Can balance exercise programmes improve balance and related physical performance measures in people with dementia? A systematic review

Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review

OBJECTIVES

To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD).

DESIGN

Systematic review of published literature without date restrictions through April 2023.

SETTING AND PARTICIPANTS

PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization.

METHODS

A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences."

RESULTS

Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD.

CONCLUSIONS AND IMPLICATIONS

Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.

Adapted Home-Based Exercises in Dementia: An Exploratory Pre-post Pilot and Feasibility Study

The goals of this exploratory pre-post pilot and feasibility study (NCT04916964) were to assess the feasibility and effectiveness of an adapted Test-and-Exercise home-based exercise program on basic functional mobility and executive functions in persons with prodromal or mild Alzheimer's disease. Participants followed an 8 week exercise program at home, once per week with a physiotherapist and twice per week with their usual caregiver or independently. Functional mobility and executive functions were assessed before and after the intervention. Feasibility criteria were recruitment opportunity, participation agreement rate, cost adequacy, and drop-out rate. Twelve participants aged 80.83 ± 4.65 years took part in the study. All the basic functional mobility measures showed small effect sizes. Concerning executive functions, 5 measures showed small to moderate effect sizes. The 4 feasibility criteria were met. A larger scale study would, however, need adaptations and prior research on the ability of this population to use touch-screen technology.

A Telehealth Home-Based Exercise Program for Community-Dwelling Older People with Dementia in Indonesia: A Feasibility Study

(1) Background: This study aimed to evaluate the feasibility of a telehealth home-based exercise program for older people with dementia living in Indonesia with support from their informal carers. (2) Methods: Pre-post intervention single group study with three assessment time-points (baseline, 12 and 18 weeks). Participants with dementia underwent a 12-week physiotherapist-delivered telehealth exercise program, with informal carer supervision between supervised online sessions, and continued the exercises for a further six weeks without physiotherapist online supervision. (3) Results: Thirty dyads of older people with dementia and their informal carers were recruited; four (13.3%) withdrew across the 12-week intervention and one (3.3%) in the 6-week self-maintenance period. Median adherence was 84.1% (IQR [25, 75] = 17.1) during the 12-week intervention, and 66.7% (IQR [25, 75] = 16.7) in the self-maintenance period. No falls/adverse events were reported. Physical activity level, some aspects of function and disability, health-related benefits of exercise, exercise enjoyment and quality of life of older people with dementia improved significantly at 12 and 18 weeks. (4) Conclusions: The telehealth exercise program is feasible and safe and may have benefits for the health outcomes of community-living older people with dementia in Indonesia. Additional strategies are necessary to enhance longer-term adherence to the program.

World guidelines for falls prevention and management for older adults: a global initiative

BACKGROUND

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

OBJECTIVES

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

METHODS

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

RECOMMENDATIONS

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

CONCLUSIONS

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

ICT-Based Individualized Training of Institutionalized Individuals With Dementia. Evaluation of Usability and Trends Toward the Effectiveness of the InCoPE-App

Physical activity interventions can alleviate the course of disease for individuals with dementia (IWD) who have been extraordinarily affected by the COVID-19 pandemic. Information and Communication Technology (ICT) provides new opportunities not only to mitigate negative effects of the pandemic but also to sustainably improve everyday life of IWD in nursing homes. The aim of the present study was to evaluate the ICT-based InCoPE-App, which was used to assess physical and cognitive performance and deliver individualized exercise for IWD, with regard to 1) user experience of nursing assistants, and 2) trends toward the effectiveness of the intervention on physical and cognitive performance of IWD. An 18-week individualized multidomain intervention (2 × 60 min/session) was delivered to an intervention group (IG; n = 10, mean age 88.4 ± 5.6, 70% female) by nursing assistants (n = 10, mean age 56.1 ± 10.4, 90% female) using the InCoPE-App. A control group (CG; n = 3, mean age 87.3 ± 3.5, 100% female) received conventional treatment. User experience was assessed among nursing assistants by different questionnaires, i.e., PSSUQ and ISONORM 9241/110-S for usability, and AttrakDiff2 for pragmatic (PQ), hedonic quality-identity and stimulation (HQI and HQS), and attractiveness (ATT). Trends toward the effectiveness of the intervention were assessed using MMSE (global cognitive function), FICSIT-4 (balance), 6MWT and TUG (mobility), and m30CST (function of lower limbs). Usability of the InCoPE-App was rated as high by nursing assistants (mean ± SD; overall PSSUQ 2.11 ± 0.75; overall ISONORM 9241/110-S 1.90 ± 0.88; ATT 1.86 ± 1.01; PQ 1.79 ± 1.03; HQI 1.8 ± 0.79; and HQS 1.37 ± 0.69). Dropout was high in the total sample (36.7%). Trends toward the effectiveness were observed within IG in nine IWD who showed positive or neutral trends in at least two physical performance outcomes. Seven participants had positive or neutral trends in the FICSIT-4, seven participants in m30CST, and four and seven participants in 6MWT and TUG, respectively. In conclusion, the InCoPE-App has good nursing assistant-rated usability, whereas training effects and intervention adherence were rather low most likely due to COVID-19 restrictions. Single-subject research revealed more positive than negative trends in IG of IWD. Further research is needed to evaluate feasibility, suitability, and effectiveness of the InCoPE-App.

InCoPE-App: Study protocol to examine usability and effectiveness of an individualized, tablet-based multidomain exercise program for institutionalized people with dementia delivered by nursing assistants. (Preprint)

Background

The COVID-19 pandemic has had drastic consequences on everyday life in nursing homes. Limited personnel resources and modified hygiene and safety measures (eg, no external exercise instructors, no group settings) have often led to interrupted physical exercise treatments. As a consequence, people with dementia benefiting from individualized exercise programs are affected by the pandemic’s impact.

Objective

Our goal is to develop an easily applicable mobile application (Individualized Cognitive and Physical Exercise [InCoPE] app) allowing nursing assistants to test cognitive function and physical performance and subsequently train people with dementia through a multidomain, individualized exercise program.

Methods

We will evaluate the usability and effectiveness of the InCoPE-App by applying a mixed method design. Nursing assistants will use the InCoPE-App for 18 weeks to assess the cognitive function and physical performance of 44 people with dementia every 3 weeks and apply the individualized exercise program. We will record overall usability using questionnaires (eg, Post-Study System Usability and ISONORM 9241/10), log events, and interviews. Perceived hedonic and pragmatic quality will be assessed using the AttrakDiff questionnaire. Effectiveness will be evaluated by considering changes in quality of life as well as cognitive function and physical performance between before and after the program.

Results

Enrollment into the study will be completed in the first half of 2022. We expect an improvement in the quality of life of people with dementia accompanied by improvements in cognitive function and physical performance. The usability of the InCoPE-App is expected to be rated well by nursing assistants.

Conclusions

To date, there is no scientifically evaluated app available that enables nursing assistants without expertise in sports science to deliver an individualized exercise program among people with dementia. A highly usable and effective InCoPE-App allows nursing assistants to test cognitive function and physical performance of people with dementia and, based thereon, select and deliver an appropriate individualized exercise program based on the cognitive and physical status of an individual, even in times of a pandemic.

Trial Registration

German Register of Clinical Trials DRKS00024069; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024069

International Registered Report Identifier (IRRID)

DERR1-10.2196/36247

Personen mit Demenz – eine besondere Zielgruppe in der Sportwissenschaft

Zusammenfassung. In sportwissenschaftlichen Studien mit Personen mit Demenz ist es wichtig, die Besonderheiten der Zielgruppe zu berücksichtigen. Bisherige Studien weisen diesbezüglich Limitationen auf. Im Projekt Bewegung gegen Demenz wurde aufbauend auf einer Analyse des Forschungsstandes ein entsprechendes Studiendesign erarbeitet und in einer randomisierten kontrollierten Studie mit 319 Personen mit Demenz eingesetzt. Eine umfassende Betrachtung motorischer Tests unterstreicht die Bedeutung von angepassten Verfahren und gibt erste Empfehlungen. Die Überprüfung eines multimodalen Bewegungsprogrammes zeigt keine statistisch signifikanten Zeit*Gruppen-Effekte auf die motorische Leistung und den Gang. Explorative Analysen decken Unterschiede in der motorischen und kognitiven Ausgangsleistung zwischen Positiv-‍, Neutral- und Negativ-Respondern auf. Zudem erklären motorische und kognitive Leistungsänderungen bis zu 39.4 % der Varianz der Gangänderung. Die Ergebnisse und das erarbeitete Studiendesign bieten eine Grundlage für zukünftige Studien, verweisen aber gleichzeitig auf weiteren Forschungsbedarf. Außerdem unterstreichen die begrenzte Eignung eines standardisierten Bewegungsprogrammes sowie Hinweise auf zugrundeliegende Mechanismen die Bedeutung der Berücksichtigung des Individuums.

Effects of a 16-Week Multimodal Exercise Program on Physical Performance in Individuals With Dementia: A Multicenter Randomized Controlled Trial

BACKGROUND AND PURPOSE

Dementia affects physical as well as cognitive performance. In individuals with dementia (IWD), decline in physical performance increases with disease progression and is associated with higher functional dependence and decreased quality of life. It is paramount to examine factors that potentially preserve physical performance in IWD, particularly in light of conflicting findings on the effectiveness of physical activity interventions on physical performance of IWD, mainly due to limited number of high-quality studies, large heterogeneity in methods used, or insufficient reporting of methods. The aim of this study was to investigate the effects of a 16-week multimodal exercise program (MEP) combining physical and cognitive tasks on physical performance in IWD, and to identify individual characteristics of MEP responders.

METHODS

A multicenter randomized controlled trial with assessment methods identified by an expert panel was conducted. We included 319 IWD of mild to moderate severity, older than 65 years, who underwent a standardized MEP specifically designed for IWD. At baseline and immediately after the MEP, we assessed physical performance (ie, mobility, balance, and strength) and function of lower extremities (primary outcomes). Potential effects of the MEP on physical performance were identified using 2-factor analyses of variance with repeated measurements within 2 samples (ie, intention-to-treat and per-protocol sample). Additionally, we compared characteristics related to physical performance between positive, non-, and negative responders.

RESULTS AND DISCUSSION

Neither analysis procedure revealed statistically significant time×group effects. However, 28% to 40% of participants were positive responders with regard to balance, and strength and function of lower extremities; and these persons had statistically significant lower baseline performance in the corresponding assessments.

CONCLUSIONS

This randomized controlled trial revealed no overall effects of the MEP on physical performance, probably due to high heterogeneity of the study sample. Findings in responder analysis showed that IWD with lower physical performance at baseline tended to benefit more than those with higher baseline performance. Thus, a higher degree of individualization of the MEP depending on baseline performance on IWD may improve overall MEP effectiveness.

Physical interventions for people with more advanced dementia - a scoping review

BACKGROUND

Dementia is a neuro-degenerative condition resulting in cognitive and physical decline over time. In the early stages of the condition, physical decline may be slow, but in the later stages, it may become more pronounced. Physical interventions may be employed to try and reduce the physical decline that people experience, yet it is unclear what interventions may be effective. The aim of this study was to explore the breadth and quantity of evidence that exists in relation to the delivery of physical interventions for people with advanced dementia.

METHODS

We undertook a scoping review in order to map the current literature. All types of study design were included in the search in order to gain a comprehensive scope of the literature. We searched a variety of databases from inception until March 2021, focusing on physical interventions. Double screening and data extraction were employed in order to increase the reliability of the results.

RESULTS

Our review found four studies which focused on physical interventions aimed at improving physical outcomes for people with more advanced dementia. The majority of studies were excluded as their interventions were not specific to people with advanced dementia. The studies that were included incorporated functional activities and, despite small sample sizes, suggested statistically significant improvements in outcomes for people with advanced dementia.

CONCLUSION

There is currently limited evidence relating to physical rehabilitation interventions for people with more advanced dementia, however, the evidence we presented suggests potential benefits for physical outcomes. Future research should focus on robust research to determine the most effective and cost-effective interventions that meet the needs of this population.

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.

Physical activity perceptions, experiences, and beliefs of older adults with mild cognitive impairment or Alzheimer's disease and their care partners

Physical activity (PA) participation provides functional and social benefits for persons with mild cognitive impairment (MCI) and Alzheimer's disease (AD), but PA participation in these populations is low. To support health promotion initiatives for cognitively impaired older adults, this study explored the perceptions, experiences, and beliefs of older adults with cognitive impairment and their caregivers concerning PA. Ten care dyads (community-dwelling adult aged ≥65 years diagnosed with MCI or mild-to-moderate AD and their care partner) participated in semi-structured interviews informed by the Theoretical Domains Framework about their PA perceptions, experiences, and beliefs. Interpretive phenomenological analysis of interview transcripts yielded 4 emergent themes: (1) PA as a meaningful activity, (2) experience versus evidence as motivating, (3) participation is possible despite dementia, and (4) care partners as enablers. Findings from this study address a research gap concerning the PA perceptions, experiences, and beliefs of cognitively impaired older adults and their care partners. Novelty Older adults with MCI/AD want to and are capable of engaging in PA. Care partners are critical supporters of PA participation in MCI/AD. Adapted health promotion strategies could enhance PA in MCI/AD.

Understanding the factors influencing physiotherapists' attitudes towards working with people living with dementia

Background: Research suggests healthcare professionals feel uncomfortable or inadequately prepared to provide care to people living with dementia. Importantly, research on the attitudes of physiotherapists toward people with dementia is limited. The objective was to assess personal, educational, and clinical experiences on physiotherapists' attitudes toward working with people with dementia.Methods: An online survey was completed by registered physiotherapists. Data were collected on their dementia knowledge, confidence, and attitudes. Structural equation modeling (SEM) evaluated the factors associated with attitudes of physiotherapists.Results: A total of 231 physiotherapists completed the survey. Participants' scores on knowledge of dementia were excellent. Interactions with people with dementia were positive (67.4%) and access to rehabilitation was important (70.4%). However, most respondents reported a lack of confidence and strategies to successfully deal with cognitive (42.5%) or behavioral (58.3%) symptoms. In the SEM, only education (p = .048) was significantly related to attitude. Specifically, more education was related to more positive attitudes.Conclusions: Scores on knowledge of dementia were high. Yet, most respondents reported reduced confidence from a lack of skills to manage behavioral or cognitive symptoms associated with dementia. More education related to working with people with dementia was significantly related to positive attitudes among physiotherapists.

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.

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].

Effectiveness of a 16-Week Multimodal Exercise Program on Individuals With Dementia: Study Protocol for a Multicenter Randomized Controlled Trial

BACKGROUND

The increasing prevalence of dementia in the next decades is accompanied by various societal and economic problems. Previous studies have suggested that physical activity positively affects motor and cognitive skills in individuals with dementia (IWD). However, there is insufficient evidence probably related to several methodological limitations. Moreover, to date adequate physical activity interventions specifically developed for IWD are lacking.

OBJECTIVE

This study aims to investigate the effectiveness of a multimodal exercise program (MEP) on motor and cognitive skills in IWD in a high-quality multicenter trial.

METHODS

A multicenter randomized controlled trial with baseline and postassessments will be performed. It is planned to enroll 405 participants with dementia of mild to moderate stage, aged 65 years and older. The intervention group will participate in a 16-week ritualized MEP especially developed for IWD. The effectiveness of the MEP on the primary outcomes balance, mobility, and gait will be examined using a comprehensive test battery. Secondary outcomes are strength and function of lower limbs, activities of daily living, and cognition (overall cognition, language, processing speed, learning and memory, and visual spatial cognition).

RESULTS

Enrollment for the study started in May 2015. It is planned to complete postassessments by the beginning of 2017. Results are expected to be available in the first half of 2017.

CONCLUSIONS

This study will contribute to enhancing evidence for the effects of physical activity on motor and cognitive skills in IWD. Compared to previous studies, this study is characterized by a dementia-specific intervention based on scientific knowledge, a combination of motor and cognitive tasks in the intervention, and high standards regarding methodology. Findings are highly relevant to influence the multiple motor and cognitive impairments of IWD who are often participating in limited physical activity.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010538; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00010538 (Archived by WebCite at http://www.webcitation.org/6oVGMbbMD).

Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review

QUESTION

Do long-term (> 3 months) home or community-based exercise programs improve function, reduce falls and prevent hospital readmissions in older people with cognitive impairment?

DESIGN

Systematic review and meta-analysis of randomised, controlled trials. Electronic databases (CINAHL, PubMed, Medline, Embase, AMED) were searched from the earliest date possible until March 2016.

PARTICIPANTS

Older adults (≥ 65 years) with cognitive impairment living in the community.

INTERVENTION

Supervised home or community-based exercise programs longer than 3 months.

OUTCOME MEASURES

The primary outcomes were function (including balance and activities of daily living), falls and hospital readmissions.

RESULTS

Of 1011 studies identified, seven trials with 945 participants met the inclusion criteria. Compared with no intervention, long-term exercise programs improved functional independence in basic activities of daily living by a moderate and significant amount (SMD 0.77, 95% CI 0.17 to 1.37, I²=67%), and improved functional independence in instrumental activities of daily living by a small and significant amount (SMD 0.44, 95% CI 0.03 to 0.86, I²=42%). Long-term exercise improved balance (mean difference in functional reach test 5.2cm, 95% CI 0.5 to 9.9, I²=76%). Data from two individual trials suggest that long-term exercise programs also reduce falls in older people with cognitive impairment. However, there was limited reporting of the effect of exercise on hospital readmissions for this group of people.

CONCLUSIONS

Long-term home and community-based exercise programs improve function in older adults living in the community with cognitive impairment. Review registration: PROSPERO CRD42015029602. [Lewis M, Peiris CL, Shields N (2016) Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review.Journal of Physiotherapy63: 23-29].

Group Balance Training Specifically Designed for Individuals With Alzheimer Disease: Impact on Berg Balance Scale, Timed Up and Go, Gait Speed, and Mini-Mental Status Examination

BACKGROUND AND PURPOSE

Individuals with Alzheimer disease (IwAD) experience more frequent and more injurious falls than their cognitively intact peers. Evidence of balance and gait dysfunction is observed earlier in the course of Alzheimer disease (AD) than once believed. Balance training has been demonstrated to be effective in improving balance and decreasing falls in cognitively intact older adults but is not well studied in IwAD. This study was designed to analyze the effects of a group balance training program on balance and falls in IwAD. The program was developed specifically for IwAD, with explicit guidelines for communication/interaction and deliberate structure of training sessions catered to the motor learning needs of IwAD.

DESIGN

This prospective, quasi-experimental, pretest-posttest design study describes the effects of a balance training program for a cohort of IwAD.

METHODS

Thirty IwAD were recruited from 3 adult day health centers; 22 completed at least 1 posttest session. Participants were tested with Berg Balance Scale (BBS), Timed Up and Go (TUG), Self-Selected Gait Speed (SSGS), Fast Gait Speed (FGS), and Mini-Mental Status Examination (MMSE) immediately before and after the 3-month intervention and again 3 months later. Group training was held at the adult day health centers for 45 minutes, twice per week. Sessions were characterized by massed, constant, and blocked practice of functional, relevant activities with considerable repetition. Ratio of participant to staff member never exceeded 3:1. Physical therapist staff members assured that participants were up on their feet the majority of each session and were individually challenged as much as possible.

RESULTS

Repeated-measures analysis of variance (ANOVA) for BBS was significant (F = 15.04; df = 1.67/28.40; P = .000) with post hoc tests, revealing improvement between pretest and immediate posttest (P = .000) and decline in performance between immediate and 3-month posttest (P = .012). Repeated-measures ANOVA posttest for MMSE was significant (F = 5.12; df = 1.73/22.53; P = .018) with post hoc tests, showing no change in MMSE between pretest and immediate posttest but decline in MMSE when comparing immediate posttest with 3-month posttest (P = .038) and pretest with 3-month posttest (P = .019). Repeated-measures ANOVA for TUG, FGS, and SSGS were not significant. Immediate effects of the intervention as assessed by the a priori paired t tests (comparing pre- and immediate posttest data) revealed significant improvement in BBS (t = -7.010; df = 20; P = .000), TUG (t = 3.103; df = 20; P = .006), and FGS (t = -2.115; df = 19; P = .048), but not in SSGS (t = -1.456; df = 20; P = .161).

DISCUSSION AND CONCLUSION

The 3-month group balance training intervention designed specifically for IwAD was effective in improving balance and mobility, as evidenced by improved BBS and TUG performances. Cognition did not decline during the course of the intervention but did decline following the intervention, suggesting a possible protective effect. Given the promising findings, a larger-scale controlled study is warranted.

Optimizing Eating Performance for Long-Term Care Residents With Dementia: Testing the Impact of Function-Focused Care for Cognitively Impaired

OBJECTIVES

The objective of this study was to evaluate the impact of a well-developed theory-based function-focused care for cognitively impaired (FFC-CI) intervention on eating performance among long-term care (LTC) residents with moderate-to-severe cognitive impairment.

DESIGN

A secondary analysis of longitudinal data from 2 cluster-randomized controlled trials that originally tested the impact of FFC-CI on all function and physical activities.

PARTICIPANTS AND SETTING

Participants were 199 residents with moderate-to-severe cognitive impairment from 4 nursing homes and 4 assisted living facilities.

MEASUREMENTS

Data at baseline, and 3 and 6 months were used. Resident outcome data used in this analysis included eating performance conceptualized using the single self-care "feeding" item in the Barthel Index, cognitive function by Mini-Mental State Examination, sitting balance conceptualized using the single "chair sit-sitting balance" item in the Tinetti Gait and Balance scale, physical capability by Physical Capability Scale, depression by Cornell Scale for Depression in Dementia, and agitation by Cohen-Mansfield Agitation Inventory (short form).

RESULTS

At baseline, almost one-third (32.2%) of the 199 residents needed help with eating. There was no significant change with regard to eating performance over time in both groups, and no significant treatment by time difference between groups in eating performance (P = .195).

CONCLUSION

Current findings support a need to revise the FFC-CI to better address eating performance. Future work may benefit from a stronger focus on eating performance rather than the more commonly addressed functional tasks, such as bathing, dressing, and ambulation. In addition, the inclusion of a more heterogeneous group of LTC residents with regard to eating performance is needed to test the impact of the revised approach on eating performance.

Assessment and management of fall risk in primary care settings

Falls among older adults are neither purely accidental nor inevitable; research has shown that many falls are preventable. Primary care providers play a key role in preventing falls. However, fall risk assessment and management is performed infrequently in primary care settings. This article provides an overview of a clinically relevant, evidence-based approach to fall risk screening and management. It describes resources, including the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) tool kit that can help providers integrate fall prevention into their practice.

Managing falls in older patients with cognitive impairment

With an aging population, both dementia and fall-related injury pose an international health challenge. Individuals with dementia fall twice as often as cognitively intact people and are more likely to have injurious falls. Higher morbidity and rates of mortality and institutionalization after falls have also been reported in this group. There is limited but emerging literature that is attempting to define and explain why fall risk is increased in this population. This will allow for targeted fall prevention programs. Currently, there are no published randomized controlled trials that have prevented falls in community-dwelling cognitively impaired older people, and conflicting evidence is reported in hospital and residential care trials. Recent exercise interventions have demonstrated significant benefits, such as improved gait speed, strength and balance in people with cognitive impairment/dementia, providing encouraging evidence for further research and clinical interventions.

Effect of rhythmic auditory cueing on gait in people with Alzheimer disease

OBJECTIVE

To determine whether rhythmic music and metronome cues alter spatiotemporal gait measures and gait variability in people with Alzheimer disease (AD).

DESIGN

A repeated-measures study requiring participants to walk under different cueing conditions.

SETTING

University movement laboratory.

PARTICIPANTS

Of the people (N=46) who met study criteria (a diagnosis of probable AD and ability to walk 100m) at routine medical review, 30 (16 men; mean age ± SD, 80±6y; revised Addenbrooke's Cognitive Examination range, 26-79) volunteered to participate.

INTERVENTIONS

Participants walked 4 times over an electronic walkway synchronizing to (1) rhythmic music and (2) a metronome set at individual mean baseline comfortable speed cadence.

MAIN OUTCOME MEASURES

Gait spatiotemporal measures and gait variability (coefficient of variation [CV]). Data from individual walks under each condition were combined. A 1-way repeated-measures analysis of variance was used to compare uncued baseline, cued, and retest measures.

RESULTS

Gait velocity decreased with both music and metronome cues compared with baseline (baseline, 110.5cm/s; music, 103.4cm/s; metronome, 105.4cm/s), primarily because of significant decreases in stride length (baseline, 120.9cm; music, 112.5cm; metronome, 114.8cm) with both cue types. This was coupled with increased stride length variability compared with baseline (baseline CV, 3.4%; music CV, 4.3%; metronome CV, 4.5%) with both cue types. These changes did not persist at (uncued) retest. Temporal variability was unchanged.

CONCLUSIONS

Rhythmic auditory cueing at comfortable speed tempo produced deleterious effects on gait in a single session in this group with AD. The deterioration in spatial gait parameters may result from impaired executive function associated with AD. Further research should investigate whether these instantaneous cue effects are altered with more practice or with learning methods tailored to people with cognitive impairment.

Feasibility, safety and preliminary evidence of the effectiveness of a home-based exercise programme for older people with Alzheimer's disease: a pilot randomized controlled trial

OBJECTIVE

To evaluate the feasibility and safety of a home-based exercise programme for people with Alzheimer's disease, and to provide preliminary evidence of programme effectiveness in improving balance and mobility and reducing falls risk.

DESIGN

A randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Forty people with mild to moderate Alzheimer's disease (mean age 81.9, SD 5.72; 62.5% female).

INTERVENTIONS

Participants were randomized to a six-month home-based individually tailored balance, strengthening and walking exercise programme (physiotherapist) or a six-month home-based education programme (control) (occupational therapist). Both programmes provided six home-visits and five follow-up phone calls.

MAIN MEASURES

Balance, mobility, falls and falls risk were measured at baseline and programme completion. Intention-to-treat analysis using a generalized linear model with group allocation as a predictor variable was performed to evaluate programme effectiveness. Feasibility and adverse events were systematically recorded at each contact.

RESULTS

Fifty-eight per cent of the exercise group finished the programme, completing an average of 83% of prescribed sessions, with no adverse events reported. Functional Reach improved significantly (P = 0.002) in the exercise group (mean (SD), 2.28 (4.36)) compared to the control group (-2.99 (4.87)). Significant improvement was also observed for the Falls Risk for Older People - Community score (P = 0.008) and trends for improvement on several other balance, mobility, falls and falls risk measures for the exercise group compared to the control group.

CONCLUSIONS

The exercise programme was feasible and safe and may help improve balance and mobility performance and reduce falls risk in people with Alzheimer's disease.

Muscle weakness in the elderly: role of sarcopenia, dynapenia, and possibilities for rehabilitation

Aging is a multifactorial process leading to changes in skeletal muscle quantity and quality, which cause muscle weakness and disability in the aging population. This paper discusses the reasons for muscle weakness—and its biological and physiological mechanisms—in the elderly and describes the role of sarcopenia and dynapenia, and the possibilities to modify the age-associated decline in muscle function and decelerate the development of muscle weakness and disability. Resistance and endurance training are effective measures of exercise therapy in the elderly, which improve muscle metabolism and thereby muscle function and life quality.