# Exercise as it relates to Disease/The impact of a community based exercise program on cognitive and physical function in adults with Alzheimer’s disease

This is an analysis of the journal article "A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: a randomized controlled trial" by Vreugdenhil, Cannell, Davies & Razay (2012).

## What is the background to this research?

Alzheimer's disease is a neurodegenerative condition that causes dementia. The condition is characterised by physical changes in the brain that affects specific functions and abilities. Common symptoms of Alzheimer's disease may include:
* Memory loss, especially of recent events
* Taking longer to do routine tasks
* Impaired ability to plan, problem solve, organise and think logically
* Language difficulties
* Disorientation
* Deterioration of social skills
* Changes in behaviour, personality and mood.
Currently, there are more than 353,800 Australians living with dementia. 70% of which are living with Alzheimer's disease, the most common form of dementia. Due to the ageing population, this number is expected to increase to 400,000 in less than five years. By the 2060s, the total expenditure on dementia in Australia is projected to be $83 billion. This huge burden on the Australian economy could be significantly reduced by treating and/or preventing the onset of dementia, particularly Alzheimer's disease, with physical activity. Vreugdenhil et al. (2012) conducted a clinical trial examining the impact of a community based exercise program on physical and cognitive function in adults with Alzheimer's disease.

## Where is the research from?

This research was conducted in Tasmania at the University of Tasmania and Launceston General Hospital. Tasmania is home to one of the oldest populations in Australia, thus their incidence rates and prevalence burden of dementia is relatively higher than other Australian states.
Dr George Razay, one of the authors of this study, has had a number of research discoveries in the field of Alzheimer's disease. Dr Razay has found a link between Alzheimer's disease and metabolic syndrome, and also with both obesity and underweight in the elderly. He's also identified the vascular risk factors that contribute to Alzheimer's disease such as, high blood pressure, cholesterol, overweight/obesity and lack of physical activity. This scientific breakthrough suggests that Alzheimer's disease could be treated or possibly even prevented.

## What kind of research was this?

This study was an assessor blinded randomised controlled trial (RCT). The assessors of the study were blinded as to the subjects allocation to the treatment (exercise) or control group. However, the participants of this study were aware of their group assignment, which has implications for the validity of the research. The participants were potentially:
* More likely to have biased psychological or physical responses to intervention
* Less likely to comply with trial regimens
* More likely to seek additional adjunct interventions.
A double blinded RCT is considered the gold standard for a clinical trial as it eliminates sources of bias and maximises validity. However, in a study like this one, it is difficult to blind the subjects to the intervention they are being exposed to as it involves active participation.

## What did the research involve?

This study involved 40 patients and their carers from a hospital outpatient memory disorders clinic. The study participants met the following inclusion/exclusion criteria:
| Inclusion Criteria | Exclusion criteria |
| Dementia was diagnosed according to the DSM IV | Evidence of any neurodegenerative disorders other than AD |
| The diagnosis of AD was made according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association | Any physical condition that could preclude full participation (i.e. non-controlled systemic illness or severe physical disability) |
| Community dwelling | Commenced dementia medication in the last 3 months |
| Either live with an informal carer (friend or family) or have a carer who could visit on a daily basis | Already participating in resistance training or aerobic exercise more than once a week |
The inclusion/exclusion criteria ensured that a baseline set of standards were established in order to yield accurate results.
The study sample were randomly allocated either to the treatment (exercise) group or the control (usual treatment) group. Those in the treatment group participated in a 4-month community exercise programme which included daily home-based exercises and walking, in addition to their usual treatment for Alzheimer's disease. The control group received their usual treatment only. The community exercise programme was performed under the supervision of the patient's carer.
Standardised assessments for cognitive function, physical function, independence in activities of daily living (ADL), depression, global change in function and carer burden were administered at baseline and at 4-month follow up.

## What were the basic results?

At 4 month follow up, the intervention group demonstrated improvement across all functional domains. For cognitive function, the exercise group, compared to the controls, had improved scores on both outcomes measures, measuring for impairments in memory, language, praxis, attention and other cognitive abilities. Physical function improvements for the exercise group were reflected in better balance, improved mobility, and increased lower body strength. Compared with controls, the exercise group became more independent in ADL after the 4-week programme. The researchers noted there were trends in decreased levels of depression and carer burden in the exercise group, however, their findings were not statistically significant.
The authors of this study acknowledged that future research should be conducted over an extended period of time to ensure the short-term benefits of this study could be maintained. The results of this study are consistent with American based research investigating the effects of a walking-exercise programme on cognitive function in patients with Alzheimer's disease. The year-long trial found that individuals who engaged in more than 2 hours of walking per week had a significant improvement in cognitive function.

## What conclusions can we take from this research?

This research shows that participation in a community-based exercise programme can improve cognitive and physical function in adults with Alzheimer's disease. There is no current evidence to support the theory that exercise can cure Alzheimer's disease. However, researchers have found that physical activity can certainly slow the process, and prolong the functional lives of adults with Alzheimer's disease.

## Practical advice

Participation in a community based exercise programme has the potential to benefit not only the person with Alzheimer's disease, but can also extend to their informal carers, and the health and aged care systems. An exercise programme for adults with Alzheimer's disease should incorporate simple exercises, focusing on upper and lower body strength and balance training. In addition, 30 minutes of brisk walking daily is also recommended.
Prior to undertaking physical activity/exercise, please seek guidance from your GP or appropriate allied health professional.
Possible risk factors for exercise in adults with Alzheimer's disease include:
* Balance or mobility issues
* Vascular factors (i.e. high blood pressure, cholesterol)
* Lack of physical activity
* Comorbid health conditions

## Further information/resources

For further information on Alzheimer's disease and other forms of dementia, visit this website: https://www.fightdementia.org.au/
Please see below for additional resources:
* Alzheimer's disease - https://www.fightdementia.org.au/files/helpsheets/Helpsheet-AboutDementia13-AlzheimersDisease_english.pdf
* Progression of Alzheimer's disease - https://www.fightdementia.org.au/files/helpsheets/Helpsheet-AboutDementia14-ProgressionOfAlzheimersDisease_english.pdf
* Physical Activity and Dementia - https://www.fightdementia.org.au/files/helpsheets/Helpsheet-DementiaQandA08-PhysicalExercise_english.pdf
* Physical Activity for Brain Health and Fighting Dementia - https://www.fightdementia.org.au/files/helpsheets/Helpsheet-YourBrainMatters03_PhysicalActivity_english.pdf
* Key Facts and Statistics 2016 - https://wa.fightdementia.org.au/files/NATIONAL/documents/Key-facts-and-statistics.pdf

## References

* 1 2 3 4 5 6 7 8 9 10 11 Vreugdenhil, A., Cannell, J., Davies, A., & Razay, G. (2012). A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: a randomized controlled trial. Scandinavian Journal of Caring Sciences, 26:12-19. doi: 10.1111/j.1471-6712.2011.00895.x
* 1 2 3 4 Alzheimer's Australia. (2012). Alzheimer's disease. Retrieved from: https://www.fightdementia.org.au/files/helpsheets/Helpsheet-AboutDementia13-AlzheimersDisease_english.pdf
* 1 2 3 Australian Institute of Health and Welfare. (2012). Dementia in Australia. Retrieved from: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737422943
* ↑ Access Economics. (2009). Keeping Dementia Front of Mind: Incidence and prevalence 2009-2050. Report for Alzheimer’s Australia. Retrieved from: https://www.fightdementia.org.au/sites/default/files/20090800_Nat__AE_FullKeepDemFrontMind.pdf
* ↑ Access Economics. (2005). Dementia estimates and projections: Australian states and territories. Retrieved from: https://www.fightdementia.org.au/sites/default/files/20050200_Nat_AE_DemEstProjAust.pdf
* ↑ Razay, G., Vreugdenhil, A., Wilcock, G. (2006). Obesity, abdominal obesity and Alzheimer disease. Dement Geriatr Cogn Disord, 22(2): 173.
* ↑ Razay, G., Vreugdenhil, A., Wilcock, G. (2007). The metabolic syndrome and Alzheimer disease. Arch Neurol. 64(1): 93-96. doi:10.1001/archneur.64.1.93.
* ↑ Razay, G., Williams, J., King, E., Smith, A.D., Wilcock, G. (2009) Blood pressure, dementia and Alzheimer’s disease: the OPTIMA longitudinal study. Dement Geriatr Cogn Disord, 28: 70-74.
* 1 2 3 Schulz, K.F., & Grimes, D.A. (2002). Blinding in randomised trials: hiding who got what. Lancet, 359: 696–700.
* 1 2 Winchester, J., Dick, M.B., Gillen, D., Reed, B., Miller, B., Tinklenberg, J., Mungas, D., Chui, H., Galasko, D., Hewett, L., & Cotman, C.W. (2013). Walking stabilizes cognitive functioning in Alzheimer's disease (AD) across one year. Archives of Gerontology and Geriatrics, 56: 96-103.
* ↑ Weih, M., Degirmenci, U., Kreil, S., & Kornhuber, J. (2010). Physical activity and Alzheimer's disease: A meta-analysis of cohort studies. Gero Psych, 23(1): 17-20.
* ↑ Erickson, K., Weinstein, A., & Lopez, O. (2012). Physical activity, brain plasticity, and Alzheimer's disease. Archives of Medical Research, 43: 615-621.
* ↑ Winchester, J., Dick, M., Gillen, D., Reed, B., Miller, B., Tinklenberg, J., Mungas, D., Chui, H., Galasko, D., Hewett, L., Cotman, C. (2013). Walking stabilizes cognitive function in Alzheimer's disease (AD) across one year. Archives of Gerontology and Geriatrics, 56: 96-103.
* ↑ Exercise and Sports Science Australia (ESSA). (2011). Adult pre-exercise screening tool. Retrieved from: https://www.essa.org.au/wp-content/uploads/2011/09/Screen-tool-version-v1.1.pdf