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

Comparing the impact of various exercise modalities on old adults with Alzheimer's disease: A Bayesian network meta-analysis

BACKGROUND AND PURPOSE

The global prevalence of Alzheimer's disease (AD) in the elderly is rising, and exercise is increasingly used as a non-pharmacological intervention. However, the most effective exercise modality for improving quality of life, alleviating depression, and reducing neuropsychiatric symptoms in AD patients remains unclear. This study aims to identify the optimal exercise modality for addressing these symptoms through a network meta-analysis.

METHODS

As of November 2024, we conducted a comprehensive search across six databases: PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO. This study included only randomized controlled trials (RCTs), with study durations ranging from 2 to 24 weeks, primarily set in clinical or community environments. Following the PRISMA-NMA guidelines, we conducted statistical analysis using the "gemtc" package in R and assessed evidence quality via the CINeMA online platform.

RESULTS

A network meta-analysis of 29 RCTs with 1507 participants showed that for global cognition, Aerobic exercise (AE) [MD = 2.83, 95 % CI (0.66, 4.85)] ranked first with 79.5 % probability; for quality of daily life, Resistance Training (RT) [SMD = 0.96, 95 % CI (-0.14, 2.07)] ranked first with 83.7 %; for depression, Physical Activity Program (PAP) [SMD = -3.76, 95 % CI (-7.06, -0.47)] ranked first with 96.0 %; and for neuropsychiatric inventory outcomes, AE [SMD = -2.35, 95 % CI (-5.95, 1.06)] ranked first with 71.1 %.

CONCLUSIONS

Based on the findings from retrospective studies, aerobic exercise may be an effective intervention for improving overall cognition and quality of life in individuals aged 60 and above with Alzheimer's disease.

Effects of Exercise Intervention on Functional Mobility among Older Adults with Cognitive Impairment: A Quantitative Evidence

OBJECTIVES

This meta-analysis aimed to assess the effect of exercise interventions on functional mobility among older adults with cognitive impairments such as dementia or mild cognitive impairment, followed by further investigation on the possible moderators of exercise-induced effects on this outcome.

DESIGN

A meta-analysis of controlled trials on exercise interventions reporting functional mobility outcomes was conducted. PubMed, Embase, EBSCO, SPORTDiscus, and Web of Science were searched for relevant studies published in English-language journals through July 2024.

SETTING AND PARTICIPANTS

Clinical and community settings across 15 countries, including a total of 1104 older adults with cognitive impairment, were involved in the study.

METHODS

We computed pooled effect sizes based on standardized mean difference (SMD) using the random-effects models. The subgroup analyses and meta-regression were conducted for multiple moderating variables (eg, exercise, sample, and study characteristics). The study quality was evaluated using the Physiotherapy Evidence Database Scale.

RESULTS

This meta-analysis finally included 22 studies. Results revealed that exercise interventions effectively improved functional mobility as compared with that of the control group (SMD, -0.42; 95% CI, -0.61 to -0.24; P < .001). Exercise intervention characteristics (ie, weekly training frequency and session duration) and sample characteristic (ie, percentage of women) moderated the exercise-induced effects on this interesting outcome. Subgroup analyses showed intervention with low frequency (1-2 times/wk) (SMD, -0.71; 95% CI, -1.01 to -0.42; P < .001) had a larger improvement in mobility, followed by medium frequency (SMD, -0.33; 95% CI, -0.56 to -0.10; P < .01). In addition, interventions with a session duration of > 60 minutes (SMD, -0.60; 95% CI, -0.84 to -0.36; P < .001) and 45 to 60 minutes (SMD, -0.60; 95% CI, -0.91 to -0.29; P < .001) had a significant improvement in mobility. Moreover, exercise training had a significant improvement in mobility for studies with a high percentage of women (SMD, -0.49; 95% CI, -0.67 to -0.31; P < .001).

CONCLUSIONS AND IMPLICATIONS

Exercise intervention is a promising way to improve functional mobility among older adults with cognitive impairment. Further evidence suggests that larger effects were observed in exercise intervention features of more than 45-minute session duration 1 to 3 times a week for at least 6 weeks regardless of exercise type. In addition, women benefit more from exercise interventions than men. Our study highlights that health care providers should prioritize integrating structured exercise programs into routine care for this population.

Adherence to a telehealth program for older adults with dementia and their caregivers: A mixed-methods study

The objectives were to analyze the association between the cognitive performance of older adults/caregivers, adherence to a telehealth program and investigate reasons for dropouts, retention and adherence. A mixed-methods study was conducted involving 41 older adults diagnosed with dementia who participated in a 12-week telehealth program that offered physical exercises for the older adults and psychoeducation for the caregivers. Cognitive performance, adherence rates, benefits and reasons for withdrawal, retention and adherence were determined with the aid of questionnaires, field records, and focus groups. No significant association was found between the adherence rate and cognitive performance. The main reason for dropouts was the occurrence of illness during the intervention. The reasons for adherence were the convenience of the online program and the fact that the program was free of cost. The benefits were improvements in the wellbeing, mood of the older adults and the mitigation of progressive symptoms of dementia.

The Impact of Regular Physical Activity on the Mental Health and Well-Being of Dementia Patients in High-Income Countries-A Systematic Scoping Review

Background: Dementia is a term used to describe a group of symptoms impacting memory, thinking, and social abilities. Evidence suggests a positive role of physical activity in physical and mental well-being in general. This systematic scoping review aimed to gather, summarise, and analyse evidence of the impact of physical activity on the mental health and well-being of dementia patients. Methods: A comprehensive systematic search of mainly primary research was conducted using several databases. Peer-reviewed studies in high-income countries published between 2005 and 2023 were included. The systematic scoping review was performed using the framework outlined by the Joanna Briggs Institute (JBI) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement. Results: Twenty-four articles (including 93,984 participants) were included in the analysis. Most articles (21) reported that physical activity (particularly regular physical activity) is associated with decreased depression score, decreased cognition impairment, and fewer falls, all of which contributed to improved well-being among dementia patients. These studies showed that there is a significant positive relationship between the level of physical activity and the level of improvement in the mental health and well-being of dementia patients. Conclusions: Findings from this systematic scoping review provide relatively reliable evidence that regular physical activity may improve the mental health and well-being of dementia patients. Systematic reviews and meta-analyses may be required to further confirm these findings.

Effects of home-based and telerehabilitation exercise on mental and physical health, and disease cost in people with Alzheimer's disease: A meta-analysis

BACKGROUND

Alzheimer's disease (AD) is a very disabling long-term disease that requires continuous regular care. A cost-effective and sustainable means of such care may be physical activity or exercise delivered at home or through telerehabilitation. The aim of this study is to determine the effects of home-based or telerehabilitation exercise in people with AD.

METHOD

PubMED, Embase, Web of Science (WoS), PEDro, and CENTRAL were searched for randomized controlled trials until January 2024. The data extracted include the characteristics of the participants, the interventions used for both experimental and the control groups, the baseline, post-intervention and follow-up mean and standard deviation values on the outcomes assessed and the findings of the included studies. Cochrane risks of bias assessment tool and PEDro scale were used to assess the risks of bias and methodological quality of the studies. The results were analyzed using narrative and quantitative syntheses.

RESULT

Eleven articles from nine studies (n=550) were included in the study. The results showed that, only global cognitive function (SMD = 0.72, 95% CI = 0.19-1.25, p=0.007), neuropsychiatric symptom (MD = -5.28, 95% CI =-6.22 to -4.34, p<0.0001) and ADL (SMD =3.12, 95% CI =0.11-6.13, p=0.04) improved significantly higher in the experimental group post-intervention. At follow-up, the significant difference was maintained only in neuropsychiatric symptoms (MD =-6.20, 95% CI =-7.17 to -5.23, p<0.0001).

CONCLUSION

There is a low evidence on the effects of home-based physical activity or exercise on global cognitive function, neuropsychiatric symptoms and ADL.

Experiences of Indonesian people with dementia and carers undertaking an online-delivered exercise program

Participating in physical activity is beneficial for older people with dementia. Little is known however about the perceptions of people living with dementia undertaking an online-delivered exercise program. This study aimed to explore the experiences and perceptions of older people with dementia and their carers in Indonesia participating in an online-delivered exercise program, and factors that may influence acceptability to the program. An exploratory qualitative study design using semi-structured interviews was used. Data were recorded, transcribed verbatim, translated into English, and analyzed thematically. Twelve participants with dementia (mean age = 63.3 years) and 30 carers (26 family carers and 4 paid carers) (mean age = 37.9 years) were interviewed separately. Seven themes were identified: (i) Motivating factors to participate; (ii) Benefits for people with dementia; (iii) Impacts on carers; (iv) Challenges and enablers to exercising; (v) Carers' strategies for exercise engagement; (vi) Roles, relationships and supports; and (vii) Participants' receptiveness to online delivery of the exercise program. This study illustrated that an online-delivered exercise program was acceptable for people with dementia and their carers in Indonesia and reinforced the importance of carers' support for the exercise program. These findings can help physiotherapists and other exercise practitioners in considering the aspects of delivery that people with dementia and their carers value in participating in online-delivered exercise programs.

A Meta-Analysis of Fall Risk in Older Adults With Alzheimer's Disease

OBJECTIVES

Falls are the leading cause of injuries in older adults. Although it is well recognized that Alzheimer's disease (AD) increases the fall risk of older adults, the reported fall risk in people with AD varies drastically. The principal purpose of this study was to summarize and synthesize previous studies reporting fall risk-related metrics in people with AD.

DESIGN

This was a meta-analysis.

SETTING AND PARTICIPANTS

Thirty-one studies reporting relevant fall data among 4654 older adults with AD were included.

METHODS

The fall prevalence, average number of falls, rate of recurrent fallers, and rate of injured fallers of included studies were meta-analyzed using random-effects models with inverse variance weights.

RESULTS

The pooled annual fall prevalence in older people with AD is 44.27% with an average annual number of falls of 1.30/person and a yearly rate of recurrent fallers of 42.08%. The reported rate of injured fallers was 45.0%.

CONCLUSIONS AND IMPLICATIONS

Our results reinforce that people with AD experience a higher fall risk than their cognitively healthy counterparts. The pooled fall metrics in this meta-analysis extend our understanding of the fall risk in people with AD. In addition, standardized approaches are needed to report fall-related data for people with AD.

The impact of exercise on Alzheimer's disease progression

INTRODUCTION

The preventive effects of chronic physical exercise (CPE) on Alzheimer's disease (AD) are now admitted by the scientific community. Curative effects of CPE are more disputed, but they deserve to be investigated, since CPE is a natural non-pharmacological alternative for the treatment of AD.

AREAS COVERED

In this perspective, the authors discuss the impact of CPE on AD based on an exhaustive literature search using the electronic databases PubMed, ScienceDirect and Google Scholar.

EXPERT OPINION

Aerobic exercise alone is probably not the unique solution and needs to be complemented by other exercises (physical activities) to optimize the slowing down of AD. Anaerobic, muscle strength and power, balance/coordination and meditative exercises may also help to slow down the AD progression. However, the scientific evidence does not allow a precise description of the best training program for patients with AD. Influential environmental conditions (e.g. social relations, outdoor or indoor exercise) should also be studied to optimize training programs aimed at slowing down the AD progression.

Maintaining independence in individuals with dementia at home after a fall: a protocol for the UK pilot cluster randomised controlled trial MAINTAIN

INTRODUCTION

Individuals with dementia face an increased risk of falls. Falls can cause a decline in the individual's overall functionality. All types of falls, including those that do not result in injury, can lead to psychosocial consequences, such as diminished confidence and a fear of falling. Projections indicate a rising trend in dementia diagnoses, implying an increase in fall incidents. Yet, there is a lack of evidence to support interventions for people living with dementia who have fallen. Our objective is to test the feasibility of a falls intervention trial for people with dementia.

METHOD AND ANALYSIS

This is a UK-based two-arm pilot cluster randomised controlled trial. In this study, six collaborating sites, which form the clusters, will be randomly allocated to either the intervention arm or the control arm (receiving treatment as usual) at a 1:1 ratio. During the 6 month recruitment phase, each cluster will enrol 10 dyads, comprising 10 individuals with dementia and their respective carers, leading to a total sample size of 60 dyads. The primary outcomes are the feasibility parameters for a full trial (ie, percentage consented, follow-up rate and cost framework). Secondary outcomes include activities of daily living, quality of life, fall efficacy, mobility, goal attainment, cognitive status, occurrence of falls, carer burden and healthcare service utilisation. Outcome measures will be collected at baseline and 28 weeks, with an additional assessment scheduled at 12 weeks for the healthcare service utilisation questionnaire. An embedded process evaluation, consisting of interviews and observations with participants and healthcare professionals, will explore how the intervention operates and the fidelity of study processes.

ETHICS AND DISSEMINATION

The study was approved by the NHS and local authority research governance and research ethics committees (NHS REC reference: 23/WA/0126). The results will be shared at meetings and conferences and will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN16413728.

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.

Role of diet and exercise in aging, Alzheimer's disease, and other chronic diseases

Alzheimer's disease (AD) is a progressive neurodegenerative disease, characterized by memory loss and multiple cognitive impairments. Genetic mutations cause a small proportion (1-2%) of early-onset AD, with mutations in amyloid precursor protein (APP), presenilin 1 (PS1) and presenilin 2 (PS2). Major contributing factors of late-onset AD are ApoE4 genotype, traumatic brain injury, diabetes, obesity, hypertension, cardiovascular conditions, in addition to lifestyle factors, such as unhealthy diet and lack of physical exercise. Disease progression can be delayed and/or prevented to a greater extent by adopting healthy lifestyle with balanced and antioxidant enriched diet and daily exercise. The interaction and interplay of diet, exercise, age, and pharmacological interventions holds a crucial role in the progression, pathogenesis and management of AD and its comorbidities, including diabetes, obesity, hypertension and cardiovascular conditions. Antioxidant enriched diet contributes to brain health, glucose control, weight management, and cardiovascular well-being. Regular exercise removes toxins including free radicals and enhances insulin sensitivity, and supports cardiovascular function. In the current article, we discussed, the role of diet, and exercise in aging, AD and other conditions including diabetes, obesity, hypertension, cardiovascular conditions. This article also highlights the impact of medication, socioeconomic and lifestyle factors, and pharmacological interventions. These aspects were discussed in different races and ethnic groups in Texas, and the US.

Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review

BACKGROUND

People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence.

METHOD

Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes.

CONCLUSION

This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.

Differences in fall-related characteristics across cognitive disorders

Approximately 40-60% of falls in the elderly lead to injuries, resulting in disability and loss of independence. Despite the higher prevalence of falls and morbidity rates in cognitively impaired individuals, most fall risk assessments fail to account for mental status. In addition, successful fall prevention programmes in cognitively normal adults have generally failed in patients with cognitive impairment. Identifying the role of pathological aging on fall characteristics can improve the sensitivity and specificity of fall prevention approaches. This literature review provides a thorough investigation into fall prevalence and fall risk factors, the accuracy of fall risk assessments, and the efficacy of fall prevention strategies in individuals with diverse cognitive profiles. We show that fall-related characteristics differ between cognitive disorders and fall risk assessment tools as well as fall prevention strategies should critically consider each patient's cognitive status to facilitate the identification of fallers at an earlier stage and support clinical decision-making.

Feasibility of a Modified Otago Exercise Program for Older Adults With Cognitive Vulnerability

Cognitive vulnerability, that is, clinically significant symptoms of dementia, depression, or delirium, puts older adults at high risk for physical inactivity and falls. Programs addressing activity and falls are needed. The purpose was to determine feasibility of an in-home, modified, Otago Exercise Program (OEP) for those with cognitive vulnerability, based on acceptability (retention and adherence), safety (pain intensity and falls), and potential positive effects (change in short physical performance battery (SPPB)). This secondary analysis of a randomized controlled trial included 80 participants who received the OEP; 64 completed it, 48% had depression, 22% had dementia, and 30% had a combination dementia/depression/delirium. Adherence to home exercise was low to moderate; pain was stable over 16 weeks; 31% of participants reported falls unrelated to OEP. SPPB increased from 6.95 to 7.74 (p < .01); age by time and diagnosis by time interactions were not significant. The modified OEP shows promising feasibility for older adults with cognitive vulnerability.

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.

Effectiveness of physical exercise at improving functional capacity in older adults living with Alzheimer's disease: a systematic review of randomized controlled trials

PURPOSE

To investigate the effects of physical exercise at improving functional capacity in older adults living with Alzheimer's disease (AD).

METHODS

Medline, Embase, Web of Science, The Cochrane Library, Lilacs, and PEDro were searched from inception until January 2021. Randomized controlled trials (RCTs) that reported functional capacity outcomes were included. The evidence was assessed using the GRADE approach.

RESULTS

Thirteen RCTs were included, involving 811 older adults living with AD. Multimodal exercise (ME), aerobic exercise (AE), and resistance exercise (RE) were used. The interventions were mainly supervised by caregivers. The evidence was low and with effect for activities of daily living (ADLs), moderate and with no effect for mobility and very low and with no effect for muscle strength, postural balance and flexibility after treatment with ME, moderate and with no effect for cardiorespiratory function and ADLs after treatment with AE. It was not possible to synthesize any type of evidence for RE.

CONCLUSIONS

Multimodal exercise promotes improvements in functional capacity (ADLs). Therefore, the practice of physical exercise can be recommended for older adults living with AD. The involvement of the caregiver in the physical exercises should also be considered, as it could enhance the benefits of exercise for these older adults.Implications for rehabilitationHealthcare providers with clinical knowledge regarding physical exercise should promote, prescribe and support the daily practice of physical exercises for older adults living with Alzheimer's disease (AD).The involvement of caregivers in home-based physical exercise programs should be considered, as it could enhance the benefits of such programs for these older adults.It is important to consider the degree of cognitive impairment in older adults living with AD when outlining goals for the improvement in functional capacity through physical exercise.Multimodal exercise involving aerobic training, postural balance, muscle strengthening, and flexibility is capable of promoting an improvement in functional capacity (activities of daily living) for these older adults.

Virtual Care Initiatives for Older Adults in Australia: Scoping Review

BACKGROUND

There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia.

OBJECTIVE

We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia.

METHODS

A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework.

RESULTS

Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers.

CONCLUSIONS

Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.

The Effect of Exercise on Falls in People Living with Dementia: A Systematic Review

BACKGROUND

People living with dementia (PWD) are at a heightened risk for falls. However, the effects of exercise on falls in PWD are unclear.

OBJECTIVE

To conduct a systematic review of randomized controlled trials (RCTs) examining the efficacy of exercise to reduce falls, recurrent falls, and injurious falls relative to usual care among PWD.

METHODS

We included peer-reviewed RCTs evaluating any exercise mode on falls and related injuries among medically diagnosed PWD aged ≥55years (international prospective register of systematic reviews (PROSPERO) ID:CRD42021254637). We excluded studies that did not solely involve PWD and were not the primary publication examining falls. We searched the Cochrane Dementia and Cognitive Improvement Group's Specialized Register and grey literature on 08/19/2020 and 04/11/2022; topical categories included dementia, exercise, RCTs, and falls. We evaluated the risk of bias (ROB) using the Cochrane ROB Tool-2 and study quality using the Consolidated Standards of Reporting Trials.

RESULTS

Twelve studies were included (n = 1,827; age = 81.3±7.0 years; female = 59.3%; Mini-Mental State Examination = 20.1±4.3 points; intervention duration = 27.8±18.5 weeks; adherence = 75.5±16.2%; attrition = 21.0±12.4%). Exercise reduced falls in two studies [Incidence Rate Ratio (IRR) range = 0.16 to 0.66; fall rate range: intervention = 1.35-3.76 falls/year, control = 3.07-12.21 falls/year]; all other studies (n = 10) reported null findings. Exercise did not reduce recurrent falls (n = 0/2) or injurious falls (n = 0/5). The RoB assessment ranged from some concerns (n = 9) to high RoB (n = 3); no studies were powered for falls. The quality of reporting was good (78.8±11.4%).

CONCLUSION

There was insufficient evidence to suggest that exercise reduces falls, recurrent falls, or injurious falls among PWD. Well-designed studies powered for falls are needed.

Ketones: potential to achieve brain energy rescue and sustain cognitive health during ageing

Alzheimer’s disease (AD) is the most common major neurocognitive disorder of ageing. Although largely ignored until about a decade ago, accumulating evidence suggests that deteriorating brain energy metabolism plays a key role in the development and/or progression of AD-associated cognitive decline. Brain glucose hypometabolism is a well-established biomarker in AD but was mostly assumed to be a consequence of neuronal dysfunction and death. However, its presence in cognitively asymptomatic populations at higher risk of AD strongly suggests that it is actually a pre-symptomatic component in the development of AD. The question then arises as to whether progressive AD-related cognitive decline could be prevented or slowed down by correcting or bypassing this progressive ‘brain energy gap’. In this review, we provide an overview of research on brain glucose and ketone metabolism in AD and its prodromal condition – mild cognitive impairment (MCI) – to provide a clearer basis for proposing keto-therapeutics as a strategy for brain energy rescue in AD. We also discuss studies using ketogenic interventions and their impact on plasma ketone levels, brain energetics and cognitive performance in MCI and AD. Given that exercise has several overlapping metabolic effects with ketones, we propose that in combination these two approaches might be synergistic for brain health during ageing. As cause-and-effect relationships between the different hallmarks of AD are emerging, further research efforts should focus on optimising the efficacy, acceptability and accessibility of keto-therapeutics in AD and populations at risk of AD.

Effects of Multicomponent Exercise Training Program on Biochemical and Motor Functions in Patients with Alzheimer’s Dementia

The aim of this study was to examine the effects of a multicomponent exercise training program on motor function and biochemical markers in patients with Alzheimer’s-type dementia. Twenty patients with Alzheimer disease, divided into the intervention group (IG; aged 84 ± 3.1 years) and the control group (CG; aged 86 ± 2.6 years) were included in this study. The intervention group was enrolled into an exercise training program for three months (two sessions of 60 min per week). The CG was instructed to follow their daily rhythm of life (e.g., rest, reading) without a physical training program. After 3 months of participation in a multicomponent exercise program, gait speed, balance and walking parameters were all improved in the intervention group as measured with the Berg Balance Scale, the Tinetti test, the 6-min walking test and the timed up and go test (p < 0.05 for all; percentage range of improvements: 3.17% to 53.40%), except the walking while talking test, and biochemical parameters were not affected (p > 0.05). Our results demonstrate that exercise improves postural control, aerobic capacity and mobility functions in patients with Alzheimer disease. Physical exercise is a safe and effective method for treating physical disorders in patients with Alzheimer’s disease and can easily be integrated in various programs for the management of Alzheimer disease.

Feasibility of a Small Group Otago Exercise Program for Older Adults Living with Dementia

Older adults with dementia experience more frequent and injurious falls than their cognitively-intact peers; however, there are no evidence-based fall-prevention programs (EBFPP) for this population. The Otago Exercise Program (OEP) is an EBFPP for older adults that has not been well-studied in people with dementia. We sought to explore the feasibility of group delivery of OEP in an adult day health center (ADHC) for people with dementia. We collected demographic data, Functional Assessment Staging Tool (FAST), and Mini Mental State Exam (MMSE) scores for seven participants with dementia. Pre- and post-test data included: Timed-Up-and-Go (TUG), 30-Second Chair-Stand (30s-CST), Four-Stage-Balance-Test (4-SBT), and Berg Balance Scale (BBS). We implemented a supervised group OEP, 3x/week × 8 weeks. Most participants required 1:1 supervision for optimal challenge and participation. Five participants completed the program. All had moderately severe to severe dementia based upon FAST; MMSE scores ranged from mild to severe cognitive impairment. Four of five participants crossed the threshold from higher to lower fall risk in at least one outcome (TUG, 30s-CST, 4-SBT, or BBS), and four of five participants improved by >Minimal Detectible Change (MDC90) score in at least one outcome. The group delivery format of OEP required significant staff oversight for optimal participation, making the program unsustainable.

Gait metrics analysis utilizing single-point inertial measurement units: a systematic review

BACKGROUND

Wearable sensors, particularly accelerometers alone or combined with gyroscopes and magnetometers in an inertial measurement unit (IMU), are a logical alternative for gait analysis. While issues with intrusive and complex sensor placement limit practicality of multi-point IMU systems, single-point IMUs could potentially maximize patient compliance and allow inconspicuous monitoring in daily-living. Therefore, this review aimed to examine the validity of single-point IMUs for gait metrics analysis and identify studies employing them for clinical applications.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) were followed utilizing the following databases: PubMed; MEDLINE; EMBASE and Cochrane. Four databases were systematically searched to obtain relevant journal articles focusing on the measurement of gait metrics using single-point IMU sensors.

RESULTS

A total of 90 articles were selected for inclusion. Critical analysis of studies was conducted, and data collected included: sensor type(s); sensor placement; study aim(s); study conclusion(s); gait metrics and methods; and clinical application. Validation research primarily focuses on lower trunk sensors in healthy cohorts. Clinical applications focus on diagnosis and severity assessment, rehabilitation and intervention efficacy and delineating pathological subjects from healthy controls.

DISCUSSION

This review has demonstrated the validity of single-point IMUs for gait metrics analysis and their ability to assist in clinical scenarios. Further validation for continuous monitoring in daily living scenarios and performance in pathological cohorts is required before commercial and clinical uptake can be expected.

Fall prevention in community-dwelling adults with mild to moderate cognitive impairment: a systematic review and meta-analysis

BACKGROUND

Cognitive impairment (CI) increases an individual's risk of falls due to the role cognition plays in gait control. Older adults with dementia fall 2-3 times more than cognitively healthy older adults and 60-80% of people with dementia fall annually. Practitioners require evidence-based fall prevention best practices to reduce the risk of falls in cognitively impaired adults living in the community.

METHODS

We conducted a systematic review and meta-analysis to identify the effectiveness of primary and secondary fall prevention interventions in reducing falls and fear of falling, and improving gait, balance, and functional mobility. We searched 7 databases for fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations, extracted data, and assessed risk of bias and certainty of evidence (GRADE). We assessed statistical and methodological heterogeneity and performed a meta-analysis of studies including subgroup analysis based on intervention and risk of bias groupings.

RESULTS

Five hundred nine community-dwelling adults (mean age 67.5 to 84.0 years) with mild to moderate CI from 12 randomized or clinical controlled trials (RCTs/CCTs) were included in this review. Eight studies were exercise interventions, 3 were multifactorial, and 1 provided medication treatment. Fall prevention interventions had significant effects of medium magnitude on fear of falling (standardized mean difference (SMD) -0.73 [- 1.10, - 0.36]), balance (SMD 0.66 [0.19, 1.12]), and functional mobility measured as Timed Up and Go test (SMD -0.56 [- 0.94, - 0.17]) and significant effects of small magnitude on gait control (SMD 0.26 [0.08, 0.43]) all with moderate certainty of evidence. The meta-analysis showed no significant effects for falls (number of events or falls incidence). Sub-analysis showed that exercise and low risk of bias studies remained significant for balance and perceived risk of falls.

CONCLUSION

The effect of fall prevention interventions on direct outcomes, such as falls, remains unclear in cognitively impaired individuals. Exercise interventions are effective at improving fall risk factors, however, high quality studies with longer follow-up and adequate sample sizes are needed to determine their effectiveness on falls directly. There remains a gap in terms of effective fall prevention interventions for older adults with CI.

Exercise interventions in Alzheimer's disease: A systematic review and meta-analysis of randomized controlled trials

AIMS

To assess the potential multi-domain benefits of exercise interventions on patients with Alzheimer's disease (AD), as well as to determine the specific effects of different exercise modalities (aerobic, strength, or combined training).

METHODS

A systematic search was conducted in PubMed and Web of Science until March 2021 for randomized controlled trials assessing the effect of exercise interventions (compared with no exercise) on patients with AD. Outcomes included cognitive function (mini-mental state examination [MMSE] test), physical function (e.g., 6-minute walking test [6MWT]), functional independence (Barthel index), and neuropsychiatric symptoms (Neuropsychiatric Inventory [NPI]). A random-effects meta-analysis was conducted.

RESULTS

28 studies (total n = 1337 participants, average age 79-90 years) were included in the systematic review, of which 21 could be meta-analyzed. Although considerable heterogeneity was found, exercise interventions induced several significant benefits, including in Barthel index (n = 147 patients, mean difference [MD]=8.36 points, 95% confidence interval [CI]=0.63-16.09), 6MWT (n = 369, MD=84 m, 95% CI=44-133)), and NPI (n = 263, MD=-4.4 points, 95% CI=-8.42 to -0.38). Benefits were also found in the MMSE test, albeit significance was only reached for aerobic exercise (n = 187, MD=2.31 points, 95% CI 0.45-4.27).

CONCLUSIONS

Exercise interventions appear to exert multi-domain benefits in patients with AD.

Current physiotherapy practice on delivering treatments for older people with dementia in Indonesia: A cross-sectional study

OBJECTIVES

The aims of the study were to i) explore the current practice, roles, and perceptions of physiotherapists who treat older people with and without dementia in Indonesia, ii) identify the characteristics of physiotherapists associated with treating older people and older people with dementia, and iii) identify the level of knowledge and attitudes about dementia among physiotherapists treating people with dementia in Indonesia.

METHODS

This was a cross-sectional study in which registered physiotherapists in Indonesia were surveyed online using Qualtrics. Descriptive statistics, linear regression and univariate logistic regression were used in this study. Multiple logistic regression was conducted to identify the characteristics of physiotherapists associated with treating older people and/or people with dementia. The Dementia Knowledge Assessment Scale (DKAS) was used to assess level of knowledge and attitudes about dementia. Qualitative data from the survey were analyzed using thematic content analysis.

RESULTS

The online survey was sent to 6327 physiotherapists who met the inclusion criteria and 1061 (16.8%) returned the survey. Eight hundred and eighty-four (83.3%) respondents worked with older patients, and 632 (59.6%) worked with people with dementia. The multiple regression analysis showed that physiotherapists who have been practicing for longer (years) (OR: 1.0, 95%CI: 1.0-1.1, p ≤ 0.001) and were working in a geriatrics area (OR: 3.0, 95%CI: 1.4-6.5, p = 0.005) were more likely to treat older people with dementia. The DKAS mean score (SD) was 32.1 (±5.1)/50 indicating some limitations in dementia knowledge by respondents, and 62% of physiotherapists reported low levels of confidence in treating older people with dementia.

CONCLUSIONS

The relatively low dementia knowledge, and generally low confidence in treating people with dementia among Indonesian physiotherapists were important findings in this study. This study highlights opportunities for improvement in physiotherapist's knowledge and skills in this emerging area of practice in Indonesia.

Impaired Cognitive Function is Associated with Motor Function and Activities of Daily Living in Mild to Moderate Alzheimer's Dementia

BACKGROUND

The deterioration of cognitive and motor functions and activities of daily living is common in Alzheimer's dementia.

OBJECTIVES

The purpose of this study was to investigate the correlation and the strength of the relationship between cognitive function and motor function and activities of daily living after a diagnosis of Alzheimer's disease dementia.

METHODS

Sixty-three patients with mild to moderate Alzheimer's disease dementia in a community setting of South Korea were examined for cognitive and motor functions, and functional levels. The test or measures used for cognitive function were the Mini-Mental State Examination (MMSE), Global Deterioration Scale (GDS), and Clinical Dementia Rating (CDR). The 10-meter walking test (10MWT), Berg Balance Scale (BBS), and Timed Up and Go Test (TUG) were used to examine motor function, while the Modified Barthel Index (MBI) and Katz Index (KI) were used to examining activities of daily living.

RESULTS

The MMSE had a positive correlation with that from the BBS (r=.338, p<.05), MBI (r=.363, p<.05), and KI (r=.276, p<.05). The GDS was negatively correlated with BBS (r=.319, p<.05). Multivariate regression analysis showed that MMSE was a major explanatory variable for BBS (R2 =.115, β=.338, p<.05) MBI (R2 =.131, β=.363, p<.05), and KI (R2 =.076, β=.276, p<.05).

CONCLUSION

The results of the present study show that cognitive function by MMSE is correlated with balance by BBS and activities of daily living by MBI and KI, and MMSE, which are tests or measures for cognitive function, can be explanatory variable to explain variations in the BBS, MBI, and KI in the persons with mild to moderate Alzheimer's dementia. It may mean that a decrease in cognitive function was found to affect motor function and activities of daily living. Based on this study, appropriate intervention approaches including physical exercise, should be considered for caring for persons with mild to moderate Alzheimer's dementia in a community setting.

Efficacy of exercise-based interventions in preventing falls among community-dwelling older persons with cognitive impairment: is there enough evidence? An updated systematic review and meta-analysis

Objective

Exercise prevents falls in the general older population, but evidence is inconclusive for older adults living with cognitive impairment. We performed an updated systematic review and meta-analysis to assess the potential effectiveness of interventions for reducing falls in older persons with cognitive impairment.

Methods

PubMed, EMBASE, CINAHL, Scopus, CENTRAL and PEDro were searched from inception to 10 November 2020. We included randomised controlled trials (RCTs) that evaluated the effects of physical training compared to a control condition (usual care, waitlist, education, placebo control) on reducing falls among community-dwelling older adults with cognitive impairment (i.e. any stage of Alzheimer’s disease and related dementias, mild cognitive impairment).

Results

We identified and meta-analysed nine studies, published between 2013 and 2020, that included 12 comparisons (N = 1,411; mean age = 78 years; 56% women). Overall, in comparison to control, interventions produced a statistically significant reduction of approximately 30% in the rate of falls (incidence rate ratio = 0.70; 95% CI, 0.52-0.95). There was significant between-trial heterogeneity (I² = 74%), with most trials (n = 6 studies [eight comparisons]) showing no reductions on fall rates. Subgroup analyses showed no differences in the fall rates by trial-level characteristics. Exercise-based interventions had no impact on reducing the number of fallers (relative risk = 1.01; 95% CI, 0.90–1.14). Concerns about risk of bias in these RCTs were noted, and the quality of evidence was rated as low.

Conclusions

The positive statistical findings on reducing fall rate in this meta-analysis were driven by a few studies. Therefore, current evidence is insufficient to inform evidence-based recommendations or treatment decisions for clinical practice.

PROSPERO Registration number: CRD42020202094.

Feasibility and Effectiveness of a Biography-Based Physical Activity Intervention in Institutionalized People With Dementia: Quantitative and Qualitative Results From a Randomized Controlled Trial

The objective of this multicenter randomized controlled trial was to evaluate the feasibility and effectiveness of a physical activity intervention for institutionalized people with dementia, individualized by capacity and biography. The intervention group (n = 34; age: mean = 86.09 years; 79.40% female; mean Mini-Mental State Examination value = 18.59) participated in a multicomponent training program, which included daily activities, dancing, gardening, and sports/games, twice weekly for 3 months. The control group (n = 29; age: mean = 86.34 years; 75.90% female; mean Mini-Mental State Examination value = 19.90) received standard care. Feasibility was evaluated by means of focus groups and feedback questionnaires. Functional performance (Short Physical Performance Battery and Timed Up and Go Test), activities of daily living, and gait were outcomes for effectiveness. A high adherence rate (80.46%) and uniformly positive feedback indicate that the piloted training program is feasible. The results show preliminary effectiveness on functional performance (Short Physical Performance Battery mean t0 = 3.15; mean t1 = 4.50; p = .006) and gait (e.g., velocity mean t0 = 46.97; mean t1 = 58.04; p = .007).

A secondary analysis of a randomised controlled trial to investigate the effect of Tai Chi on the instrumented timed up and go test in people with mild to moderate dementia

Background

Previous research has identified that Tai Chi is effective for reducing risk of falls and improving timed up and go scores. However, our previous research identified no-significant difference in time to complete the timed up and go test following a Tai Chi intervention in people with dementia.

Aim

To conduct a secondary analysis to extend our understanding of the effect of Tai Chi on the instrumented Timed Up and Go test.

Methods

This is a secondary analysis of a randomised controlled trial set in the community. People with dementia, recruited from NHS databases, memory clinics, local charities and self-referral across the south of England, received either 20 weeks of Tai Chi plus normal care or normal care. Outcomes were assessed using the instrumented Timed Up and Go test, completed at baseline and after 6 months.

Results

From 83 people with dementia volunteering for the study, 67 complete datasets were available for analysis. Within-group pairwise comparison across time revealed no-significant gains for any of the instrumented Timed Up and Go variables, and no-significant difference for between-group pairwise comparisons.

Discussion

This suggests that Tai Chi had no effect on the instrumented Timed Up and Go in people with dementia. This lack of effect may be due to the lack of specificity of the training stimulus to the outcome measure.

Conclusion

Tai Chi had no effect on any instrumented Timed Up and Go variables, suggesting Tai Chi may not be best placed to enhance the sub-elements of the instrumented Timed Up and Go to reduce fall risk among community-dwelling people with dementia.

Clinical trial registration number: NCT02864056.

Applying the RE-AIM implementation framework to evaluate fall prevention interventions in community dwelling adults with cognitive impairment: a review and secondary analysis

BACKGROUND

Cognitive impairment (CI) is a risk factor for falls due to environmental or living settings, balance, gait and vision impairments, as well as medications. While previous systematic reviews have focused on the effectiveness of fall prevention programs in adults with cognitive impairment, very limited information is available on their implementation. This review examines what aspects of fall prevention interventions for community-dwelling adults with CI have been reported using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to support successful implementation.

METHODS

We examined the included studies from our systematic review, which searched 7 databases for primary and secondary fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations and extracted data for study characteristics and the 5 dimensions (62 criteria) of the RE-AIM framework.

RESULTS

Twelve randomized or clinical controlled trials (RCTs/CCTs) consisting of 8 exercise interventions, 3 multifactorial interventions, and 1 medication treatment were included in the review. Only 4 of 62 criteria were reported by all 12 included studies and 29 criteria were not reported by any of the studies. Five of the included studies reported on 20 or more of the 62 possible RE-AIM criteria and 3 of these studies self-identified as "feasibility" studies. While Reach was the best-reported construct by the included studies, followed by Effectiveness and Implementation, the criteria within the Adoption and Maintenance constructs were rarely mentioned by these studies. In general, there was also wide variation in how each of the criteria were reported on by study authors.

CONCLUSION

Based on the reporting of RE-AIM components in this review, we are unable to make connections to successful intervention components and thus practice-based recommendations for fall prevention in those with CI. The lack of detail regarding implementation approaches greatly limits the interpretation and comparisons across studies to fully inform future research efforts.

Feasibility of improving strength and functioning and decreasing the risk of falls in older adults with Alzheimer's dementia: a randomized controlled home-based exercise trial

PURPOSE

To determine the effects of a Home-based multimodal exercise program for older people with Alzheimer's disease (AD-HOMEX) on muscle strength, mobility, the risk of falls and functioning.

MATERIALS AND METHODS

A trial with a blinded assessor was conducted involving 40 older people with mild to moderate AD randomized to an intervention group (IG) or control group (CG). The IG participated in a 16-week protocol with three 60-minute sessions per week. The sessions were performed at the participant's home by a physiotherapist and involved progressive individualized physical exercises. Muscle strength (5X Sit-to-Stand Test [5XSTS], 30-Second Chair Stand test, isokinetic and hand-grip dynamometer), functioning (DAFS-R and ADL-Q), mobility and the risk of falls (TUG) were assessed at baseline and after training. Intention-to-treat analysis was adopted.

RESULTS

There was a significant group-evaluation time interaction for the 5XSTS (p = 0.011). The IG demonstrated an improved performance on the 5XSTS (p = 0.020) and a reduced risk of falls (p = 0.000), whereas the CG exhibited a worse functional limitation (p = 0.008) after 16 weeks. The CG had an increased risk of falls (p = 0.006) and worse performance on the ADL-Q (p = 0.047) at the follow-up evaluation. An improvement in the IG and worsening in the CG were found regarding transition patterns between severity levels of functional limitation based on the ADL-Q.

CONCLUSIONS

Home-based physical exercise for older people with mild to moderate AD is an effective strategy that decreases the risk of falls and improves strength and functioning.

Feasibility of reducing frailty components in older adults with Alzheimer's dementia: a randomized controlled home-based exercise trial (AD-HOMEX)

OBJECTIVES

There is a need for interventions to reduce frailty in older people with Alzheimer's dementia (AD). The purpose of this study was to investigate the effect of a home-based multimodal exercise program for older adults with AD (AD-HOMEX) on frailty.

DESIGN

A parallel single-blind randomized controlled trial comparing a home-based exercise program and usual care.

SETTING AND PARTICIPANTS

A home-based program in Brazil. Forty individuals aged 65years or older with mild to moderate AD.

METHODS

The intervention group (IG) participated in a 16-week protocol involving three 60-minute sessions per week of progressive individualized physical exercises supervised by a physical therapist. The participants in the control group (CG) maintained their usual care. Frailty was assessed using the FRAIL questionnaire, the Edmonton Frail Scale (EFS) and a subjective assessment by the evaluator (SAE) at baseline and follow-up. Per-protocol analysis was performed.

RESULTS

Thirty-five participants completed the program (IG = 16; CG = 19). Frailty improved in the IG based on the EFS (P = .004) and FRAIL (P ≤ .001). An interaction between group and time (P = .008) and a significant difference between times (P = .047) were found for the SAE responsiveness domain. An improvement in the classification of frailty (EFS and FRAIL) was found between times in the IG (P = .003) and between groups at follow-up (P = .027). A significant difference in the SAE classification was found between groups at follow-up (P = .034), with a worsening between times in the CG (P = .032). Interestingly, a more favorable frailty transition pattern was found in the IG based on both the EFS and FRAIL.

CONCLUSIONS AND IMPLICATIONS

AD-HOMEX seems to reduce frailty and improve frailty transition patterns. Our findings provide a further theoretical basis for designing home-based physical interventions as routine practice for older frail adults with AD.

Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials

We performed a meta-analysis to synthesize evidence on the efficacy and safety of physical exercise as an add-on therapeutic intervention for quality of life (QoL), depressive symptoms and cognition across six chronic brain disorders: Alzheimer's disease, Huntington's disease, multiple sclerosis, Parkinson's disease, schizophrenia and unipolar depression. 122 studies ( = k) (n = 7231) were included. Exercise was superior to treatment as usual in improving QoL (k = 64, n = 4334, ES = 0.40, p < 0.0001), depressive symptoms (k = 60, n = 2909, ES = 0.78, p < 0.0001), the cognitive domains attention and working memory (k = 21, n = 1313, ES = 0.24, p < 0.009), executive functioning (k = 14, n = 977, ES = 0.15, p = 0.013), memory (k = 12, n = 994, ES = 0.12, p = 0.038) and psychomotor speed (k = 16, n = 896, ES = 0.23, p = 0.003). Meta-regression showed a dose-response effect for exercise time (min/week) on depressive symptoms (β = 0.007, p = 0.012). 69% of the studies that reported on safety, found no complications. Exercise is an efficacious and safe add-on therapeutic intervention showing a medium-sized effect on QoL and a large effect on mood in patients with chronic brain disorders, with a positive dose-response correlation. Exercise also improved several cognitive domains with small but significant effects.

Foot-ankle functional outcomes of using the Diabetic Foot Guidance System (SOPeD) for people with diabetic neuropathy: a feasibility study for the single-blind randomized controlled FOotCAre (FOCA) trial I

BACKGROUND

Diabetic neuropathy dramatically affects musculoskeletal structure and function of the lower limbs by impairing their muscle strength and mobility. Specific muscle strengthening through physiotherapy strategies appears to be promising; however, adherence to physiotherapy treatment is low in people with chronic diseases. Thus, an internet-based foot-ankle exercise program was created as a potential telerehabilitation alternative for people with diabetes to improve their self-monitoring and self-care management. This study assessed the feasibility, safety, acceptability, and changes in foot health and neuropathy symptoms in people with diabetes after 12 weeks of the intervention program with the Sistema de Orientação ao Pé diabético - Diabetic Foot Guidance System (SOPeD).

METHODS

Fourteen individuals were recruited and randomized to either the usual care (control group) or usual care plus an internet-based foot-ankle exercise program through SOPeD (intervention group) three times per week for 12 weeks. For feasibility, we assessed contact and recruitment rates per week; program adherence, determined as completing over 70% of the 36 sessions; and participant satisfaction and safety assessed through a questionnaire and scored on a 5-point Likert scale. We assessed changes in neuropathy symptoms and foot health and functionality from baseline to 12 weeks estimating differences or median of differences and 95% confidence intervals in the intervention group.

RESULTS

In 24 weeks, of the 822 patients in the database, 192 were contacted, 65 were assessed for eligibility, and 20 were considered eligible. The recruitment rate was 0.83 participants per week. Fourteen out of the 20 eligible participants agreed to participate, resulting in recruitment success of 70%. Adherence to the program was 66.7%, and there was no dropout. Participants' median level of satisfaction was 5.0 (IQR: 4.5-5.0) and perceived safety was 5.0 (IQR: 5.0-5.0).

CONCLUSION

The internet-based foot-ankle exercise program using SOPeD is feasible, satisfactory, and safe. Although this study had moderate adherence and a zero-dropout rate, recruitment needs to be improved in the larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04011267 . Registered on 8 July 2019.

Autoregulated heavy slow resistance training combined with radial shockwave therapy for plantar heel pain: Protocol for a mixed-methods pilot randomised controlled trial

BACKGROUND

Plantar heel pain (PHP) is considered a tendinopathy and it affects up to 10% of the population. Both heavy slow resistance training (HSRT) and extracorporeal shockwave therapy (ESWT) have shown effectiveness for treating PHP in isolation. However, more comprehensive exercise protocols and progression methods are needed due to poor long-term outcomes, and better standardisation of ESWT protocols are required. Autoregulation of resistance training involves self-selecting exercise dosage based on individual factors. Although autoregulation has proven effective for strength gains in athletes, it has not been investigated in tendinopathy. Recent studies recommend that PHP should not be treated by one treatment intervention in isolation. However, there is a dearth of research investigating the feasibility and effectiveness of combined treatment interventions for PHP. Currently, no studies have investigated autoregulated HSRT combined with ESWT, despite their individual efficacy. The optimal treatment protocol for PHP is unknown, and there is a need to ascertain whether the addition of ESWT to autoregulated HSRT leads to better outcomes compared to either alone.

METHODS

A three-arm randomised controlled trial (RCT) comparing these groups would be the ideal way to investigate this question, with a pilot RCT testing trial procedures and process evaluation required prior to a definitive RCT. Patients expectations, feasibility and acceptability of combined ESWT and exercise for PHP also remain unknown. Therefore, the addition of qualitative interviews in a mixed-methods pilot RCT would help ascertain acceptability and help explain the intervention outcomes.

The Effect of Unsupervised Home-Based Exercise Training on Physical Functioning Outcomes in Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Exercise training such as balance, aerobic, and resistance training is able to improve physical functioning of older adults. Delivering such exercise regimes at home without supervision may be useful for older adults because they do not have to leave their homes.

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials aimed to establish the effect of unsupervised home-based exercise training regimes on physical functioning (balance and muscle strength) in older adults.

DATA SOURCES

PubMed, CINAHL, Medline, Google Scholar, and Scopus databases and reference lists of included investigations were searched.

STUDY SELECTION

Thirteen randomized controlled trials (RCTs) of exercise training impact on balance and upper body strength with concurrent control groups were included in the analysis.

RESULTS

Our analyses revealed that in older adults, unsupervised home-based various exercise training was effective in improving measures of proactive balance (mean difference (MD) = -1.37 s; 95% confidence interval (CI), -2.24, -0.51 s; p = 0.002) and balance test battery (MD: 1.80; 95% CI, 0.46, 3.14 s; p = 0.009). There were no significant differences between the experimental and control groups for upper body strength (p > 0.05).

CONCLUSION

Unsupervised home-based exercise training improves balance in older adults. Future investigations are needed to clarify the mechanisms underlying unsupervised home-based exercise training's effect on this population's physical functioning outcomes.

Effects of 6-Month Multimodal Physical Exercise Program on Bone Mineral Density, Fall Risk, Balance, and Gait in Patients with Alzheimer's Disease: A Controlled Clinical Trial

We aimed to determine the short- and medium-term effects of a multimodal physical exercise program (MPEP) on bone health status, fall risk, balance, and gait in patients with Alzheimer’s disease. A single-blinded, controlled clinical trial was performed where 72 subjects were allocated in a 3:1 ratio to an intervention group (IG; n = 53) and control group (CG; n = 19), where the IG’s subjects were admitted to live in a State Reference Center of Alzheimer’s disease, which offers the targeted exercise program, while the CG’s subjects resided in independent living. A multidisciplinary health team assessed all patients before allocation, and dependent outcomes were again assessed at one, three, and six months. During the study, falls were recorded, and in all evaluations, bone mineral density was measured using a calcaneal quantitative ultrasound densitometer; balance and gait were measured using the performance-oriented mobility assessment (POMA), the timed up and go test (TUG), the one-leg balance test (OLB), and the functional reach test (FR). There were no differences between groups at baseline for all outcome measures. The prevalence of falls was significantly lower in the IG (15.09%) than in the CG (42.11%) (χ² = 5.904; p = 0.015). We also found that there was a significant time*group interaction, with a post hoc Šidák test finding significant differences of improved physical function, especially in gait, for the IG, as assessed by POMA-Total, POMA-Gait, and TUG with a large effect size (ƞ²p = 0.185–0.201). In balance, we found significant differences between groups, regardless of time, and a medium effect size as assessed by POMA-Balance and the OLB (ƞ²p = 0.091–0.104). Clinically relevant effects were observed, although without significant differences in bone health, with a slowing of bone loss. These results show that a multimodal physical exercise program reduces fall risk and produces an improvement in gait, balance, and bone mineral density in the short and medium term in institutionalized patients with Alzheimer’s disease.

A dyadic approach for a remote physical activity intervention in adults with Alzheimer's disease and their caregivers: Rationale and design for an 18-month randomized trial

Adults with Alzheimer's disease and related dementia (ADRD) and their caregivers represent a sizeable and underserved segment of the population with low levels of moderate physical activity (MPA). Options for increasing MPA in community dwelling adults with ADRD and their caregivers are limited. A home-based physical activity intervention delivered remotely via video conferencing to groups of adults with ADRD and their caregivers (RGV), represents a potentially effective approach for increasing MPA in this group. We will conduct an 18-month randomized trial (6 mos. Active intervention, 6 mos. Maintenance, 6 mos. no contact) to compare the effectiveness of the RGV approach with usual care, enhanced with caregiver support (EUC), for increasing MPA in 100 community dwelling adults with ADRD and their caregiver. The primary aim is to compare MPA (min/wk.), assessed by accelerometer, across the 6-mo. active intervention in adults with ADRD randomized to RGV or EUC. Secondarily, we will compare adults with ADRD and their caregivers randomized to RGV or ECU on the following outcomes across 18 mos.: MPA (min/wk.), sedentary time (min/wk.), percentage meeting 150 min/wk. MPA goal, functional fitness, activities of daily living, quality of life, residential transitions, cognitive function, and caregiver burden. Additionally, we will evaluate the influence of age, sex, BMI, attendance (exercise/support sessions), use of recorded sessions, self-monitoring, peer interactions during group sessions, caregiver support, type and quality of dyadic relationship, and number of caregivers on changes in MPA in adults with ADRD and their caregiver across 18 mos.

Acceptability and Feasibility of an Isometric Resistance Exercise Program for Abdominal Cancer Surgery: An Embedded Qualitative Study

Although it is recognized in the early stages of cancer recovery that changes in lifestyle including increases in physical activity improves physical function, there are no clear findings whether low versus moderate intensity activity or home or gym exercise offer optimal benefit. Isometric-resistance exercises can be carried out with very little equipment and space and can be performed while patients are bed-bound in hospital or at home. This embedded qualitative study, based in an English hospital trust providing specialist cancer care, was undertaken as a component of a feasibility trial to evaluate the acceptability and feasibility of an isometric-resistance exercise program and explore the suitability of functional assessments by drawing from the experiences of abdominal cancer patients following surgery. Telephone interviews were undertaken with 7 participants in the intervention group, and 8 interviews with the usual care group (n = 15). The gender composition consisted of 11 females and 4 males. Participants’ ages ranged from 27 to 84 (M = 60.07, SD = 15.40). Interviews were conducted between August 2017 and May 2018, with audio files digitally recorded and data coded using thematic framework analysis. Our results show that blinding to intervention or usual care was a challenge, participants felt the intervention was safe and suitable aided by the assistance of a research nurse, yet, found the self-completion questionnaire tools hard to complete. Our study provides an insight of trial processes, participants’ adherence and completion of exercise interventions, and informs the design and conduct of larger RCTs based on the experiences of abdominal cancer surgery patients.

Feasibility of a 12 Week Physical Intervention to Prevent Cognitive Decline and Disability in the At-Risk Elderly Population in Korea

There is a need for measures that can prevent the onset of dementia in the rapidly aging population. Reportedly, sustained physical exercise can prevent cognitive decline and disability. This study aimed to assess the feasibility of a 12-week physical exercise intervention (PEI) for delay of cognitive decline and disability in the at-risk elderly population in Korea. Twenty-six participants (aged 67.9 ± 3.6 years, 84.6% female) at risk of dementia were assigned to facility-based PEI (n = 15) or home-based PEI (n = 11). The PEI program consisted of muscle strength training, aerobic exercise, balance, and stretching using portable aids. Feasibility was assessed by retention and adherence rates. Physical fitness/cognitive function were compared before and after the PEI. Retention and adherence rates were 86.7% and 88.3%, respectively, for facility-based PEI and 81.8% and 62.3% for home-based PEI. No intervention-related adverse events were reported. Leg strength/endurance and cardiopulmonary endurance were improved in both groups: 30 s sit-to-stand test (facility-based, p = 0.002; home-based, p = 0.002) and 2 -min stationary march (facility-based, p = 0.001; home-based, p = 0.022). Cognitive function was improved only after facility-based PEI (Alzheimer’s Disease Assessment Scale-cognitive total score, p = 0.009; story memory test on Literacy Independent Cognitive Assessment, p = 0.026). We found that, whereas our PEI is feasible, the home-based program needs supplementation to improve adherence.

Tailored Exercise and Home Hazard Reduction Program for Fall Prevention in Older People With Cognitive Impairment: The i-FOCIS Randomized Controlled Trial

Background

The evidence to support effective fall prevention strategies in older people with cognitive impairment (CI) is limited. The aim of this randomized controlled trial (RCT) was to determine the efficacy of a fall prevention intervention in older people with CI.

Method

RCT involving 309 community-dwelling older people with CI. The intervention group (n = 153) received an individually prescribed home hazard reduction and home-based exercise program during the 12-month study period. The control group (n = 156) received usual care. The primary outcome was rate of falls. Secondary outcomes included faller/multiple faller status, physical function, and quality of life.

Results

Participants’ average age was 82 years (95% CI 82–83) and 49% were female. There was no significant difference in the rate of falls (incidence rate ratio [IRR] 1.05; 95% confidence interval [95% CI] 0.73–1.51). A sensitivity analysis, controlling for baseline differences and capping the number of falls at 12 (4 participants), revealed a nonsignificant reduction in fall rate in the intervention group (IRR 0.78; 95% CI 0.57–1.07). Analyses of secondary outcomes indicated the intervention significantly reduced the number of multiple fallers by 26% (RR 0.74; 95% CI 0.54–0.99) when adjusting for baseline differences. There was a differential impact on falls in relation to physical function (interaction term p-value = .023) with a significant reduction in fall rate in intervention group participants with better baseline physical function (IRR 0.60; 95% CI 0.37–0.98). There were no significant between-group differences for other secondary outcomes.

Conclusions

This intervention did not significantly reduce the fall rate in community-dwelling older people with CI. The intervention did reduce the fall rate in participants with better baseline physical function.

Clinical Trials Registration Number

Australian and New Zealand Trials Registry ACTRN12614000603617.

Promoting physical activity in geriatric patients with cognitive impairment after discharge from ward-rehabilitation: a feasibility study

The aim of the present study was to examine adherence and acceptance of a home-based program to promote physical activity (PA) in older persons with cognitive impairment (CI) following inpatient rehabilitation. Sixty-three older persons (≥ 65 years) with mild to moderate CI (Mini-Mental State Examination score 17-26), allocated to the intervention group of a randomized, controlled intervention trial underwent a 12-week home-based PA intervention including (1) physical training and outdoor walking to improve functional fitness and (2) motivational strategies (goal-setting, pedometer-based self-monitoring, social support delivered by home visits, phone calls) to promote PA. Training logs were used to assess adherence to physical training, outdoor walking and to motivational strategies (goal-setting, pedometer-based self-monitoring). Acceptance (subjective feasibility and effectiveness) of the program components was assessed by a standardized questionnaire. Mean adherence rates over the intervention period were 63.6% for physical training, 57.9% for outdoor walking, and between 40.1% (achievement of walking goals), and 60.1% (pedometer-based self-monitoring) for motivational strategies. Adherence rates significantly declined from baseline to the end of intervention (T1: 43.4-76.8%, T2: 36.1-51.5%, p values<.019). Most participants rated physical training, outdoor walking, goal-setting, and pedometer self-monitoring as feasible (68.2-83.0%) and effective (63.5-78.3%). Highest ratings of self-perceived effectiveness were found for home visits (90.6%) and phone calls (79.2%). The moderate to high adherence to self-performed physical training and motivational strategies proved the feasibility of the home-based PA program in older persons with CI following inpatient rehabilitation.

Increasing Physical Activity in Persons With Dementia: A Randomized Controlled Trial

This study investigated the effectivity and sustainability of a physical activity (PA) promotion and motor training programs and analyzed predictors for PA changes in persons with dementia. A total of 122 participants with mild-to-moderate dementia were randomized to the intervention program designed for persons with dementia (intervention group) or a motor placebo activity (control group). The primary outcome was the Physical Activity Questionnaire for the Elderly assessed at the baseline, after the 3-month intervention, and at a 3-month follow-up. The PA promotion program significantly increased PA in the intervention group compared with the control group during the training intervention phase. Both groups showed an increase in habitual PA when intervention-induced activities were excluded. PA was sustainably increased in both groups at follow-up. Low baseline PA was predictive for increased PA after the intervention and low baseline PA, high motor performance, and low comorbidity for increased PA at follow-up.

Effects of a 16-week multimodal exercise program on gait performance in individuals with dementia: a multicenter randomized controlled trial

Background

There is a high prevalence of gait impairments in individuals with dementia (IWD). Gait impairments are associated with increased risk of falls, disability, and economic burden for health care systems. Only few studies have investigated the effectiveness of physical activity on gait performance in IWD, reporting promising but inconsistent results. Thus, this study aimed to investigate the effectiveness of a multimodal exercise program (MEP) on gait performance in IWD.

Methods

In this parallel-group randomized controlled trial, we enrolled 319 IWD of mild to moderate severity, living in care facilities, aged ≥ 65 years, and being able to walk at least 10 m. The control group (n = 118) received conventional treatment, whereas the intervention group (n = 201) additionally participated in a 16-week MEP specifically tailored to IWD. We examined the effects of the MEP on spatiotemporal gait parameters and dual task costs by using the gait analysis system GAITRite. Additionally, we compared characteristics between positive, non-, and negative responders, and investigated the impact of changes in underlying motor and cognitive performance in the intervention group by conducting multiple regression analyses.

Results

Two-factor analyses of variance with repeated measurements did not reveal any statistically significant time*group effects on either spatiotemporal gait parameters or dual task costs. Differences in baseline gait performance, mobility, lower limb strength, and severity of cognitive impairments were observed between positive, non-, and negative responders. Positive responders were characterized by lower motor performance compared to negative and non-responders, while non-responders showed better cognitive performance than negative responders. Changes in lower limb strength and function, mobility, executive function, attention, and working memory explained up to 39.4% of the variance of changes in gait performance.

Conclusions

The effectiveness of a standardized MEP on gait performance in IWD was limited, probably due to insufficient intensity and amount of specific walking tasks as well as the large heterogeneity of the sample. However, additional analyses revealed prerequisites of individual characteristics and impacts of changes in underlying motor and cognitive performance. Considering such factors may improve the effectiveness of a physical activity intervention among IWD.

Trial registration

DRKS00010538 (German Clinical Trial Register, date of registration: 01 June 2016, retrospectively registered, https://www.drks.de/drks_web/setLocale_EN.do).

Safety and feasibility of a Dalcroze eurhythmics and a simple home exercise program among older adults with mild cognitive impairment (MCI) or mild dementia: the MOVE for your MIND pilot trial

Background

Falls represent a major health problem for older adults with cognitive impairment, and the effects of exercise for fall reduction are understudied in this population. This pilot randomized controlled trial evaluated the feasibility, safety, and exploratory effectiveness of a Dalcroze eurhythmics program and a home exercise program designed for fall prevention in older adults with mild cognitive impairment (MCI) or early dementia.

Methods

For this three-arm, single-blind, 12-month randomized controlled pilot trial, we recruited community-dwelling women and men age 65 years and older with MCI or early dementia through participating memory clinics in Zurich, Switzerland. Participants were randomly assigned to a Dalcroze eurhythmics group program, a simple home exercise program (SHEP), or a non-exercise control group. All participants received 800 IU of vitamin D₃ per day. The main objective of the study was to test the feasibility of recruitment and safety of the interventions. Additional outcomes included fall rate, gait performance, and cognitive function.

Results

Over 12 months, 221 older adults were contacted and 159 (72%) were screened via telephone. Following screening, 12% (19/159) met the inclusion criteria and were willing to participate. One participant withdrew at the end of the baseline visit and 18 were randomized to Dalcroze eurhythmics (n = 7), SHEP (n = 5), or control (n = 6). Adherence was similarly low in the Dalcroze eurhythmics group (56%) and in the SHEP group (62%; p = 0.82). Regarding safety and pilot clinical endpoints, there were no differences between groups.

Conclusion

The MOVE for your MIND pilot study showed that recruitment of older adults with MCI or early dementia for long-term exercise interventions is challenging. While there were no safety concerns, adherence to both exercise programs was low.

Trial registration

ClinicalTrials.gov, NCT02279316. Registered on 31 October 2014

Medium Chain Triglycerides induce mild ketosis and may improve cognition in Alzheimer's disease. A systematic review and meta-analysis of human studies

INTRODUCTION/AIM

The brain in Alzheimer's disease shows glucose hypometabolism but may utilize ketones for energy production. Ketone levels can potentially be boosted through oral intake of Medium Chain Triglycerides (MCTs). The aim of this meta-analysis is to investigate the effect of MCTs on peripheral ketone levels and cognitive performance in patients with mild cognitive impairment and Alzheimer's disease.

METHODS

Medline, Scopus and Web of Science were searched for literature up to March 1, 2019. Meta-analyses were performed by implementing continuous random-effects models and outcomes were reported as weighted Mean Differences (MDs) or Standardized Mean Differences (SMDs).

RESULTS

Twelve records (422 participants) were included. Meta-analysis of RCTs showed that, compared with placebo, MCTs elevated beta-hydroxybutyrate [MD = 0.355; 95 % CI (0.286, 0.424), I² = 0 %], showed a trend towards cognitive improvement on ADAS-Cog [MD = -0.539; 95% CI (-1.239, -0.161), I² = 0 %], and significantly improved cognition on a combined measure (ADAS-Cog with MMSE) [SMD = -0.289; 95 % CI (-0.551, -0.027), I² = 0 %].

CONCLUSIONS

In this meta-analysis, we demonstrated that MCTs can induce mild ketosis and may improve cognition in patients with mild cognitive impairment and Alzheimer's disease. However, risk of bias of existing studies necessitates future trials.

A Scoping Review of Physical Performance Outcome Measures Used in Exercise Interventions for Older Adults With Alzheimer Disease and Related Dementias

BACKGROUND AND PURPOSE

There is growing evidence that exercise interventions can mitigate functional decline and reduce fall risk in older adults with Alzheimer disease and related dementias (ADRD). Although physical performance outcome measures have been successfully used in older adults without cognitive impairment, additional research is needed regarding their use with individuals who have ADRD, and who may have difficulty following instructions regarding performance of these measures. The purpose of this scoping review was to identify commonly used physical performance outcome measures, for exercise interventions, that are responsive and reliable in older adults with ADRD. Ultimately, we aimed to provide recommendations regarding the use of outcome measures for individuals with ADRD across several domains of physical performance.

METHODS

A scoping review was conducted to broadly assess physical performance outcome measures used in exercise interventions for older adults with ADRD. Exercise intervention studies that included at least 1 measure of physical performance were included. All physical performance outcome measures were abstracted, coded, and categorized into 5 domains of physical performance: fitness, functional mobility, gait, balance, and strength. Criteria for recommendations were based on (1) the frequency of use, (2) responsiveness, and (3) reliability. Frequency was determined by the number of studies that used the outcome measure per physical performance domain. Responsiveness was assessed via calculated effect size of the outcome measures across studies within physical performance domains. Reliability was evaluated via published studies of psychometric properties.

RESULTS AND DISCUSSION

A total of 20 physical performance outcome measures were extracted from 48 articles that met study inclusion criteria. The most frequently used outcome measures were the 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, the Berg Balance Scale, and isometric strength measures. These outcome measures demonstrated a small, medium, or large effect in at least 50% of the exercise intervention studies. Good to excellent reliability was reported in samples of older adults with mild to moderate dementia. Fitness, functional mobility, gait, balance, and strength represent important domains of physical performance for older adults. The 6-minute walk test, Timed Up and Go, repeated chair stand tests, short-distance gait speed, Berg Balance Scale, and isometric strength are recommended as commonly used and reliable physical performance outcome measures for exercise interventions in older adults with mild to moderate ADRD. Further research is needed on optimal measures for individuals with severe ADRD.

CONCLUSIONS

The results of this review will aid clinicians and researchers in selecting reliable measures to evaluate physical performance outcomes in response to exercise interventions in older adults with ADRD.