Recreational Activity in Assisted Living Communities: A Critical Review and Theoretical Model

Recreational Activity in Assisted Living Communities: A Critical Review and Theoretical Model Abstract Background and Objectives This paper critically reviewed the scientific literature on recreational activity (RA) behaviors in assisted living (AL) communities. Research Design and Methods A search of three databases yielded 70 quantitative, qualitative, and observational articles that met criteria for inclusion. Results AL residents participated in various types of RA, however, did so infrequently. Individual, interindividual, environmental, and relocation factors influenced RA behaviors, and participation may relate to positive consequences for residents and AL communities. This review identified multiple limitations in the literature related to construct definitions, measurement protocols, and incomplete or absent theoretical frameworks. Discussion and Implications To address these limitations, the current review proposes a multivariate measurement model and an interdisciplinary theoretical model of factors relating to RA, consistent with an ecological framework. The proposed models appreciate individual psychological factors that influence the multiple facets of human choice and behavior, as well as the interaction between individuals and the unique sociophysical environment of AL. This paper concludes with recommendations for future research, emphasizing studies that have applied implications for practice and policy. Recreational therapy/activities, Institutional care/residential care, Assisted living facilities, Well-being, Conceptual development, Psychosocial Assisted living (AL) offers housing and supportive services primarily to older adults with long-term care needs that impact independent living, yet do not require the level of skilled care provided in nursing homes (Kane, Chan, & Kane, 2007). The AL industry promotes a psychosocial model of care, with engagement with life representing an important tenant of the founding philosophy and existing care paradigms (CEAL, 2010). One way that residents engage with life is through participating in recreational activity (RA). RA is defined as discretionary pursuits occurring during leisure time, usually with the purpose of entertainment, exercise, cognitive stimulation, creative expression, and-or socialization (Everard, 1999; Leitner & Leitner, 2012). AL residents participate in various forms of RA including solitary activities (e.g., reading and watching television), physical activity, socializing, outings, hobbies, and programmed group activities (Gaugler & Kane, 2005; Hanson et al., 2014). After relocation to AL, residents receive assistance with many obligatory, functional, and self-care activities (Khatutsky, Wiener, Greene, Johnson, & O’Keeffe, 2013). Therefore, AL residents spend the majority of their waking time participating in discretionary activities, making RA a major part of everyday life (Pruchno & Rose, 2002). ALs invest resources into amenities and spaces that encourage RA, as participation can promote resident health and psychosocial well-being, as well as positively contribute to the culture of the community (Ball et al., 2004; ICAA, 2009; Khatutsky et al., 2016; O’Sullivan, 2005). Further, many states require that ALs offer opportunities for RA that meet residents’ preferences, interests, and needs (Carder, O’Keeffe, & O’Keeffe, 2015). Although industry leaders and policy-makers agree on the importance of RA, the scientific community still lacks a comprehensive and in-depth analysis of RA behaviors, as well as the methodological approaches and theoretical frameworks used to assess RA in AL settings. The purpose of this paper was to review the literature addressing RA in AL. Specifically, this review aimed to describe RA behaviors and associated measurement protocols; potential factors that influence RA; and potential consequences of RA. The current review is timely given the state of the literature, growth of the AL industry, and the role of RA in ongoing culture change and policy reform (CEAL, 2010; Grabowski, Stevenson, & Cornell, 2012; Shura, Siders, & Dannefer, 2011). This paper adds to the literature by reviewing a broad scope of RA behaviors in AL and offering suggestions for future research to address measurement, theory, intervention, and policy. Method The current review searched PSYCHInfo, CINAHL, and PubMed in June 2017 using the following key terms: assisted living and activity, recreation, leisure. Searches were limited to full-text, English, and peer-reviewed articles, yielding 334 results published between 1975 and 2017. After removing duplicates, the author screened abstracts for studies that commented on social, physical, leisure, or other types of resident behaviors in an AL or residential care setting. Next, 210 articles were retained for a full review using the following inclusion criteria: (a) AL setting with a primarily older adult sample (i.e., younger samples with serious mental illness and special care units were excluded; 43 articles excluded); (b) measures or discusses RA behaviors, including social, leisure, and physical activity (66 excluded); and (c) employs descriptive quantitative, qualitative, or observational methodology (31 excluded). The author limited studies to an AL setting with primarily older adults because previous research suggests RA participation rates, policies, and practices (e.g., level of choice, transportation, and type) vary across care settings and samples, possibly influencing analysis and implications of the current review (Carder et al., 2015; Gaugler & Kane, 2005; Ice, 2002; Kuhn et al., 2004; McGuinn & Mosher-Ashley, 2001). The author excluded interventions and experimental comparisons in favor of descriptive studies because this methodological approach better aligned with the objective of the current review, which was to describe RA behaviors and related factors with the goal of generating theoretical frameworks. Results Overview of Studies and RA Behaviors The current paper reviewed 70 articles (34 quantitative, 33 qualitative, and 3 observational). Most studies measured RA as a secondary variable. Eight (six assessing physical activity) qualitative studies targeted RA, and seven (four assessing physical activity) ran quantitative analyses with RA as the dependent variable. Only one study collected longitudinal data (i.e., Gaugler & Kane, 2005). Quantitative studies sampled 21 to 2,078 (n = 33, M = 314.52, SD = 516.31) residents in 1 to 200 (n = 32, M = 33.31, SD = 56.32) ALs. Given the large national sample, Hawes et al. (2000) was an outlier and, thus, not included in these calculations; one study failed to report number of ALs sampled. Qualitative and observational studies sampled 4 to 303 (n = 32, M = 35.41, SD = 57.10) residents in 1 to 51 (n = 36, M = 6.75, SD = 10.74) ALs; four studies did not sample residents (i.e., staff interviews or observational design). Fifty-five articles reported inclusion criteria. Twenty-nine had a criterion related to cognitive ability (e.g., no dementia diagnosis or score on a screen); 25 related to age; 17 related to general ability to participate in an interview; 14 related to time in AL; 10 related to physical ability (e.g., able to ambulate or minimal assistance with activities of daily living); and 23 employed other criteria (e.g., life expectancy or previous profession). Few studies reported cognitive data and variability in measurement strategies of heath-related variables makes it difficult to generate a functional profile of residents included in the reviewed studies. The majority of sampled resident were older than 80 years and female, which is consistent with AL national data (Caffrey et al., 2012). Articles used various terms to refer to RA including activity or occupation (n = 16); physical activity or exercise (n = 14); social activity or engagement (n = 8); leisure or recreation (n = 5); programmed, planned, organized, or structured activity (n = 4); meaningful activity (n = 1); discretionary activity (n = 1); or a combination of the aforementioned terms used interchangeably (n = 21). Articles categorized RA by activity-related factors (i.e., type, demands, and features; n = 8); social or physical context (e.g., solitary-group or inside-outside; n = 2); or a combination of categories (e.g., private-group-outside or social-active-outside; n = 3). Multiple articles alluded to the difference between self-initiated and programmed RA, yet only three differentiated these constructs in measurement or when discussing results (i.e., Kuhn et al., 2004; McGuinn & Mosher-Ashley, 2001; Sandhu et al., 2013). The current review extracted specific RAs that residents mentioned or researchers observed occurring across 36 qualitative or observational articles in Table 1. When specified, the author noted whether the activity was discussed as occurring in a self-initiated and-or programmed context. Multiple activities (e.g., puzzles) occurred in both a self-initiated and programmed context, and, in general, were representative of expected or stereotypical RAs for an AL setting (e.g., Bingo). Table 1. Specific RAs Mentioned in Qualitative and Observational Studies Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Note: Frequency counts represent the number of articles that mention the activity. aDiscussed as individual-initiated. bDiscussed in the literature as community-sponsored. cDiscussed as occurring in both a community-sponsored and individual-initiated context. View Large Table 1. Specific RAs Mentioned in Qualitative and Observational Studies Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Note: Frequency counts represent the number of articles that mention the activity. aDiscussed as individual-initiated. bDiscussed in the literature as community-sponsored. cDiscussed as occurring in both a community-sponsored and individual-initiated context. View Large Thirty-three quantitative articles reported measurement strategies and statistics on the frequency of RA participation, see Table 2. Articles used self-report (n = 18), proxy ratings (n = 8), observation (n = 4), and accelerometers (n = 3) to measure RA. Seven articles utilized four different validated measurement tools (i.e., two self-report and two observational). Overall, findings suggest that the majority of residents participated in some type of RA, but less than half did so regularly, and, on average, residents reported participating in less than four activities per week or participating in RA only some of the time. In addition, residents often evidenced low rates of physical activity, particularly for strenuous activity. Across multiple studies, staff reported that, on average, residents participated in 15–20 hours of RA per week (Lyketsos et al. 2007; Samus et al., 2008; Samus et al., 2009; Samus et al., 2006; Tighe et al., 2008), which is significantly higher than resident self-reports. It should be noted that measurement issues may have biased participation rates reported in Table 2, as studies did not appear to capture the full range of RA behaviors in AL (e.g., reading in the bedroom). Table 2. Construct Definitions, Measurement Protocols, and Estimates of RA in AL Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  View Large Table 2. Construct Definitions, Measurement Protocols, and Estimates of RA in AL Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  View Large Factors Influencing RA Participation Fifty-four articles provided insight into factors that may influence RA behaviors (i.e., participation rate and type). Across multiple studies, women reported greater participation compared to men (Cummings & Cockerham, 2004; McGuinn & Mosher-Ashley, 2001; Mitchell & Kemp, 2000; Zimmerman et al., 2003). Gender also influenced RA type and satisfaction, with men reporting preference for strenuous forms of RA (Chen et al., 2015; Dermott, McDaniel, Weiss, Tomazic, & Mattfeldt-Beman, 2009; Park et al., 2009). Other demographic variables that may influence RA behaviors are socioeconomic status, age, education, and previous profession (Chen et al., 2015; Gaugler & Kane, 2005; Jang et al., 2014; Križaj et al., 2016; Mitchell & Kemp, 2000; Seipke, 2008). Lastly, studies reported that choice and control in the relocation process and time in AL influenced RA behaviors (Gaugler & Kane, 2005; Kemp et al., 2012; Križaj et al., 2016; McGuinn & Mosher-Ashley, 2001). Many studies reported that global physical and cognitive health influenced RA participation (Barnes et al., 2012; Chen et al., 2015; Crenshaw et al., 2001; Decker et al., 2006; Dobbs et al., 2005; Gaugler & Kane, 2005; Hanson et al., 2014; Jang et al., 2014; Kemp et al., 2012, 2016; Kuhn et al., 2004; Lyketsos et al., 2007; Mihalko & Wickley, 2003; Ouyang et al., 2015; Park et al., 2017; Phillips & Flesner, 2013; Samus et al., 2009; Sandhu et al., 2013; Yang & Stark, 2010; Zimmerman et al., 2003). Other health-related factors that influenced RA were sensory ability, mental health, and fluctuating factors like sleep and pain (Chen et al., 2015; Crenshaw et al., 2001; Gaugler & Kane, 2005; Kluge, LeCompte, & Ramel, 2014; Lewinson et al., 2012; Park et al., 2012, 2017; Phillips & Flesner, 2013; Pryce & Gooberman-Hill 2012; Thomas et al., 2013; Watson et al., 2006; Zimmerman et al., 2003). Some studies suggest that health may indirectly influence RA through attitudes, self-efficacy, and relationships (Dobbs et al., 2008; Hall & McAuley, 2011; Holmes et al., 2017; Kluge et al., 2014; Sandhu et al., 2013). For example, residents with higher abilities reported not wanting to participate in RA with residents with significant limitations (Buelow & Fee, 2000). Multiple psychological factors emerged from the literature that may influence RA behaviors. Studies reported that self-efficacy directly related to RA behaviors, particularly for physical activity (Chen et al., 2015; Kluge et al., 2014). Across multiple studies, residents reported participating in RA because they believed it would produce positive outcomes such as wellness or relationships (Ball et al., 2000; Hanson et al., 2014; Kluge et al., 2014; Phillips & Flesner, 2013; Mahrs Träff, Cederstund, & Nord, 2017). Residents also reported participating in RA to increase or maintain social status, or appear functionally appropriate for the community (Beel-Bates et al., 2007; Williams & Warren, 2009). Relatedly, one quantitative analysis reported that residents with greater fear of falling were less likely to participate in RA (Sharaf & Ibrahim, 2008). Residents who reported previous activity behaviors were more likely to participate in RA in AL (Kluge et al., 2014; Lewinson et al., 2012; Phillips & Flesner, 2013; Seipke, 2008; Mahrs Träff et al., 2017). Residents also reported participating in RA to uphold personal identities, such as being active and-or social (Cruz, 2006; Harmer & Orrell, 2008; Kennedy et al., 2005; Phillips & Flesner, 2013). Taken together, self-efficacy, outcome expectations, impression management, previous behaviors, and identity are psychological factors that may influence RA behaviors in AL. Multiple studies suggest that residents’ attitudes toward activities including preference, meaning, interest, and congruence with personal values influenced participation (Barnes et al., 2012; Bischoff et al., 2001; Crenshaw et al., 2001; Cruz, 2006; Cutchin et al., 2005; Decker et al., 2006; Fraher & Coffey, 2011; Harmer & Orrell, 2008; Holmes et al., 2017; Iwasiw et al., 1996; Jungers, 2010; Kemp, 2008; Kemp et al., 2016; Mihalko & Wickley, 2003; Sefcik & Abbott, 2014; Thomas et al., 2013; Williams & Warren, 2009; Yang & Stark, 2010). In general, residents reported dissatisfaction with RA offerings in AL. For example, residents often criticized programmed activities for lacking variety (Crenshaw et al., 2001; Lewinson et al., 2012; Park et al., 2009; Williams & Warren, 2009). Further, across multiple studies, families and residents described recreational opportunities as stereotypical, demeaning, childish, or lacking physical and cognitive challenge (Ball et al., 2000; Buelow & Fee, 2000; Dobbs et al., 2008; Park et al., 2009). A large body of qualitative research suggests that strong co-resident and family-resident relationships promote RA in AL (Buelow & Fee, 2000; Kluge et al., 2014; Lewinson et al., 2012; Park et al., 2012; Sandhu et al., 2013; Sefcik & Abbott, 2014; Yang & Stark, 2010). Conversely, interpersonal conflicts can pose a barrier to RA, particularly for group activities (Decker et al., 2006; Kemp et al., 2012). Social group membership may also influence RA behaviors (e.g., attending because you are a member of the “active group”; Cruz, 2006; Kennedy et al., 2005; Kluge et al., 2014; Thomas et al., 2013). Multiple studies suggest that strong staff-resident relationships, staff encouragement, and reminders positively influence RA participation (Dobbs et al., 2005; Hanson et al., 2014; Holmes et al., 2017; Park et al., 2012; Phillips & Flesner, 2013; Thomas et al., 2013; Zimmerman et al., 2003). Conversely, residents who perceived staff as acting rushed or moving too quickly were less likely to participate in RA, particularly for programmed activities (Fraher & Coffey, 2011). Other studies suggest that social motivators can turn into social pressure to participate in RA. For example, residents reported participating in RA to appease staff or family (Beel-Bates et al., 2007; Williams & Warren, 2009), and, relatedly, staff reported having difficulty encouraging activity while preserving resident autonomy (Hanson et al., 2014; Koehn et al., 2016). Multiple factors related to the sociophysical environment of the AL community may also influence RA behaviors. Residents in communities with more than 16 individuals reported higher RA participation compared to smaller communities (Zimmerman et al., 2003). Other studies suggest that small or shared living areas (Cruz, 2006; Yang & Stark, 2010) and appealing physical spaces in or around the community may promote RA by enticing residents to spend time outside of their apartment (Barnes et al., 2012; Lu, 2010; Mihalko & Wickley, 2003; Sandhu et al., 2013; Thomas et al., 2013). Residents and staff reported that physical design and community services (e.g., long walking distance and no transportation) can also pose barriers to certain types of RA (e.g., walking outside) due to safety concerns (Bischoff et al., 2001; Decker et al., 2006; Koehn et al., 2016; Lu, 2010; Phillips & Flesner, 2013; Thomas et al., 2013). The culture of a community can also influence RA behaviors through social norms around activity and social cohesion (e.g., activity encouragement; Kennedy et al., 2005; Koehn et al., 2016; Mitchell & Kemp, 2000; Sandhu et al., 2013). It is important to note that previous research suggests sociophysical factors that may influence RA behaviors, such as support from staff and physical design, vary across communities (Resnick et al., 2010a). Specific to programmed RA, policies and resources may affect participation. Residents cited advertising policies (e.g., activity calendars containing small print) as a barrier to participation (Buelow & Fee, 2000; Hanson et al., 2014; Lewinson et al., 2012). In addition, staffing and space for programmed RAs reportedly influenced the availability and quality of activity programs, contributing to resident participation (Hanson et al., 2014; Mihalko & Wickley, 2003; Thomas et al., 2013). Factors Indicating Consequences of RA Thirty-eight articles provided insight into factors that may represent consequences of RA participation. The current review interpreted factors that may both influence and represent a consequence of RA (e.g., health) based on the original author(s)’ interpretations, or by using theory and previous research to interpret a potential directional pathway (e.g., RA may produce health benefits; Grant & Kluge, 2012). Multiple quantitative analyses reported positive relationships between RA, functional ability, and global health-related measures (Jang et al., 2014; Jenkins et al., 2002; Hall & McAuley, 2011; Horowitz & Vanner, 2010; Ouyang et al., 2015; Park et al., 2017). Two studies reported that RA participation predicted longer time to discharge (i.e., by death or transfer; Tighe et al., 2008; Zimmerman et al., 2005); although, neither controlled for psychosocial variables. One study reported that participation predicted lower rates of physical dependency for residents with dementia; however, the authors failed to replicate these findings with residents without significant cognitive impairment (Samus et al., 2009). Multiple studies reported nonsignificant relationships between RA and health-related variables (e.g., self-rated health; Cummings, 2002; Cummings & Cockerham, 2004; Mitchell & Kemp, 2000; Wyrick et al., 2008). Qualitative findings suggest that RA may help form co-resident and staff-resident relationships (Harmer & Orrell, 2008; Kemp, 2008; Kluge et al., 2014; Lewinson et al., 2012; Park et al., 2012; Sandhu et al., 2013; Thomas et al., 2013; Yang & Stark, 2010). Similarly, quantitative analyses reported positive relationships between RA, perceived social support, social vitality, and social function (Cummings, 2002; Cummings & Cockerham, 2004; Horowitz & Vanner, 2010; Jenkins et al., 2002). However, some residents reported that RA facilitated interactions but did little to promote intimate relationships (Kemp et al., 2012, 2016; Sefcik & Abbott, 2014). Multiple studies suggest that RA positively relates to resident happiness, quality of life, and life satisfaction, and negatively relates to depression (Ball et al. 2000; Cummings, 2002; Cutchin et al., 2005; Horowitz & Vanner, 2010; Jang et al., 2014; Jenkins et al., 2002; McGuinn & Mosher-Ashley, 2001; Mitchell & Kemp, 2000; Park et al., 2017; Samus et al., 2006; Watkins, Walmsley, & Poling, 2017; Watson et al., 2006). However, in quantitative analyses, correlations often yielded small to moderate effect sizes, and RA was rarely a significant predictor of psychosocial variables after controlling for health and psychosocial variables (Park, 2009; Resnick et al., 2010b). Only three analyses reported that RA significantly predicted depression or life satisfaction in a multivariate model (Jang et al., 2014; Mitchell & Kemp, 2000; Ouyang et al., 2015). Multiple studies suggest that RA may promote additional individual outcomes including self-efficacy, self-determination, sense of self, self-growth, and continuing previous roles (Cruz, 2006; Hall & McAuley, 2011; Harmer & Orrell, 2008; Kemp et al., 2016; Kluge et al., 2014; Koehn et al., 2016; Križaj et al., 2016; Seipke, 2008; Thomas et al., 2013; Mahrs Träff et al., 2017). In addition, qualitative studies suggest that RA may help residents adapt and socially integrate into the AL community after relocation (Cutchin et al., 2005; Iwasiw et al., 1996; Jungers, 2010; Križaj et al., 2016). Although, other findings suggest that RA is an indicator of social integration, rather than an active contributor to the adaptation process (Kemp et al., 2012). Multiple studies also suggest that RA may simply provide residents with a source of entertainment, opportunity to combat boredom, or distraction for emotional struggles (Ball et al., 2000; Crenshaw et al., 2001; Cruz, 2006; Kennedy et al., 2005; Park et al., 2012; Mahrs Träff et al., 2017). RA may also relate to positive consequences for the social climate of the community. Multiple studies suggest that RA promotes a culture of engagement, community satisfaction, homelikeness, sense of belonging, helping behaviors, and social cohesion (Cruz, 2006; Hanson et al., 2014; Harmer & Orrell, 2008; Jungers, 2010; Kemp et al., 2012; Lewinson et al., 2012; Mitchell & Kemp, 2000; Park et al., 2012; Thomas et al., 2013). Conversely, other studies suggest that RA may be a venue for bullying and exclusionary behaviors (Kemp et al., 2012; Sandhu et al., 2013). It should be noted that previous research suggests that the aforementioned consequences likely vary by the type of RA (e.g., passive-active or group-solitary; Jenkins et al., 2002; Park et al., 2017; Phillips & Flesner, 2013). Discussion Describing the Literature This inaugural review of the scientific literature addressing RA in AL drew on studies from multiple disciplines. Although variation is expected across fields, the absence of guiding theoretical frameworks likely contributed to inconsistent construct definitions, measurement techniques, and findings. Few of the included studies defined RA in a consistent manner, and each research team utilized a different measurement protocol. The majority of studies measured RA participation as a single frequency count, and, in doing so, ignored activity-related constructs that can offer an in-depth analysis of resident activity profiles. Multiple studies alluded to, yet few captured in measurement, the distinction between RA that is self-initiated versus programmed. In AL research, differentiating between self-initiated and programmed RA in measurement may have implications for policy, staffing, and practice because, for example, if only high-functioning residents attend programmed activities, communities may consider adjusting physical design and programming to engage residents with a wide range of interests, motivations, and abilities. Additional activity-related factors that may enrich RA research include: engagement (i.e., a more active and involved construct than participation); activity demands; social context, including interindividual factors like group dynamics and others’ abilities; and physical context (e.g., common areas or private living areas; see Adams, Leibbrandt, & Moon, 2011; Levasseur, Richard, Gauvin, & Raymond, 2010; Nakamura & Csikszentmihalyi, 2014). Overall, future research should include activity-related variables in RA measurement, which may produce more detailed and translatable results. As mentioned, the field requires a consistent, applied, and comprehensive measurement tool. Nimrod and Shrira (2016) classify activity measurement into three categories: macro (i.e., frequency of participation), midway (i.e., participation in different categories of activity), and micro (i.e., participation in specific activities with varying features). Macro assessment can calculate overall RA participation rates, giving insight into resident physical, cognitive, and social stimulation. Midway assessment can differentiate between activity type (i.e., self-initiated or programmed), and micro assessment can assess engagement, activity demands, social context, and physical context for specific RAs. An ideal measurement tool would combine all three methods. Future research needs to develop and validate a measure of RA, for which these suggestions may serve as a guide. Describing RA Behaviors in AL Measurement limitations complicated efforts to establish general RA participation rates for AL residents. Overall, findings from the current review suggest that residents engage in mostly passive forms of RA, and, in general, report infrequent activity participation. This is consistent with previous research that suggests AL residents often fail to meet recommended levels of physical activity for older adults (Resnick et al., 2010a). A growing body of literature investigates interventions to increase physical stimulation (e.g., Function-Focused Care, FFC; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2013); however, the current review suggests that residents may also be at risk for low levels of cognitive and social stimulation. Therefore, future research needs to assess and consider interventions to increase stimulation across multiple dimensions. An interesting finding from the current review is that proxy ratings differed from resident self-reports of RA participation. It is unclear whether this finding reflects measurement issues, intercommunity variability, social desirability by staff, or recall difficulties by residents. Future research is needed to investigate the validity of proxy (e.g., activity director, family, and nurses) and resident ratings of behavioral variables like RA in AL, particularly as large research initiatives often recruit staff to report behavioral variables in residential care settings. Findings from the current review suggest that residents participated in various types of RAs, many of which were stereotypical of an AL population (e.g., Bingo and cards). Although the list complied in Table 1 may not be comprehensive, it suggests that residents may have limited access to a range of novel RAs, which is consistent with resident critiques of recreational opportunities in AL (Lewinson et al., 2012). Future research is needed to assess whether the activities extracted in the current review are consistent across a representative sample of ALs, and congruent with resident preferences, interests, and abilities. These topics may be particularly salient in AL, as state policies require recreational offerings to meet residents’ preferences (Carder et al., 2015). However, residents report opportunities for RA often lacks personal interest, meaning, and-or value, and RA programming is consistently among the lowest rated services in AL (Crenshaw et al., 2001; Gesell, 2001; Gregory, Gesell, & Widmer, 2007; Harmer & Orrell, 2008; Sefcik & Abbott, 2014). Taken together, the field must devote research to assessing the quality of recreational opportunities in AL with the goal of designing programming around resident preferences, interests, and biopsychosocial needs. Major Findings Related to RA Participation This review identified multiple variables that may influence RA participation consistent with an ecological framework (i.e., individual, interindividual, and environmental factors). Figure 1 offers a schematic representation of variables that relate to RA. This theoretical model offers a framework for predicting, measuring, and identifying consequences of RA behaviors in AL, and can serve as a guide for future research. Temporally, the constellations of factors depicted in this model that influence RA occur in a common sequence driven by enduring individual characteristics (e.g., demographics), which influence the relocation process. Relocation to AL is a nonnormative life event that likely impacts individual, interindividual, and environmental factors, which interact to predict RA behaviors after the move. Future research needs to test the relationships proposed in the model presented in Figure 1. Figure 1. View largeDownload slide Model of RA in AL including potential predictors of RA behaviors, activity-related variables for measurement, and consequences of participation. Figure 1. View largeDownload slide Model of RA in AL including potential predictors of RA behaviors, activity-related variables for measurement, and consequences of participation. Variability within each ecological system suggests the need for a predicative model of RA behaviors that appreciates both a person-centered approach to individuals and consideration of differences in the sociophysical environment of ALs (e.g., physical design and social norms). This framework represents a shift in the literature from an “if you build it, they will come” mentality of RA, which often tested demographics, health, and availability of activities as the sole predictors of participation, to a more flexible model that captures the intricacies of human choice and behavior. This new approach is consistent with the model recently used by Dr. Resnick’s team investigating physical activity as FFC. Their model includes validated measurement of person-centered individual variables like outcome expectations, self-efficacy, attitudes, and social support for exercise, and flexible environmental variables like person-environment fit scales (Resnick et al., 2010a; Resnick et al., 2010b; Holmes et al., 2017). Due in large part to the aforementioned research program, there is a promising intervention plan in place to address low levels of physical activity in AL (i.e., FFC). However, these efforts are not universally implemented, nor have they been translated to other forms of RA (e.g., social group activities). As a result, the literature appears divided between primarily physical and nonphysical forms of RA, with more refined science devoted to research on physical activity. It is unclear, however, whether detailed studies assessing primarily nonphysical forms of RA exist but fail to appear in the literature due to nonsignificant findings (i.e., publication bias). Implementing consistent measurement protocols and theoretical frameworks, like the ones proposed in this paper, may address some inconsistencies observed in the field and enhance the scientific understanding of a wide range of RA behaviors in AL. Major Findings Related to Consequences of RA Findings from a small and inconsistent body of research suggest that RA participation may relate to consequences for AL residents and communities. Most consequences for residents related to psychosocial well-being and most consequences for the community related to social climate. Even though policy-makers and researchers often cite the benefits of RA in AL (e.g., CEAL, 2010; ICAA, 2009), few studies offered empirical support for positive consequences of participation, and RA was rarely a significant predictor of global constructs of well-being in multivariate models. Further, when significant, relationships between RA and wellness-related constructs (e.g., health and depression) often yielded small effect sizes. It is unclear whether these findings reflect methodological limitations discussed earlier in this paper or if RA has a modest role in explaining wellness-related variables. Future research is needed to test potential consequences of RA participation with specific attention given to activity-related mediators (e.g., activity demands). Future Research One of the primary goals of activities research is to guide practice. However, few studies included in the current review offered applied results or clinically relevant interpretations. This is particularly true of studies that assessed primarily nonphysical forms of RA. As the scientific literature progresses in its understanding of RA in AL, research needs to inform program development, physical design, policies, and interventions. This includes, but is not limited to, establishing an empirically based method for planning recreational offerings based on residents’ preferences, interests, and biopsychosocial needs; creating norms for resident physical, cognitive, and social stimulation; and assessing differences in participation, engagement, personal meaning, and activity demands between self-initiated and programmed RAs. Such studies may pave the way for meaningful clinical interventions targeting RA participation. Lastly, future research needs to test outcomes of specific RAs offered in AL using the activities and factors identified in the current review (e.g., experimental manipulation of Bingo with self-determination as an outcome). Conclusion A limitation of the current review is that the author excluded experimental studies in order to focus on describing naturally occurring RA behaviors in AL settings. As a result, this review cannot comment on specific outcomes of experimentally manipulated RA participation. Reviewing intervention studies may enrich recommendations to guide programming and activity-focused randomized control trials, and, thus, should be the focus of subsequent work. Another limitation is that studies included in this review may have not sampled residents representative of an AL population. Many studies used convenience-sampling techniques, and health-related inclusion criteria may have further biased resident samples. Despite these limitations, this paper culminates in a theoretical model of RA participation, measurement, and consequence that may serve as a guide for future research. Overall, the suggestions offered in this paper may help move the field toward a more sophisticated understanding of a broad scope of RA behaviors in AL, which may allow for translatable research that can guide service delivery and AL policy. Conflict of Interest None reported. Acknowledgments I would like to specially thank Dr. Sara Qualls, PhD, for greatly assisting in the preparation of this manuscript. References Adams, K. B. , Leibbrandt, S. , & Moon, H . ( 2011). A critical review of the literature on social and leisure activity and wellbeing in later life. Ageing and Society , 31, 683– 712. doi: 10.1017/S0144686X10001091 Google Scholar CrossRef Search ADS   Ball, M. M. , Perkins, M. M. , Whittington, F. J. , Connell, B. R. , Hollingsworth, C. , King, S. V. , … Combs, B. L . ( 2004). 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Activities, Adaptation and Aging , 41, 87– 97. doi: 10.1080/01924788.2016.1272394 Google Scholar CrossRef Search ADS   Watson, L. C. , Lehmann, S. , Mayer, L. , Samus, Q. , Baker, A. , Brandt, J. , … Lyketsos, C . ( 2006). Depression in assisted living is common and related to physical burden. The American Journal of Geriatric Psychiatry , 14, 876– 883. doi: 10.1097/01.JGP.0000218698.80152.79 Google Scholar CrossRef Search ADS PubMed  Williams, K. N. , & Warren, C. A . ( 2009). Communication in Assisted Living. Journal of Aging Studies , 23, 24– 36. doi: 10.1016/j.jaging.2007.09.003 Google Scholar CrossRef Search ADS PubMed  Wyrick, S. , Parker, D. , Grabowski, D. , Feuling, H. M. , & Ng, A. V . ( 2008). Relationships among walking aids, physical activity, depression, fatigue, and perceived health in assisted-living residents: A pilot study. Journal of Applied Gerontology , 27, 511– 522. doi: 10.1177/0733464808315288 Google Scholar CrossRef Search ADS   Yang, H. Y. , & Stark, S. L . ( 2010). The role of environmental features in social engagement among residents living in assisted living facilities. Journal of Housing for the Elderly , 24, 28– 43. doi: 10.1080/02763890903547062 Google Scholar CrossRef Search ADS   Zimmerman, S. , Scott, A. C. , Park, N. S. , Hall, S. A. , Wetherby, M. M. , Gruber-Baldini, A. L. , & Morgan, L. A . ( 2003). Social engagement and its relationship to service provision in residential care and assisted living. Social Work Research , 27, 6– 18. doi: 10.1093/swr/27.1.6 Google Scholar CrossRef Search ADS   Zimmerman, S. , Sloane, P. D. , Williams, C. S. , Reed, P. S. , Preisser, J. S. , Eckert, J. K. , … Dobbs, D . ( 2005). Dementia care and quality of life in assisted living and nursing homes. The Gerontologist , 45 Spec No 1, 133– 146. doi:10.1093/geront/45.suppl_1.133 Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Gerontologist Oxford University Press

Recreational Activity in Assisted Living Communities: A Critical Review and Theoretical Model

The Gerontologist , Volume Advance Article – Oct 7, 2017

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Abstract

Abstract Background and Objectives This paper critically reviewed the scientific literature on recreational activity (RA) behaviors in assisted living (AL) communities. Research Design and Methods A search of three databases yielded 70 quantitative, qualitative, and observational articles that met criteria for inclusion. Results AL residents participated in various types of RA, however, did so infrequently. Individual, interindividual, environmental, and relocation factors influenced RA behaviors, and participation may relate to positive consequences for residents and AL communities. This review identified multiple limitations in the literature related to construct definitions, measurement protocols, and incomplete or absent theoretical frameworks. Discussion and Implications To address these limitations, the current review proposes a multivariate measurement model and an interdisciplinary theoretical model of factors relating to RA, consistent with an ecological framework. The proposed models appreciate individual psychological factors that influence the multiple facets of human choice and behavior, as well as the interaction between individuals and the unique sociophysical environment of AL. This paper concludes with recommendations for future research, emphasizing studies that have applied implications for practice and policy. Recreational therapy/activities, Institutional care/residential care, Assisted living facilities, Well-being, Conceptual development, Psychosocial Assisted living (AL) offers housing and supportive services primarily to older adults with long-term care needs that impact independent living, yet do not require the level of skilled care provided in nursing homes (Kane, Chan, & Kane, 2007). The AL industry promotes a psychosocial model of care, with engagement with life representing an important tenant of the founding philosophy and existing care paradigms (CEAL, 2010). One way that residents engage with life is through participating in recreational activity (RA). RA is defined as discretionary pursuits occurring during leisure time, usually with the purpose of entertainment, exercise, cognitive stimulation, creative expression, and-or socialization (Everard, 1999; Leitner & Leitner, 2012). AL residents participate in various forms of RA including solitary activities (e.g., reading and watching television), physical activity, socializing, outings, hobbies, and programmed group activities (Gaugler & Kane, 2005; Hanson et al., 2014). After relocation to AL, residents receive assistance with many obligatory, functional, and self-care activities (Khatutsky, Wiener, Greene, Johnson, & O’Keeffe, 2013). Therefore, AL residents spend the majority of their waking time participating in discretionary activities, making RA a major part of everyday life (Pruchno & Rose, 2002). ALs invest resources into amenities and spaces that encourage RA, as participation can promote resident health and psychosocial well-being, as well as positively contribute to the culture of the community (Ball et al., 2004; ICAA, 2009; Khatutsky et al., 2016; O’Sullivan, 2005). Further, many states require that ALs offer opportunities for RA that meet residents’ preferences, interests, and needs (Carder, O’Keeffe, & O’Keeffe, 2015). Although industry leaders and policy-makers agree on the importance of RA, the scientific community still lacks a comprehensive and in-depth analysis of RA behaviors, as well as the methodological approaches and theoretical frameworks used to assess RA in AL settings. The purpose of this paper was to review the literature addressing RA in AL. Specifically, this review aimed to describe RA behaviors and associated measurement protocols; potential factors that influence RA; and potential consequences of RA. The current review is timely given the state of the literature, growth of the AL industry, and the role of RA in ongoing culture change and policy reform (CEAL, 2010; Grabowski, Stevenson, & Cornell, 2012; Shura, Siders, & Dannefer, 2011). This paper adds to the literature by reviewing a broad scope of RA behaviors in AL and offering suggestions for future research to address measurement, theory, intervention, and policy. Method The current review searched PSYCHInfo, CINAHL, and PubMed in June 2017 using the following key terms: assisted living and activity, recreation, leisure. Searches were limited to full-text, English, and peer-reviewed articles, yielding 334 results published between 1975 and 2017. After removing duplicates, the author screened abstracts for studies that commented on social, physical, leisure, or other types of resident behaviors in an AL or residential care setting. Next, 210 articles were retained for a full review using the following inclusion criteria: (a) AL setting with a primarily older adult sample (i.e., younger samples with serious mental illness and special care units were excluded; 43 articles excluded); (b) measures or discusses RA behaviors, including social, leisure, and physical activity (66 excluded); and (c) employs descriptive quantitative, qualitative, or observational methodology (31 excluded). The author limited studies to an AL setting with primarily older adults because previous research suggests RA participation rates, policies, and practices (e.g., level of choice, transportation, and type) vary across care settings and samples, possibly influencing analysis and implications of the current review (Carder et al., 2015; Gaugler & Kane, 2005; Ice, 2002; Kuhn et al., 2004; McGuinn & Mosher-Ashley, 2001). The author excluded interventions and experimental comparisons in favor of descriptive studies because this methodological approach better aligned with the objective of the current review, which was to describe RA behaviors and related factors with the goal of generating theoretical frameworks. Results Overview of Studies and RA Behaviors The current paper reviewed 70 articles (34 quantitative, 33 qualitative, and 3 observational). Most studies measured RA as a secondary variable. Eight (six assessing physical activity) qualitative studies targeted RA, and seven (four assessing physical activity) ran quantitative analyses with RA as the dependent variable. Only one study collected longitudinal data (i.e., Gaugler & Kane, 2005). Quantitative studies sampled 21 to 2,078 (n = 33, M = 314.52, SD = 516.31) residents in 1 to 200 (n = 32, M = 33.31, SD = 56.32) ALs. Given the large national sample, Hawes et al. (2000) was an outlier and, thus, not included in these calculations; one study failed to report number of ALs sampled. Qualitative and observational studies sampled 4 to 303 (n = 32, M = 35.41, SD = 57.10) residents in 1 to 51 (n = 36, M = 6.75, SD = 10.74) ALs; four studies did not sample residents (i.e., staff interviews or observational design). Fifty-five articles reported inclusion criteria. Twenty-nine had a criterion related to cognitive ability (e.g., no dementia diagnosis or score on a screen); 25 related to age; 17 related to general ability to participate in an interview; 14 related to time in AL; 10 related to physical ability (e.g., able to ambulate or minimal assistance with activities of daily living); and 23 employed other criteria (e.g., life expectancy or previous profession). Few studies reported cognitive data and variability in measurement strategies of heath-related variables makes it difficult to generate a functional profile of residents included in the reviewed studies. The majority of sampled resident were older than 80 years and female, which is consistent with AL national data (Caffrey et al., 2012). Articles used various terms to refer to RA including activity or occupation (n = 16); physical activity or exercise (n = 14); social activity or engagement (n = 8); leisure or recreation (n = 5); programmed, planned, organized, or structured activity (n = 4); meaningful activity (n = 1); discretionary activity (n = 1); or a combination of the aforementioned terms used interchangeably (n = 21). Articles categorized RA by activity-related factors (i.e., type, demands, and features; n = 8); social or physical context (e.g., solitary-group or inside-outside; n = 2); or a combination of categories (e.g., private-group-outside or social-active-outside; n = 3). Multiple articles alluded to the difference between self-initiated and programmed RA, yet only three differentiated these constructs in measurement or when discussing results (i.e., Kuhn et al., 2004; McGuinn & Mosher-Ashley, 2001; Sandhu et al., 2013). The current review extracted specific RAs that residents mentioned or researchers observed occurring across 36 qualitative or observational articles in Table 1. When specified, the author noted whether the activity was discussed as occurring in a self-initiated and-or programmed context. Multiple activities (e.g., puzzles) occurred in both a self-initiated and programmed context, and, in general, were representative of expected or stereotypical RAs for an AL setting (e.g., Bingo). Table 1. Specific RAs Mentioned in Qualitative and Observational Studies Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Note: Frequency counts represent the number of articles that mention the activity. aDiscussed as individual-initiated. bDiscussed in the literature as community-sponsored. cDiscussed as occurring in both a community-sponsored and individual-initiated context. View Large Table 1. Specific RAs Mentioned in Qualitative and Observational Studies Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Activity  n  Activity  n  Family visitsa  26  Triviab  4  Walkingc  25  Jigsaw puzzlesc  3  Physical exercise and exercise classc  23  Crosswordc  3  Bingob  19  Coffee or tea socialsc  3  Arts and crafts (e.g., painting, embroidery, knitting, and sewing)c  16  Activities on computersa  3  Televisiona  15  Playing music (i.e., instruments) c  3  Reading or book clubc  14  Current eventsb  3  Outings (e.g., restaurants, shopping, car rides, or visiting friends or family)c  14  Volunteeringc  3  Religious activitiesc  14  Reminiscencec  2  Cardsc  11  Listening to the radioa  2  Gardeningc  11  Nature watchinga  2  Listening to musicc  10  Tai Chib  2  Singing (e.g., sing-a-long or karaoke)c  9  Pokenob  1  Talking on the telephonea  9  Scrabblea  1  Resident council meetingsb  9  Pokerb  1  Parties, socials, or cookoutsb  8  Dartsa  1  Writing (e.g., letters)a  7  Cookingb  1  Moviesb  5  Men’s groupb  1  Intergenerational or animal visitsb  5      Note: Frequency counts represent the number of articles that mention the activity. aDiscussed as individual-initiated. bDiscussed in the literature as community-sponsored. cDiscussed as occurring in both a community-sponsored and individual-initiated context. View Large Thirty-three quantitative articles reported measurement strategies and statistics on the frequency of RA participation, see Table 2. Articles used self-report (n = 18), proxy ratings (n = 8), observation (n = 4), and accelerometers (n = 3) to measure RA. Seven articles utilized four different validated measurement tools (i.e., two self-report and two observational). Overall, findings suggest that the majority of residents participated in some type of RA, but less than half did so regularly, and, on average, residents reported participating in less than four activities per week or participating in RA only some of the time. In addition, residents often evidenced low rates of physical activity, particularly for strenuous activity. Across multiple studies, staff reported that, on average, residents participated in 15–20 hours of RA per week (Lyketsos et al. 2007; Samus et al., 2008; Samus et al., 2009; Samus et al., 2006; Tighe et al., 2008), which is significantly higher than resident self-reports. It should be noted that measurement issues may have biased participation rates reported in Table 2, as studies did not appear to capture the full range of RA behaviors in AL (e.g., reading in the bedroom). Table 2. Construct Definitions, Measurement Protocols, and Estimates of RA in AL Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  View Large Table 2. Construct Definitions, Measurement Protocols, and Estimates of RA in AL Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  Author(s)  Activity definition and measurement protocol  Mean (SD or SE) or percentage  Chen, Li, & Yen (2015) n = 304 Self-report  How much time did you spend performing moderate, hard, and very hard activities over the previous 7 days? Moderate activities are as strenuous as walking at a normal pace and very hard activities are as strenuous as running. Hard activities are in between walking and running. Light activity was time was not spent engaging in the aforementioned activities. Total time in each level of activity per day was added up and multiplied by the appropriate mean metabolic equivalents (METs) and then summed to obtain a total MET score.     Light  Men: 18.15 (5.78)  Women: 17.29 (5.89)   Moderate  Men: 1.25 (1.72)  Women: 1.18 (1.81)   Hard  Men: 0.23 (0.99)  Women: 0.05 (.52)   Total physical activity  Men: 31.24 (2.76)  Women: 30.76 (2.53)  Cummings & Cockerham (2004) n = 57 Self-report  Number of times, on average, you participate in activities at the assisted living each week.  3.4 (3.7)  Cummings (2002) n = 145 Self-report  The number of times each week, on average, you participated in activities at the assisted living.  3.7 (3.6)  Decker, Cary, & Krautscheid (2006) n = 27 Self-report  How often do you participate in activities at the assisted living? 1 = not at all; 2 = 1 to 2 times per week; 3 = 3 to 4 times per week; 4 = almost daily (range: 1–4)  1.92 (NR)  Dermott et al. (2009) n = 93 Self-report  How many times per week do you performed activity that was strenuous, moderate, or mild? Were you active enough to “work up a sweat”? 1 = never; 2 = sometimes; 3 = often The physical activity score was obtained using the equation: (strenuous physical activity × 9) + (moderate physical activity × 5) + (mild physical activity × 3)  25.6 (28.3)  Dobbs et al. (2005) n = 99 Residents n = 400 Staff Self-report and staff proxies  Patient Activity Scale–Alzheimer’s Disease: How often does [resident] participate in: five outside (e.g., shopping, church, car ride, movies, and see family and friends) and ten in the community (e.g., being with pets, exercising)?  Staff rating: 9.8 (5.3)  0 = not at all; 1 = 1 to 2 times per week; 2 = 3+ times per week (range: 0–30)  Resident rating: 9.1 (5.5)  Gaugler & Kane (2005) n = 610 Self-report  How often do you/have you? 1 = Not at all, 6 = Everyday (range: 1–6)     Go to see movie, play, restaurant, etc.?  2.30 (1.22)   Go to church, senior center, club, etc.?  1.64 (1.17)   Relatives or children visit?  3.63 (1.46)   Outside friends visit?  2.18 (1.27)   Have a conversation with other tenants?  5.55 (1.21)   Have telephone contact with family members or friends?  4.18 (1.84)   Done activities such as reading books or newspapers?  5.14 (1.63)   Done group activities such as bingo, cards, exercise groups, etc.?  3.08 (1.78)  Hall & McAuley (2011) n = 106 Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (activity counts per day)  73,301 (38,960)  Hawes, Phillips, & Rose (2000) n = 192,046 Self-report, staff, & family proxies  How often do you attend activities?   None of the time  6.1% (1.0)   Some of the time  48.7% (2.2)   Most of the time  35.1% (1.6)   All of the time  10.0% (1.5)  Holmes, Galik, & Resnick (2017) n = 171 Observational  Physical Activity Survey in Long-Term Care (PAS-LTC)  162.9 (81.4)  Total physical activity (minutes per day)  Jang, Park, Dominguez, & Molinari (2014) n = 150 Self-report  Inside AL: How often do you attend social activities in the facility (e.g., meetings and recreational programs) and how often do you socialize with other residents in the facility?  Inside AL: 5.26 (1.69)  Outside AL: How often do you attend social activities outside the facility (such as church activities and going to the movies or concerts) and how often do you socialization with people outside the facility?  Outside AL: 3.19 (1.69)   0 = Never, 1 = Once in a while, 2 = Fairly often, 3 = Very often (range: 1–7)  Jenkins, Pienta, & Horgas (2002) n = 55 Self-report  Active activity: How often do you do the following: recreational activities, hobbies, socializing with friends, and taking walks or other exercise?  Active: 2.7 (0.6)   1 = Never, 4 = A lot (range: 1–4)  Passive activity: How often do you do the following: listening to the radio, reading, watching television, and sitting and thinking?  Passive: 2.9 (0.4)   1 = Never, 4 = A lot (range: 1–4)  Outside activity: Have you done any of the following in the past month: go to the movie theater, church or synagogue, library, store, home of a friend or relative, restaurant, senior center, and community recreation center? (Range: 0–8)  Outside: 2.6 (1.4)  Kuhn, Fulton, & Edelman (2004) n = 49 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.  Percentage of the sample that participated in:   Staff-led activities promoting well-being  17.8%   Resident-led activities promoting well-being  33.6%   Activities promoting ill-being  25.6%   Walking  13.6%  Kuhn, Kasayka, & Lechner (2002) n = 131 Observational  Dementia Care Mapping: detailed observation and behavior coding of persons with dementia during 5-minute increments for six continuous hours.      Percentage of the sample that participated in:     Passive social activity  16%     Walking  12%     Verbal interactions  12%     Creative activity  4%     Exercise  4%     Engaging with media (e.g., television)  4%     Crafts, games, work, religious activity, etc.  <3%  Lu (2010) n = 26 Staff report  Please answer the following:   % of residents participating in physical activity programs per facility  38.6% (16.4)   % of residents walking outdoors per facility  15.8% (16.2)   % of residents walking indoors per facility  22.7% (19.5)  Lyketsos et al. (2007) n = 64 (no dementia) n = 134 (dementia) Staff proxy  Caregiver ratings of hours of activity participation in the previous month based on self-report and available records kept at the facility.  Dementia absent: 91.29 (74.89)  Dementia present: 69.45 (62.56)  McGuinn & Mosher-Ashley (2001) n = 64 Self-report  Do you participate in the following (yes or no):   Organized activities (e.g., bingo or crafts)  23%   Self-initiated activities (e.g., crossword puzzles, reading, praying, cards, and checkers or chess)  25%   Watching television  21%   Exercise  8%   Socializing with other residents or staff  19%  Mitchell & Kemp (2000) n = 201 Self-report  Have you participated in any of the following facility social activities within the last three months: table games, ping-pong, group exercise, musical activities, arts and crafts, social gatherings, celebrations, and participation in resident council meetings?  3.3 (1.5)  You can add up to two additional activities not covered in the list, results included: discussion groups, group speakers, and cooking classes. (Range: 0–10)  Ouyang, Chong, Ng, & Liu (2015) n = 1,429 Self-report  Do you participate in the following: making handicrafts, playing games, singing and dancing, attending courses, following rehabilitation therapy, and performing mental activities (e.g., chess, jigsaw puzzles)?  15.05 (4.19)   1 = Residential care home does not organize this activity, 2 = Never attend, 3 = Participate occasionally, 4 = Participate regularly (range: 6–24)  Park (2009) n = 82 Self-report  Indicate if you have done the following in the past 7 days: going out and shopping, going to the barber or beauty shop, attending religious services, attending arts and crafts classes, playing cards and other table games, going to the movies, eating out, talking with people on the phone, doing volunteering work, doing paid work, and visiting with other residents? (Range: 0–11)  5.37 (2.03)  Park et al. 2017) n = 85 Objective measurement  Wear an ActiGraph accelerometer for 3 days, 10 hours per day (minutes per day)   Light  201.13 (71.96)   Moderate  9.74 (9.62)   Sedentary  511.93 (105.72)  Pruchno & Rose (2002) n = 51 Observational  Mean minutes per day spent (mean % of waking hours/mean % of sample):   Family interaction  75 (8.6%/76.5%)   Friend interaction  45 (5%/56.9%)   Watching TV  124 (13.4%/74.5%)   Radio  9 (.9%/7.8%)   Religious activity  1 (.1%/2%)   Reading  81 (5.5%/60.8%)   Recreation/leisure  56 (11.5%/49%)  Resnick, Galik, Gruber-Baldini, & Zimmerman (2010a, b) n = 171 Observational  PAS-LTC (minutes per day)   Locomotion  35.5 (32.6)   Exercise  8.5 (17.6)  Recreational activities—Minutes per day spent doing: cooking; arts and crafts, needlework, cards, and/or Bingo; outside gardening; bowling, golf, or putting (indoor or outdoor); or other.  16.5 (38.9)   Total physical activity  162.9 (81.4)  Samus et al. (2006)  Residents and caregivers estimate the number of hours in the past month the resident engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  76.5 (67.4)  n = 198  Resident & staff proxy reports Samus et al. (2008) n = 110 Staff proxy  Group activities: Approximate number of hours the participant spent in group activities (e.g., social hour, exercise class, bus trips) per month.  Group: 63.6 (57.8)  Watching television: Approximate number of hours the participant spent watching television.  Television: 66.7 (57.8)  Samus et al. (2009) n = 262 Resident & staff proxy reports  Residents and caregivers to estimate the number of hours in the past month they had engaged in structured group activities (e.g., discussions, clubs, games, and trips) and in solo activities (e.g., hobbies, reading, and crossword puzzles).  73.7 (58.5)  Schroeder, Nau, Osness, & Potteiger (1998) n = 23 Self-report  Physical Activity Questionnaire for the Elderly (range- 0–32)  6.8 (1.4)  Sharaf & Ibrahim (2008) n = 208 Self-report  Do you engage in leisure activities?   Yes  166 (79.8%)   No  42 (20.2%)  Tighe et al. (2008) n = 198 Resident & staff proxy reports  Estimate the total number of hours spent engaged in solo and group activities in the past month. Solo activities included reading, writing, crossword puzzles, Sudoku, knitting, and painting. Group activities could have included morning exercise class, social hour, playing bridge or poker, going on a bus trip, or attending a current events discussion.  75.8 (67.4)  Wyrick, Parker, Grabowski, Feuling, & Ng (2008) n = 8 (ambulates independently) n = 13 (assistive device) Objective measurement  Wear an ActiGraph accelerometer for period of 7 days (vector magnitude/100)   Total physical activity  Independent: 664 (225)  Assistive device: 549 (270)   Light physical activity  Independent: 639 (223)  Assistive device: 499 (275)   Medium physical activity  Independent: 35 (52)  Assistive device: 50 (40)  Zimmerman et al. (2003) n = 2,078 Self-report  In the past 7 days, have you participate in (% yes):   Attending arts and crafts  22.3–32.2%   Playing cards, Bingo, and games  38.6–45.3%   Attending religious services  37.7–61.1%   Movies  23.9–37.8%   Talking on the telephone  55.0–67.1%   Reading  49.2–66.2%   Writing Letters  14.4–22.9%   Working on a hobby  13.9–19.4%   Going for walks  59.0–66.0%   Going out to eat or drink  27.3–32.1%   Shopping or browsing in stores  20.5–23.7%   Visited with family or friends  69.4–83.3%   Telephoned family or friends  52.6–59.8%  Zimmerman et al. (2005) n = 2,078 Self-report  In the past 7 days, which of the following 11 activities have you participated in (see activities listed for Zimmerman et al., 2003)? (range: 0–11)  6.2  View Large Factors Influencing RA Participation Fifty-four articles provided insight into factors that may influence RA behaviors (i.e., participation rate and type). Across multiple studies, women reported greater participation compared to men (Cummings & Cockerham, 2004; McGuinn & Mosher-Ashley, 2001; Mitchell & Kemp, 2000; Zimmerman et al., 2003). Gender also influenced RA type and satisfaction, with men reporting preference for strenuous forms of RA (Chen et al., 2015; Dermott, McDaniel, Weiss, Tomazic, & Mattfeldt-Beman, 2009; Park et al., 2009). Other demographic variables that may influence RA behaviors are socioeconomic status, age, education, and previous profession (Chen et al., 2015; Gaugler & Kane, 2005; Jang et al., 2014; Križaj et al., 2016; Mitchell & Kemp, 2000; Seipke, 2008). Lastly, studies reported that choice and control in the relocation process and time in AL influenced RA behaviors (Gaugler & Kane, 2005; Kemp et al., 2012; Križaj et al., 2016; McGuinn & Mosher-Ashley, 2001). Many studies reported that global physical and cognitive health influenced RA participation (Barnes et al., 2012; Chen et al., 2015; Crenshaw et al., 2001; Decker et al., 2006; Dobbs et al., 2005; Gaugler & Kane, 2005; Hanson et al., 2014; Jang et al., 2014; Kemp et al., 2012, 2016; Kuhn et al., 2004; Lyketsos et al., 2007; Mihalko & Wickley, 2003; Ouyang et al., 2015; Park et al., 2017; Phillips & Flesner, 2013; Samus et al., 2009; Sandhu et al., 2013; Yang & Stark, 2010; Zimmerman et al., 2003). Other health-related factors that influenced RA were sensory ability, mental health, and fluctuating factors like sleep and pain (Chen et al., 2015; Crenshaw et al., 2001; Gaugler & Kane, 2005; Kluge, LeCompte, & Ramel, 2014; Lewinson et al., 2012; Park et al., 2012, 2017; Phillips & Flesner, 2013; Pryce & Gooberman-Hill 2012; Thomas et al., 2013; Watson et al., 2006; Zimmerman et al., 2003). Some studies suggest that health may indirectly influence RA through attitudes, self-efficacy, and relationships (Dobbs et al., 2008; Hall & McAuley, 2011; Holmes et al., 2017; Kluge et al., 2014; Sandhu et al., 2013). For example, residents with higher abilities reported not wanting to participate in RA with residents with significant limitations (Buelow & Fee, 2000). Multiple psychological factors emerged from the literature that may influence RA behaviors. Studies reported that self-efficacy directly related to RA behaviors, particularly for physical activity (Chen et al., 2015; Kluge et al., 2014). Across multiple studies, residents reported participating in RA because they believed it would produce positive outcomes such as wellness or relationships (Ball et al., 2000; Hanson et al., 2014; Kluge et al., 2014; Phillips & Flesner, 2013; Mahrs Träff, Cederstund, & Nord, 2017). Residents also reported participating in RA to increase or maintain social status, or appear functionally appropriate for the community (Beel-Bates et al., 2007; Williams & Warren, 2009). Relatedly, one quantitative analysis reported that residents with greater fear of falling were less likely to participate in RA (Sharaf & Ibrahim, 2008). Residents who reported previous activity behaviors were more likely to participate in RA in AL (Kluge et al., 2014; Lewinson et al., 2012; Phillips & Flesner, 2013; Seipke, 2008; Mahrs Träff et al., 2017). Residents also reported participating in RA to uphold personal identities, such as being active and-or social (Cruz, 2006; Harmer & Orrell, 2008; Kennedy et al., 2005; Phillips & Flesner, 2013). Taken together, self-efficacy, outcome expectations, impression management, previous behaviors, and identity are psychological factors that may influence RA behaviors in AL. Multiple studies suggest that residents’ attitudes toward activities including preference, meaning, interest, and congruence with personal values influenced participation (Barnes et al., 2012; Bischoff et al., 2001; Crenshaw et al., 2001; Cruz, 2006; Cutchin et al., 2005; Decker et al., 2006; Fraher & Coffey, 2011; Harmer & Orrell, 2008; Holmes et al., 2017; Iwasiw et al., 1996; Jungers, 2010; Kemp, 2008; Kemp et al., 2016; Mihalko & Wickley, 2003; Sefcik & Abbott, 2014; Thomas et al., 2013; Williams & Warren, 2009; Yang & Stark, 2010). In general, residents reported dissatisfaction with RA offerings in AL. For example, residents often criticized programmed activities for lacking variety (Crenshaw et al., 2001; Lewinson et al., 2012; Park et al., 2009; Williams & Warren, 2009). Further, across multiple studies, families and residents described recreational opportunities as stereotypical, demeaning, childish, or lacking physical and cognitive challenge (Ball et al., 2000; Buelow & Fee, 2000; Dobbs et al., 2008; Park et al., 2009). A large body of qualitative research suggests that strong co-resident and family-resident relationships promote RA in AL (Buelow & Fee, 2000; Kluge et al., 2014; Lewinson et al., 2012; Park et al., 2012; Sandhu et al., 2013; Sefcik & Abbott, 2014; Yang & Stark, 2010). Conversely, interpersonal conflicts can pose a barrier to RA, particularly for group activities (Decker et al., 2006; Kemp et al., 2012). Social group membership may also influence RA behaviors (e.g., attending because you are a member of the “active group”; Cruz, 2006; Kennedy et al., 2005; Kluge et al., 2014; Thomas et al., 2013). Multiple studies suggest that strong staff-resident relationships, staff encouragement, and reminders positively influence RA participation (Dobbs et al., 2005; Hanson et al., 2014; Holmes et al., 2017; Park et al., 2012; Phillips & Flesner, 2013; Thomas et al., 2013; Zimmerman et al., 2003). Conversely, residents who perceived staff as acting rushed or moving too quickly were less likely to participate in RA, particularly for programmed activities (Fraher & Coffey, 2011). Other studies suggest that social motivators can turn into social pressure to participate in RA. For example, residents reported participating in RA to appease staff or family (Beel-Bates et al., 2007; Williams & Warren, 2009), and, relatedly, staff reported having difficulty encouraging activity while preserving resident autonomy (Hanson et al., 2014; Koehn et al., 2016). Multiple factors related to the sociophysical environment of the AL community may also influence RA behaviors. Residents in communities with more than 16 individuals reported higher RA participation compared to smaller communities (Zimmerman et al., 2003). Other studies suggest that small or shared living areas (Cruz, 2006; Yang & Stark, 2010) and appealing physical spaces in or around the community may promote RA by enticing residents to spend time outside of their apartment (Barnes et al., 2012; Lu, 2010; Mihalko & Wickley, 2003; Sandhu et al., 2013; Thomas et al., 2013). Residents and staff reported that physical design and community services (e.g., long walking distance and no transportation) can also pose barriers to certain types of RA (e.g., walking outside) due to safety concerns (Bischoff et al., 2001; Decker et al., 2006; Koehn et al., 2016; Lu, 2010; Phillips & Flesner, 2013; Thomas et al., 2013). The culture of a community can also influence RA behaviors through social norms around activity and social cohesion (e.g., activity encouragement; Kennedy et al., 2005; Koehn et al., 2016; Mitchell & Kemp, 2000; Sandhu et al., 2013). It is important to note that previous research suggests sociophysical factors that may influence RA behaviors, such as support from staff and physical design, vary across communities (Resnick et al., 2010a). Specific to programmed RA, policies and resources may affect participation. Residents cited advertising policies (e.g., activity calendars containing small print) as a barrier to participation (Buelow & Fee, 2000; Hanson et al., 2014; Lewinson et al., 2012). In addition, staffing and space for programmed RAs reportedly influenced the availability and quality of activity programs, contributing to resident participation (Hanson et al., 2014; Mihalko & Wickley, 2003; Thomas et al., 2013). Factors Indicating Consequences of RA Thirty-eight articles provided insight into factors that may represent consequences of RA participation. The current review interpreted factors that may both influence and represent a consequence of RA (e.g., health) based on the original author(s)’ interpretations, or by using theory and previous research to interpret a potential directional pathway (e.g., RA may produce health benefits; Grant & Kluge, 2012). Multiple quantitative analyses reported positive relationships between RA, functional ability, and global health-related measures (Jang et al., 2014; Jenkins et al., 2002; Hall & McAuley, 2011; Horowitz & Vanner, 2010; Ouyang et al., 2015; Park et al., 2017). Two studies reported that RA participation predicted longer time to discharge (i.e., by death or transfer; Tighe et al., 2008; Zimmerman et al., 2005); although, neither controlled for psychosocial variables. One study reported that participation predicted lower rates of physical dependency for residents with dementia; however, the authors failed to replicate these findings with residents without significant cognitive impairment (Samus et al., 2009). Multiple studies reported nonsignificant relationships between RA and health-related variables (e.g., self-rated health; Cummings, 2002; Cummings & Cockerham, 2004; Mitchell & Kemp, 2000; Wyrick et al., 2008). Qualitative findings suggest that RA may help form co-resident and staff-resident relationships (Harmer & Orrell, 2008; Kemp, 2008; Kluge et al., 2014; Lewinson et al., 2012; Park et al., 2012; Sandhu et al., 2013; Thomas et al., 2013; Yang & Stark, 2010). Similarly, quantitative analyses reported positive relationships between RA, perceived social support, social vitality, and social function (Cummings, 2002; Cummings & Cockerham, 2004; Horowitz & Vanner, 2010; Jenkins et al., 2002). However, some residents reported that RA facilitated interactions but did little to promote intimate relationships (Kemp et al., 2012, 2016; Sefcik & Abbott, 2014). Multiple studies suggest that RA positively relates to resident happiness, quality of life, and life satisfaction, and negatively relates to depression (Ball et al. 2000; Cummings, 2002; Cutchin et al., 2005; Horowitz & Vanner, 2010; Jang et al., 2014; Jenkins et al., 2002; McGuinn & Mosher-Ashley, 2001; Mitchell & Kemp, 2000; Park et al., 2017; Samus et al., 2006; Watkins, Walmsley, & Poling, 2017; Watson et al., 2006). However, in quantitative analyses, correlations often yielded small to moderate effect sizes, and RA was rarely a significant predictor of psychosocial variables after controlling for health and psychosocial variables (Park, 2009; Resnick et al., 2010b). Only three analyses reported that RA significantly predicted depression or life satisfaction in a multivariate model (Jang et al., 2014; Mitchell & Kemp, 2000; Ouyang et al., 2015). Multiple studies suggest that RA may promote additional individual outcomes including self-efficacy, self-determination, sense of self, self-growth, and continuing previous roles (Cruz, 2006; Hall & McAuley, 2011; Harmer & Orrell, 2008; Kemp et al., 2016; Kluge et al., 2014; Koehn et al., 2016; Križaj et al., 2016; Seipke, 2008; Thomas et al., 2013; Mahrs Träff et al., 2017). In addition, qualitative studies suggest that RA may help residents adapt and socially integrate into the AL community after relocation (Cutchin et al., 2005; Iwasiw et al., 1996; Jungers, 2010; Križaj et al., 2016). Although, other findings suggest that RA is an indicator of social integration, rather than an active contributor to the adaptation process (Kemp et al., 2012). Multiple studies also suggest that RA may simply provide residents with a source of entertainment, opportunity to combat boredom, or distraction for emotional struggles (Ball et al., 2000; Crenshaw et al., 2001; Cruz, 2006; Kennedy et al., 2005; Park et al., 2012; Mahrs Träff et al., 2017). RA may also relate to positive consequences for the social climate of the community. Multiple studies suggest that RA promotes a culture of engagement, community satisfaction, homelikeness, sense of belonging, helping behaviors, and social cohesion (Cruz, 2006; Hanson et al., 2014; Harmer & Orrell, 2008; Jungers, 2010; Kemp et al., 2012; Lewinson et al., 2012; Mitchell & Kemp, 2000; Park et al., 2012; Thomas et al., 2013). Conversely, other studies suggest that RA may be a venue for bullying and exclusionary behaviors (Kemp et al., 2012; Sandhu et al., 2013). It should be noted that previous research suggests that the aforementioned consequences likely vary by the type of RA (e.g., passive-active or group-solitary; Jenkins et al., 2002; Park et al., 2017; Phillips & Flesner, 2013). Discussion Describing the Literature This inaugural review of the scientific literature addressing RA in AL drew on studies from multiple disciplines. Although variation is expected across fields, the absence of guiding theoretical frameworks likely contributed to inconsistent construct definitions, measurement techniques, and findings. Few of the included studies defined RA in a consistent manner, and each research team utilized a different measurement protocol. The majority of studies measured RA participation as a single frequency count, and, in doing so, ignored activity-related constructs that can offer an in-depth analysis of resident activity profiles. Multiple studies alluded to, yet few captured in measurement, the distinction between RA that is self-initiated versus programmed. In AL research, differentiating between self-initiated and programmed RA in measurement may have implications for policy, staffing, and practice because, for example, if only high-functioning residents attend programmed activities, communities may consider adjusting physical design and programming to engage residents with a wide range of interests, motivations, and abilities. Additional activity-related factors that may enrich RA research include: engagement (i.e., a more active and involved construct than participation); activity demands; social context, including interindividual factors like group dynamics and others’ abilities; and physical context (e.g., common areas or private living areas; see Adams, Leibbrandt, & Moon, 2011; Levasseur, Richard, Gauvin, & Raymond, 2010; Nakamura & Csikszentmihalyi, 2014). Overall, future research should include activity-related variables in RA measurement, which may produce more detailed and translatable results. As mentioned, the field requires a consistent, applied, and comprehensive measurement tool. Nimrod and Shrira (2016) classify activity measurement into three categories: macro (i.e., frequency of participation), midway (i.e., participation in different categories of activity), and micro (i.e., participation in specific activities with varying features). Macro assessment can calculate overall RA participation rates, giving insight into resident physical, cognitive, and social stimulation. Midway assessment can differentiate between activity type (i.e., self-initiated or programmed), and micro assessment can assess engagement, activity demands, social context, and physical context for specific RAs. An ideal measurement tool would combine all three methods. Future research needs to develop and validate a measure of RA, for which these suggestions may serve as a guide. Describing RA Behaviors in AL Measurement limitations complicated efforts to establish general RA participation rates for AL residents. Overall, findings from the current review suggest that residents engage in mostly passive forms of RA, and, in general, report infrequent activity participation. This is consistent with previous research that suggests AL residents often fail to meet recommended levels of physical activity for older adults (Resnick et al., 2010a). A growing body of literature investigates interventions to increase physical stimulation (e.g., Function-Focused Care, FFC; Resnick, Galik, Gruber-Baldini, & Zimmerman, 2013); however, the current review suggests that residents may also be at risk for low levels of cognitive and social stimulation. Therefore, future research needs to assess and consider interventions to increase stimulation across multiple dimensions. An interesting finding from the current review is that proxy ratings differed from resident self-reports of RA participation. It is unclear whether this finding reflects measurement issues, intercommunity variability, social desirability by staff, or recall difficulties by residents. Future research is needed to investigate the validity of proxy (e.g., activity director, family, and nurses) and resident ratings of behavioral variables like RA in AL, particularly as large research initiatives often recruit staff to report behavioral variables in residential care settings. Findings from the current review suggest that residents participated in various types of RAs, many of which were stereotypical of an AL population (e.g., Bingo and cards). Although the list complied in Table 1 may not be comprehensive, it suggests that residents may have limited access to a range of novel RAs, which is consistent with resident critiques of recreational opportunities in AL (Lewinson et al., 2012). Future research is needed to assess whether the activities extracted in the current review are consistent across a representative sample of ALs, and congruent with resident preferences, interests, and abilities. These topics may be particularly salient in AL, as state policies require recreational offerings to meet residents’ preferences (Carder et al., 2015). However, residents report opportunities for RA often lacks personal interest, meaning, and-or value, and RA programming is consistently among the lowest rated services in AL (Crenshaw et al., 2001; Gesell, 2001; Gregory, Gesell, & Widmer, 2007; Harmer & Orrell, 2008; Sefcik & Abbott, 2014). Taken together, the field must devote research to assessing the quality of recreational opportunities in AL with the goal of designing programming around resident preferences, interests, and biopsychosocial needs. Major Findings Related to RA Participation This review identified multiple variables that may influence RA participation consistent with an ecological framework (i.e., individual, interindividual, and environmental factors). Figure 1 offers a schematic representation of variables that relate to RA. This theoretical model offers a framework for predicting, measuring, and identifying consequences of RA behaviors in AL, and can serve as a guide for future research. Temporally, the constellations of factors depicted in this model that influence RA occur in a common sequence driven by enduring individual characteristics (e.g., demographics), which influence the relocation process. Relocation to AL is a nonnormative life event that likely impacts individual, interindividual, and environmental factors, which interact to predict RA behaviors after the move. Future research needs to test the relationships proposed in the model presented in Figure 1. Figure 1. View largeDownload slide Model of RA in AL including potential predictors of RA behaviors, activity-related variables for measurement, and consequences of participation. Figure 1. View largeDownload slide Model of RA in AL including potential predictors of RA behaviors, activity-related variables for measurement, and consequences of participation. Variability within each ecological system suggests the need for a predicative model of RA behaviors that appreciates both a person-centered approach to individuals and consideration of differences in the sociophysical environment of ALs (e.g., physical design and social norms). This framework represents a shift in the literature from an “if you build it, they will come” mentality of RA, which often tested demographics, health, and availability of activities as the sole predictors of participation, to a more flexible model that captures the intricacies of human choice and behavior. This new approach is consistent with the model recently used by Dr. Resnick’s team investigating physical activity as FFC. Their model includes validated measurement of person-centered individual variables like outcome expectations, self-efficacy, attitudes, and social support for exercise, and flexible environmental variables like person-environment fit scales (Resnick et al., 2010a; Resnick et al., 2010b; Holmes et al., 2017). Due in large part to the aforementioned research program, there is a promising intervention plan in place to address low levels of physical activity in AL (i.e., FFC). However, these efforts are not universally implemented, nor have they been translated to other forms of RA (e.g., social group activities). As a result, the literature appears divided between primarily physical and nonphysical forms of RA, with more refined science devoted to research on physical activity. It is unclear, however, whether detailed studies assessing primarily nonphysical forms of RA exist but fail to appear in the literature due to nonsignificant findings (i.e., publication bias). Implementing consistent measurement protocols and theoretical frameworks, like the ones proposed in this paper, may address some inconsistencies observed in the field and enhance the scientific understanding of a wide range of RA behaviors in AL. Major Findings Related to Consequences of RA Findings from a small and inconsistent body of research suggest that RA participation may relate to consequences for AL residents and communities. Most consequences for residents related to psychosocial well-being and most consequences for the community related to social climate. Even though policy-makers and researchers often cite the benefits of RA in AL (e.g., CEAL, 2010; ICAA, 2009), few studies offered empirical support for positive consequences of participation, and RA was rarely a significant predictor of global constructs of well-being in multivariate models. Further, when significant, relationships between RA and wellness-related constructs (e.g., health and depression) often yielded small effect sizes. It is unclear whether these findings reflect methodological limitations discussed earlier in this paper or if RA has a modest role in explaining wellness-related variables. Future research is needed to test potential consequences of RA participation with specific attention given to activity-related mediators (e.g., activity demands). Future Research One of the primary goals of activities research is to guide practice. However, few studies included in the current review offered applied results or clinically relevant interpretations. This is particularly true of studies that assessed primarily nonphysical forms of RA. As the scientific literature progresses in its understanding of RA in AL, research needs to inform program development, physical design, policies, and interventions. This includes, but is not limited to, establishing an empirically based method for planning recreational offerings based on residents’ preferences, interests, and biopsychosocial needs; creating norms for resident physical, cognitive, and social stimulation; and assessing differences in participation, engagement, personal meaning, and activity demands between self-initiated and programmed RAs. Such studies may pave the way for meaningful clinical interventions targeting RA participation. Lastly, future research needs to test outcomes of specific RAs offered in AL using the activities and factors identified in the current review (e.g., experimental manipulation of Bingo with self-determination as an outcome). Conclusion A limitation of the current review is that the author excluded experimental studies in order to focus on describing naturally occurring RA behaviors in AL settings. As a result, this review cannot comment on specific outcomes of experimentally manipulated RA participation. Reviewing intervention studies may enrich recommendations to guide programming and activity-focused randomized control trials, and, thus, should be the focus of subsequent work. Another limitation is that studies included in this review may have not sampled residents representative of an AL population. Many studies used convenience-sampling techniques, and health-related inclusion criteria may have further biased resident samples. Despite these limitations, this paper culminates in a theoretical model of RA participation, measurement, and consequence that may serve as a guide for future research. Overall, the suggestions offered in this paper may help move the field toward a more sophisticated understanding of a broad scope of RA behaviors in AL, which may allow for translatable research that can guide service delivery and AL policy. Conflict of Interest None reported. Acknowledgments I would like to specially thank Dr. Sara Qualls, PhD, for greatly assisting in the preparation of this manuscript. References Adams, K. B. , Leibbrandt, S. , & Moon, H . ( 2011). A critical review of the literature on social and leisure activity and wellbeing in later life. Ageing and Society , 31, 683– 712. doi: 10.1017/S0144686X10001091 Google Scholar CrossRef Search ADS   Ball, M. M. , Perkins, M. M. , Whittington, F. J. , Connell, B. R. , Hollingsworth, C. , King, S. V. , … Combs, B. L . ( 2004). 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All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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The GerontologistOxford University Press

Published: Oct 7, 2017

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