Environmental predictors of objectively measured out-of-home time among older adults with cognitive decline

Highlights

• This study targeted older adults with cognitive impairment.

• Their time spent out-of-home was measured using a global positioning system.

• Larger social network was a predictor of longer out-of-home time.

• However, physical environments did not significantly predict out-of-home time.

Abstract

Background

Older adults with cognitive decline are vulnerable to various health problems. Going out of home for longer time could be beneficial for their health. Identifying modifiable predictors is essential for developing effective strategies that would increase time spent out-of-home by older adults. This study examined social and physical environmental predictors of objectively measured out-of-home time spent among older adults with cognitive decline.

Methods

This study was a secondary analysis of a randomized controlled trial (n = 147). Out-of-home time per day was measured by a Global Positioning System at baseline and 1-year follow-up. Baseline data of social environment (living alone, social network [Japanese version of the Lubben Social Network Scale]), objective physical environment (road network distance from each home address to nearest supermarket store, convenience store, and public transportation), and demographic factors (gender, age, education, driving status, fear of falling) were examined as potential predictors.

Results

After adjusting main effects of allocation group, time of measures, and their interactive effect, a mixed model showed that younger age (p = 0.044), current driving status (p = 0.039), and stronger social network (p = 0.003) were predictors of out-of-home time. However, none of the physical environmental factors significantly predicted outdoor time.

Conclusions

The present study found that social network was a predictor of objectively measured out-of-home time among older adults with global cognitive decline. A sufficient social network might help increase out-of-home time among them. However, the influence of physical environment on out-of-home time might be small.

Introduction

Declines in cognitive functions are a common phenomenon among older adults. Shimada, Makizako et al. (2016) reported that 31.4% of community-dwelling older adults have mild or global cognitive impairments. Older adults with cognitive decline are more vulnerable to various health problems than healthier populations. They are at higher risk for dementia (Palmer, Wang, Bäckman, Winblad, & Fratiglioni, 2002), physical impairments (2016b, Buchman, Boyle, Leurgans, Barnes, & Bennett, 2011; Shimada, Makizako et al., 2016), and psychological distress (Vinkers, Gussekloo, Stek, Westendorp, & van der Mast, 2004).

To prevent onsets of further health problems among older adults with cognitive decline, going outside home more frequently could be beneficial. Going out-of-home shares similar concepts with homebound status and life-space. When people go out home, they usually involve certain levels of physical, cognitive, and/or social activities. Compared with other health behaviors such as smoking cessation, control of food intake, and exercise, the notable point of going out-of-home is that no special knowledge, motivation, cost, or time are required. Older adults could incorporate going out-of-home into their daily lives more easily than other health behaviors. The health benefits of going out home more frequently among average or healthier older adults have been well reported (Fujita, Fujiwara, Chaves, Motohashi, & Shinkai, 2006; Inoue, Shono, & Matsumoto, 2006; Kono, Kai, Sakato, & Rubenstein, 2004; Shimada et al., 2010). Similarly to results found in healthier populations, some studies (Harada, Lee et al., 2017, 2018) have indicated that longer time spent out-of-home positively influences the health status of older adults with cognitive decline. Thus, increasing out-of-home time would contribute to health promotion among older adults with cognitive decline.

To develop effective strategies to increase out-of-home time among older adults with cognitive decline, it is essential to identify modifiable predictors of out-of-home time. Identifying them can highlight the target factors to effectively promote behavior change. In the research field of health behavior change, the ecological model (Sallis et al., 2006) asserts the importance of the environment’s influence on health behaviors, because environmental factors can influence people’s health behaviors for a longer time than individual factors can (Sallis et al., 2006). Review studies have confirmed the environmental determinants of various health behaviors, such as physical activity (Cerin et al., 2017), healthy eating (Brug, Kremers, van Lenthe, Ball, & Crawford, 2008), and smoking behaviors (Albertsen, Borg, & Oldenburg, 2006). Especially, among health behaviors, physical activity has been intensively examined in the framework of the ecological model, and it is affirmed that physical activity behaviors are determined by both social and physical environmental factors (Bauman et al., 2012).

Although various studies have identified determinants of homebound status and out-of-home behavior (Fujita et al., 2004; Ganguli, Fox, Gilby, & Belle, 1996; Jing, Wang, Zhang, Yao, & Xing, 2017; Murayama, Yoshie, Sugawara, Wakui, & Arami, 2012; Nakamura & Yamada, 2009; Negrón-Blanco et al., 2016; Smith, Chen, Clarke, & Gallagher, 2016; Todo et al., 2015), evidences about the environmental determinants of out-of-home behavior among older adults are still inconsistent. According to physical activity studies using an ecological model, out-of-home time among older adults would be influenced by both social and physical environmental factors. Living arrangements and social network might predict out-of-home time among social environmental factors. A study found that the four most common reasons for going out home among older adults, in order of importance, were the following: shopping, walking for exercise, social visit, and running errands (Tsai et al., 2016). Among these reasons, shopping, social visiting, and running errands would relate with living arrangements and social network; older adults who live alone would have more opportunities to go out home for shopping and running errands, while those who have an adequate social network would have more opportunities for visiting their friends and relatives. Nonetheless, the associations of these social environmental factors with out-of-home behavior are still inconclusive (Fujita et al., 2004; Ganguli et al., 1996; Jing et al., 2017; Murayama et al., 2012; Nakamura & Yamada, 2009; Negrón-Blanco et al., 2016; Todo et al., 2015). On the other side, regarding the physical environmental factors, while Japanese studies (Hirai et al., 2015; Murayama et al., 2012) have reported the associations of poor food accessibility and daily errands with homebound status among older adults, a previous study in the United States did not support these results (Smith et al., 2016). Inconsistent findings for environmental correlates of out-of-home behavior in previous studies would be derived from methodological limitations among them. One methodological limitation is that most studies were cross-sectional, and few have examined the social and physical environmental predictors by prospective design (Smith et al., 2016). Another limitation is that none of these studies have examined the environmental determinants of out-of-home time by using objective methods such as Global Positioning Systems (GPS: Harada, Lee et al., 2017, 2018; Wettstein et al., 2015) or home infrared sensors (Petersen, Austin, Mattek, & Kaye, 2015; Suzuki & Murase, 2010). To better understand the environmental influences on out-of-home time, prospective examinations of objective data are also necessary.

The purpose of the present study was to examine whether social and physical environmental factors were predictors of out-of-home time among older adults with cognitive decline.