# Exercise as it relates to Disease/How can high intensity exercise help dementia in nursing homes?

This fact sheet discusses the effect physical activity has on function and mental health among nursing home patients with dementia. It is based on a randomised control trial by Telenius et al., (2015) titled: Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized control trial.
This fact sheet has been created by student u3084129 from the University of Canberra.

## What is the background to this research?

Cognitive decline can be associated with the normal process of ageing, however when deterioration is worse than normal it is often secondary to dementia. Dementia affects thought processes such as memory, thinking, and also impacts emotional control, social behaviour and motivation. There are many types of dementia, though the most common form is Alzheimer’s disease.
Signs and symptoms include both cognitive and physical. Some include forgetfulness, becoming lost and changes in behaviour. The symptoms can differ depending on the stage of dementia:
* Early: Symptoms often overlooked and are gradual.
* Middle: Symptoms more obvious and are more restriction in daily life.
* Late: Decreased independence, decline in physical function, and symptoms are more obvious.
There is a significant burden of dementia on the health care system all around the world so finding a way to decrease the effects of the disease is an important area of research.
Due to the disease dementia patients often end up in nursing homes although there is little research onf exercise in this population as dementia patients are often excluded from nursing home studies. This area of research aims to understand the effects of exercise on mental health and function of dementia patients in nursing. To then determine if it may help reduce the physical and cognitive decline associated with the disease.

## Where Is The Research From?

The study was conducted in Norway with dementia patients from nursing homes. The Oslo and Akershus University College of Applied Sciences alongside the Norwegian Centre of Aging and Health conducted the research.
The study as funded by Norwegian ExtraFoundation for Health and Rehabilitation with equipment funded by Abilso nursing home, Oslo. Neither were directly involved in the study.

## What Kind of Research Was This?

This study is an assessor blinded parallel multi-centre randomised control trial, which is level II evidence as defined by NHMRC. There is little evidence to compare against involving exercise among nursing home patients with dementia.

## What Did The Research Involve?

107 participants from nursing homes who had dementia were included in a baseline assessment then randomly allocated into two groups, an experimental (exercise group) and a control group.
| Group | Intervention | Time |
| Experimental Group | 5 Minute Warm Up 50-60 Minute High Intensity Exercise (12 rep max) 2 x lower limb strengthening exercise 2 x balance exercises | 2 x Week/12 Weeks |
| Control Group | 50-60 Minutes Light Physical Activity Reading Games Listening to music Conversations | 2 x Week/12 Weeks |
The measures used at baseline (before they began) and after 12 weeks included:
| Activity | Test |
| Balance | Berg Balance Scale (BBS) |
| Mobility | 6 Meter Walk Test (6MWT) |
| Strength | Chair Sit to Stand Test (CST) |
| Activities of Daily Living (ADL) | Barthel Index (BI) |
| Cognition | Clinical Dementia Rating Scale (CDR) Mini-Mental State Examination (MMSE) |
| Agitation Affective Apathy | Neuropsychiatric Inventory Questionnaire (NPI-Q) |
| Depression | Cornell Scale for Depression in Dementia |
| Quality of Life (QOL) | Quality of life in late stage dementia scale (QUALID) |
The article openly discusses some limitations, which include:
* Recruitment of participants
** Only through invitations and/or general meetings.
* Inclusion criteria
** Very specific.
** Meant that those with dementia, who were weaker/frailer, were not included.
* Extra physical activity
** There was also no way to monitor or record extra (if any) physical activity participants did outside of the study and if this contributed to the results.
* Duration
** Was 12 weeks enough?
* Consistency
** There was no way to ensure the exercises/measures was performed exactly the same between participants as there were 27 different physiotherapists involved.

## What Were The Basic Results?

Balance: There was a statistically significant improvement in balance (>2.9 points) in the experimental group versus the control (>1.2 points) (p=0.02). These baseline scores of balance relate to ADLs. This was seen with a decline of ADLs in the control group (no exercise).
Mobility: There was no significant change in walking speed between groups.
CST: Participants who exercises > 12 times improved (p=0.03) by average 1.2 points versus the control (0.4 points). Exercise group was significantly better (p=0.02) in stair climbing item of Barthel index also.
QOL: There was no significant difference between groups.
Mental:
* Reduced apathy and agitation was evident in the exercise groups and the control groups were seen to have an increase in these.
* Apathy was statistically significant (p=0.048).
* Agitation was a lesser problem in exercise group than controls, showing a trend (p=0.07), though was not statistically significant.
** Apathy was associated in 1 of 3 of the participants, which has negative effects on function, depression and lack of motivation.
* Results showed exercise can reduce apathy and exercise was the only predictor of lower scores on apathy after 12 weeks
* Control group maintained while the experimental group improved (lower score).
Depression: There was no significant difference between groups.
Although not all areas had significant improvements, the researchers conclude that that high-intensity exercise can provide positive improvements in dementia patients in nursing homes with balance, muscle strength and cognition.

## What Conclusions Can We Take From This Research?

This study’s methodological quality is quite good due to it being an RCT and reducing areas that may produce bias (blinding, baseline comparisons etc.). The results provide support for high intensity exercise for dementia patients in nursing that may be easily applied in the setting, as the study was performed using basic nursing home equipment.
The research coincides with more recent publications such as, Cancela et al., (2016) stating aerobic physical exercise improves cognitive functioning, behaviour and mobility in the same population as the current study. A systematic review by Brett et al., (2015) further supports the current studies findings also, and although not researched in nursing homes, a meta-analysis further support exercise for dementia.

## Practical Advice

Dementia patients can stay motivated to perform exercise. High-intensity exercise in nursing homes of mild-moderate dementia patients is achievable and there is a positive effect on balance, strength, reduces apathy and a trend to reduce agitation. Future research may consider longer intervention time and monitor extra exercise.
Before taking on this practical advice it is important to note the specific implementation of the exercises by qualified physiotherapists with 1 to every 3 patients. Further details may be found in the article.

## Further Information/Resources

* The Fight Dementia Australia website provides information about dementia. Link: https://www.fightdementia.org.au
* Dementia Care Australia has further information especially in relation to the activities in Australia can be found here: http://www.dementiacareaustralia.com/index.php?option=com_frontpage&Itemid=1
* Alzheimer's Association also has more information: http://www.alz.org/what-is-dementia.asp
* Related research information can be found here: http://dementiaresearchfoundation.org.au/tags/exercise

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 Telenius, E. W., Engedal, K., & Bergland, A. (2015). Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomised controlled trial. PLoS One, 10(5), e0126102. doi:10.1371/journal.pone.0126102
* 1 2 3 World Health Organization. (2016). Dementia (Fact sheet No. 362). Retrieved from http://www.who.int/mediacentre/factsheets/fs362/en/#
* ↑ National Health and Medical Research Council (NHMRC). NHMRC additional levels of evidence and grades for recommendations for developers guidelines. Canberra: NHMRC; 2009. Online. Retrieved from:https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/stage_2_consultation_levels_and_grades.pdf?
* ↑ Cancela, J. M., Ayan, C., Varela, S., & Seijo, M. (2016). Effects of a long-term aerobic exercise intervention on institutionalized patients with dementia. J Sci Med Sport, 19(4), 293-298. doi:10.1016/j.jsams.2015.05.007
* ↑ Brett, L., Traynor, V., & Stapley, P. (2016). Effects of Physical Exercise on Health and Well-Being of Individuals Living With a Dementia in Nursing Homes: A Systematic Review. J Am Med Dir Assoc, 17(2), 104-116. doi:10.1016/j.jamda.2015.08.016
* ↑ Groot, C., Hooghiemstra, A. M., Raijmakers, P. G., van Berckel, B. N., Scheltens, P., Scherder, E. J., . . . Ossenkoppele, R. (2016). The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res Rev, 25, 13-23. doi:10.1016/j.arr.2015.11.005