This is to our knowledge the first study exploring experiences of community-dwelling older people with dementia taking part in a person-centered multidimensional interdisciplinary rehabilitation program. The interpretation of the interviews was expressed as the overarching theme Empowered through participation and togetherness. Participants described that they were strengthened by facing individualized challenges during the rehabilitation. Mediated by the program, they gained insights about themselves and their condition, which motivated them to continue engaging in prioritized activities, but they also became concerned about how the future would turn out. Participation was experienced as a privilege and being seen made participation worthwhile. They described their experience of being part of the exercise group as togetherness in prosperity and adversity.
The participants in our study described being challenged in both exercise and daily activities as positive, which is in line with positive experiences of being challenged during exercise among people with dementia in nursing homes [45, 46]. Being challenged has also been described as a mediator of motivation to continue exercising in community-dwelling people with dementia . The importance of the challenges being individualized and achievable was also emphasized. Coping with challenges increased self-esteem and feelings of competence and being strengthened. Having something expected of you and being able to accomplish may result in improvement in mood and self-esteem . It may be important for health and well-being to feel that one can dare and cope with activities in daily life . Finding satisfaction in meaningful activities, has been emphasized in studies with people with dementia previously [49, 50]. Meaningful activities are those that one wants to do, has to do, or needs to do during the day  and being able to manage without feeling dependent on others may be of importance . Engagement in activities fills a void, enhances role identity, and helps people with dementia to express themselves positively . These factors may in turn provide control over self-identity, a critical attribute of selfhood that may endure during the course of the disease .
Our findings show that people with dementia can get new insights about themselves and their condition through rehabilitation. The participants gained insight that they were able to influence their situations. They realized that they had the ability to improve their physical status and ability in daily activities, and further, that they felt satisfied with themselves and their achievements when they came home after the rehabilitation session. Engaging in regular activities also affected their mood positively and being part of the rehabilitation group led to feelings of belonging . Having a sense of belonging, a social arena, being included in enjoyable and meaningful activities, and feeling supported [47, 56] have been described as important for the ability to cope with dementia , and may therefore positively influence health and well-being . The combination of the exercise and the social activity (drinking coffee together after), strengthened the feelings of belonging and well-being, which has been voiced before [56, 58]. Meeting people in the same situation and engaging in group activities provides opportunities for a great deal of encouragement. This is in line with our clinical experience and with a previous study in people with dementia in nursing homes . The finding that our participants realized that they were not alone in having dementia strengthened them in their situation . Additionally, engagement in group activities can trigger reflection and adaptation  and relationships with other group members and leaders seem to facilitate participation .
Although some of them were hesitant to participate at first, our participants gradually changed their minds and became positive to participation, which is similar pattern as the increased motivation seen during exercise over time in nursing home residents . People with dementia may need time to feel safe and embrace new activities and contexts . The participants expressed gratitude for being able to participate in and contribute to the rehabilitation and emphasized the importance of being invested in . This may have contributed to increased motivation and the willingness to make the most of the situation.
Participants in our study praised the professionals, whose responsiveness created security and support along with a welcoming atmosphere. This is in accordance with an activity center study, whose participants valued having the staff seeing them and treating them as normal people , and as earlier mentioned found it a motivator to engage in exercise . Professional characteristics are important for the success of exercise programs [45, 46] and the forming of a therapeutic alliance  is important, according to the authors´ clinical experiences. Physiotherapists participating in an exercise study on people with dementia noted the importance of the ability to take a flexible approach, to engage in personalized communication, and to build successful collaboration . The vast majority of professionals in this study all had experience of working with people with dementia, which probably contributed to the participants’ experiences of the program.
Although mostly positive experiences about the group setting and fellow participants emerged, perceived obstacles to interaction in groups due to their diverse needs were voiced. This might be difficult to overcome in a group with a progressive neurodegenerative disease. However, as suggested by some participants, the composition of groups with more consideration of function and ability, and a group composed of those in the early stage of the disease, needs further evaluation in the future. It seems important, however, that the professionals are supportive and apply their expertise to facilitate the communication in the group settings . The group setting also raised negative feelings and thoughts by, for example, comparison with fellow participants. Some participants expressed fear about their future situations, including the inability to perform activities later in life. Fear regarding the future, which may have been elucidated by rehabilitation, is important to consider when offering rehabilitation in this population.
The results show that people with dementia may be empowered through rehabilitation. According to the World Health Organization, patient empowerment is “a process through which people gain greater control over decisions and actions affecting their health”  building on core values, positive experiences, possibilities and capabilities rather than problems and symptoms. Being empowered may suggest having improved self-efficacy in one’s daily activities. Self-efficacy is the person’s belief in their ability to succeed in a specific task. It is a critical component of motivation and affects task choices, effort, persistence and achievement . The participants’ self-efficacy could have increased by successful management of activities in the rehabilitation program and in daily life, by watching fellow group members successfully perform exercises, and by leaders’ positive feedback and help to handle feelings . Being empowered can also be interpreted according to the self-determination theory (SDT), a theory of motivation applied in research topics such as physical activity and exercise [64, 65]. The rehabilitation program could have met participants’ essential psychological needs for optimal functioning according to the SDT: autonomy, competence, and relatedness. The person-centered approach with individual goals and the opportunity to leave home to participate in exercise might partly have satisfied the need for autonomy. By daring and coping, successfully managing exercise and activities, the participants may have gained a feeling of competence. The need for relatedness may have been satisfied by being part of a group led by skilled leaders. Altogether, such need fulfillment could have increased participants’ motivation and led to empowerment.
Some limitations of the study needs to be considered. When interviewing people with dementia, impaired memory and awareness of the disability might influence responses to questions. However, efforts were made to facilitate participants’ recall as the interviews were conducted in close conjunction with the rehabilitation visits, together with the use of recall cues. The sample was selected in the sense that all had agreed to participate in the study and all participants had a MMSE score of 15 and more, which would diminish the transferability to people with more severe dementia. The depth and richness of the conversations showed that the participants were able to reflect on and describe participation in the rehabilitation program. Considering participants’ experiences is of great importance when evaluating rehabilitation in general and for people with dementia in particular.