# Exercise as it relates to Disease/The effect of different exercise training programs on individuals living with dementia

This is an analysis of the journal article "Comparison of Effect of Two Exercise Programs on Activities of Daily Living in Individuals with Dementia: A 9-Week Randomized, Controlled Trial"

## Background

Dementia is a disease of the brain, which progressively impairs the cognitive function, leading to a decline of functional and behavioural factors. This can therefore reduce independence and quality of life, which increases the burden on caregivers and family members and contributes to health care costs for the individual. One of the main focuses of dementia is to not only delay the onset of the disease, but prevent the disability associated with dementia. Physical Activity is thought to be one way to improve the ability to perform Activities of Daily Living (ADLs) and improve the quality of life for Dementia patients.

## Where is the research from?

Participants from this study were from seven specialised nursing homes in the northern Netherlands. The research was conducted via a variety of institutes:
* Centre for Human Movement Sciences
* Centre for Rehabilitation
* Department of General Practice
* University Medical Centre Groningen
* University of Groninge, Groningen
* Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, the Netherlands.
This trial was approved by the medical ethics committee of the University Medical Centre Groningen and registered online.

## What kind of research was this?

This study was a parallel, three-group, single-blind, randomised, controlled trial. Parallel three-group study means that participants were randomly sorted into three groups, two participating in exercise and the control group being the non-exercise social group. A single-blind study meant the assessors and nurses knew who was in which group while the participants did not.

## What did the research involve?

Each participants legal representative provided written consent before participating in the study. All participants had to meet certain criteria, including:
* aged 65 years or older
* having a diagnosis of dementia reported in the individuals medical file
* absence of serious health problems
For those who met the criteria, a trained research assistant assessed performance based ADL, cognitive, and motor function.
After baseline measures were made, participants were assigned to one of three groups, each consisting of 35 participants who took part in a 9 week training program consisting of the following:
* Combined group - two strength and two walking sessions per week
* Aerobic Group - four walking sessions per week
* Social group - four non-exercise social visits per week.

## What were the basic results?

This study began with 118 participants, by the end 13 dropped out leaving 105 participants (35 in each group).
The baseline characteristics were recorded, including the Mini-Mental State Examination (MMSE), Functional Comorbidity Index, Katz Index, Erlangen Activity of Daily Living score (E-ADL), and 7-item Physical Performance Test Score (PPT-7). All had very similar mean scores, indicating all groups were very similar before the intervention. The adherence rate was also similar throughout the 3 groups (combined 89.1 ± 10.2%, aerobic 90.1 ± 9.1%, and social 92.8 ± 6.7%).
When comparing the baseline data to after intervention data for the three ADL measures (Katz index, E-ADL and PPT-7), the combined group improved notably more than the social group for all three, and the aerobic group improved more that the social group on the E-ADL:
* The Katz index showed increases in combined (5.3%) and aerobic groups (0.5%) but a decrease in the social group.
* The E-ADL test showed an increase in combined (6.0%) and aerobic groups (2.0) but a decrease in the social group (-6.0%).
* The PTT-7 test showed an increase in the combined group (10.2%) but a decrease in both the aerobic (-1.5%) and social groups (-13.2%).
* For the combined group only, there were exercise induced global cognition mediated changes in Katz index, leg muscle strength mediated changes in E-ADL, and leg muscle strength and walking endurance mediated changes in PPT-7.

## How did the researches interpret the results?

These results do not support the primary hypothesis however it does support that physical activity, whether single or multicomponent exercise, can have small improvements in ADL levels of individuals living with dementia. Furthermore, the mediated changes were only evident in the combined group in relation to motor and cognitive control and function, which may indicate that a combined strength and aerobic training program may be more beneficial than just aerobic only training to improve the individuals ability to ADLs, however, future research with larger numbers would need to be conducted to explore these findings more.

## What conclusions should be taken away from this research?

This research has shown that there is still a need for further study into exercise and benefits for individuals living with dementia. There were several limitations with this study, including the small sample size. It was stated that they needed at least 17 more participants to detect small differences in ADL results between groups. Another limitation was that this study was single-blinded, allowing room for the nurses who conducted the proxy-reported Katz index to be biased, as they were familiar with the participants. These need to be considered for further research.

## What were the Implications of this research?

Any exercise is better than no exercise for individuals living with dementia and their ability to perform every day tasks. There are many different exercise related pathways that could be studied further to provide an alternative yet affective treatment for ADLs for individuals with dementia.

## Further reading

For further information on the role exercise plays in dementia patients, read below:
* https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/dementia-activities-and-exercise
* https://www.fightdementia.org.au/files/helpsheets/Helpsheet-DementiaQandA08-PhysicalExercise_english.pdf
* http://dementiaresearchfoundation.org.au/blog/people-dementia-need-stay-physically-active

## References

* 1 2 3 4 5 6 7 8 9 10 11 Bossers W, van der Woude L, Boersma F, Hortobágyi T, Scherder E, van Heuvelen M. Comparison of Effect of Two Exercise Programs on Activities of Daily Living in Individuals with Dementia: A 9-Week Randomized, Controlled Trial. Journal of the American Geriatrics Society. 2016;64(6):1258-1266
* ↑ Kang H, Myung W, Na D, Kim S, Lee J, Han S et al. Factors Associated with Caregiver Burden in Patients with Alzheimer's Disease. Psychiatry Investigation. 2014;11(2):152.
* ↑ Andersen C, Wittrup-Jensen K, Lolk A, Andersen K, Kragh-Sørensen P. Ability to perform activities of daily living is the main factor affecting quality of life in patients with dementia. Health and Quality of Life Outcomes. 2004;2(1):52.
* ↑ Miller D, Taler V, Davidson P, Messier C. Measuring the impact of exercise on cognitive aging: methodological issues. Neurobiology of Aging. 2012;33(3):622.e29-622.e43