Exercise as it relates to Disease/Positive Emotion Motivated Tai Chi to reduce falls in Older Adults with Dementia

This is an analysis of the journal article "Developing a Positive Emotion-Motivated Tai Chi (PEM-TC) Exercise Program for Older Adults with Dementia" by Yao, Giordani and Alexander (2008)

What is the background to this research?
The World Health Organisation (WHO) defines dementia as "a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities". Falls can have drastic implications to older adults with dementia, this population is at risk of falling 3 times more than a healthy population of older adults due to cognitive and physical impairments. WHO states "falls are the second leading cause of accidental or unintentional injury deaths worldwide". Often these falls can result in severe injuries and at times death, therefore falls present as a persistent concern in older adults with dementia. There is ample research in terms of falls prevention in older adults, however older adults with dementia are often excluded from sample research populations.

Tai-Chi has been proven to reduce falls in older adults, as it is an exercise based activity that demonstrates improvements in balance by using slow movements to enhance body alignment, thus a suitable exercise for older adults with dementia to perform. Additional studies show Tai-Chi may slow down cognitive decline, emphasised by positive association evidence of exercise participation and participation with groups.

Despite lack of research of exercise interventions specifically for older adults with dementia, there is increasing evidence for a successful Tai-Chi exercise intervention program. Previous studies of older adults have shown the use of exercise to improve muscular strength, proprioception, balance and flexibility, highlight the significant improvements in results when referring to the same participants pre-test analysis. An integral aspect to the Tai-Chi exercise intervention was positive motivation, an encouraging sign of decreased symptoms of dementia was shown and is accountable the implementation of positive reinforcement.

Where is the research from?
The research was conducted by Yao, Giordani and Alexander at the University of Michigan, Ann Arbour in USA, participants were sought from the Aging/Dementia Research Registry at the Michigan Alzheimer’s Disease Research Centre (MADRC). The research was published in the Research and Theory for Nursing Practice: An International Journal, Volume 22, Number 4, in 2008.

What kind of research was this?
The research involved both qualitative and quantitative aspects. Results were gathered from a combination of questionnaires to cover the qualitative aspect of the study and a quantitative analysis was formed from results of the timed up and go and unipedal stance time results.

What did the research involve?
A sample of 20 participants presented in the study, 10 suffered from probable/possible dementia and the other 10 were their respective caregivers (spouse (5), daughter (4) and paid caregiver (1)). A 16 week intervention was carried out, utilising Positive Emotion-Motivated Tai-Chi (PEM-TC): 4 weeks (2 sessions per week) of group sessions were conducted by trainers, followed by a 12 week at home program (3, 20 minute sessions per week) with participation from both the dementia participant and the caregiver. A practice log was filled out by caregivers whilst the dementia participants served as their own controls, for pre and post test data collection. Data was collected at baseline, at the end of 4 week groups sessions and at the end of the 12 week home period. Each participant had an individualised home program in order to customise the positive motivating tool used, the Tai-Chi style of 'Sticky hands' was used for all sessions, consisting of the caregiver supporting and moving the dementia participant's hands and guiding them through the exercises.



What were the basic results?
Yao, Giordani and Alexander's qualitative data showed participation in the study was an enjoyable event for most of the participants and the sticky hands Tai-Chi technique was beneficial. This was attributed to the contact with another person the was utilised at the positive motivator for the dementia participant. The exercises allowed for dementia participants to develop a physical sensitivity to their partner's motions in conjunction with an opportunity for emotion and social engagement.

Quantitative data showed an improvement of an average of 2 seconds after 4 weeks of the program on the timed up and go assessment when compared with baseline testing, however improvement from the group sessions decreased when participants moved to at home training. The unipedal stance time also increased (quite drastically for some) at the end of the 4 week period, however again data values decreased when moving to the at home regime.

What conclusions can we take from this research?
A consistent exercise program with the incorporation of the Sticky Hands Tai-Chi technique for older adults with dementia proves to be beneficial in many aspects involving quality of life. Evidence shows increased balance, prevention and a decreased risk of falls in conjunction with decreased progression of cognitive impairment. Tai-Chi is an effective intervention of the onset of dementia, the inclusion of positive emotion-motivated Tai-Chi was beneficial to encourage participants who can often have temperamental, unpredictable and difficult behaviours to engage in a small amount of exercise. Positive stimulants often increased the dementia patients sensory ability, whilst allowing for a connection to be developed between patients and caregivers. Improvements in both quantitative and qualitative measures in the study demonstrate the benefit of improving a person who suffers from dementia balance and cognitive functioning can significantly decrease the risk and incidence of falls. As the study was conducted within a university, it lends to information being of lower significance than a similar study that was produced by a research institution.

Practical advice
The use of positive emotional motivators in conjunction with a Tai-Chi intervention exercise program shows evidence of an improved and prolonged quality of life for those who are suffering from dementia, in particular increasing the willingness of to participate in some form of exercise. However, the success of symptoms in the dementia participant was heavily reliant on the caregivers and it was found they themselves at were unable or unwilling to participate in the sticky hands Tai-Chi technique. A further investigation into the well-being of the caregivers and their relationship the dementia patient is integral. Increased benefits could be achieved by enhancing cognition for dementia sufferers by recording first hand data and feed back from the dementia participants themselves rather than the caregivers presenting on their behalf. In addition 10 participant's is not an adequate sample size to draw reliable conclusions, further investigation would benefit from a larger sample size, this is also correlated with the fact that the research is from USA, therefor results do not necessarily transfer to the respective Australian population and a further investigation would be needed to understand the significance of a positive emotion motivated Tai-Chi exercise implementation within the Australian population of older adults with dementia.

Further information/resources
For further information regarding reducing the risk of falls in dementia patients through the use of Tai-Chi; click on the links below:
 * Preventing fall among people with dementia: http://ll1.workcast.net/10182/4676547558057083/Documents/Presentation.pdf
 * Interventions for preventing falls in older people: http://www.cochrane.org/CD007146/MUSKINJ_interventions-for-preventing-falls-in-older-people-living-in-the-community
 * Evaluation of the Effectiveness of Tai Chi for Improving Balance: https://www.taijiquan.nl/wp-content/uploads/2014/12/Evaluation-of-the-Effectiveness-of-Tai-Chi-for-Improving-Balance-and-Preventing-Falls-in-the-Older-Population_A-Review.pdf
 * Effectiveness of exercise programs to reduce falls in older people with dementia: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330004/