Exercise as it relates to Disease/The effects of aerobic and strength exercise programs for patients with Dementia

This resource is a critique of a research paper that investigated the effects that aerobic and strength exercise programs had for patients with dementia. This resource has been written as an assessment for Health, Disease and Exercise, a unit at the University of Canberra.

The paper that has been critiqued is:

Bossers, W. J., Van Der Woude, L. H., Boersma, F., Hortobagyi, T., Scherder, E. J., & Van Heuvelen, M. J. (2016). Comparison of Effect of Two Exercise Programs on Activities of Daily Living in Individuals with Dementia: A 9-Week Randomized, Controlled Trial. The American Geriatrics Society, 64, 1258-1266.

What is the background to this research?
The cognitive and motor impairments associated with dementia can cause activity of daily living (ADL) disability. ADL's are activities that individuals partake in as a part of their daily living routine that are necessary for self-care. There are 6 ADL's; walking, feeding, dressing and grooming, going to the bathroom, bathing and transferring

A reduction in ADL leads to a loss of independence, poor quality of life, burden on carers and increased costs. Physical activity has been suggested as an intervention to combat these problems for dementia patients. Physical inactivity can accelerate ADL disability, and can increase an individual’s risk of motor and cognitive function decline. Therefore, increasing physical activity levels could slow the decline in physical and cognitive function and ADL in dementia patients. Previous research has provided evidence that multicomponent exercise programs can increase ADL in dementia patients. Individuals in nursing homes living with dementia who participated in an aerobic and strength exercise program experienced more motor and cognitive improvements than the individuals who participated in a single-exercise program.

The hypothesis that exercise programs are beneficial for ADL's in patients with dementia is not a widely researched topic. Only 6 studies    have investigated the topic, all having inconsistent results or data that lacked validity.

Researchers propose that combining strength and aerobic exercise can have a positive effect on levels of insulin like growth factor-1 and brain-derived neurotropic factors. The authors aim of this study was to investigate their hypothesis that combining aerobic and strength exercise programs is more effective in increasing ADL levels in individuals with dementia than single-component programs, thus looking to improve exercise recommendations in this population.

Where is the research from?
This study was conducted in the Netherlands by researchers from the Centre for Human Movement Sciences, Centre for Rehabilitation, Department of General Practice, University Medical Centre Groningen, University of Groningen, and Department of Clinics Neuropsychology. All authors have conducted research in this field prior to the current study. The research was published in the American Geriatrics Society, a reputable peer-reviewed journal. There was no conflict of interest from any authors of this study.

What kind of research was this?
This study was a parallel, three-group, single blind, randomised, controlled trial. This research design was appropriate for the study. 105 individuals from the Netherlands participated in the study. All participants had dementia and were 65 years or older. This study had quite a small sample group, making it difficult to draw valid conclusions that can be applicable to a wider population, such as individuals with dementia.

What did the research involve?
The study involved a combined aerobic and strength exercise group, an aerobic-only group and a social visit group. Participants ADL’s were measured and assessed before and after the intervention. This is an important element that must be included in an intervention study so that accurate conclusions can be drawn.

Each intervention lasted 9 weeks, consisting of thirty-six half an hour session. The combined group participated in two walking sessions and two strength sessions per week, the aerobic group engaged in four walking sessions per week and the social control group participated in four social visits a week.

The Katz index, 7-item physical performance test and the Erlangen-ADL test were used to assess ADL’s before and after the 9-week interventions. The Katz index was measured from the nurse's perspective which may have been biased due to a lack of blinding, as the nurse administering the questionnaire is likely to have been familiar with the individual, their level of activity and daily routine. This may have impacted the results of the study.

What were the basic results?
The combined aerobic and strength intervention and the aerobic-only intervention resulted in improved ADL’s in a similar way, however the results were small. Therefore, the data in this research did not support the hypothesis that a combined exercise program would be more beneficial on ADL levels of individuals with dementia. Nonetheless, the results still showed the positive benefits of exercise programs independent of exercise type, on ADL levels for individuals with dementia.

The combined aerobic and strength group’s ADL measures improved significantly compared to the social group, although the aerobic group only saw significant improvements on some ADL measures in comparison to the social group.

This study revealed the benefits that exercise can have on the quality of life of patients living with dementia. However, there was no clear distinction in which form of exercise (aerobic or strength) is more beneficial for these individuals. Future studies are needed to investigate this further.

What conclusions can we take from this research?
Although the improvements are slight and are independent of the type of exercise physical exercise can improve ADL levels in individuals with dementia. However, additional examination from the researchers of this study suggest that a combined aerobic and strength program can be more effective than an aerobic-only program in terms of targeting ADL levels in patients with dementia.

In the current study, the combined exercise group experienced greater motor and cognitive function improvements than other groups. Further research needs to focus on confirming this exercise-specific finding. Future studies should also include more participants to enhance the certainty of the results in relation to others with dementia.

Practical Advice

 * Individuals who are physically inactive are at a higher risk of experiencing cognitive, motor and physical functional decline. It is recommended that individuals increase their level of physical activity by implementing an exercise program to slow this decline and therefore, allow individuals to maintain their quality of life longer.
 * This research has shown that aerobic and strength programs (exclusively and combined) have the same effect on ADL levels in individuals with dementia. Therefore, it can be suggested that any exercise, either strength or aerobic, will be beneficial for individuals with ADL disability.
 * It is important that prescribed exercise programs are suitable for the individual, and meet the individual's requirements.

Further Information/Resources
The following resources can be used to obtain further information regarding physical activity and dementia:


 * Physical Exercise & Dementia (Dementia Australia): https://www.dementia.org.au/files/helpsheets/Helpsheet-DementiaQandA08-PhysicalExercise_english.pdf. This resource outlines the benefits of exercise for individuals with dementia, includes the exercise guidelines and what types of exercise individuals with dementia should be incorporating into their exercise programs.
 * Exercise & Physical Activity (Alzheimers Society): https://www.alzheimers.org.uk/get-support/daily-living/exercise. This resource is similar to the resource listed above, however it includes the types of exercises that should be incorporated at each of the stags of dementia.
 * Physical Exercise as a Preventive or Disease-Modifying Treatment of Dementia and Brain Aging: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258000/. This resource is an academic article from the Mayo Clinic Proceedings. Similar to this study, this article focuses on using exercise as a preventative treatment for dementia.
 * Tips on Helping with Activities of Daily Living: https://dementiacarenotes.in/caregivers/toolkit/adl/. This resource is helpful for carers, or those living with people with dementia. It outlines what ADL disability is, and how carers can assist loved ones who may be suffering from ADL disability and dementia.