individual clients with better success. By integrating the salient characteristics of successful interventions (outlined later), the 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.
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. Graham, & Montero Odasso, 2015; Ries et al., 2009; Suttanon, Hill, Dodd, & Said, 2011; Wittwer, Webster, Andrews, & Menz, 2008). Mean MMSE values are listed to describe the level of cognitive impairment of subjects in these study groups. Ries and colleagues (2009) and Blankevoort and colleagues (2013) separated their study groups into two levels of cognitive impairment and published separate MDC scores for the groups (with MDC for the more cognitively impaired groups being greater than for the less cognitively impaired groups). The values listed in the table are for entire study populations. The table represents some of the most commonly used outcome measures with individuals who have dementia. Tests may need to be slightly modified to facilitate optimal performance. For example, timed up-and-go (TUG) adaptations might include beginning to time the activity when the individual’s bottom leaves the chair (rather than upon the “go” command) to allow for delayed response time and using a cone on the floor (in lieu of a tape mark) to signal turning and cueing during the test (e.g., “walk around that cone,” “sit in that chair”). Berg Balance Scale items may need constant coaching to incentivize optimal performance. It is important to be consistent from one testing session to another in terms of the testing environment, client interaction, and cueing. McGough et al. (2017) performed a review of physical performance outcome measures used with older adults with AD and other dementias and based upon the most frequently used measures recommended the use of: 6-minute walk test, TUG, repeated chair stands, short distance gait speed, Berg Balance Scale, and isometric strength measures. Fox, Henwood, Keogh, and Neville (2016) studied the psychometric viability of measures with this population and emphasized the level of research evidence in supporting their validity and reliability is lacking. This is an area that will continue to be studied.
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 comparing group performance results in a research study) but may not necessarily be sound for repeated measurement of one person’s performance over time. To follow one individual over time, the therapist should be assured that the measurement error and the expected variability of scores (i.e., any typical variation in performance from one test administration to the next) has been accounted for; this is referred to as absolute reliability of the outcome measure. One way to assess absolute reliability is with minimal detectable change (MDC) scores. The MDC value represents a “true” change in performance (i.e., change that
is greater than the expected variability of performance and measurement error). MDC90 indicates with a 90% degree of confidence that a change in score greater than the MDC value represents a “true” change in performance (i.e., a “significant” improvement or decline in performance). One emerging theme is that absolute reliability (variability of individual performance) increases as the level of cognitive impairment increases (Blankevoort, van Heuvelen, & Scherder, 2013; Ries, Echternach, Nof, & Blodgett, 2009). Outcome measures that have been used for individuals with AD or dementia for which there are established MDC scores are listed in Table 7 (Blankevoort et al., 2013; Conradsson et al., 2007; Hesseberg, Bentzen, & Bergland, 2015; Muir-Hunter,
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