Effect of Toileting Behavior on Daytime Non-sedentary Behavior in Nursing Home Residents

Article information

Ann Geriatr Med Res. 2024;28(4):460-468
Publication date (electronic) : 2024 August 21
doi : https://doi.org/10.4235/agmr.24.0085
1Geriatric Health Services Facility Gardenia Goshomi, Fujisawa, Japan
2School of Health Sciences at Odawara, International University of Health and Welfare, Odawara, Japan
3Department of Assistive Technology Science, Graduate School, International University of Health and Welfare, Tokyo, Japan
Corresponding Author: Satoshi Kubota, PhD, OTR School of Health Sciences at Odawara, International University of Health and Welfare, 1-2-25, Shiroyama, Odawara, Kanagawa 250-8588, Japan Email: satoshi@iuhw.ac.jp
Received 2024 March 29; Revised 2024 July 5; Accepted 2024 August 9.

Abstract

Background

Nursing home residents engage in lower levels of physical activity, primarily remaining seated or lying down, except for routine activities of daily living (ADLs). Since ADLs, particularly toileting, require effort. This study investigated the relationship between physical activity and toileting activity during the daytime among older nursing home residents.

Methods

The study involved 30 participants, including a group of healthy community-dwelling older individuals and two groups of nursing home residents with independent and non-independent toileting behavior, respectively. The physical activity of participants was measured with an accelerometer, and estimated metabolic equivalents, duration, and amount of physical activity were calculated.

Results

The amount of physical activity associated with toileting was significantly higher in the independent and non-independent groups than in the community group. Moreover, the amount of non-sedentary physical activity associated with toileting positively affected the amount of non-sedentary physical activity during the daytime. These findings suggest that toileting activity can contribute significantly to the physical activity of older nursing home residents.

Conclusion

Interventions focusing on improving toileting behavior among nursing home residents may positively impact overall physical activity and functional abilities.

INTRODUCTION

Frailty, characterized by decreased physical and cognitive functions due to aging and disease, as well as increased vulnerability to stress, is associated with increased mortality.1) Frailty has been suggested as a trigger for institutionalization2) and many nursing home residents are frail. A study conducted in 14 nursing homes in Australia reported that 75% and 19% of residents were frail and pre-frail,3) respectively, whereas another study reported rates of 43.8% and 38.4%,4) respectively. A systematic review reported a frailty prevalence of approximately 50% and a pre-frailty prevalence of 40% in care facilities for older adults, indicating the need for frailty interventions.5) Frailty is reversible and can be improved with appropriate physical and nutritional interventions. Exercise6-8) and increased physical activity are beneficial in this regard.9-13)

As their physical functions decline, older adults tend to become less physically active14-17) and more sedentary.18) Poor health, physical frailty, past sedentary lifestyle, fear of falling, and environmental limitations are barriers to physical activity among nursing home residents.19) They are less physically active than healthy older adults, showing reduced standing and walking activities20) and spending most of their days inactive, either lying down or sitting, with activities of daily living (ADLs) being their primary non-sedentary activities.21) Such sedentary behavior negatively affects physical health.22-24) Physical activities associated with ADLs may be important for nursing home residents who are inactive and rarely perform activities other than ADLs. Particularly, toileting requires effort25,26) and is related to health conditions, mobility, vision, hearing, and the ability to perform ADLs,27,28) indicating that multidimensional abilities are required. Consequently, toileting is a complex activity for older nursing home residents with considerable functional impairment.29,30) Toileting involves transfers, dressing, and increased standing time for nursing home residents, which may involve high-intensity motor activity. Although previous studies have reported the activities of nursing home residents during the day through observation21) and postural patterns using activity monitors,18) the amount of physical activity associated with toileting and the effects of toileting on the amount of physical activity during the day in this population remains less known.

While community-dwelling older adults can perform high-intensity activity and their physical activity during the day is not affected by toileting, for nursing home residents with declined physical function, toileting is a relatively high-intensity activity that is performed repeatedly, thereby influencing the daily physical activity level. Therefore, the impact of toileting on physical activity levels may be a unique characteristic of nursing home residents, potentially playing a crucial role in maintaining or increasing their daily physical activity. In this study, we analyzed the relationship between the amount of physical activity associated with toileting and the daily daytime amount of physical activity by comparing data with that of healthy community-dwelling older individuals to clarify the effects of toileting on daytime physical activity for older residents of a nursing home.

The primary objective of this study was to quantify and compare the impact of toileting behavior on daily physical activity levels among three distinct groups: community-dwelling older adults, independent nursing home residents, and dependent nursing home residents. We measured and compared the amounts of physical activity associated with toileting among these three groups, assessed the proportions of daily physical activity attributed to toileting in each group, and evaluated the relationship between toileting-related physical activity and overall daily physical activity levels. By comparing these groups, we sought to understand the unique characteristics of physical activity patterns in nursing home residents and highlight the potential importance of toileting activities as a means of maintaining or increasing physical activity levels in this population.

MATERIALS AND METHODS

We examined the relationship between physical activity and toileting behavior during daytime by measuring physical activity in community-dwelling older individuals and nursing home residents with independent or assisted toilet behaviors.

Participants

The participants were men and women aged ≥65 years, with 10 individuals in each of the following groups: community-dwelling, referring to healthy community-dwelling older individuals who were not working; facility-independent, referring to residents of the nursing home with independent toileting behaviors; and facility-dependent, referring to residents of the nursing home requiring assistance with toileting behaviors. Participants in the facility-independent and facility-dependent groups resided in a geriatric health service facility in Kanagawa Prefecture. The facility is a typical nursing home in Japan. The community-dwelling group comprised residents of Kanagawa Prefecture and initially included 13 individuals who signed consent forms; however, three of them were excluded because their physical activity could not be measured. Consent forms were initially signed by 11 and 12 individuals in the facility-independent and facility-dependent groups, respectively; however, one and two participants were excluded from each respective group due to poor health conditions.

We defined independent toileting behavior as not requiring assistance with toileting during the day, whereas assisted toileting referred to instances in which a caregiver guided or manually assisted a resident in the toilet at regular intervals. The insertion of suppositories by staff to control sudden bowel movements during the measurement period was not considered to be assistance. Furthermore, we did not include facility-dependent individuals who used bedpans with caregiver assistance. Both groups of nursing home residents were studied by the authors and primary physician at the nursing home to be able to safely administer the measurement device during the study.

Procedure

Physical activity and toileting behavior were measured using an accelerometer (Active-style Pro HJA-750C; Omron Healthcare, Kyoto, Japan) between 0900 and 1700 hours (480 minutes total) for seven consecutive days. An accelerometer was attached to the participant's waist using a belt. Physical activity was calculated every minute as metabolic equivalents of tasks (METs). A trail camera installed near the toilet door recorded the frequency and duration of toileting behavior, including opening and closing the door and entering and leaving the room. The duration between entering and exiting the toilet was defined as the time for one toileting behavior, from which the METs during the activity were calculated. Activity levels of community-dwelling individuals were measured from May or July 2019 to the end of September 2019, whereas the levels among facility-independent and facility-dependent individuals were measured from May, June, or August 2019 to the beginning of November 2019.

This study was approved by the Institutional Ethics Review Committee (Approval No. 18-lo-191). Written informed consent was obtained from all community-dwelling participants after they were provided adequate information regarding the study protocol, procedures, and risks, and the same was obtained from the families of nursing home residents. Also this study complied the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research.31)

Data Analysis and Statistics

Previous studies on sedentary and non-sedentary behaviors have defined 1.5 METs as the threshold for sedentary behavior.32,33) To analyze the association between toileting and daytime non-sedentary behaviors, we distinguished between sedentary and non-sedentary behaviors. However, separating the naps of participants in the present study was challenging. Therefore, we categorized behaviors with ≤1.5 METs, including napping, as sedentary behaviors.

We calculated the following metrics for the entire daytime measurement period: time spent engaging in sedentary behavior (SB_Day_Times), time spent engaging in non-sedentary behavior (Non-SB_Day_Times), average METs across all activities (Day_METs), and average METs during non-sedentary behavior (Non-SB_Day_METs). Day_METs represented the average METs for all activities (both sedentary and non-sedentary behaviors) throughout the day, whereas Non-SB_Day_METs represented the average METs for non-sedentary behaviors throughout the day. For toileting behavior, the number of times the toilet was used (Toilet_Frequency), time required for all toileting behaviors during the day (Toilet_Times), average METs during toileting behavior (Toilet_METs), time spent in non-sedentary behavior during toileting (Non-SB_Toilet_Times), and the mean value of METs for non-sedentary behavior during toileting (Non-SB_Toilet_METs) were calculated. The amount of physical activity was calculated as the product of METs and time. The amounts of daytime physical activity for sedentary and non-sedentary behaviors combined (Day_Activity) and non-sedentary behaviors alone (non-SB_Day_Activity) were also calculated. We additionally calculated the amounts of physical activity for toileting, including sedentary and non-sedentary behavior (Toilet_Activity) and non-sedentary behavior alone for toileting activity (Non-SB_Toilet_Activity). Finally, we calculated the ratios of SB_Day_Times to daily activity time (480 minutes) (Ratio_SB_Day_Times) and the ratio of Non-SB_Toileting_Activity to Non-SB_Day_Activity (Ratio_non-SB_Toilet).

We applied a linear mixed-effects model to compare the three groups for each measure, with the group as a fixed effect and random intercepts per individual to account for repeated measurements. Tukey's method and Cohen's d were used for pairwise comparisons between groups and estimating the effect sizes, respectively.

We analyzed the effect of toileting behavior on non-sedentary behavior during the day using regression analysis with a mixed model. For each group, a regression equation was calculated with non-SB_Day_Activity as the objective variable, non-SB_Toilet_Activity as the fixed effect, and individual differences as the random intercept.

We used Kenward–Roger method to estimate the degrees of freedom of the mixed model, with the significance level set at p<0.05. Statistical analyses were performed using the lme4, pbkrtest, lmerTest, and emmeans packages in R for Windows (version 4.2.2; https://www.r-project.org).

RESULTS

Table 1 presents the characteristics of the participants in each group. The community-dwelling group included 10 participants (1 man and 9 women), none of whom lived together. The individuals in the facility-independent and facility-dependent groups all resided in the same nursing home, with 10 participants in each group (facility-independent: 4 men and 6 women, 5 wheelchair users; facility-dependent: 2 men and 8 women, 10 wheelchair users). The community-dwelling individuals had few diseases, with no orthopedic conditions. Among the facility-dependent and -independent groups, some participants had multiple conditions including orthopedic, cardiovascular, and internal diseases. The ADL independence level of facility-dependent residents was lower than that of facility-independent residents, and the former required assistance with activities in addition to toileting.

Summary of participant characteristics

Table 2 presents the results of the descriptive statistics and inter-group comparisons for each group. All indicators of daytime physical activity showed a decreasing trend from community-dwelling to facility-independent to facility-dependent groups, with community-dwelling groups exhibiting significantly higher values compared to both facility groups—vs. facility-independent (Non-SB_Day_Times, p=0.0001; Day_METs, p=0.0001; Non-SB_Day_METs, p=0.0003; Day_Activity, p=0.0001; Non-SB_Day_Activity, p<0.0001); vs. facility-dependent (Non-SB_Day_Times, p<0.0001; Day_METs, p<0.0001; Non-SB_Day_METs, p<0.0001; Day_Activity, p<0.0001; Non-SB_Day_Activity, p<0.0001). In particular, the Non-SB_Day_Times was 229.63±83.10 minutes among community-dwelling individuals, whereas it was 99.28±39.10 and 52.19±38.65 minutes in facility-independent and facility-dependent residents, respectively, showing a difference in activity time of >2 hours.

Physical activity indices for each group and results of multiple comparisons

All indicators related to sedentary behavior time (SB_Day_Times and Ratio_SB_Day_Times) were the lowest in the community-dwelling group and significantly lower than those in the facility-independent and facility-dependent groups—vs. facility-independent (SB_Day_Times, p=0.0001; Ratio_SB_Day_Times, p=0.0001); vs. facility-dependent (SB_Day_Times, p<0.0001; Ratio_SB_Day_Times, p<0.0001). In particular, the ratios of sedentary behavior time (Ratio_SB_Day_Times) were 79.32%±8.15% and 89.13%±8.10% among facility-independent and facility-dependent residents, respectively, indicating that most of the daytime was spent in sedentary behavior, compared with 52.16%±17.31% among community-dwelling individuals.

The indicators of METs during toileting (Toilet_METs and Non-SB_Toilet_METs) were significantly higher in the community-dwelling group than in the two facility groups—vs. facility-independent (Toilet_METs, p=0.0166; Non-SB_Toilet_METs, p=0.0019); vs. facility-dependent (Toilet_METs, p=0.0004; Non-SB_Toilet_METs, p=0.0001). In particular, the Toilet_METs were 2.40±0.25 METs, 2.02±0.33 METs, and 1.83±0.26 METs in the community-dwelling, facility-independent, and facility-dependent groups, respectively.

The indicators of toileting frequency, toileting time, and physical activity during toileting were all highest in the facility-independent group and lowest in the community-dwelling group, with significant differences between the two groups (Toilet_Frequency, p=0.0421; Toilet_Times, p=0.0146; Non-SB_Toilet_Times, p=0.0059; Toilet_Activity, p=0.0085; Non-SB_Toilet_Activity, p=0.0073). The Toilet_Frequency, Toilet_Times, and Non-SB_Toilet_Times were 5.04±3.73 times, 34.52±35.27 minutes, and 22.85±17.98 minutes, respectively, among facility-independent residents, whereas they were 2.40±0.80 times, 6.23±2.31 minutes, and 5.49±2.08 minutes, respectively, among community-dwelling individuals, indicating that community-dwelling individuals spent only a short amount of time on toileting during the day. Furthermore, Non-SB_Toilet_Activity was 48.49±36.80 MET min and 26.31±16.76 MET min among facility-independent and facility-dependent residents, respectively, approximately 2–3 times higher than that in community-dwelling individuals (13.65±5.10 MET min). The ratio of physical activity during toileting to physical activity during daytime non-sedentary behavior (Ratio_non-SB_Toilet) was significantly lower in community-dwelling individuals than in facility-independent and facility-dependent residents (3.35%±2.13% vs. 24.84%±13.98%, p=0.0068; and 32.93%±20.64%, p=0.0003).

Table 3 shows the results of the regression analyses using linear mixed models. This revealed significant regression coefficients for facility-independent (1.12±0.49, p=0.0295) and facility-dependent (1.69±0.31, p<0.0001) residents, suggesting that Non-SB_Toilet_Activity affected Non-SB_Day_Activity. The intercepts of the regression analyses were significant for all groups, with community-dwelling individuals having the largest intercept at 512.43±71.51 (p<0.0001), approximately three and nine times than that of facility-independent and facility-dependent residents, respectively.

Estimated fixed and random effects in all linear mixed models

DISCUSSION

Our results suggest that toileting behaviors among nursing home residents may influence their overall daily non-sedentary physical activity levels.

Physical Activity and Toileting Behaviors

Both Day_METs and Non-SB_METs were lower in the facility-independent and facility-dependent residents than in the community-dwelling individuals. We observed a similar trend for Toilet_METs and non-SB _Toilet_METs. These results indicate that physical and cognitive declines make it difficult for residents of nursing homes to perform high-intensity physical activities.34,35) Toilet_METs, which represents the average METs during toileting activities, was >1.8 METs for both facility-independent and facility-dependent residents. Thus, a substantial portion of toileting activities constituted non-sedentary behavior for these nursing home residents.

The time spent toileting (Toilet-Time and Non-SB_Toilet_Time) was higher for facility-independent residents compared to community-dwelling individuals. This difference can be attributed to two factors: the higher Toilet_Frequency of facility-independent residents and the fact that facility-independent residents experience difficulties with multiple activities, including mobility, which requires more time. Urinary frequency may increase with age and dysfunction36,37); thus, facility-independent residents may show frequent toileting behaviors owing to declines in urinary function. However, the facility-dependent residents did not show a significantly higher frequency of toileting behavior than community-dwelling individuals. The limited Toilet_Frequency in facility-dependent residents may be due to their need for assistance and difficulty in active movement.

The mean values of Toilet Time and Non-SB_Toilet_Time differed minimally in community-dwelling individuals. In contrast, facility-independent and -dependent residents exhibited differences of >10 minutes and approximately 5 minutes, respectively. Residents of nursing homes may not sustain high levels of physical activity during toileting, leading to more sedentary behavior; however, toileting behavior still largely involved non-sedentary activities across all groups. Interestingly, light physical activity is linked to a lower risk of cognitive decline,38) and low-intensity exercise improves health.39,40) Thus, toileting behavior may offer residents of nursing homes the chance to engage in such activities.

Community-dwelling individuals showed significantly higher Non-SB_Day_Activity and lower Toilet_Activity and Non-SB_Toilet_Activity than facility-independent and facility-dependent residents. Notably, the relationships between Non-SB_Day_times, Toilet_Times, and Non-SB_Toilet_Times were also similar, suggesting that time affected the amount of physical activity. Moreover, the Ratio_non-SB_Toilet was >20% in both facility-independent and facility-dependent residents, indicating that toileting behavior accounted for a large proportion of daily non-sedentary behavior. Self-care activities such as toileting may be the primary source of non-sedentary behavior among residents of nursing homes, as they have functional limitations and do not typically perform household chores. In contrast, the Ratio_non-SB_Toilet was approximately 3% among community-dwelling individuals. As they can quickly perform toileting and engage in other high-intensity physical activities such as housework, leisure, and socializing, self-care activities such as toileting have minimal impact on non-sedentary behavior in community-dwelling individuals.

Sedentary Behavior

Facility-independent and facility-dependent residents exhibited longer SB_Day_Times than community-dwelling residents, with Ratio_SB_Day_Times >80%, indicating a predominantly sedentary lifestyle. This aligns with their extremely low Non-SB_Day_Activity, suggesting a deficit in non-sedentary behavior, a result consistent with previously reported findings.19,20) Compared with community-dwelling individuals, more residents of nursing homes had diseases (Table 1); physical impairments caused by these diseases may have influenced their sedentary behavior. The low level of ADL independence in facility-dependent residents, which prevented independent performance of many self-care activities, may further contribute to increased sedentary behavior. Given these findings, the time spent on non-sedentary behavior is crucial for residents of nursing homes, and further decline in non-sedentary behavior should be minimized. Interventions focused on increasing non-sedentary behaviors are critical for improving the health of this population.

Amounts of Daytime Physical Activity and Physical Activity of Toileting

The results of the regression analyses revealed that the coefficient for community-dwelling individuals was near zero, resulting in an almost flat regression line. The intercept was approximately 510, which closely matched the mean value of Non-SB_Day_Activity in this group. These results indicate that, among community-dwelling individuals, toileting behavior did not affect the amount of physical activity in non-sedentary behaviors during the day. In contrast, the regression coefficients of facility-independent and facility-dependent residents were approximately 1.1 and 1.7, respectively, and both were significant, indicating the positive influence of Non-SB_Toilet_Activity on Non-SB_Day_Activity. These results reflect the fact that Non-SB_Toilet_Activity was smaller than Non-SB_Day_Activity in community-dwelling individuals and larger than Non-SB_Day_Activity in facility-independent and facility-dependent residents, as toileting behavior in the latter groups accounted for >20% of daytime activity. Residents of nursing homes typically exhibit low activity levels with limited opportunities for activities beyond ADLs.21) Notably, toileting, an essential ADL, is reportedly impaired in >60% of nursing home residents.29) Toileting involves specific frequencies, transferring and moving, and skillful movements such as wiping, making it a multifunctional and complex activity. Thus, this behavior requires a relatively high level of physical functioning among residents of nursing homes.25,26,41). This population may increase its physical activity during toileting by repeatedly performing toileting, which requires many physical functions and affects the overall amount of daytime physical activity. As mentioned earlier, physical activity can effectively prevent and improve frailty.9-12,42) The present results suggest that toileting behavior may contribute to the maintenance and increase in non-sedentary behavior among residents of nursing homes. A previous study reported that an intervention that provided regular toilet use improved mobility endurance, strength, and incontinence.43) These findings, together with those of the present study, suggest that supporting toileting among residents of nursing homes may help improve not only physical function but also increase physical activity levels, which could lead to enhanced physical capabilities and frailty prevention.

Limitations

In this study, we performed measurements between 0900 and 1700 hours and did not include activities outside this period. As we did not record physical activity after waking, in the evening, and at night, the actual amount of daily activity and toileting behavior was likely higher. Thus, the most accurate measurement of the amount of daily physical activity requires consideration of physical activities performed at all hours.

Additionally, this study was conducted in a single nursing home with a small sample size, and we were unable to control for participant characteristics. Therefore, sampling bias was possible. Future studies with larger sample sizes and multiple nursing homes are needed to provide more robust evidence. In addition, multivariate analyses should be used to adjust for confounding factors.

Conclusion

The results of this study revealed that non-sedentary behaviors, particularly toileting activities, significantly influenced the daily physical activity levels of both independent and dependent nursing home residents. In contrast, toileting behavior had no discernible effect on the daily non-sedentary physical activity of community-dwelling older individuals. Notably, residents of nursing homes exhibited substantially more sedentary behaviors than their community-dwelling counterparts. These findings highlight the importance of toileting-related interventions as critical opportunities for maintaining and enhancing physical activity levels among residents of nursing homes. By focusing on this essential daily activity, care providers may be able to significantly improve the overall health of vulnerable populations.

Notes

We would like to thank the participants of the study, and Professor Sumiko Yamamoto and Professor Shinichiro Ishii for their valuable assistance.

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization, YN, SK; Data curation, YN, SK, TF; Formal analysis, SK, TF; Investigation, YN, SK; Methodology, SK, YN; Project administration, YN, SK; Supervision, SK; Writing–original draft, SK; Writing–review & editing, YN, TF.

References

1. Chang SF, Lin PL. Frail phenotype and mortality prediction: a systematic review and meta-analysis of prospective cohort studies. Int J Nurs Stud 2015;52:1362–74.
2. Lee H, Chong J, Jung HW, Baek JY, Lee E, Jang IY. Association of the FRAIL scale with geriatric syndromes and health-related outcomes in Korean older adults. Ann Geriatr Med Res 2021;25:79–85.
3. Milte R, Petersen J, Boylan J, Henwood T, Hunter S, Lange B, et al. Prevalence and determinants of physical frailty among people living in residential aged care facilities: a large-scale retrospective audit. BMC Geriatr 2022;22:424.
4. Ambagtsheer RC, Beilby J, Seiboth C, Dent E. Prevalence and associations of frailty in residents of Australian aged care facilities: findings from a retrospective cohort study. Aging Clin Exp Res 2020;32:1849–56.
5. Kojima G. Prevalence of frailty in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc 2015;16:940–5.
6. Cameron ID, Fairhall N, Langron C, Lockwood K, Monaghan N, Aggar C, et al. A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial. BMC Med 2013;11:65.
7. Cesari M, Vellas B, Hsu FC, Newman AB, Doss H, King AC, et al. A physical activity intervention to treat the frailty syndrome in older persons-results from the LIFE-P study. J Gerontol A Biol Sci Med Sci 2015;70:216–22.
8. Ng TP, Feng L, Nyunt MS, Feng L, Niti M, Tan BY, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med 2015;128:1225–36.e1.
9. da Silva Coqueiro R, de Queiroz BM, Oliveira DS, das Merces MC, Oliveira Carneiro JA, Pereira R, et al. Cross-sectional relationships between sedentary behavior and frailty in older adults. J Sports Med Phys Fitness 2017;57:825–30.
10. Morley JE, Flaherty JH. It's never too late: health promotion and illness prevention in older persons. J Gerontol A Biol Sci Med Sci 2002;57:M338–42.
11. Oliveira JS, Pinheiro MB, Fairhall N, Walsh S, Chesterfield Franks T, Kwok W, et al. Evidence on physical activity and the prevention of frailty and sarcopenia among older people: a systematic review to inform the world health organization physical activity guidelines. J Phys Act Health 2020;17:1247–58.
12. RoyChoudhury A, Dam TT, Varadhan R, Xue QL, Fried LP. Analyzing feed-forward loop relationship in aging phenotypes: physical activity and physical performance. Mech Ageing Dev 2014;141-142:5–11.
13. Song J, Lindquist LA, Chang RW, Semanik PA, Ehrlich-Jones LS, Lee J, et al. Sedentary behavior as a risk factor for physical frailty independent of moderate activity: results from the osteoarthritis initiative. Am J Public Health 2015;105:1439–45.
14. Brach JS, Simonsick EM, Kritchevsky S, Yaffe K, Newman AB, ; Health, Aging and Body Composition Study Research Group. The association between physical function and lifestyle activity and exercise in the health, aging and body composition study. J Am Geriatr Soc 2004;52:502–9.
15. Ikezoe T, Mori N, Nakamura M, Ichihashi N. Age-related muscle atrophy in the lower extremities and daily physical activity in elderly women. Arch Gerontol Geriatr 2011;53:e153–7.
16. Ikezoe T, Asakawa Y, Shima H, Kishibuchi K, Ichihashi N. Daytime physical activity patterns and physical fitness in institutionalized elderly women: an exploratory study. Arch Gerontol Geriatr 2013;57:221–5.
17. Meijer EP, Goris AH, Wouters L, Westerterp KR. Physical inactivity as a determinant of the physical activity level in the elderly. Int J Obes Relat Metab Disord 2001;25:935–9.
18. Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am J Epidemiol 2008;167:875–81.
19. Chen YM. Perceived barriers to physical activity among older adults residing in long-term care institutions. J Clin Nurs 2010;19:432–9.
20. Egerton T, Brauer SG. Temporal characteristics of habitual physical activity periods among older adults. J Phys Act Health 2009;6:644–50.
21. den Ouden M, Bleijlevens MH, Meijers JM, Zwakhalen SM, Braun SM, Tan FE, et al. Daily (In)activities of nursing home residents in their wards: an observation study. J Am Med Dir Assoc 2015;16:963–8.
22. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015;162:123–32.
23. Chastin SF, Ferriolli E, Stephens NA, Fearon KC, Greig C. Relationship between sedentary behaviour, physical activity, muscle quality and body composition in healthy older adults. Age Ageing 2012;41:111–4.
24. Owen N. Sedentary behavior: understanding and influencing adults' prolonged sitting time. Prev Med 2012;55:535–9.
25. Grimsland F, Seim A, Borza T, Helvik AS. Toileting difficulties in older people with and without dementia receiving formal in-home care-A longitudinal study. Nurs Open 2019;6:1055–66.
26. King EC, Boscart VM, Weiss BM, Dutta T, Callaghan JP, Fernie GR. Assisting frail seniors with toileting in a home bathroom: approaches used by home care providers. J Appl Gerontol 2019;38:717–49.
27. Talley KM, Wyman JF, Bronas UG, Olson-Kellogg BJ, McCarthy TC, Zhao H. Factors associated with toileting disability in older adults without dementia living in residential care facilities. Nurs Res 2014;63:94–104.
28. Yeung J, Jones A, Jhangri GS, Gibson W, Hunter KF, Wagg A. Toileting disability in older people residing in long-term care or assisted living facilities: a scoping review of the literature. J Wound Ostomy Continence Nurs 2019;46:424–33.
29. Jones AL, Sonnenfeld NL, Harris-Kojetin LD. Racial differences in functioning among elderly nursing home residents, 2004. NCHS Data Brief 2009;(25):1–8.
30. Yachnin D, Finestone H, Chin A, Jutai J. Can technology-assisted toilets improve hygiene and independence in geriatric rehabilitation? A cohort study. Disabil Rehabil Assist Technol 2018;13:626–33.
31. Noh JH, Jung HW, Ga H, Lim JY. Ethical guidelines for publishing in the Annals of Geriatric Medicine and Research. Ann Geriatr Med Res 2022;26:1–3.
32. Sedentary Behaviour Research Network. Letter to the editor: standardized use of the terms "sedentary" and "sedentary behaviours". Appl Physiol Nutr Metab 2012;37:540–2.
33. Tremblay MS, Aubert S, Barnes JD, Saunders TJ, Carson V, Latimer-Cheung AE, et al. Sedentary Behavior Research Network (SBRN): terminology consensus project process and outcome. Int J Behav Nutr Phys Act 2017;14:75.
34. Marmeleira J, Ferreira S, Raimundo A. Physical activity and physical fitness of nursing home residents with cognitive impairment: A pilot study. Exp Gerontol 2017;100:63–9.
35. Masciocchi E, Maltais M, Rolland Y, Vellas B, de Souto Barreto P. Time effects on physical performance in older adults in nursing home: a narrative review. J Nutr Health Aging 2019;23:586–94.
36. Huang Foen Chung JW, van Mastrigt R. Age and volume dependent normal frequency volume charts for healthy males. J Urol 2009;182:210–4.
37. Zhang Y, Wang XD, Song Y, Peng R, Tang T, Li M, et al. Epidemiology of frequent/urgent urination in older adults in China: a multicenter, cross-sectional study. Front Public Health 2021;9:669070.
38. Stubbs B, Chen LJ, Chang CY, Sun WJ, Ku PW. Accelerometer-assessed light physical activity is protective of future cognitive ability: a longitudinal study among community dwelling older adults. Exp Gerontol 2017;91:104–9.
39. Kopperstad O, Skogen JC, Sivertsen B, Tell GS, Sæther SM. Physical activity is independently associated with reduced mortality: 15-years follow-up of the Hordaland Health Study (HUSK). PLoS One 2017;12e0172932.
40. Kubota A, Ishikawa-Takata K, Ohta T. Effect of daily physical activity on mobility maintenance in the elderly. Int J Sport Health Sci 2005;3:83–90.
41. Farage MA, Miller KW, Berardesca E, Maibach HI. Psychosocial and societal burden of incontinence in the aged population: a review. Arch Gynecol Obstet 2008;277:285–90.
42. Borda MG, Perez-Zepeda MU, Samper-Ternent R, Gomez RC, Avila-Funes JA, Cano-Gutierrez CA. The influence of lifestyle behaviors on the incidence of frailty. J Frailty Aging 2020;9:144–9.
43. Schnelle JF, Kapur K, Alessi C, Osterweil D, Beck JG, Al-Samarrai NR, et al. Does an exercise and incontinence intervention save healthcare costs in a nursing home population? J Am Geriatr Soc 2003;51:161–8.

Article information Continued

Table 1.

Summary of participant characteristics

Characteristic Community-dwelling (n=10) Facility-independent (n=10) Facility-dependent (n=10)
Sex
 Male 1 4 2
 Female 9 6 8
Age (y) 75.3±7.2 82±8.7 88.5±10
Height (cm) 152.0±4.8 153.0±10.0 148.4±9.5
Weight (kg) 50.0±6.2 47.7±4.5 47.5±10.7
Barthel Index 100.00±0.00 82.50±8.90 43.50±24.84
Disease
 Fractures 3 5
 Osteoarthritis 1
 Heart failure 3 1
 Cerebrovascular disease 4 5
 Hyper tension 1 4 1
 Asthma 2
 Gastric cancer 1
 Diabetes 1
 Chronic nephritis 1
 Prostatic hyperplasia 1 2

Values are presented as mean±standard deviation.

Community-dwelling: healthy, community-dwelling older individuals. Facility-independent: older individuals with independent toileting behavior while residing in a nursing home.

Facility-dependent: older individuals requiring assistance with toileting behavior while residing in a nursing home.

Table 2.

Physical activity indices for each group and results of multiple comparisons

Item Description Community-dwelling (A) Facility-independent (B) Facility-dependent (C) p-value (effects size)
Between A & B Between A & C
SB_Day_Times Sedentary behavior times during the day (min) 250.4±83.10 380.7±39.10 427.8±38.65 0.0001 (4.54) <0.0001 (6.18)
Ratio_SB_Day_Times Ratio of sedentary behavior time (%) 52.16±17.31 79.32±8.15 89.13±8.10 0.0001 (4.54) <0.0001 (6.18)
Non-SB_Day_Times Non-sedentary behavior time during the day 229.63±83.10 99.28±39.10 52.19±38.65 0.0001 (4.54) <0.0001 (6.18)
Day_METs Mean METs during the day 1.68±0.25 1.30±0.12 1.16±0.10 0.0001 (4.75) <0.0001 (6.54)
Non-SB_Day_METs Mean METs of daytime non-sedentary behavior 2.25±0.12 1.99±0.17 1.86±0.08 0.0003 (3.89) <0.0001 (5.96)
Day_Activity Physical activity during the day (MET min) 805.7±119.90 625.0±59.76 556.8±49.37 0.0001 (4.75) <0.0001 (6.54)
Non-SB_Day_Activity Physical activity during the day for non-sedentary behavior (MET min) 524.48±208.86 200.56±87.79 96.67±72.11 <0.0001 (5.04) <0.0001 (6.65)
Toilet_Frequency Toileting frequency during the day 2.40±0.80 5.04±3.73 2.92±1.17 0.0421 (2.08)
Toilet_Times Total toileting time during the day (min) 6.23±2.31 34.52±35.27 17.81±8.27 0.0146 (5.25)
Non-SB_Toilet_Times Non-sedentary behavior time of total toileting time (min) 5.49±2.08 22.85±17.98 12.79±8.07 0.0059 (4.46)
Toilet_METs Mean METs during toileting (METs) 2.40±0.25 2.02±0.33 1.83±0.26 0.0166 (1.90) 0.0004 (2.87)
Non-SB_Toilet_METs Mean METs of non-sedentary behavior during toileting (METs) 2.52±0.20 2.17±0.25 2.06±0.13 0.0019 (1.98) 0.0001 (2.66)
Toilet_Activity Toileting physical activity (MET min) 14.51±5.12 64.09±56.68 32.59±16.41 0.0085 (4.95)
Non-SB_Toilet_Activity Physical activity of toileting non-sedentary behavior (MET min) 13.65±5.10 48.49±36.80 26.31±16.76 0.0073 (3.98)
Ratio_non-SB_Toilet Ratio of physical activity of toileting non-sedentary behavior (%) 3.35±2.13 24.84±13.98 32.93±20.64 0.0068 (13.65) 0.0003 (18.83)

Values are presented as mean±standard deviation.

Community-dwelling: healthy, community-dwelling older individuals.

Facility-independent: older individuals with independent toileting behavior while residing in a nursing home.

Facility-dependent: older individuals requiring assistance with toileting behavior while residing in a nursing home.

Table 3.

Estimated fixed and random effects in all linear mixed models

Community-dwelling Facility-independent Facility-dependent
Fixed effects Intercept Estimate (SE) 512.43 (71.51) 147.24 (33.90) 51.42 (17.66)
p-valuea) <0.0001 0.00062 0.012
Non-SB_Toilet_Activity Estimate (SE) 0.72 (2.11) 1.12 (0.49) 1.69 (0.31)
p-value 0.73 0.0295 <0.0001
Random effects Intercept Variance 41221 5403 2421
SD 203 73.5 49.2
Residual Variance 9942 2628 326
SD 99.7 51.3 18.1

SE, standard error; SD, standard deviation.

Community-dwelling: healthy, community-dwelling older individuals.

Facility-independent: older individuals with independent toileting behavior while residing in a nursing home.

Facility-dependent: older individuals requiring assistance with toileting behavior while residing in a nursing home.

a)

Calculated based on the Kenward-Roger method.