Exercise Space Planning and Design for an Aging Society: A Case Study of Space, Exercise Behavior, and Cognitive Function of Older Women in Taiwan

Tzu-Yuan Stessa Chao and Yun Chou

Introduction

Because the global population is aging, the number of people with dementia is steadily increasing. People with dementia have higher mortality rates and shorter survival times. According to the World Alzheimer Report 2015 (Alzheimer’s Disease International — ADI 2015), there were 46.8 million people with diagnosed dementia in 2015. This number is estimated to reach 74.7 million by 2030 and 131.5 million by 2050 (ADI 2015). Also, the average prevalence of dementia in adults aged over 60 is 4.7% in Asia, 5.9% in Europe, 6.4% in America, and 4.6% in Africa. Dementia shortens the lives of patients. Although the independent contribution of dementia to mortality is difficult to assess, people with dementia often have comorbid health conditions and diseases related to dementia. In Taiwan, the prevalence of dementia in people aged 65 or over was 4.97% in 2013 (Taiwan ADI 2013). As shown in Table 9.1, the proportionate increases in Taiwan will be 84% between 2015 and 2030, and 240% between 2015 and 2050. Thus, the number of elderly people with dementia is increasing rapidly in Taiwan and will soon present serious challenges to the medical and long-term care sectors. Mild cognitive impairment (MCI) is considered to be the transitional phase between normal cognitive function and dementia, and is sometimes considered early-stage dementia. According to clinical researchers, 10%—15% of people with MCI will further degrade into dementia every year. This proportion is ten times higher than that of the population in the same age cohort without MCI. They are considered as a high-risk group for dementia (Chen et al. 2006; Petersen 2011).

Because the average life expectancy of females is longer than that of males, females comprise a significant majority of the elderly population (United Nations 2014). Accordingly, the prevalence of dementia as well as MCI is higher in women than in men (ADI 2015). This was confirmed by

Table 9.1 Proportionate increases of dementia patients in four continents and Taiwan

Year

America (%)

Europe (°/o)

A frica (%)

Asia (%)

Taiman (%)

2015-2030

67

28

74

69

84

2015-2050

216

78

291

194

240

Source-. Adapted from ADI (2015); Taiwan ADI (2013).

Table 9.2 The prevalence of MCI and dementia in people aged 65+ by gender in Taiwan

Age

MCI (%)

Dementia (%)

Male

Female

Total

Male

Female

Total

65—69

10.74

16.50

13.92

3.74

3.21

3.40

70-74

13.18

19.20

16.43

2.37

4.39

3.46

75-79

17.45

26.02

21.95

5.36

8.85

7.19

80-84

20.62

26.40

23.47

10.37

15.78

13.03

85-89

23.75

29.18

26.24

15.57

29.41

21.92

90

23.63

21.67

22.60

26.93

45.81

36.88

Standardized age

15.57

21.63

18.76

6.36

9.71

8.04

Source: Taiwan ADI (2013) data.

the results of an official dementia survey by the Executive Yuan, Taiwan, in 2013 (Table 9.2). At present, there are no effective treatment or intervention strategies for dementia patients. However, according to many studies, some approaches have proven to be effective in slowing the rate of degradation in dementia patients in the early stages of the disease. For instance, encouraging greater exercise intensity in older adults at the stage of MCI is highly recommended to mitigate related medical and long-term care costs (Chen et al. 2006). This chapter reports the results of face-to-face questionnaires conducted with 301 women aged over 60 in four communities in Tainan City to explore their exercise habits and cognitive levels and to further understand their preferences of an ideal exercise space. It also explores practical approaches to building a healthy built environment for an aging society by planning appropriate exercise spaces.

Dementia Prevention and Exercise Behavior

Several approaches have been proven to be effective for enhancing cognitive function and lowering the risk of MCI in older adults, including diet control, regular exercise, and cognition training (Kivipelto and Hakansson 2017). Many studies (Huang et al. 2013; Kramer et al. 2011) have indicated that practicing aerobic exercise can increase the volume of cerebral white matter and gray matter and promote cerebral blood flow. The higher the intensity of aerobic exercise, the greater the positive effects. Some studies have indicated that undertaking aerobic exercise for more than four hours per day or more than twice a week regularly can effectively reduce the risk of dementia by approximately 50% (Huang et al. 2013; Rovio et al. 2005). Even though today most elderly people generally acknowledge the importance of physical activity, a significant number do not engage in regular exercise. Many elderly people may be unable or unwilling to exercise at a higher intensity. Yet, in fact, even walking can reduce the risk of cognitive impairment. Raji et al. (2010) found that healthy elderly individuals or those with MCI and Alzheimer’s disease had less damage to brain structure and volume as a result of walking more.

Both personal factors and external environmental factors affect the exercise behavior of elderly people (Boyette et al. 2002; Chen et al. 2006; Sherwood and Jeffery 2000). In the case of personal factors, exercise habits play a significant role in affecting the exercise behavior of elderly people. The exercise habits of elderly people involve deciding the way, time, and the place in which they exercise. Both Addy et al. (2004) and Chen et al. (2006) indicated that well-designed, accessible open spaces and exercise facilities in urban areas have a strong positive correlation with regular exercise behavior. Accordingly, a supportive environment can have a significant positive impact on people’s behavior, especially their physical activity behavior. Generally, elderly women participate in lower intensity physical activities and exercise less frequently than elderly men

(Moschny et al. 2011; Tsai et al. 2009; Yeh 2013). This may be because elderly women are more involved in household activities and have a fragmented daily schedule. In terms of exercise space preference, according to Hsieh et al. (2010), a convenient, accessible exercise space is especially important to elderly women.

Urban Exercise Spaces

In an urban area, the quality, quantity, and distribution of exercise spaces are usually decided through urban planning and the urban design processes following urban planning ordinances. According to a research report on the movement policies for the elderly in Taiwan released by the Taiwan Sports Administration in 2010, the main obstacles to elderly exercise are a lack of suitable exercise spaces and the fact that most elderly people prefer to exercise in or near their home (Sports Administration, Taipei Ministry of Education 2010). The distance from one’s home to exercise spaces has significant impacts on the amount and frequency of exercise in older people (Webster et al. 2015). Hence, the distribution of exercise spaces is an important factor affecting whether the elderly will exercise. It is also important to increase older people’s awareness of available exercise spaces. Elderly women can exercise for longer than elderly men once they develop regular exercise habits (Moschny et al. 2011; Sports Administration, Taipei Ministry of Education 2010). Therefore, in view of elderly women’s higher risk of dementia, the first task in promoting their exercise behavior is to improve their willingness to participate.

Major factors affecting elderly women’s exercise willingness include self-rated body functions, social support systems, weather, exercise spaces, and community environment (Chad et al. 2005; Chen et al. 2006; Chiu 2009; Lui 2008; Moschny et al. 2011; Sherwood and Jeffery 2000; Tsai et al. 2009; Yeh 2013). It may be difficult for a spatial planner to change the exercise habits of elderly people; however, it is possible to reduce environmental obstacles to exercise in this population and to promote exercise by modifying the distribution of exercise spaces or improving the attractiveness of such spaces to elderly women. In terms of designing an exercise space that appeals to elderly women, good accessibility and quality amenities are very important. In addition, improving the safety and aesthetics of exercise spaces will certainly increase users’ willingness to exercise (Ball et al. 2001; Chen et al. 2006; Hsieh et al. 2010). Studies have confirmed that smooth pavements, well-maintained sidewalks, and road trees may also increase preferences related to physical activities (Addy et al. 2004; Chen et al. 2006; Pikora et al. 2006; Webster et al. 2015).

In terms of environmental settings, public and exercise spaces with multiple functions may be more attractive to older adults since they may like the idea of fulfilling many goals, such as sightseeing and visiting friends in one trip to a park. Sugiyama et al. (2009) and Webster et al. (2015) further emphasize the importance of walkable environments since elderly adults will gain the benefit of exercise on their way to open spaces by walking.

Clearly, creating a supportive, inclusive environment that could promote physical activities in older people, and, in turn, slow down the degradation from MCI to dementia, is essential in an aging society. As a legally authorized tool, urban planning can actively respond to this urgent need based on the users’ actual needs and preference. Most spatial design research in the past has tended to focus on interior design elements for dementia patients from the perspective of long-term care services instead of providing a supportive environment intended to prevent dementia. Hence, more field studies on the people-environment relationship are needed involving cross-disciplinary research methods and proposed systematic approaches at the neighborhood level from an urban planning perspective. Accordingly, in the case study discussed in the next section, we explore the exercise behavior of elderly women with MCI using a questionnaire survey to collect demand information from users.

Case Study: Tainan City, Taiwan

Given the knowledge gap between supply and demand for exercise spaces in an aging society, and the fact that elderly women are the population cohort with the highest risk of dementia and the least regular exercise behavior, we selected women aged over 60 as our research target group. While many studies have focused on exercise space design and the workout behavior of users, few have discussed the degradation of cognitive functions of older adults from the perspective of prevention. Hence, this study is based on empirical research results identifying elderly women with MCI in more than 100 communities in Tainan City in a pilot study conducted by the Research Center for Humanities and Social Science at the National Cheng Kung University from 2012 to 2014. This was the first field study in Taiwan intended to identify possible dementia patients at the MCI stage (Table 9.3). We selected communities with a higher proportion of elderly women with MCI and more women over the age of 60 in the pilot study as our survey sites. In addition, we selected the two communities with the most exercise space per capita and the two communities with the least exercise space per capita, to conduct a second questionnaire in order to further explore older peoples use behavior and perceptions of public exercise spaces as provided by urban planners. The term ‘exercise spaces’ was defined as stadiums, playgrounds, parks, plazas, and green spaces provided by the public sector through urban planning.

Table 9.3 Information on survey communities

Community

Total population

Females aged over 60

Exercise spaces (m~)

MCI pilot study results

Male

Female

Total

Amount

Ratio (%)

Coverage

Area per capita

MCI proportio (%)

No. of n study

North District

Shen-an

618

614

1,232

204

33.22

582,772

473.03

77.78

18

North District

Ran-ai

967

1,071

2,038

295

27.54

934,396

458.49

75.00

8

Yung Kang

Chen-

1,162

1,246

2,408

349

28.01

203,185

84.38

60.87

23

District

South District

kung Jing-hua

2,865

3,064

5,929

765

24.97

360,717

60.84

58.62

29

Source: Adapted from Annan District Household Registration Office (HRO) (2017); East District HRO (2017); North District HRO (2017); South District HRO (2017); West Central District HRO (2017); Yongkang District HRO (2017); National Land Surveying and Mapping Center (2007); Wang (2014).

This study was approved by the National Cheng Kung University Human Research Ethics Committee. Questionnaires were conducted face-to-face from March to May 2017 in public spaces within a 700-meter periphery of the four community centers. Due to the limitation of time and difficulty of selecting older adults, convenience sampling was used. A total of 310 valid samples were collected in four communities with a <95% confidence level and a sampling error of (±)5%.

 
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