Existing evidence for exercise or activity interventions in individuals with Alzheimer’s and other dementias Individuals with AD were historically excluded from research studies and clinical interventions under the assumption that they would not be able to fully participate because of their cognitive deficits. This notion has proven to be unfounded. The feasibility of supervised exercise and/or physical activity programs for older adults with dementia has been repeatedly demonstrated both in institutionalized and community-dwelling individuals and is no longer in question. Early systematic reviews examining the effectiveness of
a PRE protocol to a control group that met for social gatherings, demonstrated positive effects on functional outcome measures (i.e., climbing stairs, rising from the floor, donning socks) in the experimental group as compared to the control group. Many intervention protocols for individuals with dementia have included a strength training component, but this study used PRE exclusively, in the form of weight training machinery and free weights, which proved to be feasible for this population with mild to moderate AD. Because individuals with AD have difficulty learning new skills, some individuals may not respond 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 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
exercise with individuals who have dementia identified many methodological problems with published studies, and therefore advised careful interpretation of positive study findings (Forbes et al., 2008; Hauer, Becker, Lindemann, & Beyer, 2006). More recent systematic reviews continue to identify issues with research rigor, but evidence is mounting to confirm that exercise in older adults with cognitive impairment and/or dementia improves physical functioning and ADL status (Lam et al., 2018; Lee, Park, & Park, 2016; Lewis, Peiris, & Shields, 2017) as well as balance and falls (Burton et al., 2015; Chan et al., 2015; Lam et al., 2018; Lewis et al., 2017). Cognitive and behavioral benefits from physical exercise interventions have been reported, but strong evidence for these findings is lacking in this population (Barreto, Demougeot, Pillard, Lapeyre-Mestre, & Rolland, 2015; Cai & Abrahamson, 2015; Fleiner, Leucht, Förstl, Zijlstra, & Haussermann, 2017; Groot et al., 2016). Many of the exercise interventions represented in the literature are multimodal in design, so it is difficult to draw specific conclusions about strength, aerobic, and/or balance training interventions. Recent reviews also share the benefits of congruent and integrated physical and cognitive training interventions in older adults with MCI and dementia (Booth, Hood, & Kearney, 2016; Lipardo, Aseron, Kwan, & Tsang, 2017), given the real-life implications of superimposing cognitive demands on physical demands. The following are brief summaries related to the evidence supporting different dimensions of exercise interventions and some pragmatic suggestions related to types of exercise interventions. Strength training Age-related muscle atrophy, or sarcopenia, commonly impacts functional mobility in older adults. There is some evidence that loss of bone mineral density and lean body mass is accelerated in individuals with AD (Burns, Johnson, Watts, Swerdlow, & Brooks, 2010; Loskutova, Honea, Vidoni, Brooks, & Burns, 2009). Resistance training is considered the safest and most effective intervention to combat sarcopenia (Jones et al., 2009). It is well established that progressive resistance exercise (PRE) improves strength and function in older adults (C. Liu, 2009), so it is not surprising that individuals with dementia would show these same benefits. The same basic physiological principles of resistance training that are relevant for strengthening in a general population (e.g., overload, adaptation, specificity) are relevant for older adults and individuals with AD. In geriatric medicine, physicians and health professionals must recognize the importance of endorsing and creating programs that are appropriately rigorous to allow for neuromuscular and physiological improvements in the given exercise domain (e.g., aerobic, strength training); however, submaximal training is better than no training, and clinical improvements in muscle power, muscle endurance, and function may result from strengthening programs that are at a lower threshold or disguised as functional tasks. Lower extremity strength, specifically quadriceps strength, in nursing home residents with dementia has been shown to be related to, and predictive of, lower extremity function, such as transfers, gait, toileting, and lower body dressing (Suzuki et al., 2012). This serves as excellent motivation to maintain or improve lower extremity strength early and throughout the disease process. Garuffi et al. (2013), comparing participants in
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