Enhancing Physical Activity Recommendations to Support Cognition in Homecare

A recent quality improvement project published in Home Health Care Management & Practice reveals something telling. Occupational therapists and physiotherapists—the very professionals positioned to recommend physical activity—often don’t, despite recognising its importance for cognitive health. The gap isn’t knowledge alone; it’s confidence, training, and integrated practice pathways.

This is where the conversation needs to shift.

Why Physical Activity Matters for Cognitive Impairment

Physical activity is defined broadly by the World Health Organization as any bodily movement produced by skeletal muscles requiring energy expenditure. This includes both structured exercise and daily living activities like cooking or climbing stairs.

For older adults with MCI, dementia, or Alzheimer’s disease, the benefits are substantial and measurable:

Mechanisms of Action

Physical activity enhances cognition through multiple pathways. It increases the size of the hippocampus—the brain region critical for memory formation—stimulates neurogenesis (growth of new brain cells), and boosts blood flow to the brain. These aren’t theoretical benefits; they’re documented across decades of neuroimaging and clinical research.

Functional Outcomes

Beyond slowing cognitive decline, physical activity improves memory and attention, enhances performance in activities of daily living (bathing, dressing, cooking), and reduces caregiver burden. For older adults who may struggle with motivation or safety concerns due to comorbid conditions like arthritis, tailored physical activity recommendations can be transformative.

Prevention and Progression

The evidence is particularly compelling for prevention. Regular physical activity can prevent MCI from advancing to dementia and slow the rate of cognitive decline in those already diagnosed. Given that dementia prevalence doubles every five years among older populations, early intervention through physical activity represents a high-impact prevention strategy.

The Practice Gap: Why Recommendations Aren’t Happening

Despite this evidence, physical activity remains a neglected intervention in home care. A local needs assessment at a major Canadian homecare organisation revealed the paradox: occupational therapists and physiotherapists acknowledged that physical activity was important for cognitive health, yet rarely recommended it to clients with MCI or dementia.

The barriers are systematic:

1. Limited training on individualised approaches. Clinicians lack confidence in tailoring recommendations to clients with cognitive impairment who may struggle with instructions or fear injury.
2. Awareness gaps. Not all allied health professionals understand the direct link between physical activity and specific cognitive outcomes.
3. Competing priorities. With limited visit time and multiple clinical concerns, cognitive health often takes a backseat.
4. Absence of clinical tools. Without structured recommendation templates or patient handouts, clinicians must create guidance from scratch—a barrier to consistent practice.

 

What Actually Works: The Intervention Model

The Edwards et al. quality improvement project tested a multimodal intervention designed to overcome these barriers. The approach was three-fold:

1. Provider Education

In-person training sessions combined with asynchronous online video modules (37 minutes across five videos) covered:

• Mechanisms of how physical activity improves cognition
• Research evidence and recommended activity levels
• Safe activity types for clients with cognitive impairment
• Adherence strategies for maintaining consistency
  
  

Clinicians were compensated for their time, ensuring uptake. The flexible delivery—both synchronous and asynchronous—accommodated geographically dispersed home care teams.

2. Client and Caregiver Handouts

Four tailored handouts were developed:

• Educational handouts explaining why physical activity matters for cognitive health
• Safety guides with practical tips for supporting older adults during activity
• Recommendation sheets listing low- and moderate-intensity activities clinicians could customise for each client
• Resource lists pointing to community-based activities and programmes
  
  

All materials were co-designed with clinicians, clinical leaders, and caregivers with lived experience.

3. Accessible Implementation Tools

Recommendation templates allowed clinicians to prescribe activities quickly, reducing documentation burden and supporting consistency.

The Results: What Changed

The project achieved measurable practice change, particularly for physiotherapists:

For Physiotherapists

• Statistically significant increase (p=0.046) in patient education about the relationship between physical activity and cognitive health
• Broadened activity recommendations beyond seated exercises to include walking, gait training, and community fitness programmes
• Increased specificity in recommendations
  
  

For Occupational Therapists

• Non-significant but meaningful increases in physical activity recommendations
• Expansion from balance and posture exercises to day programmes and structured movement activities
• Higher rates of education about benefits for cognition
  
  

Across Both Professions

• Greater individualisation of recommendations tailored to client preferences and comorbidities
• Improved confidence in discussing physical activity with clients and caregivers
• Broader range of activity types prescribed
  
  

Importantly, the intervention addressed a key finding: that education alone—without clinical tools and client resources—is insufficient. The combination of training, templates, and take-home materials created sustained practice change.

Translating This to Your Practice

The Edwards et al. findings offer clear guidance for occupational therapists, physiotherapists, and home care teams aiming to integrate physical activity into cognitive impairment management.

For Occupational Therapists

Frame physical activity within occupational performance. Physical activity isn’t separate from activities of daily living—it’s embedded within them. Walking to the shops, gardening, dancing, cooking, or climbing stairs are all forms of physical activity that also address occupational goals. Help clients see movement as purposeful, not prescriptive.

For Physiotherapists

Develop a standard protocol for clients with cognitive impairment. Rather than treating cognitive status as a barrier to movement, use it as a reason to individualise. Low-intensity activities (slow walking, cooking, household tasks) are equally effective for some clients as structured programmes—and often more adherent.

For All Allied Health Professionals

• Educate clients and caregivers explicitly about the cognitive benefits of physical activity. Many assume movement is “just for fitness.” Shifting this perception increases motivation.
• Use client handouts. Having written or visual reminders at home sustains adherence better than verbal instruction alone.
• Document the cognitive benefit, not just the physical outcome. This reinforces its importance and supports continuity of care.
• Collaborate with other team members. An occupational therapist may identify occupational activities suitable for movement; a physiotherapist may assess safety and progression. Together, they’re more effective.

 

Activity Recommendations: What the Evidence Supports

The study emphasises that the best cognitive outcomes come from a combination of low- and moderate-intensity activities, with consistency mattering more than intensity.

Moderate-Intensity Examples

• Brisk walking (30 minutes, at least 3 times weekly)
• Gardening or yard work
• Dancing
• Recreational swimming

Low-Intensity Examples

• Slow walking (incorporate into daily routines)
• Cooking and meal preparation
• Household chores
• Tai chi or gentle movement

 

Key Principle

Aim for approximately 150 minutes of physical activity per week, which can be broken into 10-minute bouts. For clients with advanced dementia or significant comorbidities, even small amounts of movement are beneficial—consistency and safety trump intensity.

Overcoming Common Barriers

“My client won’t follow instructions.”

Simplify. Instead of a formal exercise prescription, embed movement into existing routines. If a client enjoys cooking, that’s a 20–30 minute bout of moderate activity three times weekly. Make the activity purposeful.

“What if they’re afraid of falling?”

Safety assessment and environmental modification come first. Work with occupational therapists to remove fall hazards. Start with activities requiring support (walking with a person, using furniture), progressing as confidence builds. Fear often diminishes with successful experience.

“There isn’t time in a single visit.”

Education and recommendation sheets can be left with clients and caregivers. Discuss during one visit; the client and caregiver implement between visits. Position yourself as an enabler, not the sole exercise provider.

“My client has arthritis/cardiac issues/other comorbidities.”

This is precisely why individualisation matters. A client with arthritis might do water-based walking instead of land-based; one with cardiac concerns needs lower intensity. Comorbidities don’t contraindicate activity—they inform the type and intensity.

The Broader Context: Why This Matters Now

Cognitive impairment is reshaping home and community healthcare demand. As prevalence rises, prevention and slowing progression become increasingly cost-effective and humane interventions. Physical activity isn’t just another recommendation—it’s one of the few interventions with strong evidence across MCI, dementia, and Alzheimer’s disease.

Yet knowledge alone doesn’t change practice. The Edwards et al. study demonstrates that integrating physical activity into standard care requires three elements:

1. Training that connects evidence to practice (not generic information, but application)
2. Clinical tools that reduce friction (templates, handouts, recommendations)
3. Sustained access to resources (online videos, printable guides, periodic refresher education)

Without these, the gap between what we know and what we do widens.

Looking Forward: Sustainability and Evolution

The research team embedded several sustainability strategies into their approach:

• Ongoing access to online education modules
• Client handouts available on intranet and in print
• Integration of physical activity prompts into electronic documentation systems
• Periodic in-person refresher sessions

For your own team or organisation, consider adopting similar structures. Small changes—like adding a physical activity recommendation field to client assessments or creating a shared folder of activity guides—can normalise the practice.

Future research opportunities include measuring client and caregiver outcomes (adherence, actual behaviour change, functional improvements) and refining interventions for occupational therapists, who showed promise but lag physiotherapists in uptake.

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Frequently Asked Questions

Q: Is physical activity safe for someone with dementia?

A: Yes, when individualised and supervised appropriately. Safety concerns like falls or injury are managed through assessment, environmental modification, and starting with supported activities. Comorbidities (arthritis, heart disease) don’t contraindicate activity—they inform the type and intensity. Consult the older adult’s primary care provider if medical concerns exist.

Q: How much physical activity does someone with cognitive impairment need?

A: Current evidence supports approximately 150 minutes per week of physical activity, which can be accumulated in bouts as short as 10 minutes. For someone with advanced dementia or severe comorbidities, even 30 minutes of low-intensity activity several times weekly provides cognitive benefits.

Q: Can physical activity prevent dementia?

A: For older adults with MCI, regular physical activity can prevent or delay progression to dementia. For those already diagnosed, it slows the rate of cognitive decline. It’s not a cure, but it’s one of the most robust preventive interventions available.

Q: What kinds of activities work best?

A: A combination of low- and moderate-intensity activities works best. Moderate-intensity (brisk walking, dancing, gardening) and low-intensity (slow walking, cooking, household tasks) are equally effective. The key is consistency and choosing activities the older adult enjoys—adherence matters more than intensity.

Q: Can family caregivers support physical activity at home?

A: Absolutely. Caregiver education about safety, encouragement, and activity ideas increases adherence. Simple strategies like walking together, doing household tasks as a team, or attending community activities can be powerful. Handouts and guides help caregivers feel confident supporting movement.

Q: What if my client has multiple health conditions?

A: Comorbidities are common and require individualisation, not avoidance. Work with your team (occupational therapist, physiotherapist, primary care provider) to identify safe, appropriate activities. For example, someone with arthritis might do water-based walking; someone with cardiac concerns needs lower intensity. The goal is always to find activities that are both safe and engaging.

Q: How do I measure whether physical activity is helping cognition?

A: Formal cognitive testing (Montreal Cognitive Assessment, Mini-Cog) can be administered by trained clinicians. Informally, observe improvements in memory, attention, mood, or independence in activities of daily living. Caregiver feedback is valuable—they often notice subtle changes in alertness or engagement first.

Q: How long before we see cognitive benefits?

A: Some benefits appear within weeks (improved mood, better sleep), whilst cognitive improvements typically emerge over months. Consistency matters more than duration—regular activity over time builds neuroplasticity. Encourage clients and caregivers to expect gradual change rather than rapid transformation.