# Exercise as it relates to Disease/Physical Activity with Cognitive Tasks Improves Executive Functioning and Reduces Falls in Elderly with Alzheimer's Disease

This is an analysis of the journal article Balance, executive functions and falls in elderly with Alzheimer's disease (AD): A longitudinal study (2011). This has been created by University of Canberra student, for a university assignment for the unit; Health, Disease and Exercise.

## What is the background to this research?

Alzheimer’s Disease (AD) is a chronic neurodegenerative process commonly found in individuals 65 years and younger, which results in dementia as the disease progresses with age. According to the World Health Organisation, there are 47.5 million people living with dementia worldwide. The most common cause is AD which accounts for 60-70% of cases.
This disease is characterized by a progressive decline in cognitive abilities effecting daily tasks. There are behavioral and personality alterations as well as a decline in executive functioning which effects planning and initiating actions, and leads to a loss of attention and working memory.
Older adults with dementia have a twofold increased risk of sustaining a fall compared to those without the condition. Balance is the coordination between motor process, cognitive ability such as attention, planning, and perceptual processes. Conditions such as AD effects this coordination due to cognitive impairments, this decreases their balance and increases their risk of falls.
Falls contribute considerably to injuries such as fractures, which lead to periods of hospitalization, decrease in quality of life, loss of mobility and the loss of independence. This study aimed to examine if a combined program of physical activity and cognitive tasks, had an effect on balance, executive functioning and falls in elderly AD patients. They also wanted to determine if there was any relationship between falls, balance and executive functioning.

## Where is the research from?

This study was carried out in the research facility, Laboratory of Physical Activity and Ageing, at the Universidade Estadual Paulista, Rio Claro, Sao Paulo, Brazil. Fundunesp and PROEX-UNESP sponsored the study and was approved by, The Committee of Ethnics in Research of the Institute of Biosciences of Universidade Estadual Paulista, Rio Claro Campus.

## What kind of research was this?

The study was a randomised control trial (RCT). When deciding the outcome for an intervention or treatment, RCT are deemed the most reliable method. Participants were 21 patients who were clinically diagnosed with AD. They were randomly assigned to either the training group or the control group. The training group consisted patients who were required to complete a dual task of cognitive stimulation and physical exercise program. The control group did not engage in any regularly physical exercise.

## What did the research involve?

Participants in the training group, over the course of 4 months, completed a program of physical activity paired with cognitive tasks, each session lasting 60 minutes, three times a week. The exercises were specifically based on agility, balance, flexibility, coordination and aerobic resistance.

#### Measures

The Clock Drawing Test (CDT) and the Frontal Assessment Battery (FAB) were both used to measure executive functioning.
Balance was tested using the Timed-Up-And-Go (TUG) and the Berg Balance Scale (BBS). The TUG is an indicator of fall risks. The test measures how long it took an individual to stand up from a chair, walk 3 meters and walk back to the chair and the number of steps taken.

#### Limitations

The authors acknowledged that a limitation of the study was that falls were not associated with balance and executive function. Other elements such as environmental circumstances and changes in proprioception influence the events of falls. Therefore determining the role balance and executive function play on falls was difficult and required further research. Another limitation was that patients had mild to moderate AD. This doesn’t provide information about whether such combined physical and cognitive programs have any effect on patients with more sever AD.

## What were the basic results?

An important finding of the study were improvements in balance as well as executive functioning in the trained group who completed the program. The results also showed a correlation between the two factors when looking at their results between the FAB and TUG; and CDT and TUG. The trained group had only significant improvements in the BBS, which was present four months after initial testing. No significant correlations among executive functions, balance and falls post-intervention were found in the control group.

## What conclusions can we take from this research?

This study shows that participating in an intervention combining cognitive stimulation and physical exercise, delays the decline in balance and executive functioning in AD patients. The results also indicated that there is a correlation between the two variables. The patients who completed the program, had a reduction in the number of falls post-intervention compared to the control group. This however it wasn’t a significant reduction. This suggests that further research needs to be conducted because of it’s importance in allowing for independence, better quality of life and decreases mortality within this population group.

## Practical advice

It is very important to conduct pre-exercise screening questionnaire to assess the participants current fitness, general health and activity levels before subscribing an exercise intervention.
Considerations that need to be taken into account when working with elderly patients with AD:
* AD is associated with cardiovascular risk factors such as hypertension, atherosclerosis and diabetes mellitus.
* Lack of motivation to participate in any physical activity
* They have poor memory and attention which leads to disorientation and distraction
* Common for patients to also have dyspraxia

## Further reading

For further information on Alzheimer's Disease view the following links:
* Alzheimer’s Australia : https://www.fightdementia.org.au/
* Alzheimer's Disease Fact Sheet – National Institute of Aging: https://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-fact-sheet
* Stay Physically Active – Alzheimer’s Association: http://www.alz.org/brain-health/stay_physically_active.asp
* Exercise and Physical Activity – Alzheimer’s Society: https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=1764

## References

* 1 2 3 4 5 6 7 8 9 10 11 Pedroso, R. V., Coelho, Flávia Gomes de Melo, Santos-Galduróz, R. F., Costa, J. L. R., Gobbi, S., & Stella, F. (2011). Balance, executive functions and falls in elderly with alzheimer's disease (AD): A longitudinal study. Archives of Gerontology and Geriatrics, 54(2), 348-351. doi:10.1016/j.archger.2011.05.029
* ↑ Castellani, J. R., Rolston, K. R., & Smith, A. M. (2010). Alzheimer disease. Dis Mon, 56(9), 484-546. doi:10.1016/j.disamonth.2010.06.001
* ↑ World Health Organisation (2016). Retrieved 20th September 2016, from http://www.who.int/mediacentre/factsheets/fs362/en/
* ↑ National Institute of Neurological Disorders and Stroke (2016). Retrieved 20th September 2016, from http://www.ninds.nih.gov/disorders/alzheimersdisease/alzheimersdisease.htm
* 1 2 Sheridan, P. L., & Hausdorff, J. M. (2007). The role of higher-level cognitive function in gait: Executive dysfunction contributes to fall risk in alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 24(2), 125-137. doi:10.1159/000105126
* ↑ Kearney, F. C., Harwood, R. H., Gladman, J. R. F., Lincoln, N., & Masud, T. (2013). The relationship between executive function and falls and gait abnormalities in older adults: A systematic review. Dementia and Geriatric Cognitive Disorders, 36(1-2), 20.
* ↑ Tangen, G. G., Engedal, K., Bergland, A., Moger, T. A., & Mengshoel, A. M. (2014). Relationships between balance and cognition in patients with subjective cognitive impairment, mild cognitive impairment, and alzheimer disease. Physical Therapy, 94(8), 1123. doi:10.2522/ptj.20130298
* ↑ Martins, W.R., de Oliveira, R.J., Carvalho, R.S., de Oliveira Damasceno, V., da Silva, V.Z.M. & Silva, M.S. Elastic resistance training to increase muscle strength in elderly: A systematic review with meta-analysis, Archives of Gerontology and Geriatrics, 2013; 57 (1): 8-15
* ↑ Rothwell, P. M. (2005). Treating individuals 1: External validity of randomised controlled trials: "to whom do the results of this trial apply?". The Lancet, 365(9453), 82.
* 1 2 Brown, D., et al. (2015). Development of an exercise intervention to improve cognition in people with mild to moderate dementia: Dementia And Physical Activity (DAPA) Trial, registration ISRCTN32612072. Physiotherapy, 101(2), 126-134.
* ↑ Obisesan, T. O., et al., (2012). Neuroprotection and neurodegeneration in alzheimer's disease: Role of cardiovascular disease risk factors, implications for dementia rates, and prevention with aerobic exercise in african americans. International Journal of Alzheimer's Disease, 2012, 568382. doi:10.1155/2012/568382