Applicability and Effects of Physical Exercise on Physical and Cognitive Functions and Activities of Daily Living Among People With Dementia: A Systematic Review

Effects of aerobic exercise on cognitive function and quality of life in patients with Alzheimer's disease: a systematic review and meta-analysis

OBJECTIVES

Numerous studies have examined the effects of physical activity on cognitive performance and executive function in people with Alzheimer's disease (AD), although the findings are not entirely consistent. There are also insufficient study reviews for specific workout and assessment tool types. Therefore, the purpose of this study was to systematically investigate the effects of aerobic exercise on the quality of life, cognitive performance and depressive symptoms in people with AD.

DESIGN

Risk of bias was assessed using the Cochrane risk of bias tool, systematic reviews and meta-analyses using random-effects modelling, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation tool.

DATA SOURCES

PubMed, Web of Science, Cochrane Library, EMBASE, Scopus, CINAHL and CNKI through 12 March 2024.

ELIGIBILITY CRITERIA

The analysis includes all randomised controlled trials (RCTs) that used aerobic exercise as an intervention for individuals with AD.

DATA EXTRACTION AND SYNTHESIS

Two writers selected and searched for data using defined techniques. To investigate possible sources of heterogeneity between studies, meta-regression was carried out using Stata MP V.18.0 and V.14.0 software, standardised mean differences (SMDs) and 95% CIs were computed, and data were reviewed using Review Manager V.5.4 software, which was made available by the Cochrane Collaboration. Sensitivity analyses were employed to ascertain the stability and reliability of the results, and funnel plots and Egger's test were employed to check for publication bias. Correction and assessment of publication bias was done using Duval and Tweedie clipping methods.

RESULTS

Aerobic exercise enhanced cognitive function. For the Minimum Mental State Examination (MMSE) (SMD=0.95, 95% CI 0.58 to 1.32, Z=5.06, p<0.00001), Alzheimer's Disease Assessment Scale-Cognitive Section (ADAS-cog) (SMD=-0.67, 95% CI -1.15 to -0.2, Z=2.77, p=0.006) and quality of life (SMD=0.36, 95% CI 0.08 to 0.64, Z=2.51, p=0.01), but not statistically significant for depressive symptoms (SMD=-0.25, 95% CI -0.63 to 0.13, Z=1.27, p=0.21). Subgroup analysis showed that duration greater than 16 weeks and less than 50 min per intervention improved MMSE Scores. Duration greater than 16 weeks and more than 30 min per intervention improved ADAS-cog Scores in patients with AD. Aerobic exercise greater than 16 weeks, with more than three interventions per week and 30-50 min per intervention improves quality of life in patients with AD.

CONCLUSION

The study revealed that aerobic exercise was conducive to the improvement of cognitive function and quality of life among patients with AD, yet it did not exert a significant impact on the amelioration of depressive symptoms. Nevertheless, given the high level of heterogeneity and the variations in the quality of the included studies, the conclusions require further verification through more scientifically objective RCTs.

PROSPERO REGISTRATION NUMBER

CRD42024526067.

A Qualitative Study Investigating Health Care Professionals' Views on Barriers to Integrating Physical Activity Into Mild Cognitive Impairment/Dementia Care

This study aimed to investigate health care professionals' (HCPs) views on barriers to integrating physical activity (PA) into mild cognitive impairment/dementia care. Semistructured online interviews form 16 HCPs were completed between November 2022 and December 2022. Data were subjected to thematic analysis and were later mapped deductively to the Theoretical Domains Framework. Four themes were identified: (1) "Dementia-inclusive infrastructure or PA recommendations have not yet been systematically developed and implemented;" (2) "Roles and challenges of the multidisciplinary team;" (3) "HCPs believe that patients' PA participation is influenced by their disease or individual factors;" and (4) "HCPs' thoughts on current practice and opinions." Deductive mapping of these themes revealed that 13 of the 14 Theoretical Domains Framework domains influenced it. Integrating PA into mild cognitive impairment/dementia care is subject to several modifiable determinants. Policymakers should focus on improving the environmental context and resources to encourage PA in mild cognitive impairment/dementia.

Characteristics and Effectiveness of Physical Therapist-Supervised Exercise Interventions for Nursing Home Residents With Dementia: A Systematic Review

Background and Objectives

Although physical therapy, in particular exercise therapy, is widely used in nursing home residents with dementia, the literature on this topic is relatively scarce. This systematic review aimed to summarize the literature on the characteristics and effectiveness of exercise interventions supervised by physical therapists in nursing home residents with dementia.

Research Design and Methods

Six electronic databases were systematically searched for relevant studies up to August 17, 2022. Randomized controlled trials (RCTs) comparing exercise interventions supervised by a physical therapist to any other form of intervention or usual care in nursing home residents with dementia were selected. Data were narratively analyzed and forest plots visualizing exercise effects were created.

Results

From the 1 377 records retrieved and screened, 6 RCTs, reported in 11 papers, met the selection criteria. Included studies used multimodal or aerobic exercise interventions, with the frequency, duration and intensity varying across studies. Three of the 6 studies were at high risk of bias. Due to inconsistency in the findings and variety in outcome measures, results on the effectiveness of the interventions are inconclusive.

Discussion and Implications

Our review emphasizes the need for more robust studies to offer understanding of the efficacy of exercise interventions supervised by physical therapists for nursing home residents with dementia.

Occupational Therapy Interventions to Improve the Quality of Life of Older Adults with Dementia Living in Nursing Homes: A Systematic Review

The increase in older adults with dementia presents challenges in promoting research to improve the quality of life of this population. The objective of this study was to assess the scientific evidence on the effectiveness of occupational therapy interventions in improving the quality of life of older adults over 65 years old with dementia living in nursing homes. The databases used were PubMed, Web of Science, OTSeeker, clinicaltrials.gov, Dialnet, Scopus, Cochrane, and SciELO between 2013 and 2023. The studies were selected and evaluated according to the Cochrane guidelines. The review was carried out following the PRISMA 2020 Statement. Sixteen articles met the inclusion criteria and were categorized into four groups according to the focus of the intervention: "meaningful activities/occupations", "physical, cognitive and sensory functioning", "performance areas", and "physical and social environment and staff training". The strength of evidence was moderate, and the risk of bias was low. The findings revealed that occupational therapy interventions based on participation in recreational activities, reminiscence, performance-based activities and the physical and social environment, and specialized staff training, could improve the perceived quality of life of older adults with dementia living in nursing homes.

Balance-based exercise programs on balance in older adults with mild to moderate dementia: A critically appraised topic

OBJECTIVE

It is well established that exercise programs including balanced-based exercises are practical and beneficial for cognitively healthy older adults. However, there is limited evidence to determine if these types of training regimens are effective for individuals with dementia. We conducted a critical appraisal to determine if the addition of balance-based exercise programs, compared with usual care at residential homes, improved balance in adults diagnosed with mild to moderate dementia.

MATERIALS AND METHODS

Four databases were searched for randomized control trials implementing balanced-based exercise programs with individuals diagnosed with mild to moderate dementia. The articles were evaluated based on the Centre for Evidence Based Medicine level of evidence criteria and appraised using the PEDro scale.

RESULTS

A comprehensive literature search revealed four studies relevant to the clinical question that fit the inclusion and exclusion criteria. All four studies indicated an improvement in balance following a weekly physical therapy program implementing balance-based exercises.

CONCLUSIONS

There is sufficient evidence to suggest that the use of physical therapy programs that include balance-based exercises, performed 1-2 times a week over the course of 12-25 weeks, improves balance in elderly adults with mild to moderate dementia.

Barriers and motivators to promotion of physical activity participation for older adults with mild cognitive impairment or dementia: An umbrella review

BACKGROUND

Due to the growing aging population worldwide, cognitive disorders including mild cognitive impairment and dementia is considered a major public health priority. Currently, physical activity is a promising non-drug therapy, however, people with mild cognitive impairment or dementia are more likely to be physically inactive.

OBJECTIVE

To identify the barriers and motivators affecting participation in physical activity in older people with mild cognitive impairment or dementia.

DESIGN

An umbrella review.

METHODS

The Joanna Briggs Institute (JBI) methodology for umbrella reviews was adopted in this study. We searched the PubMed, Embase, Web of science, CINAHL, Cochrane, Scopus and Proquest to identify relevant articles published in English from inception to October 2022. Two researchers independently screened and selected articles against preselected inclusion criteria. Eligible studies were appraised for methodological quality using the combined Meta Quality Appraisal Tool and Assessment of Multiple Systematic Reviews Tool. The Grading of Recommendations Assessment Development and Evaluation- Confidence in the Evidence from Reviews of Qualitative Research tool was employed to determine the confidence level in the evidence of the extracted factors. Theoretical Domain Framework (TDF) was used to map barriers and motivators to physical activity participation. Behavior change techniques (BCTs) was utilized to develop theoretically-informed implementation strategies.

RESULTS

Fourteen relevant reviews (covered over 219 primary studies) were included in this review. A total of 31 factors were identified from the selected reviews. Three factors with the strongest supporting evidence for their influence on participation were: resources/material resources, social support, and perceived competence. According to the behavior change techniques, six implementation strategies (providing supervision, developing tailored interventions, providing safe and promoting environment, helping to increase participants' motivation and adherence, integrating all kinds of social support, and providing suitable staffing) were developed.

CONCLUSIONS

The evidence presented in this umbrella review suggests that a multilevel stakeholder approach and a system-wide viewpoint should be adopted. Through the Theoretical Domain Framework, we not only identified construct factors for future interventions, but also revealed understudied fields in this research areas. This umbrella review generates data that is expected to inform the development of implementation strategies based on the intervention-mapping approach, which will promote participation in physical activity.

REGISTRATION

This study was registered with the PROSPERO (CRD42022371535).

Long-Term Effectiveness of Physical Exercise-Based Swallowing Interventions for Older Adults with Dementia in a Day-Care Center

Swallowing safety is one of the top health concerns of dementia. Coughing and choking (coughing/choking) are signs of impaired swallowing safety. This study aimed to investigate the effectiveness of regular physical exercise-based swallowing intervention for reducing coughing-choking at the dementia day-care center. This was a retrospective analysis with data from medical records, including age, the clinical dementia rating (CDR), and the frequencies of coughing/choking in ten days (10-day coughing/choking). Those who complied with the exercise programs were assigned to the exercise-based group (n = 22), and those who could not comply were assigned to the non-exercised-based group (n = 7). The non-exercised-based group showed more advanced age and higher CDR than the exercise-based group (p < 0.05). The 10-day coughing/choking showed significant decreases at the 5-month and 19-month in the exercise-based group and at the 5-month in the non-exercise-based group (p < 0.05). Our findings suggested that regular physical exercise-based swallowing intervention effectively alleviated coughing/choking problems of older adults with dementia and its effectiveness was long-lasting. For those who could not comply with exercise programs, noticeably with more advanced age and dementia, the effective swallowing intervention period was short-term.

The Effects of Exergaming on Executive and Physical Functions in Older Adults With Dementia: Randomized Controlled Trial

BACKGROUND

Despite increasing interest in the effects of exergaming on cognitive function, little is known about its effects on older adults with dementia.

OBJECTIVE

The purpose of this is to investigate the effects of exergaming on executive and physical functions in older adults with dementia compared to regular aerobic exercise.

METHODS

In total, 24 older adults with moderate dementia participated in the study. Participants were randomized into either the exergame group (EXG, n=13, 54%) or the aerobic exercise group (AEG, n=11, 46%). For 12 weeks, EXG engaged in a running-based exergame and AEG performed a cycling exercise. At baseline and postintervention, participants underwent the Ericksen flanker test (accuracy % and response time [RT]) while recording event-related potentials (ERPs) that included the N2 and P3b potentials. Participants also underwent the senior fitness test (SFT) and the body composition test pre- and postintervention. Repeated-measures ANOVA was performed to assess the effects of time (pre- vs postintervention), group (EXG vs AEG), and group×time interactions.

RESULTS

Compared to AEG, EXG demonstrated greater improvements in the SFT (F_1.22=7.434, P=.01), reduction in body fat (F_1.22=6.476, P=.02), and increase in skeletal mass (F_1.22=4.525, P=.05), fat-free mass (F_1.22=6.103, P=.02), and muscle mass (F_1.22=6.636, P=.02). Although there was a significantly shorter RT in EXG postintervention (congruent P=.03, 95% CI 13.581-260.419, incongruent P=.04, 95% CI 14.621-408.917), no changes occurred in AEG. EXG also yielded a shorter N2 latency for central (Cz) cortices during both congruent conditions compared to AEG (F_1.22=4.281, P=.05). Lastly, EXG presented a significantly increased P3b amplitude compared to AEG during the Ericksen flanker test (congruent: frontal [Fz] F_1.22=6.546, P=.02; Cz F_1.22=5.963, P=.23; parietal [Pz] F_1.22=4.302, P=.05; incongruent: Fz F_1.22=8.302, P=.01; Cz F_1.22=15.199, P=.001; Pz F_1.22=13.774, P=.001).

CONCLUSIONS

Our results suggest that exergaming may be associated with greater improvements in brain neuronal activity and enhanced executive function task performance than regular aerobic exercise. Exergaming characterized by both aerobic exercise and cognitive stimulation can be used as an effective intervention to improve cognitive and physical functions in older adults with dementia.

TRIAL REGISTRATION

Clinical Research Information Service KCT0008238; https://cris.nih.go.kr/cris/search/detailSearch.do/24170.

Perspectives of substitute decision-makers and staff about person-centred physical activity in long-term care

INTRODUCTION

This paper aims to explore the care processes that best exemplify person-centred care during physical activity (PA) for long-term care (LTC) residents with dementia from the perspectives of substitute decision-makers (SDMs) and LTC home staff. Little is known about how person-centred care is reflected during PA for residents with dementia, or the barriers and benefits to enacting person-centred care during PA.

METHODS

Semistructured interviews were used to collect SDMs and LTC home staffs' perspectives on the importance of person-centred care during PA from two LTC homes in Canada. The McCormack and McCance person-centredness framework was used to guide thematic content analysis of responses.

RESULTS

SDM (n = 26) and staff (n = 21) identified actions categorized under the sympathetic presence or engagement care processes from the person-centredness framework as most reflecting person-centred care. Benefits of person-centred care during PA were categorized into three themes: functional and physical, behavioural and communication and psychosocial improvements. Barriers to person-centred care during PA identified were lack of time, opportunities for meaningful activity in LTC setting and staff experiences with resident aggression.

SIGNIFICANCE

Understanding the care processes that are most recognized as person-centred care and valued by SDMs and LTC home staff has implications for education and training. Insights into SDMs' care expectations regarding person-centred care can inform staff about which actions should be prioritized to meet care expectations and can foster relationships to the benefit of residents with dementia.

PATIENT AND PUBLIC CONTRIBUTION

Study participants were not involved in the development of research questions, research design or outcome measures of this study.

Depression and Functional Mobility Decline in Long Term Care Home Residents with Dementia: a Prospective Cohort Study

Objective

Assess the association between depression among new long-term care residents (<3 months stay) with dementia and functional mobility decline.

Methods

A multi-site prospective cohort study was carried out among 26 participants diagnosed with dementia. Functional mobility was measured by Timed-Up-and-Go (TUG) and 2-Minute walk test (2MWT) at baseline, and 60-day post-baseline while participants received usual care. Linear mixed models were applied to examine the association between depression and functional mobility decline.

Results

Residents experienced a statistically significant decline in functional mobility in as soon as 60 days. Each additional year of age was associated with a 2% increase in TUG. The interaction between depression and time spent in LTC was statistically significant. Age and time living in LTC were significantly associated with functional mobility decline in new residents with dementia.

Discussion

Further work determining why residents with dementia experience decline in functional mobility at an accelerated rate is needed.

Effects of a 16-week multimodal exercise program on activities of daily living in institutionalized individuals with dementia

We aimed to examine the effects of a 16-week multimodal exercise program (MEP) on activities of daily living (ADL) in individuals with dementia (IWD). Furthermore, we investigated the participants’ individual response to the MEP and whether baseline cognitive and motor performance explain ADL performance. We conducted a multicenter randomized controlled trial (RCT) involving 319 participants aged ≥ 65 years with mild to moderate dementia. ADL were assessed at baseline and after the 16-week intervention using the Barthel Index (BI), the Erlangen Test of Activities of Daily Living (E-ADL) and the 7‑item Physical Performance Test (PPT-7). We additionally assessed cognitive and motor performance using standardized and validated assessments. Intervention effects were examined through two-factor analysis of variance with repeated measurements applying a per protocol and an intention-to-treat analysis. We compared baseline cognitive and motor performance between positive-responders (positive-R), non-responders (non-R), and negative-responders (negative-R) and examined cognitive and motor performance as potential cofounders of ADL by conducting multiple regression analyses. There were no significant time×group effects on ADL. Between 20 and 32% of participants responded positively to the intervention, i.e., improved ADL performance from baseline to follow-up. Positive-R had worse baseline motor performance compared to non-R. Cognitive and motor performance explained up to 51.4% of variance in ADL. The MEP had no significant overall effect on ADL in IWD. This may be related to insufficient exercise intensity. However, our results indicate that the response to the MEP depends on individual prerequisites which should thus be considered in further research on individual exercise approaches.

Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

Introduction

The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.

This work aimed to agree clear statements for use by healthcare professionals about medical risks of physical activity for people living with LTCs through expert consensus. These statements addressed the following questions: (1) Is increasing physical activity safe for people living with one or more LTC? (2) Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels? (3) What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTCs to increase their physical activity levels?

Methods

Statements were developed in a multistage process, guided by the Appraisal of Guidelines for Research and Evaluation tool. A patient and clinician involvement process, a rapid literature review and a steering group workshop informed the development of draft symptom and syndrome-based statements. We then tested and refined the draft statements and supporting evidence using a three-stage modified online Delphi study, incorporating a multidisciplinary expert panel with a broad range of clinical specialties.

Results

Twenty-eight experts completed the Delphi process. All statements achieved consensus with a final agreement between 88.5%–96.5%. Five ‘impact statements’ conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty.

Conclusion

Clear, consistent messaging on risk across healthcare will improve people living with LTCs confidence to be physically active. Addressing the fear of adverse events on an individual level will help healthcare professionals affect meaningful behavioural change in day-to-day practice. Evidence does not support routine preparticipation medical clearance for people with stable LTCs if they build up gradually from their current level. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms. As part of a system-wide approach, consistent messaging from healthcare professionals around risk will also help reduce cross-sector barriers to engagement for this population.

Physical Activity and its Influencing Factors in Community-Dwelling Older Adults With Dementia: A Path Analysis

Dementia is prevalent in worldwide, and increases the care burden and potential costs. Physical activity (PA) has been increasingly shown to be beneficial for them. This was a cross-sectional observational study aiming to investigate the status of PA among community-dwelling older adults with dementia in Beijing or Hangzhou, China, and verify the relationships between neuropsychiatric symptoms, activities of daily living (ADL), caregivers' fear of patients' falling and their PA using a path analysis approach. The level of PA among 216 included people with dementia was low. PA was related to the neuropsychiatric symptoms, with ADL and caregivers' fear of patients' falling have mediation roles. The findings indicated that person-centered strategies related to the management of these symptoms might be helpful to improve ADL, relieve caregivers' concerns about them falling and consequently foster positive participation in PA.

Feasibility of Multicomponent Training for People with Moderate to Severe Dementia Living in a Long-Term Care Home: A Social Ethical Approach

Multicomponent training is recommended for people with dementia living in long-term care homes. Nevertheless, evidence is limited and people with severe dementia are often excluded from trials. Hence, the aim of this study was to investigate (1) the feasibility and (2) the requirements regarding multicomponent training for people with moderate to severe dementia. The study was conducted as an uncontrolled single arm pilot study with a mixed methods approach. Fifteen nursing home residents with a mean age of 82 years (range: 75–90 years; female: 64%) with moderate to severe dementia received 16 weeks of multicomponent training. Feasibility and requirements of the training were assessed by a standardized observation protocol. Eleven participants regularly attended the intervention. The highest active participation was observed during gait exercises (64%), the lowest during strength exercises (33%). It was supportive if exercises were task-specific or related to everyday life. This study confirms that multicomponent training for the target group is (1) feasible and well accepted, and (2) to enhance active participation, individual instructions and the implementation of exercises related to everyday life is required. The effectiveness of the adapted training should be tested in future randomized controlled trials.

Annual dialysis data report of the 2018 JSDT Renal Data Registry: dementia, performance status, and exercise habits

According to the annual survey of the Japanese Society for Dialysis Therapy Renal Data Registry (JRDR) conducted at the end of 2018, there were a total of 339,841 patients receiving dialysis (hereinafter, dialysis patients) in Japan. The survey included questions regarding the presence/absence of dementia, the performance status (PS), and the exercise habits of individual patients. The survey revealed that 10.8% of all dialysis patients had dementia (1.8% in the age group of less than 65 years, 6.8% in the age group of 65–74 years, and 22.7% in the age group of 75 years or older). These prevalences of dementia were approximately equal to those estimated from the survey conducted in 2010. Regarding PS, the percentage of patients with lower activity levels tended to be relatively high among patients who were less than 15 years old and those who were 60 years old or older. Concerning the exercise habits of dialysis patients, the percentage of patients who were classified as “not at all or hardly” in response to the question about exercise habit was the highest (60–80%) of all the exercise habit classifications in each of the age groups analyzed.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

The role of physical and cognitive function in performance of activities of daily living in patients with mild-to-moderate Alzheimer's disease - a cross-sectional study

BACKGROUND

Several factors may play a role in the ability of patients with Alzheimer's disease to perform activities of daily living (ADL). The aim of this study was to examine the impact of different aspects of physical performance and cognitive functions on ADL in patients suffering from mild-to-moderate Alzheimer's disease.

METHODS

We conducted secondary analyses on cross-sectional baseline data from the randomized controlled multicentre study "Preserving quality of life, physical health and functional ability in Alzheimer's Disease: The effect of physical exercise" (ADEX). In total, 185 AD patients (76 women and 109 men), with a mean age on 70,4 years, were included. Data from physical performance tests (Astrand cycle test, Timed up & Go (TUG), Sit to Stand test (STS)) and cognitive tests (Mini Mental Status Examination (MMSE), Symbol Digit Modalities Test (SDMT), Stroop Color and Word test (Stroop)) were used. Their associations with ADL, measured on the ADCS-ADL scale was assessed in multivariable regression analyses.

RESULTS

SDMT and MMSE had significant, moderate correlations with total ADL (SDMT: r = 0.33, MMSE: r = 0.42) and instrumental ADL (SDMT: r = 0.31, MMSE: r = 0.42), but not with basic ADL. Adjusting for age and sex, the associations between SDMT and MMSE to total ADL and instrumental ADL persisted. No significant associations were found between Astrand, TUG, STS or Stroop and total ADL, basic ADL or instrumental ADL.

CONCLUSION

Total ADL and instrumental ADL are associated with cognitive functions, including executive function. No significant association between examined physical performance parameters and ADL functions was observed, and consequently does not support an impact of physical function on ADL functions in patients with mild-to-moderate Alzheimer's disease and relatively well-preserved physical function. Strategies aimed to improve cognition may be better suited to improve ADL function in patients with mild-to-moderate Alzheimer's disease.

TRIAL REGISTRATION

NCT01681602 . Registered 10 September 2012, retrospectively registered.

Psychophysiological Effects of Dance Movement Therapy and Physical Exercise on Older Adults With Mild Dementia: A Randomized Controlled Trial

OBJECTIVES

Dementia interferes with older adults' functioning in cognitive, daily, psychosocial, and neuroendocrine domains. The present study examined the psychophysiological effects of dance movement therapy (DMT) and physical exercise for older adults with dementia.

METHODS

This randomized controlled trial recruited 204 older adults diagnosed with mild dementia into the DMT, exercise, or waitlist control group. Both DMT and exercise interventions had similar intensity and comprised 24 hr of intervention that spanned over 12 weeks. All participants completed self-report questionnaires on psychosocial well-being, daily functioning, neurocognitive assessments, and salivary cortisol measures at baseline and 3 follow-up measurements more than 1 year.

RESULTS

The DMT group showed significant decreases in depression, loneliness, and negative mood (d = 0.33-0.42, p < .05) and improved daily functioning (d = 0.40, p < .01) and diurnal cortisol slope (d = 0.30, p < .01). The effects on daily functioning and cortisol slope remained at 1-year follow-up. The exercise group of matched intensity showed no significant effects on the outcomes.

DISCUSSION

The study findings support the potential utility of DMT as a multifaceted intervention for improving various aspects of functioning in older adults with declining cognitive abilities. The lack of beneficial effects for our exercise intervention and long-term DMT effects highlights the need to maintain persistent levels of exercise with adequate intensity and duration.

Combining cognitive stimulation therapy and fall prevention exercise (CogEx) in older adults with mild to moderate dementia: a feasibility randomised controlled trial

Background

People living with dementia (PLwD) have a high fall risk as cognitive impairment compromises control of gait and balance. Fall prevention exercises that are effective in healthy older adults may not work for PLwD. Cognitive stimulation therapy (CST) has been shown to improve global cognition in PLwD. A programme which combines cognitive (CST) with physical exercises may reduce falls in PLwD. The aim of this study was to assess the feasibility of undertaking a full scale randomised controlled trial to test the effectiveness of CogEx in decreasing falls in PLwD. Specific objectives included recruitment strategy, data collection, outcome measures, intervention fidelity and facilitator/participant experience.

Methods

A mixed methods feasibility randomised controlled trial recruited people from residential aged care. Inclusion criteria were ≥ 65 years old, Montreal Cognitive Assessment (MoCA) score of 10 to 26 and able to participate in a group. Participants were randomised to CST or CST combined with strength and balance exercises (CogEx). Both CST and CogEx groups were for an hour twice a week for 7 weeks. Descriptive statistics were used to report pre- and post-intervention outcome measures (MoCA, Geriatric Depression Scale–15, Quality of Life-Alzheimer’s Disease, Alzheimer’s Disease Assessment Scale—Cognitive 11, Brief Balance Evaluation Systems Test and Short Form Physical Performance Battery) and attendance. Qualitative analysis of participant focus groups and facilitator interviews used a conventional approach. Sessions were video recorded and exercise completion documented.

Results

Thirty-six residents were screened with 23 participants randomised to intervention (CogEx, n = 10) or control (CST, n = 13). The assessments took 45 min to 1.5 h, and there was repetition between two cognitive measures. Ten facilitators completed training with the manualised programme. Exercises were combined into the hour-long CST session; however, limited balance training occurred with participants exercising predominantly in sitting. The facilitators felt the participants engaged more and were safer in sitting.

Conclusions

The results demonstrated that while fall prevention exercises could be scheduled into the CST structure, the fidelity of the combined programme was poor. Other components of the study design need further consideration before evaluation using a randomised controlled trial is feasible.

Trial registration

anzctr.org.au (ACTRN12616000751471) 8 Jun 2016, Australian New Zealand Clinical Trials Registry.

The Applicability of a High-Intensity Functional Exercise Program Among Older People With Dementia Living in Nursing Homes

Exercise programs for people with dementia need to be optimized. We therefore evaluated the applicability of a high-intensity functional exercise program among people with dementia in nursing homes with regard to attendance, achieved exercise intensity, adverse events, a focus on dementia type, and whether symptoms of dementia or other medical conditions common in this population were associated with program applicability.

Exercise and dementia: what should we be recommending?

Purpose

Exercise has the potential to provide benefits for people living with dementia, yet the balance of evidence is uncertain. This paper aims to provide an evidence synthesis to determine whether exercise improves their health and well-being and what exercise should be recommended.

Design/methodology/approach

Structured search for existing literature reviews on exercise for dementia. Relevant articles were selected and critically appraised against systematic criteria. The findings from 15 high quality reviews were collated by using a best evidence synthesis approach.

Findings

The evidence is convincing for improving physical health, promising for cognitive benefits, mixed for psychological benefits and limited for behavioural outcomes. No evidence of harm was found. Overall, exercise can improve physical and mental health for people living with dementia: there is sufficient evidence to recommend multimodal exercise.

Social implications

The potential beneficial outcomes are of significant importance both for people with dementia and their caregivers. In the absence of more specific findings, the current recommendation for older adults in general is pragmatically justified – some activity is better than none, more activity provides greater benefits. Adding social interaction may be important for psychological and behavioural outcomes.

Originality/value

To the best of the authors’ knowledge, this paper is the first to encapsulate the literature to date on exercise for dementia. Combining the findings from previous reviews enabled a novel synthesis across the range of relevant interventions and outcomes.

[Improving cognitive resources of nursing home residents: a systematic review of prevention and health promotion interventions]

BACKGROUND

The German Prevention Act mandated long-term care insurance funds to support long-term care facilities in designing health-promoting structures. One area of action is the promotion of the cognitive resources of nursing home residents. The objective of this systematic review was to describe and analyze interventions and intervention components that improve cognitive resources of nursing home residents.

METHODS

First, we conducted a search for systematic reviews to identify relevant randomised controlled trials in Medline via PubMed, the Cochrane Library, CINAHL, Gerolit, Embase, Psyndex, and Livivo; additional sources were hand-searched. Second, references of all relevant randomized controlled trials (n=43) were extracted from the identified systematic reviews (n=26). The original articles of the primary studies included were then considered and data extracted using criteria for the evaluation of complex interventions. The quality of evidence was assessed using the GRADE approach.

RESULTS

Nine interventions to promote cognitive resources were identified: cognitive stimulation, cognitive training, physical training, art and music interventions, bright light, multicomponent stimulation, multisensory stimulation, care staff training and reminiscence. The quality of the underlying evidence in the inpatient long-term care setting was predominantly low, therefore, it was not always possible to draw clear conclusions regarding the efficacy of the interventions. The low quality of evidence was mainly due to the high heterogeneity as well as the low number and limited methodological quality of the primary studies.

CONCLUSION

In general, a wide range of nonpharmacological interventions were reported. Due to the limited evidence, however, these may be regarded as ideas only or possible options for promoting the cognitive resources of nursing home residents.

Effects of Geriatric Interdisciplinary Home Rehabilitation on Independence in Activities of Daily Living in Older People With Hip Fracture: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of early discharge followed by geriatric interdisciplinary home rehabilitation for older people with hip fracture on independence in activities of daily living (ADL) compared with inhospital geriatric care according to a multifactorial rehabilitation program.

DESIGN

Planned analysis of a randomized controlled trial with 3- and 12-month follow-ups.

SETTING

Geriatric ward, ordinary housing, and residential care facilities.

PARTICIPANTS

Of 466 people screened for eligibility, participants (N=205) with acute hip fracture, aged 70 years or older, including those with cognitive impairment and those living in residential care facilities, were randomized to intervention or control groups.

INTERVENTION

Individually designed interdisciplinary home rehabilitation for a maximum of 10 weeks. The intervention aimed at early hospital discharge and focused on prevention of falls, independence in daily activities, and walking ability indoors and outdoors.

MAIN OUTCOME MEASURES

Independence in ADL was measured using the Barthel ADL Index, and the ADL Staircase including the Katz ADL Index during hospital stay (prefracture performance) and at the follow-up visits in the participants' homes.

RESULTS

There were no significant differences in ADL performance between the groups, and they recovered their prefracture level of independence in personal and instrumental ADL comparably. At 12 months, 33 (41.3%) in the intervention group vs 33 (41.8%) in the control group (P=.99) had regained or improved their prefracture ADL performance according to the Barthel ADL Index, and 27 (37.0%) vs 36 (48.6%) according to the ADL Staircase (P=.207).

CONCLUSIONS

In older people with hip fracture, early discharge followed by geriatric interdisciplinary home rehabilitation resulted in a comparable recovery of independence in ADL at 3 and 12 months as inhospital geriatric care and rehabilitation.

An integrative review of exercise interventions among community-dwelling adults with Alzheimer's disease

AIMS

To synthesise the current research on exercise interventions and health-related outcomes among community-dwelling adults with Alzheimer's disease (AD).

METHODS

Integrative review of the literature reporting exercise interventions among people with AD living in the communities.

RESULTS

Seventeen studies presented in 24 quantitative papers with 1,068 participants diagnosed with Alzheimer's disease were reviewed. The interventions varied in intervention programme characteristics (e.g. baseline assessments, type of exercise, exercise dose, outcome measurements). Among them, (a) 13 studies appeared beneficial to physical fitness in different areas; (b) 9 studies reported the effects on cognitive ability and two studies showed the positive effects; (c) 12 studies reported the participants' adherence, but only 2 studies reported the participants' adherence using attendance and training intensity.

CONCLUSION

Exercise is proven to be effective in physical fitness among community-dwelling patients with AD. Future studies should verify the effects on cognitive function and possible mechanisms of different exercise types using more sensitive and objective outcome measurements. Additionally, treatment fidelity, cost-effectiveness and long-term effects should be explored.

IMPLICATION FOR PRACTICE

Exercise may be effective and feasible for community-dwelling people with AD, but its effects on cognition need to be verified in the future. This review provided recommendations for assisting nurses and other clinicians in developing, implementing, and/or evaluating exercise interventions for patients with AD.

The efficacy of cognitive interventions on the performance of instrumental activities of daily living in individuals with mild cognitive impairment or mild dementia: protocol for a systematic review and meta-analysis

BACKGROUND

Cognitive changes associated with mild cognitive impairment or mild dementia can lead to difficulties in completing instrumental activities of daily living. The ability to live independently at home and in the community is often compromised due to the inability to complete these activities. Cognitive interventions have been reported as beneficial in maintaining or improving cognitive functions among this group of adults. However, the effectiveness of different types of cognitive interventions on the performance of instrumental activities of daily living in older adults with mild cognitive impairment and mild dementia is not well established. The aim of this paper is to develop a protocol for a systematic review and meta-analysis to investigate the effectiveness of cognitive interventions in maintaining or improving the performance of instrumental activities of daily living in individuals with mild cognitive impairment or mild dementia.

METHODS

Randomised control studies which investigate the effectiveness of cognitive interventions on the performance in instrumental activities of daily living for older adults with mild cognitive impairment and mild dementia will be sought. A systematic search will be conducted in five databases: CINAHL, MEDLINE, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials. The search strategy was developed with assistance from a health science librarian. Two independent reviewers will perform the study selection and data extraction. Quality assessment will be implemented using the Physiotherapy Evidence Database (PEDro) scale. A narrative synthesis of the findings will be used to report outcomes of all included studies. If appropriate, a meta-analysis will combine the results of individual studies.

DISCUSSION

This systematic review and meta-analysis will determine the effectiveness of cognitive interventions in maintaining or improving the performance of IADL in individuals with MCI or mild dementia. It is anticipated that the results will inform rehabilitation professionals of the most effective cognitive interventions to be implemented into clinical practice. It will potentially provide substantial benefit to both the persons with MCI or dementia and the health care system by keeping more people out of full-time care and allowing those in full-time care to require less intensive support.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016042364.

Change in Fitness and the Relation to Change in Cognition and Neuropsychiatric Symptoms After Aerobic Exercise in Patients with Mild Alzheimer's Disease

BACKGROUND

Physical activity has the potential to improve physical function in patients with Alzheimer's disease (AD) and may contribute to modify disease processes and cognitive function.

OBJECTIVE

The aim of this study was to investigate 1) the effect of moderate-high-intensity aerobic exercise on cardiorespiratory fitness, i.e., peak oxygen uptake (VO2peak) determined by direct breath-by-breath cardiopulmonary exercise test, and 2) the association between changes in VO2peak and changes in cognition and neuropsychiatric symptoms in patients with mild AD.

METHODS

The study is based on secondary outcome analyses from the large single-blinded multi-center study ADEX (Preserving Cognition, Quality of Life, Physical Health and Functional Ability in Alzheimer's Disease: The Effect of Physical Exercise). A preselected sub-group of 55 participants (age 52-83 years), 29 from the intervention group (IG) and 26 from the control group (CG), was included. IG performed 16 weeks of supervised moderate-to-high intensity aerobic exercise. Assessments of VO2peak, mental speed and attention (Symbol Digit Modalities Test, SDMT), and neuropsychiatric symptoms (Neuropsychiatric Inventory, NPI) were performed at baseline and at 16 weeks.

RESULT

VO2peak increased 13% in the IG and a between-group difference in mean change (3.92 ml/kg/min, 95% CI 6.34-1.51, p = 0.003) was present in favor of the IG. Combined data from IG and CG showed positive associations between changes in VO2peak and changes in NPI (Rho = - 0.41, p = 0.042) and changes in SDMT (Rho = 0.36, p = 0.010), respectively.

CONCLUSION

Aerobic exercise improves VO2peak in community-dwelling patients with mild AD. Furthermore, changes in VO2peak appear to be associated to changes in cognition and neuropsychiatric symptoms.

Effects of Fumanet exercise on Korean older adults with mild dementia

AIM

This study aimed to examine the effects of Fumanet exercise on cognitive function, walking ability, and depression in older adults with mild dementia.

METHODS

A quasi-experimental pre- and post-test design with a non-equivalent control group was used. Participants were 45 patients with mild dementia (experimental group = 22, control group = 23). In the experimental group, Fumanet exercise was performed 60 minutes per day, once per week for 8 weeks. Data were analyzed using descriptive statistics, t test, Chi-square, Fisher's exact test, and two-way repeated measures analysis of variance.

RESULTS

Gait ability in the experimental group was significantly improved compared with the control group (F = 9.08, P = .004). There were no significant differences in cognitive function or depression between the experimental and control groups. Although the intervention did not show a reduction in depression, participants exhibited a high participation rate and brighter mood with increasing sessions.

CONCLUSIONS

It was confirmed that Fumanet exercise is an effective nursing intervention to improve gait ability among older adults with mild dementia.

[Self-design and prevention potential for older people in institutional long-term care]

Healthcare in inpatient long-term care facilities (nursing homes) should not be limited to medical curative measures, but should also include strengthening social participation, autonomy, self-responsibility and joint responsibility of the residents. Prevention and rehabilitation should therefore be even more integrated into care concepts.This article first introduces various areas of prevention physical activity, nutrition, cognitive competence, psychosocial health, abuse, and freedom-removing measures and then discusses their evidence. Essential for the implementation and the success of such measures is the ability and willingness of people in need of care to engage actively in these therapies; here, appropriate and motivating information plays an important role.Subsequently, geriatric rehabilitation is referred to. In the 2013-2017 empirical study Organization and Rehabilitation for Residents in the Nursing Home to Improve Independence and Participation (ORBIT), 215 people in need of care participated in three-month therapeutic interventions, which were followed by three-months of rehabilitative care. Improvements in mobility and quality of life (Barthel index, QOL-AD) could be demonstrated compared to a control group (n = 28). The results have to be considered against the background of a worsening health and reduced functional capacities in old age. A stronger integration of prevention and rehabilitation services into long-term institutional care is functional for strengthening participation and independence - an important condition for the residents' certainty that their dignity will be respected, competence and strive for self-responsibility and self-determination.

Non-pharmacological interventions for people with dementia: A review of reviews

Objective

Aged care services increasingly respond to the needs of people with dementia. Non-pharmacological approaches are preferable to reduce responsive behaviours, improve/maintain functional capacity and reduce emotional disorders. This rapid review of systematic reviews aimed to consolidate the evidence for non-pharmacological interventions and determine outcome effectiveness.

Methods

Systematic review literature was comprehensively searched for non-pharmacological interventions for dementia in residential care. Quality ratings used adapted GRADE methodology, and ease of implementation assessed.

Results

Of 629 abstracts screened, 81 full-text articles were retrieved, 38 articles included. The strongest evidence for reducing responsive behaviours was music, sensory stimulation, simulated presence and validation therapies. Exercise and light therapy improved/maintained activities of daily living, while cognitive stimulation and reminiscence improved cognition. Strongest evidence for reducing emotional disorders was music, psychological interventions and reminiscence.

Conclusion

Much evidence of varying quality exists, with resource-constrained residential care providers now able to make evidence-based decisions about non-pharmacological interventions.

Interventions to Improve Gait in Older Adults with Cognitive Impairment: A Systematic Review

OBJECTIVES

To review intervention programs that measure gait to investigate what features of the intervention may contribute to improving gait in older adults with cognitive impairment or dementia.

DESIGN

Systematic review using Medline, Cinahl, Scopus, PsychInfo, Amed, Embase, Web of Science, and PubMed for original research published in English between January 1, 2000, and July 23, 2018, to identify interventional controlled trials. Narrative synthesis was undertaken.

RESULTS

Of 6,379 citations, 36 articles met inclusion criteria. Interventions were categorized as medication or medical devices (8 studies), exercise (19 studies), and exercise plus cognitive training (9 studies). Antidementia medication may improve gait variability in people with Alzheimer's disease. Exercise programs focusing on strength and balance training, especially when combined with functional mobility training, improve gait in people with mild cognitive impairment or dementia. Exercise plus cognitive training programs combining strength and balance training, functional mobility training, and training on attention and executive function also improve gait.

CONLUSION

Physical and cognitive factors affect gait performance, and both should be addressed in intervention programs. Physical exercises including functional mobility training, especially walking, have better results than physical programs with only static, resistance, and flexibility training. Cognitive intervention should be concomitant with physical exercises rather than separate, with a focus on attention and executive function. Combining physical training with cognitive training in a functional context may assist older adults with cognitive impairment generalize from training to everyday activity. J Am Geriatr Soc 67:381-391, 2019.

Comparison of Cognitive Intervention Strategies for Older Adults With Mild to Moderate Alzheimer's Disease: A Bayesian Meta-analytic Review

OBJECTIVES

We aimed to identify the best form of cognitive therapy among 3 main cognitive interventions of Alzheimer's disease (AD) including cognitive training (CT), cognitive stimulation (CS), and cognitive rehabilitation (CR).

DESIGN

Systematic review and Bayesian network meta-analysis.

SETTING AND PARTICIPANTS

An exhaustive literature search was conducted based on PubMed, Embase, the Cochrane Central Register of Controlled Trials, PsycINFO, the China National Knowledge Infrastructure database, the Chinese Biomedical Literature database, the Wan Fang database, and Web of Science and other database and randomized controlled trials were identified from their inception to May 1, 2018. Older adult participants diagnosed with AD were recruited.

MEASURES

We conducted a Bayesian network meta-analysis (NMA) to rank the included treatments. Cognitive functions were measured based on the Mini-Mental State Examination (MMSE). A series of analyses and assessments, such as the Pairwise meta-analysis and the risk of bias, were performed concurrently.

RESULTS

Only 22 studies were included in our analysis based on a series of rigorous screenings, which comprised 1368 participants. No obvious heterogeneities were found in NMA (I² = 32.7%, P = .07) after the data were pooled. The mean difference (MD) of CT [MD = 2.1, confidence interval [CI]: 1.0, 3.2), CS (MD = 0.92, CI: -0.20, 2.0), and CR (MD = 2.0, CI: 0.73, 3.4) showed that CT and CR could significantly improve cognitive function as measured by MMSE in the treatment group whereas the CS was less effective. CT had the highest probability among the 3 cognitive interventions [the surface under the cumulative ranking curve (SUCRA) = 84.7%], followed by CR (SUCRA = 50.0%) and CS (SUCRA = 47.4%).

CONCLUSIONS/RELEVANCE

Our study indicated that the CT might be the best method for improving the cognitive function of AD patients. The findings from our study may be useful for policy makers and service commissioners when they make choices among different alternatives.

Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes

Background

Motivation to participate in exercise among people with dementia has not been well studied. The symptoms of dementia, including apathy, may lead to low motivation to participate in exercise. The aim of this study was to evaluate the motivation of older people with dementia to participate in a high-intensity exercise program compared with motivation of those participating in a social group activity.

Methods

The Umeå Dementia and Exercise Study (UMDEX) was a cluster-randomized controlled intervention trial including 186 people (mean age; 85, 75% female) with dementia in nursing homes. Participants were randomized to participate in the High-Intensity Functional Exercise (HIFE) Program (n = 93) or a seated social group activity (n = 93). The activities were conducted in groups of 3–8 participants for 45 minutes, five times per two-week period, for 4 months (40 sessions in total). Participants’ motivation to go to and during activity sessions were assessed by the activity leaders and nursing homes staff using a five-point Likert scale. Data were analyzed using cumulative link mixed models.

Results

Motivation was high or very high during 61.0% of attended sessions in the exercise group and 62.6% in the social activity group. No overall significant difference between groups was observed, but motivation increased over time in the exercise group and decreased in the social activity group (p < 0.05). Motivation during the sessions was significantly higher than motivation to go to the sessions, especially in the exercise group [OR 2.39 (95% CI 2.38–2.40) and 1.50 (95% CI 1.32–1.70), respectively].

Conclusions

Among older people with dementia in nursing homes, motivation to participate in a high-intensity functional exercise program seems to be high, comparable to motivation to participate in a social activity, and increase over time. Since motivation during activity sessions was higher than motivation to go to sessions the promotion of strategies to encourage people with dementia to join exercise groups is of great importance.

Effects of Physical Exercise on Depressive Symptoms in Patients With Cognitive Impairment: A Systematic Review and Meta-Analysis

We aimed to evaluate the efficacy of physical exercise in ameliorating depressive symptoms in patients with cognitive impairment. The databases of PubMed, EMBASE, Web of Science, the Cochrane Library, PsycINFO, China National Knowledge Infrastructure, WanFang, and WeiPu (VIP) were searched to identify randomized controlled trials (RCTs) that involved physical exercise for patients with cognitive impairment. A random effects model and a fixed effects model were used to calculate the pooled effect size. Twenty-one studies were identified. The meta-analysis showed that physical exercise significantly ameliorated depressive symptoms (standardized mean difference [SMD] = -0.23; 95% confidence interval [CI], -0.39 to -0.07; p = 0.004). In addition, beneficial improvements in neuropsychiatric symptoms (mean difference, -4.62; 95% CI, -9.07 to -0.16, p = 0.04), quality of life (SMD = 0.23; 95% CI, 0.01-0.46; p = 0.04), and activities of daily living (SMD = 0.27; 95% CI, 0.12-0.43; p = 0.0005) were observed in our study. No significant improvements were found in anxiety or apathy. Nevertheless, further high-quality, multicenter RCTs are needed to identify the clinical value of our results.

Physical activity can improve cognition in patients with Alzheimer's disease: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND/OBJECTIVE

Alzheimer's disease (AD) is mainly characterized by decline of cognitive functions such as memory and learning, which has a high prevalence and poor drug efficacy in treatment regimes. A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to evaluate the effectiveness of exercise on cognitive function in patients diagnosed with AD.

METHODS

The bibliographic databases (PubMed, Cochrane Library and Embase, and Web of Science) and four Chinese databases (Wanfang data, CBM, CNKI, and VIP) were searched to identify RCTs published in any language between January 1, 1960, and January 1, 2018. Only peer-reviewed articles and RCTs were included. The collected data were analyzed by Review Manager (5.3).

RESULTS

Overall, 869 patients diagnosed with AD were included from 13 RCTs. Patients in the intervention group received pure exercise interventions and a cognitive test. Although there was heterogeneity in intervention methods and cognitive measures among studies, meta-analysis (seven studies) supports positive effects of physical activity on cognitive function of patients with AD (mean difference [MD] =2.53, the 95% CI=0.84 to 4.22, test for overall effect: Z=2.93 [P=0.003]). Eight studies demonstrated that exercise improves cognitive function for individuals with AD. However, the remaining five studies did not display a beneficial effect of exercise on cognitive function in patients with AD.

CONCLUSION

This meta-analysis and systematic review indicated that exercise intervention might improve the cognitive function of AD or slow down the decline of cognition; however, this relationship was not always true across studies. RCTs with clear intervention criteria, large samples, and long-term follow-up are needed in the future to demonstrate the benefits of exercise for cognitive function in AD patients.

Motor-cognitive effects of a computerized game-based training method in people with dementia: a randomized controlled trial

OBJECTIVES

To examine the effects of a computerized, game-based training on motor-cognitive performances, the transfer of training effects on untrained tasks, and the sustainability of training gains in people with dementia.

METHOD

Ninety-nine individuals with a mean age of 82.9 (5.8) and dementia participated in a 10-week randomized controlled trial with three-month follow-up. The intervention group (IG) received a motor-cognitive training on (Physiomat®) including concurrent dual-tasks of balance control with cognitive demands (Physiomat®-Trail Making Tasks (PTMTs)). The control group (CG) performed non-specific, low-intensity exercises. Duration and accuracy at different complexity levels of trained and untrained PTMTs and the number of successfully performed tasks (PTMT score) were assessed.

RESULTS

Physiomat® training significantly improved the duration and accuracy at almost all complexity levels of trained (P ≤ 0.001-0.047, η_p² = 0.065-0.589) and untrained PTMTs (P < 0.001-0.005, η_p² = 0.073-0.459). Significant effects were also found for the PTMT score of trained (P < 0.001, η_p² = 0.211) and untrained PTMTs (P < 0.001, η_p² = 0.184). Training gains were partly sustained at follow-up.

CONCLUSION

Physiomat® is feasible and has the potential to sustainably improve motor-cognitive performances in people with dementia.

Effects of Physical Activity in Nursing Home Residents with Dementia: A Randomized Controlled Trial

BACKGROUND/AIMS

There is no consensus regarding the optimal nonpharmacological intervention to slow down dementia-related decline. We examined whether physical stimulation interventions were effective in reducing cognitive, physical, mood, and behavioral decline in nursing home residents with dementia.

METHODS

Eighty-seven nursing home residents with dementia were randomly assigned to 3 physical activity interventions: activities of daily living (ADL) training, multicomponent exercise training, or combined multicomponent exercise and ADL training. Outcomes were measured at baseline, and after 3 and 6 months.

RESULTS

A 6-month ADL training benefitted executive functions, physical endurance, and depression among men. Exercise training benefitted only grip strength of participants with mild-to-moderate cognitive impairment. A combined training benefitted functional mobility compared to ADL training, depressive symptoms and agitation compared to exercise training, and physical endurance compared to no physical stimulation.

CONCLUSIONS

ADL training appears to be effective for nursing home residents with moderately severe dementia. It remains unclear whether exercise training is an effective type of stimulation.

Effects of Physical Exercise on Alzheimer's Disease Biomarkers: A Systematic Review of Intervention Studies

Physical exercise may be an important adjunct to pharmacological treatment of Alzheimer's disease (AD). Animal studies indicate that exercise may be disease modifying through several mechanisms including reduction of AD pathology. We carried out a systematic review of intervention studies of physical exercise with hippocampal volume (on MRI), amyloid-β, total tau, phosphorylated tau in cerebrospinal fluid (CSF), 18F-FDG-PET or amyloid PET as outcome measures in healthy subjects, patients with subjective memory complaints, mild cognitive impairment, or AD. We identified a total of 8 studies of which 6 investigated the effects of exercise on hippocampal volume in healthy subjects and 1 on CSF biomarkers and 1 on hippocampal volume in AD, and none investigating the remaining outcome measures or patient groups. Methodological quality of identified studies was generally low. One study found a detrimental effect on hippocampal volume and one found a positive effect, whereas the remaining studies did not find an effect of exercise on outcome measures. The present systematic study identified a relatively small number of studies, which did not support an effect of exercise on hippocampal volume. Methodological issues such small to moderate sample sizes and inadequate ramdomization procedures further limits conclusions. Our findings highlight the difficulties in conducting high quality studies of exercise and further studies are needed before definite conclusions may be reached.

Comparison of multiple interventions for older adults with Alzheimer disease or mild cognitive impairment: A PRISMA-compliant network meta-analysis

BACKGROUND

The increasing prevalence of Alzheimer disease (AD) emphasizes the need for effective treatments. Both pharmacological therapies such as nutrition therapy (NT) and nonpharmacologic therapies including traditional treatment or personalized treatment (e.g., physical exercise, music therapy, computerized cognitive training) have been approved for the treatment of AD or mild cognitive impairment (MCI) in numerous areas.

METHODS

The aim of this study was to compare 4 types of interventions, physical exercise (PE), music therapy (MT), computerized cognitive training (CCT), and NT, in older adults with mild to moderate AD or MCI and identify the most effective intervention for their cognitive function. We used a system of search strategies to identify relevant studies and include randomized controlled trials (RCTs), placebo-controlled trials evaluating the efficacy and safety of 4 interventions in patients with AD or MCI. We updated the relevant studies which were published before March 2017 as a full-text article. Using Bayesian network meta-analysis (NMA), we ranked cognitive ability based objectively on Mini-Mental State Examination (MMSE), and assessed neuropsychiatric symptoms based on Neuropsychiatric Inventory (NPI). Pairwise and network meta-analyses were sequentially performed for efficacy and safety of intervention compared to control group through RCTs included.

RESULTS

We included 17 RCTs. Fifteen trials (n = 1747) were pooled for cognition and no obvious heterogeneity was found (I = 21.7%, P = .212) in NMA, the mean difference (MD) of PE (MD = 2.1, confidence interval [CI]: 0.44-3.8) revealed that PE was significantly efficacious in the treatment group in terms of MMSE. Five trials (n = 660) assessed neuropsychiatric symptoms with an obvious heterogeneity (I = 61.6%, P = .034), the MD of CCT (MD = -7.7, CI: -14 to -2.4), revealing that CCT was significantly efficacious in NPI.

CONCLUSIONS

As the first NMA comparing different interventions for AD and MCI, our study suggests that PE and CCT might have a significant improvement in cognition and neuropsychiatric symptoms respectively. Moreover, nonpharmacological therapies might be better than pharmacological therapies.

The effects of movement stimulation on activities of daily living performance and quality of life in nursing home residents with dementia: a randomized controlled trial

Background

Nursing home (NH) residents with dementia experience a reduced quality of life (QoL), in part, due to a dependence in performing activities of daily living (ADL). Stimulating movement is associated with improvements in ADL performance. Therefore, movement stimulating interventions, such as ADL training and exercise, focus on optimizing ADL performance to improve QoL. This study aimed to evaluate the effect of three movement stimulating interventions on QoL and ADL performance in NH residents with dementia.

Methods

In this 6-month double parallel randomized controlled trial, the effects of ADL training, a multicomponent aerobic and strength exercise training, and a combined ADL and exercise training were analyzed in 87 NH residents with dementia. The Global Deterioration Scale was used to classify the severity of dementia. Participants were screened at baseline using the 6 minute walk test and Mini-Mental State Examination. The Qualidem, and the Care Dependency Scale and Erlangen ADL test were evaluated at baseline, and after 3 and 6 months to measure QoL and ADL, respectively. Multilevel analyses were adjusted for baseline performance, age, and gender.

Results

A 6-month ADL training positively affected overall QoL (p = 0.004) and multiple aspects of QoL, including care relationship (p = 0.004), positive self-image (p = 0.002), and feeling at home (p = 0.001), compared to care-as-usual. No benefits were observed of exercise on QoL. No benefits were observed of a combined ADL and exercise intervention on QoL. No effects were found of the three movement interventions on ADL performance.

Conclusion

The results indicate that ADL training can improve QoL. The results contribute to the limited knowledge regarding the effect of movement stimulation on resident outcomes. Further large-scale studies are recommended.

A Systematic Review of Nonpharmacological Interventions for Moderate to Severe Dementia: A Study Protocol for a Systematic Review and Meta-Analysis

The study is designed as a systematic review on nonpharmacological interventions for patients with moderate to severe dementia. This review will be conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The following databases will be searched: Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, KoreaMED, KMbase, and KISS. The primary outcome will include the effect of the interventions on activities of daily living and behavioral and psychological symptoms of dementia. The literature search will be conducted based on search strategies designed for each database. The reviewers will independently assess the identified studies and extract the data. The risk of bias will be assessed and a meta-analysis will be conducted in accordance with the methodology for meta-analysis described in the Cochrane handbook. This systematic review will provide clinicians and policy makers with reliable evidence for developing and implementing nonpharmacological interventions for moderate to severe patients with dementia.

Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review

QUESTION

Does physical exercise training improve physical function and quality of life in people with cognitive impairment and dementia? Which training protocols improve physical function and quality of life? How do cognitive impairment and other patient characteristics influence the outcomes of exercise training?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

People with mild cognitive impairment or dementia as the primary diagnosis.

INTERVENTION

Physical exercise.

OUTCOME MEASURES

Strength, flexibility, gait, balance, mobility, walking endurance, dual-task ability, activities of daily living, quality of life, and falls.

RESULTS

Forty-three clinical trials (n=3988) were included. According to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system, the meta-analyses revealed strong evidence in support of using supervised exercise training to improve the results of 30-second sit-to-stand test (MD 2.1 repetitions, 95% CI 0.3 to 3.9), step length (MD 5cm, 95% CI 2 to 8), Berg Balance Scale (MD 3.6 points, 95% CI 0.3 to 7.0), functional reach (3.9cm, 95% CI 2.2 to 5.5), Timed Up and Go test (-1second, 95% CI -2 to 0), walking speed (0.13m/s, 95% CI 0.03 to 0.24), and 6-minute walk test (50m, 95% CI 18 to 81) in individuals with mild cognitive impairment or dementia. Weak evidence supported the use of exercise in improving flexibility and Barthel Index performance. Weak evidence suggested that non-specific exercise did not improve dual-tasking ability or activity level. Strong evidence indicated that exercise did not improve quality of life in this population. The effect of exercise on falls remained inconclusive. Poorer physical function was a determinant of better response to exercise training, but cognitive performance did not have an impact.

CONCLUSION

People with various levels of cognitive impairment can benefit from supervised multi-modal exercise for about 60minutes a day, 2 to 3days a week to improve physical function. [Lam FMH , Huang MZ, Liao LR, Chung RCK, Kwok TCY, Pang MYC (2018) Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of Physiotherapy 64: 4-15].

Experiences of older people with dementia participating in a high-intensity functional exercise program in nursing homes: "While it's tough, it's useful"

The objective of the study was to describe the views and experiences of participation in a high-intensity functional exercise (HIFE) program among older people with dementia in nursing homes. The study design was a qualitative interview study with 21 participants (15 women), aged 74-96, and with a Mini-Mental State Examination score of 10-23 at study start. The HIFE-program comprises exercises performed in functional weight-bearing positions and including movements used in everyday tasks. The exercise was individually designed, supervised in small groups in the nursing homes and performed during four months. Interviews were performed directly after exercise sessions and field notes about the sessions were recorded. Qualitative content analysis was used for analyses. The analysis revealed four themes: Exercise is challenging but achievable; Exercise gives pleasure and strength; Exercise evokes body memories; and Togetherness gives comfort, joy, and encouragement. The intense and tailored exercise, adapted to each participant, was perceived as challenging but achievable, and gave pleasure and improvements in mental and bodily strength. Memories of previous physical activities aroused and participants rediscovered bodily capabilities. Importance of individualized and supervised exercise in small groups was emphasized and created feelings of encouragement, safety, and coherence. The findings from the interviews reinforces the positive meaning of intense exercise to older people with moderate to severe dementia in nursing homes. The participants were able to safely adhere to and understand the necessity of the exercise. Providers of exercise should consider the aspects valued by participants, e.g. supervision, individualization, small groups, encouragement, and that exercise involved joy and rediscovery of body competencies.

Effectiveness of Occupational Therapy Interventions to Enhance Occupational Performance for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to describe the evidence for the effectiveness of interventions designed to establish, modify, and maintain occupations for adults with Alzheimer's disease (AD) and related neurocognitive disorders.

METHOD

Titles and abstracts of 2,597 articles were reviewed, of which 256 were retrieved for full review and 52 met inclusion criteria. U.S. Preventive Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

RESULTS

Articles were categorized into five themes: occupation-based, sleep, cognitive, physical exercise, and multicomponent interventions. Strong evidence supports the benefits of occupation-based interventions, physical exercise, and error-reduction learning.

CONCLUSION

Occupational therapy practitioners should integrate daily occupations, physical exercise, and error-reduction techniques into the daily routine of adults with AD to enhance occupational performance and delay functional decline. Future research should focus on establishing consensus on types and dosage of exercise and cognitive interventions.

The Effects of a Multicomponent Dyadic Intervention With Physical Exercise on the Cognitive Functioning of People With Dementia: A Randomized Controlled Trial

The objective was to evaluate the effects of a multicomponent dyadic intervention on the cognitive functioning of people with dementia living at home in a randomized controlled trial. People with dementia and their family caregivers (n = 111) were randomly assigned to 8 home-based sessions including physical exercise and support or a minimal intervention consisting of monthly written information bulletins and monthly phone calls. Memory, executive functioning (EF), and attention were assessed at baseline, and after 3 (postmeasurement) and 6 months (follow-up). Data were analyzed by using generalized estimating equations (GEE). A small, significant effect was found on attention. No effects were found on memory and EF. Finding only a small significant effect might be explained by the ineffectiveness of the intervention, but also by moderate treatment adherence or a lack of room for improvement because half of the people with dementia were already receiving care in a day care facility.

Aquatic exercise for residential aged care adults with dementia: benefits and barriers to participation

BACKGROUND

Pilot work by our group has demonstrated that aquatic exercise has valuable functional and psychosocial benefits for adults living in the residential aged care setting with dementia. The aim of the currents study was to advance this work by delivering the Watermemories Swimming Club aquatic exercise program to a more representative population of older, institutionalized adults with dementia.

METHODS

The benefits of 12 weeks of twice weekly participation in the Watermemories Swimming Club aquatic exercise program were assessed among an exercise and usual care control group of residential aged care adults with advanced dementia. A battery of physical and psychosocial measures were collected before and after the intervention period, and program implementation was also investigated.

RESULTS

Seven residential aged care facilities of 24 approached, agreed to participate and 56 residents were purposefully allocated to exercise or control. Twenty-three participants per group were included in the final analysis. Both groups experienced decreases in skeletal muscle index and lean mass (p < 0.001), but exercise stifled losses in muscle strength and transition into sarcopenic. Behavioral and psychological symptoms of dementia and activities of daily living approached significance (p = 0.06) with positive trends observed across other psychosocial measures.

CONCLUSIONS

This study demonstrates the value of exercise participation, and specifically aquatic exercise in comparison to usual care for older, institutionalized adults with advanced dementia. However, it also highlights a number of barriers to participation. To overcome these barriers and ensure opportunity to residents increased provider and sector support is required.

Association Between Therapy Intensity and Discharge Outcomes in Aged Medicare Skilled Nursing Facilities Admissions

OBJECTIVES

To determine the association between therapy intensity and discharge outcomes for aged Medicare skilled nursing facilities (SNFs) fee-for-service beneficiaries and to determine the association between therapy intensity and time to community discharge.

DESIGN

Retrospective observational design.

SETTING

SNFs.

PARTICIPANTS

Aged Medicare fee-for-service beneficiaries (N=311,338) in 3605 SNFs.

INTERVENTIONS

The total minutes of physical therapy, occupational therapy, and speech therapy per day were divided into intensity groups: high (≥60min); medium-high (45-<60min); medium-low (30-<45min); and low (<30min).

MAIN OUTCOME MEASURES

Four discharge outcomes-community, hospitalization, permanent placement, and death-were examined using a multivariate competing hazards model. For those associated with community discharge, a Poisson multivariate model was used to determine whether length of stay differed by intensity.

RESULTS

High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95).

CONCLUSIONS

High intensity therapy was associated with desirable discharge outcomes and may shorten SNF length of stay. Despite growing reimbursements to SNFs for rehabilitation services, there may be desirable benefits to beneficiaries who receive high intensity therapy.