Balance exercise programs have proven to be effective in improving balance and reducing falls in older adults with dementia. A common theme among effective balance interventions is that they are of sufficient intensity and challenge (Ries et al., 2015; Telenius et al., 2015; Toots et al., 2016). A program designed to improve upright balance must employ strategies that have participants up on their feet as much as possible, and must give participants the opportunity to practice losing and recovering their balance such that they can experience their limits of stability. The balance exercise protocol designed by Ries et al. (2015) was geared toward the motor learning, communication, and cueing needs of individuals with AD. Although participants did not have a cognitive (explicit) memory of having participated in the exercise class, they clearly had a motor memory (implicit), as evidenced by their improvement in balance skills. Alternative activity-based training Alternative strategies for activity-based interventions to achieve physical/functional benefit, such as dance and gaming, are relatively new to the literature and show evidence for feasibility, but there are limitations in the methodological rigor of studies (Klimova, Valis, & Kuca, 2017; van Santen et al., 2018). Tai chi has developed a track record as an efficacious intervention in older adults and those with Parkinson’s disease, but is new to dementia research (J. Y. W. Liu, Kwan, Lai, & Hill, 2018; Lyu et al., 2018) A willingness to utilize different strategies for exercise may allow therapists to appeal to the interests of a broader range of individual clients with better success. By integrating the salient characteristics of successful interventions (outlined later), the vehicle by which activity-based interventions are delivered may not be that important. ● Include multimodal interventions (strength, endurance, and balance) in the guise of functional training, yet be mindfully geared toward the specific goals and interests of the individual. ● Focus on functional skills versus abstract tasks. ● Be carried out with participants in an upright posture, on their feet, for as much of the session as possible. ● Continue for a minimum of 12 to 16 weeks (ideally ongoing), at least two or three times per week, for 45- to 60-minute sessions. ● Be sufficiently intense, challenging, and repetitious, and embody the motor learning principles relevant for individuals with AD, to elicit physiological and neurophysiological adaptations. ● Include dual task demands (cognitive and physical). ● Be individualized to personal, cultural, and family needs, with caregiver participation whenever possible. ● Integrate environmental, communication, and cueing strategies to create an optimal therapeutic relationship. ● Potentially teach the caregiver how to help lead. most frequently used nonpharmacological interventions for agitation (Janzen, Zecevic, Kloseck, & Orange, 2013). As little as 30 minutes of exercise, three times per week, for 3 weeks, has been shown to significantly decrease agitation in individuals with severe cognitive impairment (Aman & Thomas, 2009). It is the responsibility of rehabilitation professionals to educate families and other healthcare providers about the potential impact of activity and exercise as a nonpharmacological treatment for behavioral and mood disorders associated with AD.
well to strength training with unfamiliar equipment or even exercises that do not have an inherently obvious purpose to the participant, in which case functional strength training (e.g., squats, sit-to-stand, seated push-ups) may be preferable. Aerobic training Most clinical studies on aerobic training are in the context of multimodal treatments, and the intensity of aerobic activity is either unclear or of fairly low intensity (Yu, 2011). Although many intervention protocols have included an aerobic component, few have monitored exercise intensity. The feasibility of moderate- and high-intensity training with exercise equipment (e.g., bicycle ergometer, cross-trainer, or treadmill) has been demonstrated (Sobol et al., 2018). Ideally, an aerobic intervention should be at an intensity to provide maximal cardiovascular and functional benefit; however, if training at high or even moderate intensity is not possible, there is some evidence that even relaxed walking programs have cognitive and physical benefits for individuals with AD. Leisurely walking in community-dwelling individuals with mild AD has been associated with maintenance (1 hour per week) or improvement (more than 2 hours per week) in MMSE scores, as compared to a sedentary control group that showed a significant decline in MMSE scores over a 1-year period (Winchester et al., 2013). In nursing home residents, a small study of individuals with moderate to severe AD determined that a family caregiver-led walking program (30 minutes per day, 4 times per week, for 6 months) was effective in mitigating the MMSE score decline that was seen in a control group, and that a 6-minute walk test and Barthel ADL index performance showed significant improvements (Venturelli, Scarsini, & Schena, 2011). Active is better than not active, and a simple walking program, even if it is leisurely walking, is better than no walking. Balance training Characteristics of successful programs Practical guidelines for research and clinical practice regarding exercise interventions for individuals with AD are offered in the following list. This is a synthesis of suggestions by multiple authors (Blankevoort et al., 2010; Forbes, 2015; Littbrand, Stenvall, & Rosendahl, 2011; Ries, 2018). Regardless of whether the vehicle of delivery is a general exercise program for residents in a long-term care facility, a balance training program for adult daycare center participants, individual physical therapy sessions for patients in a subacute setting, or home exercise programs, successful programs share certain characteristics. The most important feature of an exercise intervention for individuals with dementia may not necessarily be what is provided, but rather how it is provided. The characteristics of the exercise intervention are more important than the specific protocol. Exercise or physical activity interventions should: ● Be provided at all stages of dementia.
Impact of exercise on mood and behavioral symptoms of Alzheimer’s disease There are several mood and behavioral symptoms that can coexist with AD, such as apathy, depression, agitation, and wandering. Physical activity or exercise may have a role in lessening these symptoms. Individuals with dementia who
engage in physical activity have fewer neuropsychiatric disorders than those who do not (Christofoletti et al., 2011). Depression is a common comorbidity seen with dementia, and there is some evidence that a consistent exercise program can positively impact depression and other neuropsychiatric symptoms (Barreto et al., 2015). Supervised physical activity is one of the
Choosing outcome measures for use with individuals with dementia The use of outcome measures and objective data to document change in performance is a necessity for reimbursement of rehabilitation services. Outcome measures must be established as valid and reliable for the specific population in which they are being used. In recent years, methodological studies of outcome
measures for use in older adults with dementia have provided some guidance, but the findings are not entirely consistent across studies. Outcome measures that have strong relative reliability, as evidenced by high intra-class correlation coefficient (ICC) are appropriate for use with groups of people (i.e., in
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