Exercise as it relates to Disease/The effects of community-based exercise interventions in people with Alzheimer’s Disease

This page is a university assignment critiquing the article 'A community-based exercise program to improve functional ability in people with Alzheimer’s disease: a randomised controlled trial' conducted by Anthea Vreugdenhil, John Cannell, Andrew Davies and George Razay, for the Health, Disease and Exercise unit at the University of Canberra.

What is the background to this research?
Dementia is a degenerative neurological disorder that affects 35 million people across the world and it causes cognitive impairment, behavioural disturbances and physical decline. The study looks at how a community-based exercise program improves functional ability and increases the independence of patients in activities of daily living (ADL). Other similar studies have been conducted and found that exercise can improve the areas of life that decline with the progression of dementia, such as cognition, behaviour and functional ability, but they are few exercise programs that have been specifically designed for the needs of dementia patients. The increasing rates of people with dementia and the limited benefit of pharmacological treatments in reducing decline, show that it is important to explore other treatment variations for Alzheimer's disease (AD).

Where is the research from?
The patients in the study are community-dwelling AD patients from Tasmania, Australia. They were included in the study from a hospital outpatient memory disorders clinic and they live in a community dwelling and have a carer who visits on a daily basis or that lives with them. The authors of the study have completed previous studies on AD, showing their knowledge of the disease. The study was funded by the Tasmanian Community Fund and the Clifford Craig Medical Research Trust.

What kind of research was this?
The study was a randomised controlled trial. This type of study when exploring effectiveness of interventions, is considered to be the gold standard in terms of reliable evidence, because of the reduced risk of confounding factors which could affect the results.

What did the research involve?
64 patients were invited to take part in the study and 40 patients agreed to participate. The reasons for not participating ranged from being too busy or not interested in exercising. The patients were then randomly allocated to the control group, that conducted their usual treatment, or the treatment group, that participated in the exercise intervention. Patients in the control group participated in a 4 month at home exercise program as well as receiving their usual treatment. The exercise program was adapted from an earlier study and was trialled in a feasibility and safety study of 12 people with AD. The program involved 10 simple exercises, with 3 levels that got progressively more challenging, focusing on strength in the upper and lower body, and balance training, as well as at least 30 minutes of brisk walking. The patients were asked to complete the exercise daily and they were trained in the exercise program and provided with a manual that contained information and illustrations on how to complete the exercises. Patients of the control group continued their usual treatment. Patients in the study had two calls at 2 weeks and 2 months, to ask about well-being and how they were progressing with the exercises. Patients were assessed at baseline and at 4 months on various anthropometric measurements as well as outcome measures which are listed along with the assessment names :


 * Cognitive function - The Alzheimer's Disease Assessment Scale - Cognitive Sub-Scale (ADAS-Cog) and the Mini-Mental State Examination
 * Physical function - The Functional Reach Test (balance), the Timed Up and Go Test (mobility) and the Sit-to-Stand Test (lower body strength)
 * ADL (Activities of Daily Living) - The Barthel Index of Activities of Daily Living and the Instrumental Activities of Daily Living assessments
 * Depression - The Geriatric Depression Scale - Short Form
 * Global change in function - The Clinician's Interview-Based Impression of Change plus Caregiver Input (CIBIC-plus)
 * Carer burden - The Zarit Burden Interview

The format that the study was completed in is an effective approach because it allows the participant to fit the exercise into their daily routine and does not force them to complete the exercise with an external trainer or in an external location. Although it is important to note that in other studies of older populations, it has been found that group-based exercise is just as effective as home-based exercise in community-dwelling older adults. The limitations of this study are that participation and compliance is placed on the patient and their carer, the study relies on self-reporting and it was not double blinded because patients knew what group they were in.

What were the basic results?
16 men and 24 women participated in the study with a mean age of 74.1 years. The key baseline measures indicated that there was no difference between the control and treatment groups. At the 4 month follow-up, patients in the treatment group had increased positively in each of the functional domains, while the control group decreased in areas and had much less positive change. The researchers interpretation of the results was that they were significant in showing the benefit of community-based exercise programs. The researchers made a point that this is the first study to their knowledge, to show improvements in all functional domains and emphasised that the most important finding was the improvement in ADL as it is the strongest predictor of care hours for patients with AD. The implications of this research are not over-emphasised, as this is an increasingly important area of research due to the increasing amount of people affected by AD.

What conclusions can we take from this research?
The main conclusion to take from the study is the benefit that a specific exercise program for AD patients can provide for daily quality of life. A 2018 study on exercise interventions for cognitive improvement in individual's with AD, found that exercise can slow down the process of cognitive impairment and is an effective alternative to pharmacological therapy. Similar findings can also be found in a study of people over 50 from 2019, which concluded that physical exercise improved cognitive function, through aerobic and resistance exercise in line with exercise guidelines. While this study is not specific to AD patients, it provides more evidence that exercise will assist the daily function of patients.

Practical advice
The study, while not specifically describing exercises involved in their program, highlighted key areas of focus for exercise in upper and lower body strength and balance, as well as walking. The study also describes how the carer acts as a personal trainer and how the manual of exercises assisted patients in completing the program. These two points are highly important in providing recommendations for exercise for AD patients. The study also shows the effectiveness of community-based exercise. Another consideration could be how would the exercise need to be changed for patients with other pre-existing conditions.

Further information/resources
Further sources of information are listed below, for patients and allied health professionals:


 * What is Alzheimer's Disease? https://www.dementia.org.au/information/about-dementia
 * Exercise and Alzheimer's Disease Fact Sheet https://www.dementia.org.au/sites/default/files/helpsheets/Helpsheet-DementiaQandA08-PhysicalExercise_english.pdf
 * Australian Physical Activity Guidelines for Older Adults https://www.health.gov.au/health-topics/physical-activity-and-exercise/physical-activity-and-exercise-guidelines-for-all-australians/for-older-australians-65-years-and-over
 * Cognitive Improvement with Exercise in AD paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866875/
 * Exercise Intervention for Cognitive Function in Older Adults paper https://bjsm.bmj.com/content/52/3/154.citation-tools