Exercise can promote physical, psychological and social health in older people.1 Despite the benefits of exercise for older people, those living in long-term care facilities remain largely inactive because of low exercise self-efficacy and a fear of falling (FOF), with 40% to 70% of long-term care facility residents reporting a FOF.2, 3, 4 A FOF is a person's anxiety towards usual or normal walking or ambulation, with the perception that a fall will occur whether or not there has been a fall experience in the past.2 Exercise self-efficacy refers to an individual's self-perceived abilities and willingness to exercise.5 FOF and low exercise self-efficacy may reduce the level of exercise participation, which may then reduce social interactions and further lead to a reduction in physical function and self-care ability, depression, and worse quality of life. This subsequently becomes a vicious circle of FOF, low self-efficacy, reduced physical activity, and poor physical, psychological and social function.2,4 To promote exercise in older people, it is important to decrease a FOF, improve exercise self-efficacy and consequently improve physical function, especially among older people living in long-term care facilities.6

Promoting adherence to exercise in older people cannot be just about teaching exercise, it needs to start from a psychological level.2,7 Mindfulness-based interventions can effectively stabilize a psychological state and re-establish the ability to exercise.8,9 Mindfulness is commonly defined as a compassionate way of knowing and being aware in the present moment without judgment.10 The founder of mindfulness-based stress reduction, Kabat-Zinn, was the first to apply mindfulness-based interventions to athletes. Practicing mindfulness-based interventions has been shown to help athletes to perceive and identify emotions without evaluating or coexisting with them, and then through the usual practice of mindfulness techniques to focus all awareness on the present, to further improve a flow state and achieve their best performance. If mindfulness can be combined with exercise, it can not only improve physical function, but also improve mental health and make exercise more efficient.9,11

Mindfulness-based interventions are a suitable activity for older people, and they have been shown to lead to improvements in executive function and depression.12,13 The second character of the Chinese word for mindfulness (正念) represents the “present mind” (今心), and mindfulness (正念) means putting the mind in the present moment. Connecting mindfulness and exercise emphasizes focusing on the present moment of the exercise, so as to improve concentration and focus on the contraction and relaxation of muscles during exercise and increase the sensation, which can increase exercise effectiveness.11,14 Mindfulness-based exercises include "Outer Wisdom" and "Inner Wisdom".15 Outer wisdom is the knowledge of motion. Inner wisdom enables the individual to perceive the body's response and regulation of movement through the practice of mindful behavior.15 Mindfulness can help older people to be aware of their own behavior, and then put aside past unhealthy habits and change their behavior with an accepting and non-judgmental attitude, calmly face the world in which they live, and focus on living in the present, thereby reducing emotional responses (ie, FOF) and increasing confidence in exercising.16 In addition, improving the psychological barriers of exercise and increasing self-confidence, so as to promote individual exercise, can improve the physical function of older people. Dynamic balance and muscle strength are important physical functions which can prevent falls.17 To the best of our knowledge, no mindfulness-based exercise programs have been proposed for older people to reduce a FOF and improve exercise self-efficacy and physical function. Therefore, the aim of this study was to develop and assess the effectiveness of a mindfulness-based exercise program in older residents of a long-term care facility in Taiwan. We hypothesized that older people exposed to a mindfulness-based exercise program would demonstrate improvements in psychological outcomes (i.e., FOF, exercise self-efficacy) and physical function (i.e., dynamic balance and muscle strength) when compared to those who are exposed to routine care.