier to the
group’s success for some of the participants, and poten-
tially also for the TR staff. Such a barrier can potentially
be addressed by preparing the activity for all holidays
practiced in that part of the world. Similarly, the relative
failure of the poetry activity could be related to the
particular poems used rather than to the use of poetry
for a discussion group.
Another issue encountered relates to ‘positive mood’
as an outcome and criterion for success. Sometimes,
participants wished to discuss negative experiences. For
example, one participant always brought up her experi-
ences from the holocaust during a discussion about life
events. She would usually get upset by the memory, as
did some other group members, and yet she clearly
wanted to discuss those experiences. Should this be
counted as a negative outcome for the group activity?
This article focuses on the impact of group activities
and the differences among different contents of group
activities, showing that group activities are beneficial
and that there are statistically significant differences
among different contents of group activities in terms of
their impact. Yet the results show a much greater impact
of participants’levels of cognitive functioning than of
group content on the impact of groups. Indeed, many of
the comparisons among groups were not statistically
different. Thus, despite significant differences among the
groups, the presentation of group activities may be more
crucial than the specific content.
An inherent limitation to this kind of study is the use
of unblinded raters. We countered this to some extent
by using two types of raters: the TR staff who delivered
the intervention as well as research observers who rated
participants’responses independently. Correlations between
Fig. 2 Impact of group by participants’cognitive function
Cohen-Mansfield Alzheimer's Research & Therapy (2018) 10:37 Page 6 of 8
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those raters were high [2], and analyses concerning the
general impact of the group on engagement and mood
were statistically significant for both, yet the effect sizes
obtained by TR ratings were higher than those for
observers (Table 1). This can be explained in two ways.
First, TR staff are experienced with this population and
may be better attuned to nuances in participants' reactions
and behaviors. Alternately, it is possible that they are biased
in wanting to see positive outcomes from their work.
Both of these factors could have contributed to the results.
However, there is no a priori reason to assume that staff
members would be biased toward one activity or another.
Both the strengths and the limitations of the study are
based on this being a clinical field study. It used one
large facility in one location and its TR staff members to
conduct the groups. Although TR staff ratings could be
biased by their wish to see positive effects on their
groups, their results were highly concordant with those
of research observers [2].
Conclusions
Group activities form an important tool in providing
persons with dementia an adequate quality of life and as
a nonpharmacological intervention to prevent behavior
problems in this population. These benefits are based on
activities diminishing boredom and loneliness in this
population. This article provides the first comprehensive
evidence that such groups can significantly impact
engagement and mood—as compared to unstructured
time. The article also shows that group content does
matter, in that different contents may result in signifi-
cantly different outcomes, although it appears that good
use of quality groups may be more important than their
content, as many group contents did not differ signifi-
cantly from each other. As such, the findings provide
basic building blocks for forming the science of group
activities for persons with dementia. In addition, the
process presented in this article of immediate assessment
of the impact of group activities provides a timely
feedback for detecting failures in protocols or materials or
in mismatch between those who participate in the groups
and the content of the activities presented. This provides
information allowing for continuous improvement in the
content of activities. This study demonstrated that this
content makes a difference, thus indicating the import-
ance of using such improvement mechanisms in the
selection and design of activities.
Abbreviations
CPS: Cognitive Performance Scale; df: Degrees of Freedom; MDS: Minimum
Data Set; REB: Research Ethics Board; SD: Standard deviation; TR: Therapeutic
recreation
Acknowledgements
This work was made possible by the generous support of the Rotman Family
and the Morris Justein Visiting Scholars Program and by the Minerva Foundation.
Funding
Support from the Rotman Family and the Morris Justein Visiting Scholars
Program and from the Minerva Stiftung.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Author contribution
The author read and approved the final manuscript.
Ethics approval and consent to participate
This study was approved by the Research Ethics Board (REB) of Baycrest
Health Sciences.
Consent for publication
Not applicable.
Competing interests
The author declares that she has no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Minerva Center for the Interdisciplinary Study of End of Life, Tel-Aviv
University, P.O.B. 39040, Ramat Aviv, 6139001 Tel-Aviv, Israel.
2
Department of
Health Promotion, School of Public Health, Sackler Faculty of Medicine,
Tel-Aviv University, P.O.B. 39040, Ramat Aviv, 6139001 Tel-Aviv, Israel.
3
The
Herczeg Institute on Aging, Tel-Aviv University, P.O.B. 39040, Ramat Aviv,
6139001 Tel-Aviv, Israel.
Received: 20 November 2017 Accepted: 7 February 2018
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