# Exercise as it relates to Disease/The Effect of Exercise on Nursing Home Residents with Alzheimer's Disease

This Wikibooks analysis is on the journal article "Exercise Program for Nursing Home Residents with Alzheimer's Disease: A 1‐Year Randomized, Controlled Trial" by Rolland et al., (2007).

## What is the background to this research?

Alzheimer's Disease is a debilitating neurodegenerative disease which results in a loss of neurons and impairs the synaptic pathways in the cerebral cortex. This damage often leads to neuropsychiatric symptoms, cognitive dysfunction and an inability to perform activities of daily living (ADLs). In 2006, 26.6 million people worldwide had Alzheimer's and this number is believed to quadruple by 2050, with 1 in 85 living with the disease. These daunting statistics mean identifying Alzheimer's in its early stages is crucial to reducing the global burden.
The authors' of the article analysed state that exercise and its effect on ADLs is yet to be studied, which means there is limited data relating to nursing home populations and the effect of exercise on not only their health, but the management of falls and malnutrition.
Therefore, the aim of the research was to determine whether a 12-month exercise program would reduce ADL decline in those with Alzheimer's. It was believed that exercise would improve physical health, nutritional status and psychological disturbance.

## Where is the research from?

This study was conducted in the main author's birthplace, Toulouse, France, which is where some of his previous studies have been completed. Yves Rolland's focus is on the mental health of elderly people and caregivers, with work spanning into the protective factors against Alzheimer's. This location provides advancements in his field of Alzheimer's research, however, it is limited in its applicability to the general population. No conflict of interest was reported.

## What kind of research was this?

A randomised controlled, single-blind trial was used in which the nursing homes, rather than the patients, were randomly allocated to either the exercise or control group to reduce any confounding effects on the setting. The experimenter was blind to this to reduce bias and increase validity when compared to previous randomised controlled studies that have found positive effects from exercise compared to control groups.

## What did the research involve?

Of all 429 nursing home residents, informed consent was gained from 134 patients. Each had a score of 25 or less on the Mini-Mental State Examination, an instrument used in research and clinical practice that assesses short-term memory, speech, reading and other cognitive components. Nutrition, behaviour and depression were assessed using three different scales which have been shown to be reliable and are frequently used with the cognitively impaired.
The program ran from February 2004 to February 2005 and involved 88 sessions that were individualised for each participant based on their physical performance in tests such as the 6-meter walking speed test and the one-leg balance test, which have both been tested before on frail, elderly people. Hour long sessions were conducted in the afternoon twice a week with groups of two to seven patients.
Sessions involved:
* Stretching warm up
* Brisk walk (moderate breathlessness)
* Flexibility exercises
* Strength exercises - stand ups from a chair, squats, lateral elevation of legs from a standing position and rising on toes
* Balance exercises - one or two-leg balance exercises and small step exercises with cones
Overall, the recruitment process was limited due its specific Alzheimer's criteria and since only 134 patients participated, this left room for error, which became apparent when adherence rates were analysed. Despite the safety measures put in place, a number of patients were injured, suggesting more than one therapist was needed per group.

## What were the basic results?

Improvements in walking speed were seen at 6 and 12 months, particularly at the 6 month mark for the exercise group and at 12 months for the control group. The overall improvement was significantly higher in the exercisers than the control. ADL scores declined significantly in both groups at 6 and 12 months with a larger decline at 12 months for the exercise group.
Adherence was analysed with 19.4% of patients having high adherence (> 60 sessions), 28.4% had intermediate adherence (> 30-60 sessions), 41.8% had low adherence (< 30 sessions) and 10.4% attended no sessions, due to either unwillingness, behaviour disorder difficulties, or increased disability. No significant effect on nutrition, behavioural disturbance or depression was obtained.

## What conclusions can we take from this research?

This study found a small, yet significant difference in walking speed and ADL scores, but there were no changes to nutritional status, behavioural disturbance, or depression, suggesting that a more targeted approach would have been beneficial to these factors. Instead, these factors should receive a greater focus during the sessions, rather than just at the pre-screening stage. As this study was the first to target ADL decline in patients with Alzheimer's comparisons are difficult to make, however, the use of previously validated health scales will allow future research to build upon the findings of this study.

## Practical advice

This study observed the effect exercise had on the role of ADLs and Alzheimer's. The increases found in walking speed are important, especially in an elderly population and although insignificant results were found for nutrition, behaviour and depression, it did not mean that exercise had no impact. Instead, future studies should take a longitudinal approach to examine the combination of exercise and cognitive strategies in order to understand the true effects exercise can have on nutritional, behavioural and mental status. Research should also aim to increase adherence, all while taking extra precaution, as falls were common throughout this study due to the nature of the tasks and frailty of patients.

## Further information

For more information about Alzheimer's Disease, click on the links below.
* Alzheimer's Australia: https://nsw.fightdementia.org.au/
* Alzheimer's Australia Dementia Research Foundation (AADRF): http://dementiaresearchfoundation.org.au/

## References

* 1 2 3 4 5 6 7 8 9 Rolland, Y., Pillard, F., Klapouszczak, A., Reynish, E., Thomas, D., Andrieu, S., ... & Vellas, B. (2007). "Exercise Program for Nursing Home Residents with Alzheimer's Disease: A 1‐Year Randomized, Controlled Trial." Journal of the American Geriatrics Society, 55(2), 158-165. doi:10.1111/j.1532-5415.2007.01035.x
* ↑ Wenk, G. L. (2003). Neuropathologic changes in Alzheimer's disease.Journal of Clinical Psychiatry, 64, 7-10. Retrieved from http://faculty.psy.ohio-state.edu/wenk/documents/JClinPsychiatry2003.pdf
* ↑ Burns, A., & Iliffe, S. (2009). Alzheimer’s disease. British Medical Journal, 338, b158. doi:10.1136/bmj.b158
* 1 2 Brookmeyer, R., Johnson, E., Ziegler-Graham, K., & Arrighi, H. M. (2007). Forecasting the global burden of Alzheimer’s disease. Alzheimer's & Dementia, 3(3), 186-191. doi:10.1016/j.jalz.2007.04.381
* ↑ Buchner, D. M., & Larson, E. B. (1987). Falls and fractures in patients with Alzheimer-type dementia. Jama, 257(11), 1492-1495. doi:10.1001/jama.1987.03390110068028
* ↑ White, H., Pieper, C., Schmader, K., & Fillenbaum, G. (1997). A longitudinal analysis of weight change in Alzheimer's disease. Journal of the American Geriatrics Society, 45(4), 531-532. doi:10.1111/j.1532-5415.1997.tb05187.x
* 1 2 3 Sourdet, S., Van Kan, G. A., Soto, M. E., Houles, M., Cantet, C., Nourhashemi, F., ... & Rolland, Y. (2012). Prognosis of an abnormal one-leg balance in community-dwelling patients with Alzheimer’s disease: A 2-year prospective study in 686 patients of the REAL. FR study. Journal of the American Medical Directors Association, 13(4), 407-e1. doi:10.1016/j.jamda.2011.11.003
* 1 2 Rolland, Y., van Kan, G. A., & Vellas, B. (2008). Physical activity and Alzheimer's disease: from prevention to therapeutic perspectives. Journal of the American Medical Directors Association, 9(6), 390-405. doi:10.1016/j.jamda.2008.02.007
* ↑ Folstein, M. F., Folstein, S. E., McHugh, P. R., & Fanjiang, G. (2010). Mini-mental state examination: MMSE-2. Psychological Assessment Resources
* ↑ Tappen, R. M., Roach, K. E., Buchner, D., Barry, C., & Edelstein, J. (1997). Reliability of physical performance measures in nursing home residents with Alzheimer's disease. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 52(1), M55-M52. doi:10.1093/gerona/52A.1.M52
* ↑ Vellas, B. J., Rubenstein, L. Z., Ousset, P. J., Faisant, C., Kostek, V., Nourhashemi, F., ... & Albarede, J. L. (1997). One-leg standing balance and functional status in a population of 512 community-living elderly persons. Aging Clinical and Experimental Research, 9(1-2), 95-98. doi:10.1007/BF03340133