# Exercise as it relates to Disease/Combined exercise and cognitive activity to fight dementia in mild cognitive impairment

This is an analysis of the journal article "A complex multimodal activity intervention to reduce the risk of dementia in mild cognitive impairment--ThinkingFit: Pilot and feasibility study for a randomized controlled trial" by Dannhauser et al (2014).

# Background

Dementia is a neurodegenerative condition that currently affects 35 million people worldwide. Onset is associated with numerous risk factors; however, the most significant risk factor is old age. Dementia is incurable and leads to a decline in quality of life. Those with dementia may experience:
* Memory loss
* Disorientation
* Confusion
* Ability to conduct daily activities
* Maintaining conversation
Older adults who engage in a wider spectrum of activities (comprising physical, cognitive and socialising components) are less likely to develop dementia than those that engage in only one type of activity or no activity at all. This case-control study accessed the efficacy of a complex multimodal activity intervention program called ThinkingFit over the course of 16 weeks - targeted at high-risk groups with Mild Cognitive Impairment (MCI). Patients who were subjected to the ThinkingFit program included those with:
* Complaints of cognitive deficits,
* More than a single impairment in cognitive domains,
* Preserved cognitive function,
* The ability to function during daily activities
* No existing diagnostic criteria for dementia.
Engagement was promoted by applying psychological preparation techniques both prior and during the intervention program in order to overcome barriers to activities associated to reduced dementia risk. The study found significant treatment effects in elderly MCI patients. Adequate recruitment, retention and engagement rates made the methods practical and reasonable to conduct randomised controlled trails towards the potential of programs like ThinkingFit in preventing dementia. The study demonstrates that individuals can alter their risk of developing dementia with various activities. Some examples include:

## Modifiable Factors vs Non-modifiable Factors

| Modifiable Factors | Non-modifiable Factors |
| Alcohol/diet | Genetics |
| Exercise | Ageing |
| Social leisure activities | |
| Education | |
| Modifiable dementia risk factors cause an estimated 50% of dementia. This includes physical- and cognitive-inactivity, obesity, hypertension and diabetes. ||

## Where did the study come from?

The research was carried out in the University College London in London, UK by researchers of the North Partnership University NHS Foundation Trust. This study was supported by NHS and sponsored by the UK Dementia and Neurodegenerative Diseases Research Network. It was published in the peer reviewed medical journal BMC Psychiatry in May 2014. This is an Open Access article, electronic versions of this article can be found online.

## What kind of study is this?

The research looked at a study design that engaged people with MCI within a complex multimodal activity intervention to prevent dementia. This is a preliminary open label study serving as a foundation for future randomised control trials.

## What did the study involve?

Of the 212 patients screened from two local memory hospitals, only 67 MCI patients (with a mean age of 74 years) were recruited for the study. Inclusion was based on complete psychiatric assessment and physical examination that emphasised neurological examination. For the open label study, each participant served as their own control. The study design is made up of a control period and the intervention period. The control period consisted of four weeks of preparation with the aim of increasing participation and behavioural flexibility before starting the intervention period. A choice of 36 Do-something-different (DSD) activities was carried out by the participants and a document of when/where/what was recorded during the first four weeks. The intervention period is made up of 12 weeks of three activity components: physical activity (PA), group based cognitive stimulation training (GCST) and individual cognitive stimulation training (ICST). Supervision was provided during some sessions, telephone contact was also offered to promote adherence to each activity. Each activity hopes to delay onset of dementia by:
* Encouraging brain activity and participation
* Acquiring an acceptable BMI
* Decreasing systolic blood pressure
* Improved working memory

# Results

Comparisons between control and intervention conditions on physical, cardiovascular, cognitive, functional and life quality measures in the DSD, physical, GCST, and ICST activities :
| Activity | Duration | Number of Sessions | Supervised Sessions | Session Duration | Setting | Results |
| Do Something Different (DSD) | 4 weeks, in early pre-phase | 36 | 0 | Variable | Home or Community | • No significant changes |
| Physical Activity | 12 weeks | 36 | 7 | 30–45 minutes | Home or Community | • Decreased systolic and diastolic blood pressure • Reduced BMI • Decreased resting heart rate (beats/min) • Decreased 1 minute recovery heart rate (beats/min) |
| Group based cognitive stimulation (GCST) | 10 weeks | 10 | 10 | 2.5 hours | Community centre | • Improved forward digit span – prospective memory (forward recall) • Improved backwards digit span – working memory (backwards recall) • Improved letter fluency • Improved Category fluency • Significant improvement on quality of life and functional abilities (WHO-QOL total) |
| Individual cognitive stimulation (ICST) | 10 weeks | 30 | 10 | 30 minutes | Community centre or home | • Improved forward digit span – prospective memory (forward recall) • Improved backwards digit span – working memory (backwards recall) • Improved letter fluency • Improved Category fluency • Significant improvement on quality of life and functional abilities (WHO-QOL total) |

# Conclusion and Implications
## How were the results interpreted?

It was concluded that the MCI patients who are at high risk of dementia and relatively elderly were safely engaged in a complex multimodal activity intervention and developed to reduce the risk of dementia through combined health promoting activities, engagement of people with MCI and results in sufficient adherence rates. It was therefore feasible to conduct future randomized controlled trials to examine the effects of long term participation on rates of conversion to dementia from MCI.

## Limitations

Some limitations of this study and its application include:
* Relatively high cost
* Intervention covered only a single geographical location
* Methods may not have allowed analysis to determine the relative contribution of the different activities to the results and a future randomized control trial
* DSD (Do something different) activities, as they were not monitored, did not contribute to the results. However, the improvements on physical health, fitness, and cognitive measures were unlikely the direct results of the DSD activities. DSD contributed significantly to the high adherence due to behavioural change.

## Supporting studies

This particular study in MCI in elderly patients appears to support all prior research associated with reducing dementia risk factors, including poor lifestyle, physical and cognitive inactivity. Systematic reviews analysing longitudinal studies also show that combinations of social, cognitive and physical activities reduced the risk of dementia in comparison to looking at a single factor Consequently, future complex multimodal activity based dementia prevention studies can further the findings of this study, specifically randomised controlled clinical trials.

## Further reading

* Alzheimer's Australia - http://www.fightdementia.org.au/
* National Dementia Helpline - 1800 100 500
* For further information about exercise programs and diets suited to you please contact your local General Practitioner.

# References
## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Dannhauser, T. M., Cleverley, M., Whitfield, T. J., Fletcher, B. C., Stevens, T., & Walker, Z. (2014). A complex multimodal activity intervention to reduce the risk of dementia in mild cognitive impairment--ThinkingFit: Pilot and feasibility study for a randomized controlled trial. BMC Psychiatry, 14, 129-244X-14-129. doi:10.1186/1471-244X-14-129 [doi]
* 1 2 3 Hindin, S. B., & Zelinski, E. M. (2012). Extended practice and aerobic exercise interventions benefit untrained cognitive outcomes in older adults: A meta‐analysis. Journal of the American Geriatrics Society, 60(1), 136-141.
* ↑ Clare, L., Hindle, J. V., Jones, I. R., Thom, J. M., Nelis, S. M., Hounsome, B., et al. (2012). The AgeWell study of behavior change to promote health and wellbeing in later life: Study protocol for a randomized controlled trial. Trials, 13, 115-6215-13-115. doi:10.1186/1745-6215-13-115 [doi]
* ↑ Barnes, D. E., & Yaffe, K. (2011). The projected effect of risk factor reduction on alzheimer's disease prevalence. The Lancet Neurology, 10(9), 819-828.
* ↑ Larson, E. B., Wang, L., Bowen, J. D., McCormick, W. C., Teri, L., Crane, P., et al. (2006). Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Annals of Internal Medicine, 144(2), 73-81.
* ↑ Fratiglioni, L., Wang, H., Ericsson, K., Maytan, M., & Winblad, B. (2000). Influence of social network on occurrence of dementia: A community-based longitudinal study. The Lancet, 355(9212), 1315-1319.
* ↑ Fratiglioni, L., Paillard-Borg, S., & Winblad, B. (2004). An active and socially integrated lifestyle in late life might protect against dementia. The Lancet Neurology, 3(6), 343-353.