# Exercise as it relates to Disease/The effects of physical activity on people with Dementia
### Physical Activity and Dementia

Physical activity is a fundamental and valuable human capability that can be described as any bodily movement that enhances or maintains physical fitness and overall health and wellness.[1][2] It is performed for various reasons including strengthening muscles and the cardiovascular system, honing athletic skills, weight loss or maintenance, as well as for the purpose of enjoyment.[1][2] Frequent and regular physical exercise boosts the immune system, and helps prevent the "diseases of affluence" such as heart disease, cardiovascular disease, Type 2 diabetes and obesity.[1][2]
Furthermore my study is based on people affected by dementia: a broad category of brain diseases that cause long term loss of the ability to think and reason clearly that is severe enough to affect a person's daily functioning.[3] The most common form of dementia is Alzheimer's disease (75%).[3] Other forms include Lewy body dementia, vascular dementia, frontotemporal dementia, progressive supranuclear palsy, corticobasal degeneration, normal pressure hydrocephalus and Creutzfeldt–Jakob disease.[3] There is no cure for these diseases, which worsen as they progress. A person may live from three to twenty years with dementia, with the average being seven to ten years. However over the past thirty years, substantial progress has been made in how best to support people with dementia. Perceptively people have viewed dementia as the ‘living death’ about which little could be done beyond watchful care. However new evidence has shown that adequate improvement in physical activity for people with dementia —especially in the early to middle stages—can ease disability from diagnosis to death. This ensures maximum quality of life through empowering an individual with dementia to feel confident in going for a walk, gardening, shopping, doing housework and socially interacting with family, friends and carers; and more so to prevent unnecessary disability and suffering from falls, comorbidities, anxiety, depression and loneliness.[4][5].

### Introduction to people with dementia and aims of physical activity

The target population of this study is people in the early to moderate stages of dementia. Most often, dementia is diagnosed in people over 65 years of age,[6] although the less-prevalent early-onset dementia can occur much earlier. In 2006, there were 26.6 million people worldwide with dementia. Dementia is predicted to affect 1 in 85 people globally by 2050.[7] In the early stages the symptoms of dementia can be very subtle. However, it often begins with lapses in memory and difficulty in finding the right words for everyday objects.[8] Other symptoms may include: Persistent and frequent memory difficulties (especially of recent events), vagueness in everyday conversation, apparent loss of enthusiasm for previously enjoyed activities, taking longer to do routine tasks, forgetting well-known people or places, inability to process questions and instructions, deterioration of social skills and Emotional unpredictability.[8] Symptoms vary and the diseases progress at a different pace according to the individual and the areas of the brain affected. A person's abilities may fluctuate from day to day, or even within the one day, becoming worse in times of stress, fatigue or ill-health.[8] We must note that that other conditions such as strokes and depression have similar symptoms as those shown by dementia, so you should never presume, but instead consult a doctor or specialist for a correct diagnosis. Furthermore the requirements for people with early to moderate-stage dementia include: confidence in their surroundings (e.g. being able to sit down, walk up and down stairs, using appliances), engagement in relationships with family or carers, pleasure, communication, and coping as they do to deficiencies and dysfunction.[9] The aim of my program, which is titled ‘Coping with Dementia’, is to minimise risk of physical and psychological ill-health, improve motivation and commitment to be active and promote optimal quality of life from diagnosis until death. Moreover I have implemented exercises in my program that can be done at home or in care. They focus primarily on improving balance and coordination with the eventual goal of making people with early to moderate-stage dementia to feel confident in their motor skills in order to lessen the anxiety they may feel when moving around the home. The need for keeping the brain active in my patients is of high importance in my programs and this will be achieved through the practice of puzzles, crosswords and social activities by engaging in conversations with friends, family and carers. Furthermore my patients will be required to undertake activities such as gardening which helps remove stress, participating in music or dance which helps with mobility and getting involved in exercise whether that be swimming, water palates, yoga, Thai Chi, walking or exercises one can do at home. [10] The goal with the activities I have just mentioned will be to empower the person to be motivated and confident in their actions, and have trust in what they are doing.

### Benefits of physical activity on people with Dementia

The physical activity intervention is completely evidence based, credible and scientifically knowledgeable. When constructing a physical activity program for patients with early to moderate-stage dementia, relevant and informed material was needed prior to the design. I found that the correlation between physical activity and dementia is a new and ongoing study, although there is emerging signs that physical activity intervention for people with early to moderate-stage dementia may be of significant benefit for cognition and behaviour,[11] which is promising. A review of thirty studies by Patricia Heyn, PhD, Beatriz C. Abreu, PhD, OTR, and Kenneth J. Ottenbacher, PhD, OTR recognised 2020 participants and found that Exercise training increases fitness, physical function, cognitive function, and positive behaviour in people with dementia and related cognitive impairments.[12] Thus this evidence supports my logic for implementing activities such as aqua aerobics, walking, gardening and dancing in my program in order to maintain mobility and allow patients with early to moderate-stage dementia to achieve confidence in simple functional activities with little anxiety in what to do. Furthermore as stated in: Introduction to the target population and aims, most often dementia is diagnosed in people over 65 years of age.[6] Evidence suggests that only a small amount of people who are over the age of 65 (less than 20%), undertake an appropriate level of physical activity and people with dementia this is even less.[13] As a result of this statistic it is significant to implement an exercise program into a person’s lifestyle, during the early to moderate-stages of dementia as it is more likely to be maintained as the condition worsens. This will help broaden the benefits to health and well-being for as long as possible until death. When observing the design process for my program ‘Coping with Dementia’ the need to make people with early to moderate-stage dementia more motivated, confident, understanding, knowledgeable and more physically competent—the main aspects of physical literacy—was my top priority in establishing purposeful physical pursuits as an integral part of their lifestyle and to promote optimal quality of life for the individual.[14]

### Applied considerations & limitations

It is essential that optimal quality of care is given to people with dementia and their families. Any individual with early to middle staged dementia may live with a carer or alone—due to the poor disposition they put on people around them or they are country people trying to deal with bad health, poor finances and daunting distances from home to medical facilities—need to be provided for in order to improve or steady their overall wellbeing. It is important that any specialists or doctors trying to improve this human capability must care for and monitor their patients with dementia from diagnosis until death. This requires comprehensive assessment to identify changes in cognitive functioning—such as memory, day to day functioning, and behaviour—alongside identification and treatment of additional disorders or diseases, in order to prevent unnecessary admissions to hospital and associated excess disability.[9][15] Thus the time constraint for this programme is lifetime and referral to specialist psychological and psychosocial services is integral to provision of high quality care during the process of my physical literacy programme.[9][16] Furthermore this programme is most effective when provided in partnership with organisations in the public and private health sectors, such as Dementia Australia and research institutions such as Australian universities. This sharing of knowledge and skills though collaborative relationships and applied research will ensure that we are able to provide training programmes that will meet the patient’s needs.

## Overall Proposal

My program ‘Coping with Dementia’ focuses on the fundamental and valuable human capability of physical activity in patients with early to moderate-stage dementia. The lesson plans in the program look at positively maintaining motor control, in particular mobility, strength, flexibility and balance. The primary aim of the lesson plans in the program will be to reduce falls and remove anxiety associated with patients with developing early to moderate-stage dementia who may not have trust in themselves to undertake a simple task. This will intentionally result in patients managing their physical fitness—in order to promote optimum quality of life— in due course of degenerative cognitive and functional impairments which is inevitable, as the disease develops. Furthermore a research study was conducted by Alison Bowes, Alison Dawson, Ruth Jepson and Louise McCabe on how physical activity may benefit people with dementia; how and/or if current service provide these benefits; and what support they need to do so.[17] They found that there is potential effectiveness of physical activity for people with early to moderate-stage dementia, including improvements in cognition and mood, behaviour and physical condition.[17] Moreover the social benefits to increased physical activity have also been found to be significant. A study by S Cooper and J D W Greene showed that physical activity undertaken in a group can increase social networks, help in reducing the feelings of loneliness and isolation all common issues associated with people who have dementia.[18] Hence, the benefits for including walking outdoors in my program will be to ascertain a connection with nature and the local community. Additional activities such as gardening and Lawn bowls will help provide enjoyment and feelings of well-being.[10] Definitively these are just a few examples of lesson plans that will be incorporated in my program: ‘Coping with Dementia.’ The first lesson and last lesson will both be comprehensive assessment and evaluation of the patient by a specialist to identify changes in cognitive functioning—such as memory, day to day functioning, and behaviour—alongside identification and treatment of additional disorders or diseases.[9][15] In order to inform myself, other doctors and specialists, certified instructors/carers and the patient’s family the progress or decline of the Dementia patient undertaking my program.

### Lesson Plan Table

| Lesson Number | Lesson in Brief | Equipment | Duration |
| 1 | Lesson 1 is an Assessment, which will include the instructor to write down responses to the following questions and whether the patient is correct or incorrect: • Orientation—in time and place • Attention—for example, serial sevens, months of the year or WORLD backwards • Memory—for example, address recall, name of prime minister, etc • Language—for example, naming of items, reading, writing, comprehension, repetition • Executive function—for example, letter and category fluency • Praxis—for example, alternating hand movements, imitation of gestures • Visuospatial function—for example, drawing a clock face, overlapping pentagons. [19] | Notepad and pen | 30 minutes to 1 hour |
| 2 | Chair squat: stand with feet-hip width apart.Extend arms, push butt back, squat until bum taps chair, repeat 20 times for 3 sets | Chair, notepad and pen | 10–15 minutes |
| 3 | Bridge: lie on back with knees bent, heels on floor with toes pointed towards shins. Lift hips of the floor. Lower to start. Repeat 20 times, three sets | Notepad and pen | 10–15 minutes |
| 4 | Chair squat progression: same as lesson two but progress by lifting left leg a few centimetres, squat. Switch legs. Repeat 10 times three sets | Chair, notepad and pen | 10–15 minutes |
| 5 | Bridge progression: same as lesson three, but progress by extending left leg, lift hips of the floor 10 reps, 3 sets. Switch legs and then repeat. | Notepad and pen | 10–15 minutes |
| 6 | Walking: go for a walk outdoors, would be ideal if you could do this with a friend if possible. | Notepad and pen | 30 minutes |
| 7 | Gardening: this can involve mowing, weeding or whatever has to be done at your place | Use the required gardening tools relevant to the work you are doing, for example a trowel for digging out weeds. Note pad and pen | 30 minutes |
| 8 | Kicking ball around in a group. This is more of a group session to encourage social interaction | Need at least 3 people for activity to be beneficial, as we are promoting social interaction. Equipment required 3 or more soccer balls. Note pad and Pen | 30 minutes |
| 9 | Dancing or a group swimming class (aqua class) or tai chi, to name a few examples. Lesson nine is group orientated which is also promoting social interaction and aerobic exercise | Getting involved in a group class, the instructor will provide equipment necessary. Note pad and Pen | 30 minutes |
| 10 | Lesson 10 is an Assessment, which will include the instructor to write down responses to the following questions and whether the patient is correct or incorrect, compare with Lesson 1 plan to see if there is notable improvements • Orientation—in time and place • Attention—for example, serial sevens, months of the year or WORLD backwards • Memory—for example, address recall, name of prime minister, etc • Language—for example, naming of items, reading, writing, comprehension, repetition • Executive function—for example, letter and category fluency • Praxis—for example, alternating hand movements, imitation of gestures • Visuospatial function—for example, drawing a clock face, overlapping pentagons. [19] | Note pad and Pen | 30 minutes to 1 hour |
Figure. 1 Table of lesson plans for ‘Coping with Dementia.’

## Reflective Summary

In applying a physical activity programme, we need to pay as much attention to the essential human worth of person with dementia and their retained capacity for meaningful engagement in relationships, pleasure, communication, and coping as they do to deficiencies and dysfunction.[9][20][21][22] We also need to be aware many people with dementia and their families wait years for a diagnosis, and some never receive one due to socioeconomic, sociocultural and environmental factors.[5] Furthermore more research is being done to see whether links between exercise and dementia can be definitively established and the mechanisms better understood.[10] In the meantime, regular exercise is recommended as a key strategy for maintaining good health and it might also help keep the ageing brain healthy and reduce cognitive decline, minimise risk of physical and psychological ill-health, improve motivation and commitment to be active and promote optimal quality of life.[4][5][9][10][23] Research shows that there are health and lifestyle factors that indicate greater risk of developing dementia.[10] While you may reduce that risk or delay of the advanced staged dementia with physical exercise, mental exercise and improved diet, this program does not guarantee prevention and cure of dementia.[10]

## Further reading

* Alzheimer's Australia: https://fightdementia.org.au/
* Alzheimer's Australia video: https://www.youtube.com/watch?v=z15-0xZTng4
* National Dementia Support Program, Australian Government, 2011. Physical Exercise and Dementia. Alzheimer’s Australia, 1/1, 1-3.
* Lautenschlager, Nicola T., 2012. The influence of exercise on brain aging and dementia. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, [Online]. Volume 1822, Issue 3, 474-481.

## Bibliography

1. ^ Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC; Hu; Manson; Rimm; Willett (2000). "Primary Prevention of Coronary Heart Disease in Women through Diet and Lifestyle". New England Journal of Medicine 343 (1): 16–22. doi:10.1056/NEJM200007063430103. PMID 10882764.
2. Jump up ^ Hu FB, Manson JE, Stampfer MJ, Colditz G, Liu S, Solomon CG, Willett WC; Manson; Stampfer; Colditz; Liu; Solomon; Willett (2001). "Diet, lifestyle, and the risk of type 2 diabetes mellitus in women". The New England Journal of Medicine 345 (11): 790–797. doi:10.1056/NEJMoa010492. PMID 11556298.
3. Solomon, Andrew E. Budson, Paul R. (2011). Memory loss : a practical guide for clinicians. [Edinburgh?]: Elsevier Saunders. ISBN 9781416035978.
4. Knapp M, Prince M, Albanese E, Banerjee S, Dhanasiri S, Fernandez JL, et al. Dementia UK. London: Alzheimer’s Society, 2007.
5. National Audit Office. Improving services and support for people with dementia London: Stationery Office, 2007.
6. Brookmeyer R., Gray S., Kawas C.. Projections of Alzheimer's Disease in the United States and the Public Health Impact of Delaying Disease Onset. American Journal of Public Health. 1998;88(9):1337–42.
7. 2006 prevalence estimate: Brookmeyer R, Johnson E, Ziegler-Graham K, MH Arrighi. Forecasting the global burden of Alzheimer's disease. Alzheimer's and Dementia. 2007;3(3):186–91; World population prospects: the 2006 revision, highlights [PDF]. 2007
8. Alzheimer's Disease - what is it? | Alzheimer’s Australia. 2014. Alzheimer's Disease - what is it? | Alzheimer’s Australia.
9. Downs, M, 2008. Caring for people with dementia. BMJ : British Medical Journal, [Online]. 336(7638), 225-226.
10. National Dementia Support Program, Australian Government, 2011. Physical Exercise and Dementia. Alzheimer’s Australia, 1/1, 1-3.
11. Lautenschlager, Nicola T., 2012. The influence of exercise on brain aging and dementia. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease, [Online]. Volume 1822, Issue 3, 474-481.
12. Patricia Heyn, PhD, Beatriz C. Abreu, PhD, OTR, Kenneth J. Ottenbacher, PhD, OTR, 2004. The effects of exercise training on elderly persons with cognitive impairment and dementia: A meta-analysis. Archives of Physical Medicine and Rehabilitation, [Online]. Volume 85, Issue 10, 1694–1704.
13. National Dementia Support Program, Australian Government, 2011. Physical Exercise and Dementia. Alzheimer’s Australia, 1/1, 1-3.
14. Almond, L; Whitehead, M (2012). "Physical Literacy: Clarifying the Nature of the Concept". Physical Education Matters
15. Silverstein NM, Maslow K, eds. Improving hospital care for persons with dementiaNew York: Springer, 2005.
16. National Audit Office. Improving services and support for people with dementiaLondon: Stationery Office, 2007.
17. Alison Bowes, Alison Dawson, Ruth Jepson and Louise McCabe, 2013. Physical activity for people with dementia: a scoping study. BMC Geriatrics, [Online]. 13:129
18. S Cooper, J D W Greene, 2005. The clinical assessment of the patient with early dementia. J Neurol Neurosurg Psychiatry, [Online]. 6/5, 1.
19. Dementia: out of the shadows. London: Alzheimer's Society; 2008
20. Kitwood T. Dementia reconsidered: the person comes first Buckingham: Open University Press, 1997.
21. Normann HK, Norberg A, Asplund K. Confirmation and lucidity during conversations with a woman with severe dementia. J Advanced Nursing2002;39:370-6.
22. Clare L. Neuropsychological rehabilitation and people with dementia. Hove, East Sussex: Psychology Press, 2008.
23. National Institute for Health and Clinical Excellence/Social Care Institute for Excellence. Dementia: supporting people with dementia and their carers in health and social care. 2006.