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Dementia and Physical Activity

Dementia is defined as a significant loss of intellectual abilities such as memory capacity that interferes with social or occupational functioning (medicinenet.com, 2020). As a person ages, his/her brain ages as well. Age-related changes in cognitive function, such as momentary memory lapses also known as “senior moments,” aren’t necessarily indicative of dementia.

According to the American Psychological Association’s guidelines as outlined in DSM IV, criteria for dementia diagnosis include:

In cases of dementia- an umbrella term that includes Alzheimer’s disease, dementia with Lewy bodies (DLB), vascular dementia (VaD) and frontotemporal dementia (FTD)- there are significant changes in the brain’s anatomy including overall shrinkage, permeability of the blood brain barrier (BBB), accumulation of amyloid plaques and neurofibrillary tangles leading to dramatic changes in a person’s behavior. (Raz, Knoefel & Bhaskar, 2016). Although some types of dementia including Alzheimer’s have a genetic component (Raz, Knoefel & Bhaskar, 2016), there are a number of modifiable risk factors, including diabetes, hypertension, obesity, smoking and physical inactivity (Cheng, 2016).

Pharmacological treatments including cholinesterase inhibitors can mitigate but not eliminate symptoms (Ringman & Cummings, 2006). As the population ages globally, dementia is rapidly increasing in prevalence, with 7.7 million new cases diagnosed annually, and an economic burden surpassing that of cancer and heart disease combined (Raz, Knoefel & Bhaskar, 2016). Current research indicates that helping patients to maintain physical fitness can significantly slow disease progression and improve quality of life for patients and caregivers alike. (Atherton et al., 2016).

The purpose of this guide is twofold:

Alzheimer’s Disease

Alzheimer’s is the most common form of dementia, affecting about one eighth of all persons ages 65 and older (Kandel et al, 2013). The disease takes its name from Alois Alzheimer, who first made the connection between its symptoms and specific alterations in the cerebral cortex, that he discovered during an autopsy of a middle aged Alzheimer’s patient who had been institutionalized.

The three hallmark symptoms of Alzheimer’s include brain atrophy, extracellular amyloid plaques, and neurofibrillary tangles. (Kandel et al., 2013). The disease is most prevalent in patients ages 85 and older, where rates average 25-35%. (Kandel et al., 2013).

Early symptoms that appear ahead of the full-blown syndrome include mild cognitive impairment:

As the disease progresses to mild dementia, affected individuals may have difficulty with problem solving or exhibit lapses in judgement, difficulty organizing or expressing thoughts, getting lost or misplacing belongings. Friends and family may also notice personality changes: irrationality, anger and/or withdrawal in social situations (Mayo Clinic, 2020).

The middle stage of the disease is marked by increasingly poor judgement and deepening confusion, greater memory loss and significant personality changes, particularly developing unfounded suspicions (Mayo Clinic, 2020). At this point, the individual will require at least some assistance with activities of daily living.

In the late stages of the disease, physical limitations become severe. The person will have difficulty walking, maintaining bowel and bladder control, and may experience rigid muscles and abnormal reflexes (Mayo Clinic, 2020). At this point, the patient will require assistance with most if not all daily activities, including eating, dressing and other types of self-care.

In some advanced cases, persons may also experience verbal or visual hallucinations. (Alzheimer’s Association, 2020).

Dementia with Lewy Bodies

This is the second most common form of dementia, and is often comorbid with Parkinson’s disease. It is characterized by the abnormal accumulation of abnormal proteins called Lewy bodies. Other disease symptoms include vascular abnormalities and altered inflammatory response within the central nervous system, as evidenced by the presence of auto-antibodies in the cerebrospinal fluid (Raz, Knoefel & Bhaskar, 2016).

The disease typically occurs in adults ages 50 and older, and affects more men than women (NIH National Institute on Aging, 2020). Risk factors include Parkinson’s disease, REM sleep disorders and genetics.

Cognitive problems include difficulty with remembering things, trouble with attention, visual or spatial abilities, changes in mood, poor judgement, confusion about time and place, and difficulty with language and numbers (NIH, 2020). Hallucinations, particularly visual hallucinations, occur in about 80% of patients with LBD and can occur early on (NIH, 2020).

Movement disorders are similar to Parkinson’s disease: small handwriting, muscle rigidity, festinating gait, stooped posture, “masked” face, balance problems, tremor or shaking, difficulty swallowing and soft voice. Patients may also experience vivid (and sometimes violent) dreams, insomnia and restless leg syndrome (NIH, 2020).

Vascular Dementia

This is a heterogeneous group of dementias associated with cardioembolic, large and small vessel diseases, all of which cause diminished cerebral blood flow. (Raz, Knoefel & Bhaskar, 2016). VaD shares risk factors with the conditions that lead to its development: hypertension, hyperlipidemia, hypercholesterolemia, smoking and of course, physical inactivity.

Vascular dementia can co-occur with Alzheimer’s in older patients, who develop both ischemic lesions and amyloid plaques. In fact, Alzheimer’s increases persons’ risks for CVA (stroke) and VaD.

Treating Patients with Dementia

Treating patients with declining cognitive function is challenging. Not only do these individuals experience concurrent physical decline, but it is not unusual for them to forget that their physical capabilities are no longer what they once were, which leads to an increased risk for falling.

Despite these barriers, it is particularly important to make sure that these individuals remain as strong and active as possible, in order to slow the loss of function. Because exercise is one of the few treatment options for patients with dementia, it has become the subject of extensive research, including DAPA (Dementia and Physical Activity) trial at the Warwick Medical School, University of Warwick, UK. (Atherton et al., 2016).

DAPA targeted patients with mild to moderate dementia, utilizing a four-month protocol of moderate-to-hard intensity exercise training as compared to usual treatment. The trial involved 468 participants over the course of a year. At its conclusion, DAPA did not slow cognitive decline, but was effective in maintaining physical fitness of those in the treatment arm. (Lamb, 2018). Therefore the DAPA exercise protocol can serve as a framework for practices interested in physical activity programs for dementia patients.

Eligibility for the trial included patients with memory impairment in language, motor activities, object recognition and/or executive function, as well as declines in occupational, social and/or self-care function related to cognitive function. Adults in the program had to be able to sit in a chair and walk ten feet unassisted, and could not have life-threatening co-morbid conditions such as unstable angina (DAPA protocol, 2014). Researchers used the Mini-Mental State Examination to assess participant’s cognitive status prior to the exercise program, and the 6-minute walk test for physical function and endurance.

Exercise classes were delivered in groups of six-to-eight patients, and included aerobic conditioning on stationary bikes and guided resistance exercise. Patients used a modified version of the Borg Ratings of Perceived Exertion (RPE) scale to report effort. Strength training was based on a 10 repetitions max effort. Classes were held twice per week, with patients attending at least 75% of classes during the four months considered compliant (Atherton et al., 2016). Researchers encouraged patients to continue exercising in community based programs following the intervention.

A Basic Exercise Program for Your Clinic

Using the DAPA protocol as a guide, a basic exercise program for patients with mild-to-moderate dementia should initially focus on balance and strength. Work with caregivers on aerobic exercise out of the clinic, that can include either walking or stationary bicycling. (See downloadable PDF for details).

The goal of the aerobic program should be 150 minutes of moderate intensity activity weekly in keeping with the Healthy People 2030 guidelines. If patients are unable to perform 30 minutes of continuous exercise, shorter bouts (5-10 minutes) throughout the day are also effective.

Begin your program with a timed balance assessment, including feet shoulder width apart, feet together, semi-tandem and tandem stance with eyes open. This can serve as a baseline measure. Encourage patients to work on balance with their caregivers at home, making sure that they have a stable support to prevent falling (sturdy chair, table, railing etc.).

A good basic balance exercise is the clock, since it challenges both cognitive and physical skills. The patient stands in the middle of an imaginary clock. The trainer calls out times of the day and the patient uses his/her right or left foot to indicate the position of the clock hand. Patients with poor balance can hold onto a railing, and if necessary, exercise one leg at a time.

Sit-to-stand and standing-to-seated exercises are particularly important for maintaining independence in activities of daily living. This exercise requires a sturdy chair with a moderately high seating height. Begin by having the patient using his/her hands on the arms of the chair to rise up and return to a seated position. When the patient masters this basic move, he/she can move to using the hands on the knees, and shifting the weight forward to maintain stability. The final step is being able to rise and sit back down with the arms crossed over the chest. Again, leaning forward in the chair shifts the patient’s center of gravity to make it easier to stand up and sit back down.

Step-up and step-down exercises help patients maintain the ability to climb and descend stairs and to navigate curbs outside the home. Begin with a 2-inch aerobic platform, having the patient step up and step back down on the same side. Progress to the patient stepping up and over the platform. Once the patient masters this, try adding a two-inch riser to replicate normal step height.

Manual dexterity exercises are also important, using a Finger Web, exercise ball or putty. Simple exercises such as stacking coins will improve fine motor movement.

Patient and Caregiver Resources

Following is a short list of resources for patients living with dementia, their caregivers and families:

The Alzheimer’s Association is a good place to start. The website includes downloadable educational materials for patients and their caregivers, information about community resources, a science hub covering ongoing research and an online caregiver community called ALZConnected. The organization also hosts a toll-free 24-hour helpline: 800-272-3900.

The Family Caregiver Alliance includes a Dementia Caregiver Resources section with links to information about communication, dental health, nutrition, physical activity, dressing and grooming, etc.

Dementia Friendly America helps patients living with dementia and their families find resources in the community, including legal assistance, memory cafes, libraries, first responders, faith communities, disaster planning, transportation and specialty care.

References

Atherton, N. et al. (2016). Dementia and Physical Activity (DAPA)- an exercise intervention to improve cognition in people with mild to moderate dementia: study protocol for a randomized controlled trial. BioMed Central Open Access.

Bondi, M., Edmonds, E. & Salmon, D. (2017). Alzheimer’s Disease: Past, Present and Future. Journal of the International Neuropsychology Society. Vol 23. Nos. 9-10. pp. 818-831.

Cheng, S. (2016). Cognitive Reserve and the Prevention of Dementia: the Role of Physical and Cognitive Activities. Current Psychiatry Report. Vol. 18. No. 85. Springer Science. pp. 1-12.

Mayo Clinic (2020). Dementia: Symptoms and Causes. Mayoclinic.org.

NIH: National Institute on Aging (2020). What is Lewy Body Dementia? nia.nih.gov./health/what-lewy-body-dementia.

Raz, L., Knoefel, J. & Bhaskar, K. (2016). The neuropathology and cerebrovascular mechanisms of dementia. Journal of Cerebral Blood Flow & Metabolism. Vol. 36. No. 1. pp. 172-186