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