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This is a critique of research article: Effects of a Physical Training Programme on Cognitive Function and Walking Efficiency in Elderly Persons with Dementia. by Kemoun G, Thibaud M, Roumagne N, Carette P, Albinet C, Toussaint L, Paccalin M, Dugué B. 2010 Apr 1;29(2):109.

What Is The Background To This Research?
Cognitive function commonly refers to the ability to be able to perform a variety of skills including memory, thinking, orientation, comprehension reasoning, attention, learning capacity, imagination, language, calculation, visuospatial abilities and judgement. An impairment in cognitive function can result in a declined ability to perform these skills as well as a deterioration in emotional control, social behaviour or motivation may be present. A decline or deterioration in ones’ cognitive function may be indicative of a diagnosis of chronic or progressive Dementia. Dementia can be associated with a variety of diseases and / or injuries that primarily or secondarily affect the brain, example the onset of Alzheimers’s Disease or Stroke

The progression of Dementia can lead to motor impairments such as balance issues and gait abnormalities and a decline in physical activity may arise. There is an underlying risk of fear of falling in elderly patients. Therefore, participation in physical activity is important in managing and supressing the progression of dementia.

Where Is The Research From?
This study was completed at University of Poitiers, France and University Hospital of Poitiers, France, by lead Author Prof. Gilles Kemoun. Kemoun works as head of Department of Physical Medicine and Rehabilitation within the University Hospital of Poitiers. Kemoun has published many studies and reviews looking at various cognitive impairments in the elderly population as well as a variety of exercise and performance based studies.

Although this study was conducted in France and examined the cognitive decline in elderly people living in a nursing home, there is a wide variety of international studies that obtained similar results. A systematic review conducted by Blankevoort CG, Van Heuvelen MJ, Boersma F, Luning H, De Jong J and Scherder EJ stated that there is a strong association between higher levels of physical activity reducing the risk of cognitive decline and dementia.

What Kind Of Research Was This?
This study was a randomised controlled trail that looked at the effects of physical stimulation based on walking exercises, equilibrium and endurance on cognitive function and walking efficiency in patients with dementia A randomised control trail is a type of study in which participants are randomly assigned to one of two clinical interventions. Randomised controlled trials are the most scientifically rigorous method of hypothesis testing available and therefore there is a minimal risk of confounding factors influencing the results. This trail method is considered to provide the most reliable evidence on the effectiveness of the tested intervention and because of this it is regarded as the gold standard trial.

What Did The Research Involve?
This trail compared 16 subjects who suffer from dementia to a control group of 15 participants who had not been diagnosed with dementia or any other cognitive impairment. All 31 subjects (aged 81 +/-5.3 years) were recruited from the same nursing home and were evaluated with the Rapid Evaluation of Cognitive Functions test (ERFC French version) as well as undertook a walking analysis before and after the rehabilitation process. The intervention group (n = 16) undertook a 15-week physical activity programme involving three 1-hour supervised sessions per week. The control group (n = 15) did not practice any physical activities. Each session focused on a specific walking parameter to aid in gait efficiency. One session was dedicated to motor route exercises (e.g. walking by striding over boards, going up a step, zigzagging). The second weekly session was devoted to stamina-based exercises, particularly on an ergocycle. The final weekly session involved activities that combined stamina, equilibrium and walking e.g. dance and stepping activities.

The inclusion of the participants was based on two criteria: one looked at cognition, a diagnosis of Alzheimer-type dementia by a neurologist according to DSM IV criteria with a score on the Mini Mental State Examination lower than 23; the other assessed motor-based skill, the ability to walk 10 metres without technical assistance. Each participant walked the 10 metres while the longitudinal movement of each foot and spatiotemporal walking cycle data was collected. The analysis of their walking efficiency data was measured with a Bessou locometer and SATEL software. The movement of each foot was transmitted, by means of a thread attached from each of the participants foot, to an optical sensor. Although this study found that physical activity programme can slow the cognitive decline and improve the quality of walking efficiency in elderly persons suffering from dementia, further research in this area is necessary.

Whilst the methodology and recruitment of participants in this study was effective in obtaining results, a reasonably low number of participants (a total of 31) were used. The study did not include intensity, frequency, duration or type of activity as a parameter. It was also deemed difficult to standardise the amount of activity each participant partook pre-study intervention. Medications and co-morbidities of the participants were unknown, this may have affected their locomotion abilities.

What Were The Basic Results?

 * The study found a strong correlation (p < 0.001) between changes in cognitive score and walking efficiency in dementia patients.


 * A significant correlation between higher cognitive scores and walking speed ( p = 0.76, p < 0.01), stride length ( p  = 0.61, p <  0.01) and double limb support time (p = 0.74, p <  0.01) was also found.

What Conclusions Can We Take From This Research?
The authors of this article conclude that partaking in a regular exercise programme can supress the effects and slow the progression of cognitive impairments such as Dementia and Alzheimer's Disease. The results obtained within this study follow trends reflected in other literature. Authors state that stamina-based physical activity programmes have proven beneficial in slowing cognitive decline and improving locomotion and walking efficiency in patients suffering cognitive impairment

The conclusion I draw from this study and other literature in this field, is that, like the authors, regular physical activity and participation in training programmes slows the onset and decreases the effects of cognitive impairments in the elderly.

Practical Advice
This article provides practical advice for the general public, health practitioners and future researchers interested in this area of health.


 * For those who suffer from cognitive impairments, exercising has been shown to improve cognition whilst slowing the onset of Dementia and Alzheimer's Disease. As cognitive decline is most prevalent in the elderly population, adopting exercise programmes within nursing homes may encourage more motivation and interest with being active at an older age. Public activities such aqua aerobics and Pilates has been seen to improve walking efficiency and decreases the risk of falling within this population.


 * For researchers interested in further developing this area, in-depth research could be undertaken to look at participation frequency, activity intensity and the minimum duration needed to design an optimum intervention.

Further Information / Resources
For interest in more readings regarding exercise and its effect on cognition in the elderly population, the following reviews and websites provide a sufficient overview of the topic:


 * 'Does Physical Activity Prevent Cognitive Decline and Dementia?: A Systematic Review and Meta-Analysis of Longitudinal Studies' (Research article)
 * 'The Effect of Exercise Interventions on Cognitive Outcome in Alzheimer's Disease: A Systematic Review' (Research article)
 * 'Recommended Measures for the Assessment of Cognitive and Physical Performance in Older Patients with Dementia: A Systematic Review' (Research article)
 * Health Direct - Dementia Prevention (website)
 * Integrated Living - Dementia Care (website)