A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia

Effects of exercise training on the cognitive function of older adults with different types of dementia: a systematic review and meta-analysis

OBJECTIVES

To assess the effect of exercise training on the cognitive function of older adults living with different types of dementia, as well as potential moderators of exercise efficacy.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Central, PsycINFO, Embase, Medline and CINAHL.

ELIGIBILITY CRITERIA

Peer-reviewed, randomised controlled trials, in English (1990-present), which examined the effects of exercise training on the cognitive function of older adults living with dementia.

STUDY APPRAISAL AND SYNTHESIS

Risk of bias and study quality were assessed (Cochrane Risk of Bias Tool 2.0 and Physiotherapy Evidence Database Scale). We performed random-effects models using robust variance estimation and tested moderators using the approximate Hotelling-Zhang test.

RESULTS

Twenty-eight studies (n=2158) were included in the qualitative review and 25 in the meta-analysis. For all-cause dementia, a small effect of exercise training on cognitive function was observed (g=0.19; 95% CI 0.05 to 0.33; p=0.009). Type of dementia and exercise training characteristics did not moderate the effects of exercise training on cognitive function (p>0.05). Adherence to the intervention moderated the cognitive outcome effect size such that greater mean adherence was associated with greater cognitive outcome effect sizes (b=0.02; SE=0.01; p=0.005).

CONCLUSION

Exercise training showed small benefits for the cognitive function of older adults living with all-cause dementia. More research and standardised reporting of exercise training characteristics can strengthen the evidence for what works best for which types of dementia.

PROSPERO REGISTRATION NUMBER

CRD42020198716.

Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: A systematic review and network meta-analysis

BACKGROUND

Exercise is a promising nonpharmacological therapy for cognitive dysfunction, but it is unclear which type of exercise is most effective. The objective of this study was to compare and rank the effectiveness of various exercise interventions on cognitive function in patients with mild cognitive impairment (MCI) or dementia and to examine the effects of exercise on the symptoms relevant to cognitive impairment.

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, SPORTDiscus, and PsycInfo through September 2019 and included randomized controlled trials that examined the effectiveness of exercise interventions in patients with MCI or dementia. Primary outcomes included global cognition, executive cognition, and memory cognition. Secondary outcomes included activities of daily living, neuropsychiatric symptoms, and quality of life. Pairwise analyses and network meta-analyses were performed using a random effects model.

RESULTS

A total of 73 articles from 71 trials with 5606 participants were included. All types of exercise were effective in increasing or maintaining global cognition, and resistance exercise had the highest probability of being the most effective intervention in slowing the decrease in global cognition (standard mean difference (SMD) = 1.05, 95% confidence interval (95%CI): 0.56-1.54), executive function (SMD = 0.85, 95%CI: 0.21-1.49), and memory function (SMD = 0.32, 95%CI: 0.01-0.63) in patients with cognitive dysfunction. Subgroup analyses for patients with MCI revealed different effects, and multicomponent exercise was most likely to be the optimal exercise therapy for preventing the decline of global cognition (SMD = 0.99, 95%CI: 0.44-1.54) and executive function (SMD = 0.72, 95%CI: 0.06-1.38). However, only resistance exercise showed significant effects on memory function for patients with MCI (SMD = 0.35, 95%CI: 0.01-0.69). Exercise interventions also showed various effects on the secondary outcomes.

CONCLUSION

Resistance exercise has the highest probability of being the optimal exercise type for slowing cognitive decline in patients with cognitive dysfunction, especially in patients with dementia. Multicomponent exercise tends to be most effective in protecting global cognition and executive function in patients with MCI.

Physical Activity Interventions and Their Effects on Cognitive Function in People with Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

Physical activity (PA) has emerged as an alternative nonpharmacological approach to effectively address the effects of dementia. The primary aim was to identify and summarize PA interventions and their effects on cognitive function among persons with dementia (PwD).

METHODS

A systematic review was conducted with a meta-analysis using different electronic databases, such as PubMed, Embase, APA PsycNET, and the Web of Science. The identified and selected studies were randomized controlled trials (RCTs) that were written in English, published between 2000 and 2020, and implemented among PwD who received a PA intervention and whose cognitive function was measured at baseline and during a follow-up.

RESULTS

Twenty-two PA intervention studies met the eligibility criteria and showed a medium-size effect on the cognitive function of PwD, 0.4803 (95% CI = 0.1901-0.7704), with a high percentage of heterogeneity (I² = 86%, p ≤ 0.0001). Moreover, this review complements other reviews by including eight studies that have not previously been considered. Overall, studies have methodological limitations. However, six studies implemented in the past five years have shown more robust methodological designs, including larger sample sizes and more comprehensive measurement tools.

CONCLUSION

It is not yet possible to draw a conclusion on the ideal PA intervention for this population due to the high proportion of heterogeneity within the included studies. More emphasis is needed on the intensity of PA monitoring and adherence to such programs.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018

BACKGROUND/OBJECTIVES

High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents.

DESIGN

The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident.

SETTING

Australian NHs.

PARTICIPANTS

Nursing home residents.

MEASUREMENTS

Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome.

RESULTS

Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6).

CONCLUSION

This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

No changes in corticospinal excitability, biochemical markers, and working memory after six weeks of high-intensity interval training in sedentary males

A single bout of aerobic exercise modulates corticospinal excitability, intracortical circuits, and serum biochemical markers such as brain‐derived neurotrophic factor (BDNF) and insulin‐like growth factor 1 (IGF‐1). These effects have important implications for the use of exercise in neurorehabilitation. Here, we aimed to determine whether increases in cardiorespiratory fitness (CRF) induced by 18 sessions of high‐intensity interval training (HIIT) over 6 weeks were accompanied by changes in corticospinal excitability, intracortical excitatory and inhibitory circuits, serum biochemical markers and working memory (WM) capacity in sedentary, healthy, young males. We assessed motor evoked potential (MEP) recruitment curves for the first dorsal interosseous (FDI) both at rest and during tonic contraction, intracortical facilitation (ICF), and short‐interval intracortical inhibition (SICI) using transcranial magnetic stimulation (TMS). We also examined serum levels of BDNF, IGF‐1, total and precursor (pro) cathepsin B (CTSB), as well as WM capacity. Compared to pretraining, CRF was increased and ICF reduced after the HIIT intervention, but there were no changes in corticospinal excitability, SICI, BDNF, IGF‐1, total and pro‐CTSB, and WM capacity. Further, greater CRF gains were associated with larger decreases in total and pro‐CTSB and, only in Val/Val carriers, with larger increases in SICI. Our findings confirm that HIIT is efficacious in promoting CRF and show that corticospinal excitability, biochemical markers, and WM are unchanged after 18 HIIT bouts in sedentary males. Understanding how aerobic exercise modulates M1 excitability is important in order to be able to use exercise protocols as an intervention, especially in rehabilitation following brain injuries.

Effects of low- and high-intensity physical exercise on physical and cognitive function in older persons with dementia: a randomized controlled trial

BACKGROUND

Potential moderators such as exercise intensity or apolipoprotein-E4 (ApoE4) carriership may determine the magnitude of exercise effects on physical and cognitive functions in patients with dementia (PwD). We determined the effects of a 24-week aerobic and strength training program with a low- and high-intensity phase on physical and cognitive function.

METHODS

In an assessor-blinded randomized trial, 91 PwD (all-cause dementia, recruited from daycare and residential care facilities, age 82.3 ± 7.0 years, 59 women, Mini-Mental State Examination 20.2 ± 4.4) were allocated to the exercise or control group. In the exercise group, PwD participated in a walking and lower limb strength training program with 12 weeks low- and 12 weeks high-intensity training offered three times/week. Attention-matched control participants performed flexibility exercises and recreational activities. We assessed adherence, compliance, and exercise intensity for each session. We assessed physical (endurance, gait speed, mobility, balance, leg strength) and cognitive (verbal memory, visual memory, executive function, inhibitory control, psychomotor speed) functions with performance-based tests at baseline and after 6, 12, 18, 24, and 36 weeks (follow-up). ApoE4 carriership was determined post-intervention.

RESULTS

Sixty-nine PwD were analyzed. Their mean attendance was ~ 60% during the study period. There were no significant effects of the exercise vs. control intervention on endurance, mobility, balance, and leg strength in favor of the exercise group (Cohen's d = 0.13-0.18). Gait speed significantly improved with ~ 0.05 m/s after the high-intensity phase for exercise participants (Cohen's d = 0.41) but declined at follow-up. There were no significant effects of the exercise vs. control intervention on any of the cognitive measures (Cohen's d ~ - 0.04). ApoE4 carriership did not significantly moderate exercise effects on physical or cognitive function.

CONCLUSIONS

Exercise was superior to control activities for gait speed in our sample of PwD. However, the training effect provided no protection for mobility loss after detraining (follow-up). There were no beneficial effects of the exercise vs. control group on cognitive function. Exercise intensity moderated the effects of exercise on gait speed. ApoE4 carriership moderated the effect of exercise on global cognition only (trend level).

TRIAL REGISTRATION

Netherlands Trial Register, NTR5035. Registered on 2 March 2015.

Physical exercise attenuates cognitive decline and reduces behavioural problems in people with mild cognitive impairment and dementia: a systematic review

QUESTIONS

What is the effect of physical exercise on cognitive decline and behavioural problems in people with mild cognitive impairment (MCI) or dementia? What is the effect of physical exercise on particular domains of cognitive function? How do training protocols and patients' characteristics influence the outcomes?

DESIGN

Systematic review and meta-analysis of randomised trials.

PARTICIPANTS

People with MCI or dementia as their primary diagnosis.

INTERVENTION

Physical exercise.

OUTCOME MEASURES

Cognitive function including global cognition, memory, executive function, reasoning, attention, language, and behavioural problems.

RESULTS

Forty-six trials involving 5099 participants were included in this review. Meta-analysis of the data estimated that aerobic exercise reduced the decline in global cognition, with a standardised mean difference (SMD) of 0.44, 95% CI 0.27 to 0.61, I² = 69%. For individual cognitive functions, meta-analysis estimated that exercise lessened working memory decline (SMD 0.28, 95% CI 0.04 to 0.52, I² = 40%). The estimated mean effect on reducing the decline in language function was favourable (SMD 0.17), but this estimate had substantial uncertainty (95% CI -0.03 to 0.36, I² = 67%). The effects of exercise on other cognitive functions were unclear. Exercise also reduced behavioural problems (SMD 0.36, 95% CI 0.07 to 0.64, I² = 81%).

CONCLUSION

Physical exercise can reduce global cognitive decline and lessen behavioural problems in people with MCI or dementia. Its benefits on cognitive function can be primarily attributed to its effects on working memory. Aerobic exercise at moderate intensity or above and a total training duration of > 24 hours can lead to a more pronounced effect on global cognition.

Aerobic and strength training exercise programme for cognitive impairment in people with mild to moderate dementia: the DAPA RCT

BACKGROUND

Approximately 670,000 people in the UK have dementia. Previous literature suggests that physical exercise could slow dementia symptom progression.

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of a bespoke exercise programme, in addition to usual care, on the cognitive impairment (primary outcome), function and health-related quality of life (HRQoL) of people with mild to moderate dementia (MMD) and carer burden and HRQoL.

DESIGN

Intervention development, systematic review, multicentred, randomised controlled trial (RCT) with a parallel economic evaluation and qualitative study.

SETTING

15 English regions.

PARTICIPANTS

People with MMD living in the community.

INTERVENTION

A 4-month moderate- to high-intensity, structured exercise programme designed specifically for people with MMD, with support to continue unsupervised physical activity thereafter. Exercises were individually prescribed and progressed, and participants were supervised in groups. The comparator was usual practice.

MAIN OUTCOME MEASURES

The primary outcome was the Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-Cog). The secondary outcomes were function [as measured using the Bristol Activities of Daily Living Scale (BADLS)], generic HRQoL [as measured using the EuroQol-5 Dimensions, three-level version (EQ-5D-3L)], dementia-related QoL [as measured using the Quality of Life in Alzheimer's Disease (QoL-AD) scale], behavioural symptoms [as measured using the Neuropsychiatric Inventory (NPI)], falls and fractures, physical fitness (as measured using the 6-minute walk test) and muscle strength. Carer outcomes were HRQoL (Quality of Life in Alzheimer's Disease) (as measured using the EQ-5D-3L) and carer burden (as measured using the Zarit Burden Interview). The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained from a NHS and Personal Social Services perspective. We measured health and social care use with the Client Services Receipt Inventory. Participants were followed up for 12 months.

RESULTS

Between February 2013 and June 2015, 494 participants were randomised with an intentional unequal allocation ratio: 165 to usual care and 329 to the intervention. The mean age of participants was 77 years [standard deviation (SD) 7.9 years], 39% (193/494) were female and the mean baseline ADAS-Cog score was 21.5 (SD 9.0). Participants in the intervention arm achieved high compliance rates, with 65% (214/329) attending between 75% and 100% of sessions. Outcome data were obtained for 85% (418/494) of participants at 12 months, at which point a small, statistically significant negative treatment effect was found in the primary outcome, ADAS-Cog (patient reported), with a mean difference of -1.4 [95% confidence interval (CI) -2.62 to -0.17]. There were no treatment effects for any of the other secondary outcome measures for participants or carers: for the BADLS there was a mean difference of -0.6 (95% CI -2.05 to 0.78), for the EQ-5D-3L a mean difference of -0.002 (95% CI -0.04 to 0.04), for the QoL-AD scale a mean difference of 0.7 (95% CI -0.21 to 1.65) and for the NPI a mean difference of -2.1 (95% CI -4.83 to 0.65). Four serious adverse events were reported. The exercise intervention was dominated in health economic terms.

LIMITATIONS

In the absence of definitive guidance and rationale, we used a mixed exercise programme. Neither intervention providers nor participants could be masked to treatment allocation.

CONCLUSIONS

This is a large well-conducted RCT, with good compliance to exercise and research procedures. A structured exercise programme did not produce any clinically meaningful benefit in function or HRQoL in people with dementia or on carer burden.

FUTURE WORK

Future work should concentrate on approaches other than exercise to influence cognitive impairment in dementia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN32612072.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full programme and will be published in full in Health Technology Assessment Vol. 22, No. 28. See the NIHR Journals Library website for further project information. Additional funding was provided by the Oxford NIHR Biomedical Research Centre and the Oxford NIHR Collaboration for Leadership in Applied Health Research and Care.

Effect of Exercise on Behavioral Symptoms and Pain in Patients With Dementia Living in Nursing Homes

OBJECTIVES

Examine the effects of a 6-month exercise intervention on neuropsychiatric symptoms, pain, and medication consumption in older people with dementia (PWD) living in nursing homes (NH).

METHODS

Ninety-one older PWD living in NH performed a 6-month structured exercise intervention (n = 44) or a social activity intervention (n = 47). Neuropsychiatric symptoms were measured by the neuropsychiatric inventory (NPI), pain was assessed using the Algoplus scale, and dementia-related drug prescriptions were obtained for all participants.

RESULTS

Between-group analysis found a nonsignificant difference that could be of clinical relevance: a 4-point difference in the NPI and 1.3-point difference in the reduction of the number of medications favoring exercisers. No significant differences were found for pain, and a trend was found for an increase in medication consumption in the social group.

CONCLUSION

Exercise effects did not differ from social intervention effects on neuropsychiatric symptoms, pain, and medication consumption in older PWD living in NH.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Caregivers in Physical Activity for Older Adults With Alzheimer's Disease

This study examined the determinants of physical activity (PA) for older adults with Alzheimer's disease (AD) to learn more about how to promote PA in this population. Caregivers of older adults with AD (N = 99) provided information related to care recipient's PA, as well as addressed sociodemographics and perceptions about their care recipient's PA. Gender of care recipient was a significant predictor of PA (β = .80, P < .05); men with AD participated in more PA than women with AD. Also, caregiver's outcome expectation for care recipient's PA also predicted more PA (β = .82, P < .05). Caregiver's perceived benefits of PA (outcome expectation) for their care recipient partially mediated the relationship between self-efficacy for care recipient's PA and the reported levels of PA for the care recipient. This study demonstrated the importance of caregiver perceptions about care recipient's PA.

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].

Structured physical exercise improves neuropsychiatric symptoms in acute dementia care: a hospital-based RCT

Background

The primary objective of this trial is to investigate the effects of a short-term exercise program on neuropsychiatric signs and symptoms in acute hospital dementia care.

Methods

Within a hospital-based randomized controlled trial, the intervention group conducted a 2-week exercise program with four 20-min exercise sessions on 3 days per week. The control group conducted a social stimulation program. Effects on neuropsychiatric signs and symptoms were measured via the Alzheimer’s Disease Cooperative Study-Clinical Global Impression of Change, the Neuropsychiatric Inventory, and the Cohen-Mansfield Agitation Inventory. The antipsychotic and sedative dosage was quantified by olanzapine and diazepam equivalents.

Results

Eighty-five patients were randomized via minimization to an intervention group (IG) and a control group (CG). Seventy patients (82%) (mean age 80 years, 33 females, mean Mini Mental State Examination score 18.3 points) completed the trial. As compared to the CG (n = 35), the IG (n = 35) showed significantly reduced neuropsychiatric signs and symptoms. Especially, agitated behavior and lability improved. There were no between-group differences concerning antipsychotic and benzodiazepine medication.

Conclusions

This exercise program is easily applicable in hospital dementia care and significantly reduces neuropsychiatric signs and symptoms in patients suffering from predominantly moderate stages of dementia.

Trial registration

German Clinical Trial Register DRKS00006740. Registered 28 October 2014.

Effect of exercise on cognitive function in chronic disease patients: a meta-analysis and systematic review of randomized controlled trials

Background

The purpose of this study was to conduct a meta-analysis and systematic review to assess the effect of exercise on cognitive function in people with chronic diseases.

Methods

PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, PsycINFO, and three Chinese databases were electronically searched for papers that were published until September 2016. This meta-analysis and systematic review included randomized controlled trials that evaluated the effect of exercise on cognitive function compared with control group for people with chronic diseases.

Results

Totally, 35 studies met the inclusion criteria, with 3,113 participants. The main analysis revealed a positive overall random effect of exercise intervention on cognitive function in patients with chronic diseases. The secondary analysis revealed that aerobic exercise interventions and aerobic included exercise interventions had a positive effect on cognition in patients with chronic diseases. The intervention offering low frequency had a positive effect on cognitive function in patients with chronic diseases. Finally, we found that interventions offered at both low exercise intensity and moderate exercise intensity had a positive effect on cognitive function in patients with chronic diseases. The secondary analysis also revealed that exercise interventions were beneficial in Alzheimer’s disease patients when grouped by disease type.

Conclusion

This meta-analysis and systematic review suggests that exercise interventions positively influence cognitive function in patients with chronic diseases. Beneficial effect was independent of the type of disease, type of exercise, frequency, and the intensity of the exercise intervention.

Does physical exercise improve ADL capacities in people over 65 years with moderate or severe dementia hospitalized in an acute psychiatric setting? A multisite randomized clinical trial

BACKGROUND

Several studies on the effect of physical exercise on activities of daily living (ADL) for people with dementia exist; yet, data concerning the specific context of acute psychiatric hospitals remain scant. This study measured the effect of a physical exercise program on ADL scores in patients with moderate to severe dementia hospitalized in an acute psychiatric ward.

METHODS

A multicenter clinical trial was conducted in five Swiss and Belgian psychiatric hospitals. Participants were randomly allocated to either an experimental group (EG) or a control group (CG). Members of the EG received 20 physical exercise sessions (strengthening, balance, and walking) over a four-week period while members of the CG participated in social interaction sessions of equivalent duration and frequency, but without physical exercise. The effect of exercise on ADL was measured by comparing scores of the Barthel Index and the Functional Independence Measure in the EG and CG before and after the intervention, and two weeks later.

RESULTS

Hundred and sixty patients completed the program. Characteristics of participants of both groups were similar at the inception of the study. The mean ADL score of EG decreased slightly over time, whereas that of the CG significantly decreased compared to initial scores. Overall differences between groups were not significant; however, significant differences were found for mobility-related items.

CONCLUSIONS

ADL scores in elderly with moderate to severe dementia deteriorate during acute psychiatric hospitalization. An exercise program delays the loss of mobility but does not have a significant impact on overall ADL scores.

Effects of a multicomponent exercise program in institutionalized elders with Alzheimer's disease

This study examined the effect of a Multicomponent Training (MT) intervention on cognitive function, functional fitness and anthropometric variables in institutionalized patients with Alzheimer's disease (AD). Thirty-seven institutionalized elders (84.05 ± 5.58 years) clinically diagnosed with AD (mild and moderate stages) were divided into two groups: Experimental Group (EG, n = 19) and Control Group (CG, n = 18). The EG participated in a six-month supervised MT program (aerobic, muscular resistance, flexibility and postural exercises) of 45-55 minutes/session, twice/week. Cognitive function (MMSE), physical fitness (Senior Fitness Test) and anthropometric variables (Body Mass Index and Waist Circumference), were assessed before (M1), after three months (M2) and after six months (M3) of the experimental protocol. A two-way ANOVA, with repeated measures, revealed significant group and time interactions on cognitive function, chair stand, arm curl, 2-min step, 8-foot up-and-go (UG), chair sit-and-reach (CSR) and back scratch tests as well as waist circumference. Accordingly, for those variables a different response in each group was evident over the time, supported by a significantly better EG performance in chair stand, arm curl, 2-min step, UG, CSR and back scratch tests from M1 to M3, and a significant increase in MMSE from M1 to M2. The CG's performance decreased over time (M1 to M3) in chair stand, arm curl, 2-min step, UG, CSR, back scratch and MMSE. Results suggest that MT programs may be an important non-pharmacological strategy to improve physical and cognitive functions in institutionalized AD patients.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials

Non-pharmacological therapies, such as physical activity interventions, are an appealing alternative or add-on to current pharmacological treatment of cognitive symptoms in patients with dementia. In this meta-analysis, we investigated the effect of physical activity interventions on cognitive function in dementia patients, by synthesizing data from 802 patients included in 18 randomized control trials that applied a physical activity intervention with cognitive function as an outcome measure. Post-intervention standardized mean difference (SMD) scores were computed for each study, and combined into pooled effect sizes using random effects meta-analysis. The primary analysis yielded a positive overall effect of physical activity interventions on cognitive function (SMD[95% confidence interval]=0.42[0.23;0.62], p<.01). Secondary analyses revealed that physical activity interventions were equally beneficial in patients with Alzheimer's disease (AD, SMD=0.38[0.09;0.66], p<.01) and in patients with AD or a non-AD dementia diagnosis (SMD=0.47[0.14;0.80], p<.01). Combined (i.e. aerobic and non-aerobic) exercise interventions (SMD=0.59[0.32;0.86], p<.01) and aerobic-only exercise interventions (SMD=0.41[0.05;0.76], p<.05) had a positive effect on cognition, while this association was absent for non-aerobic exercise interventions (SMD=-0.10[-0.38;0.19], p=.51). Finally, we found that interventions offered at both high frequency (SMD=0.33[0.03;0.63], p<.05) and at low frequency (SMD=0.64[0.39;0.89], p<.01) had a positive effect on cognitive function. This meta-analysis suggests that physical activity interventions positively influence cognitive function in patients with dementia. This beneficial effect was independent of the clinical diagnosis and the frequency of the intervention, and was driven by interventions that included aerobic exercise.

APOE Stabilization by Exercise Prevents Aging Neurovascular Dysfunction and Complement Induction

Aging is the major risk factor for neurodegenerative diseases such as Alzheimer's disease, but little is known about the processes that lead to age-related decline of brain structures and function. Here we use RNA-seq in combination with high resolution histological analyses to show that aging leads to a significant deterioration of neurovascular structures including basement membrane reduction, pericyte loss, and astrocyte dysfunction. Neurovascular decline was sufficient to cause vascular leakage and correlated strongly with an increase in neuroinflammation including up-regulation of complement component C1QA in microglia/monocytes. Importantly, long-term aerobic exercise from midlife to old age prevented this age-related neurovascular decline, reduced C1QA+ microglia/monocytes, and increased synaptic plasticity and overall behavioral capabilities of aged mice. Concomitant with age-related neurovascular decline and complement activation, astrocytic Apoe dramatically decreased in aged mice, a decrease that was prevented by exercise. Given the role of APOE in maintaining the neurovascular unit and as an anti-inflammatory molecule, this suggests a possible link between astrocytic Apoe, age-related neurovascular dysfunction and microglia/monocyte activation. To test this, Apoe-deficient mice were exercised from midlife to old age and in contrast to wild-type (Apoe-sufficient) mice, exercise had little to no effect on age-related neurovascular decline or microglia/monocyte activation in the absence of APOE. Collectively, our data shows that neurovascular structures decline with age, a process that we propose to be intimately linked to complement activation in microglia/monocytes. Exercise prevents these changes, but not in the absence of APOE, opening up new avenues for understanding the complex interactions between neurovascular and neuroinflammatory responses in aging and neurodegenerative diseases such as Alzheimer’s disease.

Ileana Soto, Gareth Howell, and coauthors find that age-related deterioration of the neurovascular unit and increased neuroinflammation in aging mice is prevented by long-term exercise, but not in the absence of apolipoprotein E.

Aging is frequently accompanied with frailty and cognitive decline. In recent years, increasing evidence has linked physical inactivity with the development of dementias such as Alzheimer’s disease. In fact, it is recognized that exercise combats frailty and cognitive decline in older adults, but the biological mechanisms involved are not completely known. Understanding the biological changes that trigger cognitive deterioration during aging and the mechanisms by which exercise improves health and brain function is key to ensuring the quality of life of the elderly population and to reducing risk of dementias such as Alzheimer’s disease. Here, we show that the cerebrovascular system in mice significantly deteriorates with age, and the structure and function of the blood brain barrier is progressively compromised. These age-related neurovascular changes are accompanied by neuroinflammation and deficits in common and spontaneous behaviors in mice. We found, however, that exercise from middle to older age preserves the cerebrovascular health, prevents behavioral deficits and reduces the age-related neuroinflammation in the cortex and hippocampus in aged mice. Mice deficient in Apoe, a gene associated with longevity and Alzheimer’s disease, are resistant to the beneficial effects of exercise, suggesting a possible mediating role for APOE in the maintenance and function of the neurovascular system during aging.

Increased self-efficacy: the experience of high-intensity exercise of nursing home residents with dementia - a qualitative study

Background

There has been increasing interest in the use of non-pharmacological interventions, such as physical exercise, to improve the well-being of nursing home residents with dementia. For reasons regarding disease symptoms, persons with dementia might find it difficult to participate in exercise programs. Therefore, it is important to find ways to successfully promote regular exercise for patients in residential care. Several quantitative studies have established the positive effects of exercise on biopsychosocial factors, such as self-efficacy in older people; however, little is known regarding the qualitative aspects of participating in an exercise program among older people with dementia. From the perspective of residents, we explored the experiences of participating in a high-intensity functional exercise program among nursing home residents with dementia.

Methods

The participants were eight elderly people with mild-to-moderate dementia. We conducted semi-structured interviews one week after they had finished a 10-week supervised high-intensity exercise program. We analyzed the data using an inductive content analysis.

Results

Five overreaching and interrelated themes emerged from the interviews: “Pushing the limits,” “Being invested in,” “Relationships facilitate exercise participation,” “Exercise revives the body, increases independence and improves self-esteem” and “Physical activity is a basic human necessity—use it or lose it!” The results were interpreted in light of Bandura’s self-efficacy theory. The exercise program seemed to improve self-efficacy through several mechanisms. By being involved, “being invested in” and having something expected of them, the participants gained a sense of empowerment in their everyday lives. The importance of social influences related to the exercise instructor and the exercise group was accentuated by the participants.

Conclusions

The nursing home residents had, for the most part, positive experiences with regard to participating in the exercise program. The program seemed to increase their self-efficacy through several mechanisms. The instructor competence emerged as an important facilitating factor. The participants emphasized the importance of physical activity in the nursing home.

Perceptions of exercise for older people living with dementia in Bangkok, Thailand: an exploratory qualitative study

BACKGROUND

Dementia is a significant issue globally, including in Thailand, and exercise is known to have health benefits for people living with dementia. However, little is known about exercise acceptable to, and feasible for, this population group in low-to-middle income countries although, more broadly, it is recognised that health-related behaviours are influenced by the perceptions of the individual, which exist within a cultural context.

OBJECTIVES

To explore and describe perceptions of appropriate exercise for people living with dementia in Bangkok, Thailand.

DESIGN

Qualitative exploratory descriptive.

SETTING

Bangkok, Thailand.

PARTICIPANTS

Nine professionals - experts in exercise, dementia care and relevant policy development - and nine dyads of people with dementia and their family caregivers all recruited using purposive sampling.

METHODS

Semi-structured interviews subjected to thematic analysis.

RESULTS

Three themes emerged: how exercise was defined, perceived benefits of exercise and how exercise should be implemented. Professionals recognised three exercise elements: aerobic exercise plus balance and strength training. Dyads recognised home-based activities (e.g., housework) and walking. Both groups recognised benefits of exercise in maintaining health and function and improving mood and sleep. Only health professionals identified falls risk reduction. There was limited appreciation of benefits for caregivers by maintaining function in care recipients. Professionals deemed that exercise should address all three elements, using easily accessible low-cost resources. The need for safety was emphasised, and there was agreement that in-home exercise was appropriate. Family/cultural values were evident that could present barriers to exercise implementation.

CONCLUSION

Changing health-related behaviours requires an understanding of individual perspectives, which exist within a cultural context. This study has illuminated the Thai context and has implications beyond this. Findings emphasise a need for potential benefits to be sufficiently understood by family caregivers to overcome any culturally based reluctance to promote exercise in older people.

IMPLICATIONS FOR PRACTICE

Nurses have a key role in supporting care givers of older persons with dementia supervise home based exercise. Nurses need to develop knowledge of aerobic exercise to teach caregivers and the older person with dementia. Muscle strength and aerobic exercise assists in the older person's ability to undertake ADL.

Exercise programs for people with dementia

BACKGROUND

This is an update of our previous 2013 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings.

OBJECTIVES

Primary objectiveDo exercise programs for older people with dementia improve their cognition, activities of daily living (ADLs), neuropsychiatric symptoms, depression, and mortality? Secondary objectivesDo exercise programs for older people with dementia have an indirect impact on family caregivers' burden, quality of life, and mortality?Do exercise programs for older people with dementia reduce the use of healthcare services (e.g. visits to the emergency department) by participants and their family caregivers?

SEARCH METHODS

We identified trials for inclusion in the review by searching ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 4 September 2011, on 13 August 2012, and again on 3 October 2013.

SELECTION CRITERIA

In this review, we included randomized controlled trials in which older people, diagnosed with dementia, were allocated either to exercise programs or to control groups (usual care or social contact/activities) with the aim of improving cognition, ADLs, neuropsychiatric symptoms, depression, and mortality. Secondary outcomes related to the family caregiver(s) and included caregiver burden, quality of life, mortality, and use of healthcare services.

DATA COLLECTION AND ANALYSIS

Independently, at least two authors assessed the retrieved articles for inclusion, assessed methodological quality, and extracted data. We analysed data for summary effects. We calculated mean differences or standardized mean difference (SMD) for continuous data, and synthesized data for each outcome using a fixed-effect model, unless there was substantial heterogeneity between studies, when we used a random-effects model. We planned to explore heterogeneity in relation to severity and type of dementia, and type, frequency, and duration of exercise program. We also evaluated adverse events.

MAIN RESULTS

Seventeen trials with 1067 participants met the inclusion criteria. However, the required data from three included trials and some of the data from a fourth trial were not published and not made available. The included trials were highly heterogeneous in terms of subtype and severity of participants' dementia, and type, duration, and frequency of exercise. Only two trials included participants living at home.Our meta-analysis revealed that there was no clear evidence of benefit from exercise on cognitive functioning. The estimated standardized mean difference between exercise and control groups was 0.43 (95% CI -0.05 to 0.92, P value 0.08; 9 studies, 409 participants). There was very substantial heterogeneity in this analysis (I² value 80%), most of which we were unable to explain, and we rated the quality of this evidence as very low. We found a benefit of exercise programs on the ability of people with dementia to perform ADLs in six trials with 289 participants. The estimated standardized mean difference between exercise and control groups was 0.68 (95% CI 0.08 to 1.27, P value 0.02). However, again we observed considerable unexplained heterogeneity (I² value 77%) in this meta-analysis, and we rated the quality of this evidence as very low. This means that there is a need for caution in interpreting these findings.In further analyses, in one trial we found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program. The mean difference between exercise and control groups was -15.30 (95% CI -24.73 to -5.87; 1 trial, 40 participants; P value 0.001). There was no apparent risk of bias in this study. In addition, there was no clear evidence of benefit from exercise on neuropsychiatric symptoms (MD -0.60, 95% CI -4.22 to 3.02; 1 trial, 110 participants; P value .0.75), or depression (SMD 0.14, 95% CI -0.07 to 0.36; 5 trials, 341 participants; P value 0.16). We could not examine the remaining outcomes, quality of life, mortality, and healthcare costs, as either the appropriate data were not reported, or we did not retrieve trials that examined these outcomes.

AUTHORS' CONCLUSIONS

There is promising evidence that exercise programs may improve the ability to perform ADLs in people with dementia, although some caution is advised in interpreting these findings. The review revealed no evidence of benefit from exercise on cognition, neuropsychiatric symptoms, or depression. There was little or no evidence regarding the remaining outcomes of interest (i.e., mortality, caregiver burden, caregiver quality of life, caregiver mortality, and use of healthcare services).

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background

The needs of people with dementia and their carers are inadequately addressed at all key points in the illness trajectory, from diagnosis through to end-of-life care. The EVIDEM (Evidence-based Interventions in Dementia) research and development programme (2007–12) was designed to help change this situation within real-life settings.

Objectives

The EVIDEM projects were (1) evaluation of an educational package designed to enhance general practitioners’ (GPs’) diagnostic and management skills; (2) evaluation of exercise as therapy for behavioural and psychological symptoms of dementia (BPSD); (3) development of a toolkit for managing incontinence in people with dementia living at home; (4) development of a toolkit for palliative care for people with dementia; and (5) development of practice guidance on the use of the Mental Capacity Act (MCA) 2005.

Design

Mixed quantitative and qualitative methods from case studies to large database analyses, including longitudinal surveys, randomised controlled trials and research register development, with patient and public involvement built into all projects.

Setting

General practices, community services, third-sector organisations and care homes in the area of the North Thames Dementia and Neurodegenerative Diseases Research Network local research network.

Participants

People with dementia, their family and professional carers, GPs and community mental health team members, staff in local authority social services and third-sector bodies, and care home staff.

Main outcome measures

Dementia management reviews and case identification in general practice; changes in behavioural and psychological symptoms measured with the Neuropsychiatric Inventory (NPI); extent and impact of incontinence in community-dwelling people with dementia; mapping of pathways to death of people with dementia in care homes, and testing of a model of collaborative working between primary care and care homes; and understandings of the MCA 2005 among practitioners working with people with dementia.

Results

An educational intervention in general practice did not alter management or case identification. Exercise as a therapy for BPSD did not reduce NPI scores significantly, but had a significant positive effect on carer burden. Incontinence is twice as common in community-dwelling people with dementia than their peers, and is a hidden taboo within a stigma. Distinct trajectories of dying were identified (anticipated, unexpected and uncertain), and collaboration between NHS primary care and care homes was improved, with cost savings. The MCA 2005 legislation provided a useful working framework for practitioners working with people with dementia.

Conclusions

A tailored educational intervention for general practice does not change practice, even when incentives, policy pressure and consumer demand create a favourable environment for change; exercise has potential as a therapy for BPSD and deserves further investigation; incontinence is a common but unrecognised problem for people with dementia in the community; changes in relationships between care homes and general practice can be achieved, with benefits for people with dementia at the end of life and for the UK NHS; application of the MCA 2005 will continue to improve but educational reinforcements will help this. Increased research capacity in dementia in the community was achieved. This study suggests that further work is required to enhance clinical practice around dementia in general practice; investigate the apparent beneficial effect of physical activity on BPSD and carer well-being; develop case-finding methods for incontinence in people with dementia; optimise working relationships between NHS staff and care homes; and reinforce practitioner understanding of the MCA 2005.

Trial registration

EVIDEM: ED-NCT00866099; EVIDEM: E-ISRCTN01423159.

Funding

This project was funded by the Programme Grants for Applied Research programme of the National Institute for Health Research.

A research on functional status, environmental conditions, and risk of falls in dementia

This study aimed to determine the effects of disability, physical activity, and functional status as well as environmental conditions on the risk of falls among the elderly with dementia after adjusting for sociodemographic factors. Data were derived from a group including 1210 Malaysian elderly who were demented and noninstitutionalized. The study was a national cross-sectional survey that was entitled “Determinants of Health Status among Older Malaysians.” Approximately 17% of subjects experienced falls. The results showed that ethnic non-Malay (OR = 1.73) and functional decline (OR = 1.67) significantly increased the risk of falls in samples (P < 0.05). The findings indicated that increased environmental quality (OR = 0.64) significantly decreased the risk of falls (P < 0.05). Disability, age, marital status, educational level, sex differences, and physical activity were found irrelevant to the likelihood of falls in subjects (P > 0.05). It was concluded that functional decline and ethnic non-Malay increased the risk of falls but the increased environmental quality reduced falls.

Barriers to Physical Activity and Restorative Care for Residents in Long-Term Care: A Review of the Literature

Despite the benefits of physical activity, residents living in long-term care (LTC) are relatively sedentary. Designing successful physical activity and restorative care programs requires a good understanding of implementation barriers. A database search (2002–2013) yielded seven studies (nine articles) that met our inclusion criteria. We also reviewed 31 randomized controlled trials (RCTs) to determine if the authors explicitly discussed the barriers encountered while implementing their interventions. Eleven RCTs (13 articles) included a discussion of the barriers. Hence, a total of 18 studies (22 articles) were included in this review. Barriers occurred at resident (e.g., health status), environmental (e.g., lack of space for physical activity), and organizational (e.g., staffing and funding constraints) levels. These barriers intersect to adversely affect the physical activity of older people living in LTC. Future studies targeting physical activity interventions for residents living in LTC are needed to address these multiple levels of influence.

Exercise programs for people with dementia

BACKGROUND

This is an update of our previous 2008 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings. 

OBJECTIVES

Primary: Do exercise programs for older people with dementia improve cognition, activities of daily living (ADLs), challenging behaviour, depression, and mortality in older people with dementia?Secondary: Do exercise programs for older people with dementia have an indirect impact on family caregivers' burden, quality of life, and mortality?Do exercise programs for older people with dementia reduce the use of healthcare services (e.g. visits to the emergency department) by participants and their family caregivers?

SEARCH METHODS

We identified trials for inclusion in the review by searching ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 4 September 2011, and again on 13 August 2012. The search terms used were: 'physical activity' OR exercise OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR 'tai chi'.

SELECTION CRITERIA

In this review, we included randomized controlled trials in which older people, diagnosed with dementia, were allocated either to exercise programs or to control groups (usual care or social contact/activities) with the aim of improving cognition, ADLs, behaviour, depression, and mortality. Secondary outcomes related to the family caregiver(s) and included caregiver burden, quality of life, mortality, and use of healthcare services.

DATA COLLECTION AND ANALYSIS

Independently, at least two authors assessed the retrieved articles for inclusion, assessed methodological quality, and extracted data. Data were analysed for summary effects using RevMan 5.1 software. We calculated mean differences or standardized mean difference (SMD) for continuous data, and synthesized data for each outcome using a fixed-effect model, unless there was substantial heterogeneity between studies, when we used a random-effects model. We planned to explore heterogeneity in relation to severity and type of dementia, and type, frequency, and duration of exercise program. We also evaluated adverse events.

MAIN RESULTS

Sixteen trials with 937 participants met the inclusion criteria. However, the required data from three trials and some of the data from a fourth trial were not published and not made available. The included trials were highly heterogeneous in terms of subtype and severity of participants' dementia, and type, duration and frequency of exercise. Only two trials included participants living at home. Our meta-analysis suggested that exercise programs might have a significant impact on improving cognitive functioning (eight trials, 329 participants; SMD 0.55, 95% confidence interval (CI) 0.02 to 1.09). However, there was substantial heterogeneity between trials (I(2) value 80%), most of which we were unable to explain. We repeated the analysis omitting one trial, an outlier, that included only participants with moderate or severe dementia. This reduced the heterogeneity somewhat (I(2) value 68%), and produced a result that was no longer significant (seven trials, 308 participants; SMD 0.31, 95% CI -0.11 to  0.74). We found a significant effect of exercise programs on the ability of people with dementia to perform ADLs (six studies, 289 participants; SMD 0.68, 95% CI 0.08 to 1.27). However, again we observed considerable unexplained statistical heterogeneity (I(2) value 77%) in this meta-analysis. This means that there is a need for caution in interpreting these findings. In further analyses, we found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program (one study, 40 participants; MD -15.30, 95% CI -24.73 to -5.87), but we found no significant effect of exercise on challenging behaviours (one study, 110 participants; MD -0.60, 95% CI -4.22 to 3.02), or depression (six studies, 341 participants; MD -0.14, 95% CI -0.36 to 0.07) . We could not examine the remaining outcomes, quality of life, mortality, and healthcare costs, as either the appropriate data were not reported, or we did not retrieve trials that examined these outcomes.

AUTHORS' CONCLUSIONS

There is promising evidence that exercise programs can have a significant impact in improving ability to perform ADLs and possibly in improving cognition in people with dementia, although some caution is advised in interpreting these findings. The programs revealed no significant effect on challenging behaviours or depression. There was little or no evidence regarding the remaining outcomes of interest.

The effects of sleep quality, physical activity, and environmental quality on the risk of falls in dementia

OBJECTIVES

This study aimed to identify the effects of sleep quality, physical activity, environmental quality, age, ethnicity, sex differences, marital status, and educational level on the risk of falls in the elderly individuals with dementia.

METHODOLOGY

Data were derived from a group of 1210 Malaysian elderly individuals who were noninstitutionalized and demented. The multiple logistic regression model was applied to estimate the risk of falls in respondents.

RESULTS

Approximately the prevalence of falls was 17% among the individuals. The results of multiple logistic regression analysis revealed that age (odds ratio [OR] = 1.03), ethnicity (OR = 1.76), sleep quality (OR = 1.46), and environmental quality (OR = 0.62) significantly affected the risk of falls in individuals (P < .05). Furthermore, sex differences, marital status, educational level, and physical activity were not significant predictors of falls in samples (P > .05).

CONCLUSION

It was found that age, ethnic non-Malay, and sleep disruption increased the risk of falls in respondents, but high environmental quality reduced the risk of falls.

Monitoring exercise delivery to increase participation adherence in older adults with Alzheimer's disease

There are many established benefits of exercise for older adults. Emerging studies suggest that it may even be able to slow the progression of Alzheimer's disease (AD) in older adults with the disease. However, it is yet unknown how bedside nurses can monitor ongoing exercise participation in this population due to the complexity and impact of AD symptoms. The purpose of this study is to provide bedside nurses with tools to capture actual received exercise doses to ensure adequate exercise participation by older adults with AD. This study is a secondary data analysis of a master study in which 8 participants who were clinically diagnosed with AD participated in moderate intensity aerobic exercise for 10 to 45 minutes, three times per week, for 6 months. The results show that participants were able to meet the overall exercise prescription 74.3% of the time. The findings of this study suggest that bedside nurses are able to monitor the actual exercise delivery (frequency, intensity, and duration) to ensure exercise participation.

Physical rehabilitation for older people in long-term care

BACKGROUND

The worldwide population is progressively ageing, with an expected increase in morbidity and demand for long-term care. Physical rehabilitation is beneficial in older people, but relatively little is known about effects on long-term care residents. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

To evaluate the benefits and harms of rehabilitation interventions directed at maintaining, or improving, physical function for older people in long-term care through the review of randomised and cluster randomised controlled trials.

SEARCH METHODS

We searched the trials registers of the following Cochrane entities: the Stroke Group (May 2012), the Effective Practice and Organisation of Care Group (April 2012), and the Rehabilitation and Related Therapies Field (April 2012). In addition, we searched 20 relevant electronic databases, including the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2009, Issue 4), MEDLINE (1966 to December 2009), EMBASE (1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009), and PsycINFO (1967 to December 2009). We also searched trials and research registers and conference proceedings; checked reference lists; and contacted authors, researchers, and other relevant Cochrane entities. We updated our searches of electronic databases in 2011 and listed relevant studies as awaiting assessment.

SELECTION CRITERIA

Randomised studies comparing a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention in older people (over 60 years) who have permanent long-term care residency.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We contacted study authors for additional information. The primary outcome was function in activities of daily living. Secondary outcomes included exercise tolerance, strength, flexibility, balance, perceived health status, mood, cognitive status, fear of falling, and economic analyses. We investigated adverse effects, including death, morbidity, and other events. We synthesised estimates of the primary outcome with the mean difference; mortality data, with the risk ratio; and secondary outcomes, using vote-counting.

MAIN RESULTS

We included 67 trials, involving 6300 participants. Fifty-one trials reported the primary outcome, a measure of activities of daily living. The estimated effects of physical rehabilitation at the end of the intervention were an improvement in Barthel Index (0 to 100) scores of six points (95% confidence interval (CI) 2 to 11, P = 0.008, seven studies), Functional Independence Measure (0 to 126) scores of five points (95% CI -2 to 12, P = 0.1, four studies), Rivermead Mobility Index (0 to 15) scores of 0.7 points (95% CI 0.04 to 1.3, P = 0.04, three studies), Timed Up and Go test of five seconds (95% CI -9 to 0, P = 0.05, seven studies), and walking speed of 0.03 m/s (95% CI -0.01 to 0.07, P = 0.1, nine studies). Synthesis of secondary outcomes suggested there is a beneficial effect on strength, flexibility, and balance, and possibly on mood, although the size of any such effect is unknown. There was insufficient evidence of the effect on other secondary outcomes. Based on 25 studies (3721 participants), rehabilitation does not increase risk of mortality in this population (risk ratio 0.95, 95% CI 0.80 to 1.13). However, it is possible bias has resulted in overestimation of the positive effects of physical rehabilitation.

AUTHORS' CONCLUSIONS

Physical rehabilitation for long-term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. There is insufficient evidence to reach conclusions about improvement sustainability, cost-effectiveness, or which interventions are most appropriate. Future large-scale trials are justified.

Exercise and physical activity in mental disorders: clinical and experimental evidence

Several epidemiological studies have shown that exercise (EX) and physical activity (PA) can prevent or delay the onset of different mental disorders, and have therapeutic benefits when used as sole or adjunct treatment in mental disorders. This review summarizes studies that used EX interventions in patients with anxiety, affective, eating, and substance use disorders, as well as schizophrenia and dementia/mild cognitive impairment. Despite several decades of clinical evidence with EX interventions, controlled studies are sparse in most disorder groups. Preliminary evidence suggests that PA/EX can induce improvements in physical, subjective and disorder-specific clinical outcomes. Potential mechanisms of action are discussed, as well as implications for psychiatric research and practice.

Recommended measures for the assessment of cognitive and physical performance in older patients with dementia: a systematic review

Aim/Goal

To recommend a set of neuropsychological and physical exercise tests for researchers to assess cognition and physical fitness in clinical trials with older patients with dementia; to create consensus, decrease heterogeneity, and improve research quality.

Methods

A literature search (2005–2011) yielded 89 randomized controlled trials. To provide information on test recommendations the frequency of test use, effect size of the test outcome, study quality, and psychometric properties of tests were analyzed.

Results

Fifty-nine neuropsychological tests (cognitive domains: global cognition, executive functioning, memory, and attention) and 10 exercise tests (physical domains: endurance capacity, muscle strength, balance, and mobility) were found.

Conclusion

The Severe Impairment Battery, Mini Mental State Examination, and Alzheimer Disease Assessment Scale – cognitive subscale were recommended to measure global cognition. The Verbal Fluency Test Category/Letters, Clock Drawing Test, and Trail Making Test-B were recommended to measure executive functioning. No specific memory test could be recommended. The Digit Span Forward, Digit Span Backward, and Trail Making Test-A were recommended to measure attention. As physical exercise tests, the Timed Up and Go and Six Meter Walk for mobility, the Six Minute Walk Distance for endurance capacity, and the Tinetti Balance Scale were recommended.

Efficacy of physical exercise intervention on mobility and physical functioning in older people with dementia: a systematic review

Numerous trials have shown that physical activity and exercise training have beneficial effects in general older populations. However, few have studied its effectiveness among people with dementia. The aim of this systematic review is to examine the efficacy of trials using a rigorous randomised, controlled design and including physical activity or exercise as a major component of intervention on the physical functioning, mobility and functional limitations of people with dementia. We found 20 randomised controlled trials that included a total of 1378 participants. Of these, only three were of high methodological quality, and six of moderate quality. Nevertheless, these studies consistently show that intensive physical rehabilitation enhances mobility and, when administered over a long period, may also improve the physical functioning of patients with dementia.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Impact of physical activity on activity of daily living in moderate to severe dementia: a critical review

The objectives of this study were to describe the different modalities of physical activity programs designed for moderate to severe dementia and to identify their impact on functional independence in activities of daily living (ADL). A critical review of randomized controlled trials related to the impact of physical activity programs in moderately to severely demented persons on ADL performance and meta-analysis of the identified studies were performed. Among the 303 identified articles, five responded to the selection criteria. Four out of the five studies demonstrated limited methodological quality. In one high-quality study, physical activity programs significantly delayed deterioration of ADL performance. The program components and ADL assessment tools vary widely across studies. Although the proposed treatments have not proven their efficiency in improving the ADL status of the patients, they were able to limit the decline in ADL functioning. Future research is warranted in order to identify clinically relevant modalities for physical activity programs for people with moderate to severe dementia.

The effectiveness of exercise on improving cognitive function in older people: a systematic review

BACKGROUND

The well-documented physical benefits of exercise and the value of exercise for improving mental health have raised the profile and role of exercise in healthcare. However, studies evaluating the effects of exercise on neurocognitive function have produced equivocal results.

PURPOSE

This study was designed to examine the effectiveness of exercise on improving cognitive function in older people.

METHODS

Researchers used a narrative synthesis approach in this review and conducted a computer-based search in MEDLINE, CINAHL, Cochrane Library, and Airiti Library (Chinese) from 2006 to 2009 using the search terms exercise, physical activity, and cognition. Research quality appraisal was rated using Consolidated Standards of Reporting Trials criteria.

RESULT

This review included 12 medium- to high-quality randomized controlled trials. Most studies examined used a 60-minute exercise regimen scheduled three times per week that was continued for 24 weeks. Of the 12 studies, 8 revealed that exercise can improve cognitive function. Five studies focused on healthy older people and three studied older people who had impaired cognition at baseline. Analysis of the studies showed simple, one-component exercise as better for older people with cognitive impairment and multicomponent exercise as better for those without such impairment.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This systematic review demonstrated that an exercise regimen of 6 weeks and at least 3 times per week for 60 minutes had a positive effect on cognition. Whether multicomponent exercise is significantly more effective in improving cognitive function, particularly in healthy older people, should be tested using larger trials with more rigorous methodology.

Stand up for dementia: Performance, improvisation and stand up comedy as therapy for people with dementia; a qualitative study

The aim of this qualitative study was to describe and investigate the effects of a programme of stand up comedy and improvisation workshops on people with early stage dementia. Interviews from participants ( n = 6), their carers ( n = 6), and the comedian facilitator were analysed using constant comparative analysis. The findings indicated that dementia did not prevent participants from laughing appropriately or successfully creating and performing comedy. The data suggest that the programme may have therapeutic benefits as improvements in memory, learning, sociability, communication and self esteem were demonstrated. The study also develops a set of hypotheses for further research which includes: that active participation by people with dementia (PWD) in performing to create laughter is more beneficial therapeutically than passively induced laughter.

Six-month walking program changes cognitive and ADL performance in patients with Alzheimer

Motor inactivity is typical in the later stages of Alzheimer's disease although there is evidence that physical exercise can reduce depression and enhance performance of daily activities. The aim of this study was to determine whether a walking program could reduce the functional and cognitive decline of elderly nursing home residents in the later stages of Alzheimer's disease. A total of 21 patients (84 ± 5 years) were randomly assigned to a walking program (WG) or to a control group (CG). A 6-minute walking test (6WT), the Barthel index of activities of daily living (ADLs), and Mini-Mental State Examination (MMSE) tests were performed before and after 24 weeks of the program. The WG showed significant improvement in the 6WT (20%) and ADLs (23%), while the CG decreased in MMSE (-47%), the WG had a slower decline (-13%). This study indicates that it is possible to stabilize the progressive cognitive dysfunctions in nursing home residents with Alzheimer's disease through a specific walking program.

Aerobic exercise improves hippocampal function and increases BDNF in the serum of young adult males

Physical activity has been reported to improve cognitive function in humans and rodents, possibly via a brain-derived neurotrophic factor (BDNF)-regulated mechanism. In this study of human subjects, we have assessed the effects of acute and chronic exercise on performance of a face-name matching task, which recruits the hippocampus and associated structures of the medial temporal lobe, and the Stroop word-colour task, which does not, and have assessed circulating concentrations of BDNF and IGF-1 in parallel. The results show that a short period of high-intensity cycling results in enhancements in performance of the face-name matching, but not the Stroop, task. These changes in cognitive function were paralleled by increased concentration of BDNF, but not IGF-1, in the serum of exercising subjects. 3 weeks of cycling training had no effect on cardiovascular fitness, as assessed by VO2 scores, cognitive function, or serum BDNF concentration. Increases in fitness, cognitive function and serum BDNF response to acute exercise were observed following 5 weeks of aerobic training. These data indicate that both acute and chronic exercise improve medial temporal lobe function concomitant with increased concentrations of BDNF in the serum, suggesting a possible functional role for this neurotrophic factor in exercise-induced cognitive enhancement in humans.

A community-based exercise programme to improve functional ability in people with Alzheimer's disease: a randomized controlled trial

RATIONALE

Dementia is a common neurodegenerative condition in older age associated with functional decline across multiple domains. This decline impacts not only on the person with dementia, but also on their informal carers and health and aged care systems. With the number of people with dementia rapidly increasing and few effective treatments, there is now a critical need for interventions to improve functional ability in those with the condition.

AIMS AND OBJECTIVE

This study assesses the effectiveness of a community-based home exercise programme in improving cognitive and physical function and independence in activities of daily living (ADL) in people with Alzheimer's disease, the most common form of dementia.

METHODS

In a 4-month randomized controlled trial, 40 community-dwelling patients diagnosed with Alzheimer's disease and their informal carers were randomly allocated to either the treatment (exercise plus usual treatment) or control (usual treatment) group. The exercise programme consisted of daily exercises and walking under the supervision of their carer. Patients were assessed at baseline and 4-months follow-up by a blinded assessor on primary outcome measures of cognitive and physical function and ADL using standardized assessment scales.

RESULTS

Sixteen men and 24 women diagnosed with Alzheimer's disease participated in the study. They had a mean age of 74.1 years (range 51-89) and a mean Mini Mental State Examination score of 22.0 (range 10-28), indicating mild to moderate dementia. At 4-months follow-up, patients who exercised, compared with controls, had improved cognition (increased Mini Mental State Examination scores by 2.6 points, p < 0.001), better mobility (2.9 seconds faster on Timed Up and Go, p = 0.004) and increased Instrumental Activities of Daily Living scores by 1.6 (p = 0.007).

CONCLUSION

This study suggests that participation in a community-based exercise programme can improve cognitive and physical function and independence in ADL in people with Alzheimer's disease.