Exploring the Drive, Challenges, and Choices for Lifestyle Transformation in Older Adults Facing Frailty and Mild Cognitive Impairment: A Qualitative Scoping Expedition

The motivations recognized under intrinsic factors were the perceived advantages of the intervention, self-efficacy, awareness, and diagnosis of the condition.The influences examined under external factors included the information source, community support, component related to intervention, and availability. Table 4 presents a summary of themes pertaining to motivational factors.

1.1 Internal motivators for participation in the lifestyle intervention. a. Perceived advantages of lifestyle intervention: Ten articles emphasized the gains from lifestyle interventions as driving forces for engagement to implement changes [38, 40–43]. Participants noted experiencing improvements in physical and mental health through involvement in interventions [43]. Sustaining physical condition alleviated the stress and burden for care partners and family members [40, 42, 46]. Furthermore, social interaction during interventions was also recognized as a perceived advantage [40, 41, 43, 46].

b. Self-efficacy: Self-efficacy serves as a motivator for involvement in lifestyle interventions. It plays a pivotal role in executing lifestyle modifications, as it indicates the determination to initiate or refrain from lifestyle alterations [55]. Participants from one study expressed that behaviors linked with autonomy and lifelong self-improvement were drivers for them to adopt lifestyle changes. They also recognized that these behavioral modifications positively impacted brain health [45]. A favorable mood facilitates their participation in lifestyle change intervention programs [43]. Individuals with MCI aimed to sustain or boost their existing physical status, which influenced their engagement in PA. The self-efficacy attributes of strong internal drive, commitment to exercise, time management proficiency, and adaptability to shifting schedules determine their involvement in interventions [42].

c. Knowledge: Comprehending the illness aids older adults in shaping their perspectives towards cognitive impairments and preventative measures, while moderating their anticipations and motivations for participating in preventive trials [21]. Awareness of local services and the ability to utilize them (e.g., completing forms) also encouraged older adults to engage or modify their lifestyles [38]. Moreover, the intention to enhance scientific understanding of MCI and its prevention has been identified as a motivating factor for their involvement in such initiatives [46].

d. Condition diagnosis: Participants in one investigation indicated that being diagnosed with MCI or early dementia motivated them to increase their exercise [43]. A few studies suggest that family history or indirect exposures to cognitive disorders could encourage some older adults to seek medical guidance and information regarding health and preventive strategies. Anxiety and familial history of cognitive disorders were cited as significant influences towards lifestyle alterations and prevention engagement [45]. Those diagnosed with cognitive disorders feel compelled to participate as they aspire to lessen the burden on their family and caregivers [46]. Participants shared that their encounters with affected individuals made them more inclined to join lifestyle intervention programs [21].

1.2 External motivations for joining the lifestyle intervention. a. Information source: Endorsements from healthcare professionals [doctors or therapists] produce urgency and anxiety, propelling them to begin and uphold exercise routines [43]. For many participants, knowledge or guidance from their providers was perceived as essential to cultivate their confidence to instigate changes [42].

b. Community support: Seven of the reviewed studies highlighted community support as a facilitator for engaging in lifestyle interventions. Motivation to exercise and influence on health behaviors were found from the encouragement and aid of others [43, 45–47]. Care partners significantly impacted participation in the PA among individuals with MCI [42]. A support network offers assistance, freedom, and opportunities to socialize and engage with the community [39]. Formulating action plans with others, holding oneself accountable, and sharing motivation and new ideas also encourage participation in lifestyle modifications [45].

c. Availability: Accessibility to the intervention program was identified as a motivating aspect for frail participants to engage and adhere to the lifestyle intervention. The nearness of community resources, access to exercise tools, and supportive care constituted a favorable physical environment that encouraged and enabled participants [42]. Additionally, the provision of assistive devices to ease PA also improved their access to the intervention program [40].

Numerous hurdles to commencing or sustaining lifestyle changes exceed the motivations. These challenges can be further classified into intrinsic and extrinsic factors. The intrinsic barriers identified encompassed perceived negative experiences with the intervention, insufficient knowledge, family obligations, and absent internal motivation. The examined extrinsic barriers included care partner support and availability, accessibility issues, societal stigma, and components related to the intervention (Table5).

2.1 Innate obstacles to engaging in lifestyle interventions. a. Perceived adverse experiences in intervention: Participants noted unfavorable encounters during PA (e.g., disliking the sensation of perspiration or being in water while swimming), post-PA (e.g., muscle soreness, tiredness), as a major hurdle to participating in interventions [43]. Another research indicated that participants lacked comprehension of the advantages of exercise, viewing it as difficult and possibly ineffective for older adults [40]. Experiences and discrepancies between their own encounters and what they had heard regarding prevention were also highlighted as obstacles to joining lifestyle interventions [21].

b. Insufficient knowledge: A deficiency in knowledge acts as a barrier to participation in lifestyle interventions, impeding the ability of participants to engage in activities and obtain relevant information [40]. In initiatives employing digital technology, participants may disengage due to inadequate skills with devices [46, 49]. Individuals diagnosed with MCI may feel fearful and embarrassed about their condition, resulting in hesitance to educate themselves regarding their diagnosis [21].

c. Family obligations: Family obligations as a barrier were primarily reported by female participants. Their duties towards family members often cause their role as a caregiver to supersede their self-care, hobbies, and other pursuits [38, 49].

d. Physical and cognitive impairments: Participants indicated that their physical limitations [mobility restrictions, pain and arthritis, vision impairment, and other physiological changes] restricted their ability to exercise, particularly walking [45, 48]. Cognitive issues and disorientation also obstructed participation in the intervention, notably exercise at home [43]. Physical disabilities were consistently recognized as barriers to engagement [38].

e. Lack of inherent motivation: Motivation is vital for lifestyle alterations. With sufficient motivation, the majority of participants managed to implement necessary changes. Participants who exhibited a lack of motivation faced challenges in making essential changes, like increasing their exercise levels [43]. Some felt too aged to walk or exercise, which discouraged their willingness to participate [47]. Frail older adults conveyed a lack of drive to exercise independently without supervision, affecting the program [49].

2.2 External barriers to participating in lifestyle interventions. a. Support and availability of care partners: Due to aging and disease processes, individuals experiencing cognitive decline may depend more on their care partners for companionship and assistance with exercise. Furthermore, participants require their caregivers to co-participate as they may need help or guidance throughout the intervention or regarding transportation. However, caregivers may not always be accessible because of other obligations. The health condition of caregivers may also influence their capacity to join the program [42, 43].

b. Accessibility issues: Three selected studies highlighted accessibility as a barrier to engaging in lifestyle interventions. Various aspects of accessibility were discussed, including environmental accessibility, transportation, the availability of specific programs, and climate considerations. Transportation emerged as a significant obstacle for older adults to reach intervention or program locations since some cannot drive or utilize public transport [43]. Another accessibility barrier involved the availability of specific programs corresponding to their mental or physical condition. Many programs necessitated a care partner’s presence, which was unfeasible for all individuals living with MCI or early dementia [42]. Individuals living with MCI or early dementia did not qualify for community-assisted transport for persons with disabilities as this condition was not recognized as a disability [38].

c. Social stigma implications: Perceived societal stigma was stated to adversely impact participation in exercise. They sensed that others viewed them as afflicted rather than as individuals [43]. Insufficient awareness from peers and fitness professionals regarding cognitive impairment also created awkward situations, dissuading some participants from engaging in PA [43].

d. Aspects related to the intervention: Participants in one study noted that the tasks assigned in the computerized cognitive training were overly complex and demotivated them to persist in their participation. When tasks are too challenging for individuals with MCI, they may hesitate to interact online with unfamiliar individuals [37]. Moreover, an intervention not customized to a participant’s abilities and conditions often leads to demotivation for them to participate [21]. Conversely, factors related to service providers were also discussed in one study, highlighting that the consistency of service providers (therapists/trainers) impacts motivation to remain engaged in intervention programs. Frequent alterations or reliance on temporary staff can indirectly diminish the interpersonal relationships between participants and service providers, dissuading them from continuing with the program [47].

We identified two sub-themes emerging fromthe primary theme choices (Table 6). Initially, preferences pertain to qualities or elements of any lifestyle modifications that participants recognized as appealing or motivating.

3.1 Preferences specific to interventions. Seven of the chosen studies documented participants’ preferences for various lifestyle modifications. Participants expressed a preference for a tailored group exercise program with individuals who have similar challenges. Such involvement fostered feelings of comfort and pleasure, along with a sense of self-esteem [43]. Furthermore, participants indicated that interventions should be customized to align with their physical and mental requirements to enhance fun and enjoyment [40, 43, 47]. In another study, participants favored interventions arranged into different groups according to their skill levels [41]. In research regarding older adults’ perspectives on computer-based cognitive training, participants conveyed a preference for consistent training sessions explicitly intended to enhance cognitive abilities rather than infrequent ones [37].

Participants conveyed a desire for a progressive intervention program featuring a feedback mechanism to inform them about their progress and performance, which would serve as a motivating factor [37]. They also suggested shorter initial assessments and advocated for feedback sessions between service providers and participants to enhance coordination and their understanding of progress [49].

Moreover, the intervention program (computer-based cognitive training) should involve daily activities. Participants favored activities conducted in small groups with a mix of light, yet challenging exercises [43, 46, 48]. Additionally, participants preferred the training site to be easily accessible within the community or that transportation be provided [38].

Furthermore, participants from one study indicated a preference for face-to-face interventions/programs rather than online delivery methods. Face-to-face interactions are valued as they facilitate social interaction and support during the intervention program [48]. Participants also recommended extending the program period to maintain the benefits achieved [49].

Preferences concerning the intervention were also highlighted regarding the service providers. Participants leaned towards instructors who are knowledgeable and amiable, as this encourages greater engagement [39, 47]. This, in turn, could enhance adherence among older adults, particularly those with MCI or frailty. It was suggested that religious, governmental organizations or medical service providers oversee the intervention. Some participants expressed a desire for the program to continue at an affordable price. Delivering free or low-cost frailty prevention programs would serve as a critical strategy for mitigating frailty [21, 37, 38, 44].

3.2 Information. In one study, participants remarked that local authorities should play a greater role in promoting physical activity programs for older individuals [40]. Additionally, there should be a collaborative effort between healthcare providers and clients to enhance knowledge sharing. Participants expressed a preference for brochures containing information, such as the health benefits of exercise for seniors and available physical activity programs in the community [43]. They preferred intervention-related materials to be presented in written form, as they found it more comprehensible and helpful for memorization [46].