Alzheimer’s Disease (AD) is a neurodegenerative disease that strikes fear and terror into those who are getting on in years and family members who are in line to care for them. According to the Alzheimer’s Disease Foundation, in 2015 it is estimated that 5.3 million Americans have the disease. It is the 6th leading cause of death behind heart disease, strokes, and cancer but it is the only one that cannot be prevented (1) although some experts now estimate that it may be the third highest (2).
AD afflicts mostly those over 65 but approximately 200,000 individuals under 65 get what’s called ‘younger-onset Alzheimer’s’. Too, women seem more prone to AD – two-thirds of those over 65 with AD are women. And while there are more non-Hispanic whites with AD, older African-Americans and Hispanics are more likely to have other dementias and AD compared to Caucasians. Estimates for the frequency of AD are that it will be a greater burden on families, the health care system and the individuals themselves as the Boomer generation ages: by 2025, some 7 million will have the disease and that number could double by 2050.(1, 2)
While it is not the purpose of this essay to delve into the details or causes of AD, it still warrants some background in order to appreciate the impact it has on the lives of both the victims and their caregivers.
As an “irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks”, AD will disrupt the cognitive as well as behavioral capabilities of sufferers to do activities of daily living (ADLs).(2) Like other forms of dementia, AD, as it progresses, may leave its victims totally under the care of others for simple things like eating, dressing, toileting, showering, etc. The capacity to be mobile if not dexterous may be the greatest argument in support of exercise therapies, especially if they can be instituted while cognition and memory are not too far advanced. Proper, and simplified, training in movement may enhance the patient’s/client’s ability to assist caregivers in many of the basic ADLs to ensure safety and functionality.
As of now, science does not know what causes AD or why it progresses in some and not others. It is believed that causality “probably include[s] a combination of genetic, environmental, and lifestyle factors” that varies from person to person. For those who get it late in life, after 60, there is a strong correlation with the apolipoprotein E (APOE) gene being present. However, again, correlation is not causation despite the many changes in the brain’s wiring and circuitry that occur due to ‘tangles” and plaques that biopsies show in many older people. (2)
While it would be nice to be able to say that proper nutrition, physical fitness, social interaction and cognitive engagement are buffers to the disease, the evidence is not so convincing in light of the environmental, genetic and other correlational influences. At best, it’s a matter of reducing risk but there are no good data to say how much of what one needs to precisely determine how much risk has been reduced.(2)
Some of the behavioral changes that mark the onset and advancement of AD are sleeplessness (which may be shrugged off as insomnia that many older people experience), wandering (which may initially be attributed to mild cognitive impairment (MCI), and agitation or anxiety (which may be attributed to both MCI and depressive disorders.) Aggression, especially in later stages, or resistance to the mores, values, and demands of caregivers or others does seem to distinguish AD from MCI, depression and insomnia. (2) Clearly there are psychopharmaceutical interventions for many of these symptoms but the ability to slow down the progression let alone reverse it is still out of reach.
This essay will try to answer two main questions: What role does physical activity or regimented exercise play in helping sufferers of AD stave off some of the effects of the disease? And which exercises or exercise types are best suited to do so? First, though, we should consider what is currently known about the role of fitness in prevention and progression of AD.
The Role of Exercise and Fitness in AD Prevention & Progression
According to a variety of sources (2, 3, 4), exercise and fitness do not have a known effect on one’s risk for AD but do have an effect on one’s risk for some forms of dementia. For example, those with vascular disease such as coronary heart disease, hypertension, diabetes, etc. are more at risk for impaired blood flow to the brain that could alter cognition and function. The longer one has one of these diseases, the greater one’s risk. In fact, autopsy studies show that about 80% of those with AD also had vascular disease. (4) Therefore the current take on this is that doing more aerobic-type of activities to stimulate the many benefits of cardiovascular fitness reduces the risk of vascular dementia and maybe even AD. (4) To the extent that vascular disease can be reversed, it is believed dementia can be deferred and hoped that AD can, too.
Ozioma Okonkwo, an assistant professor of medicine at the University of Wisconsin School of Medicine and Public Health, proposes that fitness may even override the deleterious effects of aging on the brain. Exercisers had “less accumulation of “beta amyloid plaque….less shrinkage of the hippocampus and less reduction in use of glucose in the brain… and fewer neurofibrillary tangles, [the] twisted fibers inside brain cells of people with Alzheimer’s.” (5)
“A large body of work, including observational and intervention studies, has shown that physical activity is beneficial for maintaining cognitive function and delaying the onset of [Alzheimer’s Disease] and related diseases among older adults,” the researchers wrote. “However, it is only recently that studies have begun to investigate the potential effects of physical activity on biological markers.” (5)
According to Ronald Petersen, M.D., many studies demonstrate the benefits of exercise for the brain. While he does not argue that it can prevent the progression of AD, he does contend that exercise can “delay the start of Alzheimer’s for people at risk of developing the disease or slow the progress of the disease.” (6) Radak et. al., on the other hand, do contend that exercise may prevent AD based on what scientists know about its value in “healthy vascularization and energy metabolism of different brain regions” which, “taken together …. [act] upon a variety of factors to improve and keep our brain healthy and productive.” (7)
Nonetheless, at this time, most researchers are unwilling to claim that exercise prevents AD in those most at risk and that it can’t stop its progression let alone cure it. They all say more research is needed before we can know for sure.
The Benefits of Exercise for Those with AD
Although exercise per se will not defer the onset nor will it change the pace of AD, it can serve to “prevent muscle weakness and to help prevent other health complications associated with inactivity.” (3) It may also elevate “brain chemicals that help protect nerve cells”, promote normal daytime and nighttime routines to facilitate better sleep, and may even improve or stabilize mood. (3) “Repetitive exercises such as walking, indoor bicycling, and even tasks such as folding laundry may lower anxiety in people with the disease because they don’t have to make decisions or remember what to do next. They also can feel good knowing that they’ve accomplished something when they’re finished.” (5) There is some evidence that 5 days/week of exercise may reduce “age-related changes in the brain that are associated” with AD and even improve performance on some cognitive tests in undiagnosed older adults. (5) Clearly, while there is a lot of research that demonstrates these benefits in normal, healthy adults, there is more to be done with AD patients before definitive statements can be made regarding the effects of an active lifestyle.
According to Rolland et al., exercise for those with mild to severe AD for one hour twice a week may help functionality, that is, the ability to perform ADLs. They studied 134 AD patients for a year testing 6-meter walking speed, the get-up-and-go test, and the one leg-balance. Neuropsychological assessments were also performed. They concluded that their sessions of aerobic, strength and balance resulted in “significantly slower decline in ADL score in patients with AD living in a nursing home than routine medical care.” (8)
It should be noted that of the 429 eligible AD patients at the nursing homes studied by Rolland et al., fewer than a third volunteered and stuck with the program. Although these low participation rates occurred for a variety of reasons, exercise professionals need to find creative ways to get buy-in from patients and their caregivers despite the demonstrated rewards. Furthermore, the authors acknowledged that several factors may have influenced the gains they reported, including participants’ willingness to join the program, their better initial health and possibly emotional and cognitive status, and perhaps their slower rates of disease progression. Regardless, those who participated regularly experienced superior results compared to those who did not, supporting the value of a regimented and supervised exercise program for many of these patients. (8)
Starting an Exercise Program for AD
Many studies have been implemented to see what benefits a patient with AD might get from an exercise program. Some were discussed above. In general, a precise prescription is not yet agreed upon as it might be for generally healthy adults or for those with specific metabolic or cardiovascular conditions. In the modern paradigm of fitness training, four main components receive primary emphasis with the specific exercises and progressions individualized to each person’s needs: aerobic (or cardiovascular), strength, flexibility and balance. Thus, the Rolland et al. study had their subjects do start exercises at light intensity and gradually increase intensity during the first month of the intervention. (8)
For the most part, organizations such as the Alzheimer’s Association and many medical school newsletters recommend some simple and sound advice suitable for the elderly who likely have co-morbidities with only a few specifics aimed at those with AD. For example, they recommend a physician’s clearance, short bouts of 10 minutes or more for beginners, a longer, slower warm up, observation for safety concerns (flooring, lighting, support systems, etc.), caution for feelings of sickness, light-headedness, etc., and implementation of activities they might enjoy. (3, 9) But it may be worth the exercise professional’s researching programs enacted by researchers in order to get a better feel for how to actually create a program for an individual or a group.
For example, the Rolland et al. study. Working with this population, they took into consideration the “participants’ behavioral readiness for the proposed program.” (8) The researchers drew from other studies of exercise “for frail and cognitively impaired subjects” and incorporated music into the sessions. They developed an inside circular walking trail that “went past the room of each exerciser to enhance adherence to the session.” (8) This ‘trail’ was used for the full 12 months to “ritualize the session and encourage confidence.” After stretching, the participants were encouraged to walk to the point of mild but not uncomfortable breathlessness. Stations for strength, flexibility, and balance training were set up with guardrails in the corridor or foam rubber ground sheets for safety sake. Strength exercises focused on the lower body; various types of squats at different levels (or repeated stand ups from a chair), lateral elevation of the legs in a standing position, and rising on the toes constituted the thrust of the program. Subjects imitated the occupational therapist who led all the sessions at any one facility on simple flexibility exercises. Balance drills “consisted of small step trial exercises using cones and hoops on the ground and one- or two-leg balance exercises on the ground or on foam-rubber ground sheets.” (8)
In other words, whether or not the exercise professional is an expert in AD itself, he/she can use the fundamentals outlined by the Alzheimer’s Association or the Cleveland Clinic in designing a program comparable to that developed by professional researchers. The following tips are based on these and my own experiences with clients with AD.
First, a quiet environment is preferred as distractions, visual or auditory, simply add to the emotional distress an elderly person, especially one with cognitive impairment, might experience with a new person and a new environment. This suggests that at home, or in a reserved space if in a facility, or at a time of day and in a more or less secluded space if at a gym would be optimal.
Second, if the environment permits, low-volume and age-relevant music could put the participant(s) at ease as well as be used to provide auditory accompaniment for some of the exercises, especially the cardiovascular ones like walking or some of the gentle range of motion/flexibility ones. It is unlikely that this population will perform more vigorous strength work if you play the heavy metal music popular in many weight rooms.
Third, provide solid support systems on an individual basis. Thus, some using walkers may do better with a ballet barre while those who are able to walk without support may suffice with the back of a chair. For those confined or best confined to a seated position, while it may be optimal to not have the arms of the chair in the way, that may not be an option where safety is concerned. Therefore, the trainer needs to adapt the variety of exercises to that person’s needs and limitations.
Fourth, choose exercise modalities that are more or less risk free. Thus, a treadmill, unless the person has been acclimated to using one in the recent past, is more risky than simply walking around an open space. Elliptical machines are easy on the lower body joints but require some learning; and since they are elevated may also be scary for some of these clients. Recumbent cycles are quite safe although they could be challenging to access and de-access. Optimal exercise devices for aerobic activity include a step-through recumbent cycle or the NuStep seated stepping machine especially if it has the rotating seat for accessibility. As far as resistance training is concerned, using elastic bands or cable machines could be risky if the client does not understand to not release the handles until you have given the appropriate signal – which should include releasing tension on the tubing or cable for the client. Using free weights, which have multiple benefits beyond strength, is also dependent on the person’s ability to understand the rules of use, which include slow, controlled movements and to always hold onto them until you have given a signal that it’s okay to let go. Finally, stretching exercises that can be done seated in a firm chair or on a training table are preferred over ones done on the floor.
Finally, as far as strength training is concerned, focus on the lower body first, then the core, then the upper extremities. While it would be good to encourage better posture, adding too many cues to any one exercise can be overwhelming and maybe frustrating. Encourage good posture during posture exercises such as rows and squats, the former because it trains the posture muscles, the latter for spine safety. Recognize that too many fine points of training will be de-motivating even if you know from what you’ve read and practiced that perfect technique yields better results.
What Exercises Should You Do?
For this section, I will focus primarily on warm up and strength exercises. Flexibility exercises are best incorporated into these components if the exercises themselves progressively increase the joint’s or joints’ ranges of motion. I will break the body down into three parts: lower body, core/middle body, and upper body. While balance exercises could be incorporated into any program, I will let many of the lower and upper body exercises work towards balance and stability by suggesting simple adjustments; keep in mind, though, safety first, so position the client in such a way as to ensure some mechanism of security.
Starting with a warm up, simple walking or doing some seated cardiovascular exercise is a safe bet. If you feel you must warm up the upper body more, perhaps because the person’s lower body is out of commission due to other medical or orthopedic issues, then use increasingly large, fluid movements that incorporate familiar patterns.
To music or a cadence supplied by your own voice, start with neck rolls, shoulder shrugs, scapular pinches and lateral raises. Once the arms are out to the sides, small circles in both directions or even writing their names in the air, or the alphabet to the ABC song, might be an option. Front shoulder raises gradually increasing the degree of flexion can also be transferred into fluid, dance-like movements or simple shapes such as circles, squares, triangles or letters. Marching, seated or standing, and simple abduction/adductions, seated or standing, will top off the warm up. Encourage verbal counting or reciting a simple ditty such as the alphabet or the words to a familiar song may encourage bigger, more dynamic movements as well as compliance.
Let me reiterate that the goal of strength work has nothing to do with enhancing physique, muscularity, body composition or even bone density. It is all about helping the client be able to function more independently or to assist caregivers to help the person move about with less risk of injury to both the person with AD and the caregiver her/himself. Keep in mind, too, that while basic reps and sets and load prescriptions are an option, attention span, enjoyment span, and other emotional factors may mitigate against your preference to enact strict programming. Nonetheless, if you follow the KISS principle – Keep It Simple, Stupid – you can develop enough redundancy within each session such that you can still get enough stimulus to generate appropriate gains. The exercises may be listed in a progressive manner but the trainer must accommodate the client’s abilities and co-morbidities as best as possible.
- Knee extensions
- Wall sits
- Wall squats
- Chair squats
- Hand-held weighted squats
- Leg press
- Seated hip abduction (adduction if warranted)
- Standing supported/unsupported abduction
- Standing supported/unsupported hip extension
- Seated or standing supported/unsupported heel raises
- Seated or standings supported/unsupported toe raises (for tibialis anterior)
- Long step forward, without lunging or with a modified, partial lunge
- Long step sideways, shifting weight to the stepping leg without or with flexing hips and knees like a squat
Seated leaning back (sit with back off the back of the chair and tilt back slightly)
- Seated ‘crunch’ (sit to the back of the chair and have the client hold a beach ball or large balloon in the lap and against the chest, then use the chest to squish the ball)
- Seated or standing Pallof Press, cable or tubing, but do not hold more than a couple of seconds (see: https://www.youtube.com/watch?v=QGnd7P55xoo); vary stance width to challenge balance as well as core
- Supine bridges/hip lifts – taught for home exercise in the bed
- Partial or Full tandem stance for time
- Wall push ups
- Counter-top (about hip level) push ups (could be done on a Smith machine)
- Seated row – machine, cable, tubing
- Standing row – cable, tubing (in split stance); if you can progress to doing it with one arm at a time, it will provide a better core exercise and challenge balance somewhat
- Open can supraspinatus raises – for the rotator cuff, done in the scapular plane
- Biceps curls – free weights, tubing
When working with an individual or a group of individuals with AD, one has an opportunity to enhance the participant’s or participants’ quality of life substantially even if the program does not ‘sink in’ or alter the course of the disease. If it helps the client be able to transfer from sit to stand and back to sit safely; if it enhances the client’s ability to toilet or shower safely; if it improves the client’s ability to ambulate alone or with friends, in quiet or even crowded spaces like a store; if it improves musculoskeletal function and reduces painful joints; and if it assists caregivers in providing safer and more meaningful interactions, the program has been a success. If, by some odd chance, cognitive function, emotional quality of life, memory or any other brain-related benefits accrue, the program has exceeded expectations. And if the client comes away from a session with a sense of human connectedness and accomplishment, even if the client cannot remember your name or what you just did during the session – and this is very likely, not simply a bad joke – you have given at least three people a gift: the client, their caregiver and you.
Fitness Pros: Continuing Education for Working with Alzheimer’s
If you’re a fitness professional looking to work with Alzheimer’s clients — both correctly and effectively — visit MedFit Classroom’s partner course page, to find a curated list of continuing education courses and programs for medical conditions, including Alzheimer’s, as well as senior fitness and active/healthy aging.
Dr. Irv Rubenstein graduated Vanderbilt-Peabody in 1988 with a PhD in exercise science, having already co-founded STEPS Fitness, Inc. two years earlier — Tennessee’s first personal fitness training center. One of his goals was to foster the evolution of the then-fledgling field of personal training into a viable and mature profession, and has done so over the past 3 decades, teaching trainers across through country. As a writer and speaker, Dr. Irv has earned a national reputation as one who can answer the hard questions about exercise and fitness – not just the “how” but the “why”.
- Alzheimer’s Association. Science and Progress: Prevention. www.alz.org/ Accessed 7/8/2011. http://my.clevelandclinic.org/health/diseases_conditions/hic_Alzheimers_and_Dementia_Overview/hic_Exercise_and_Alzheimers_Disease
- http://www.washingtonpost.com/news/to-your-health/wp/2014/12/16/more-evidence-that-exercise-can-help-fight-alzheimers-disease/. Lenny Bernstein, Dec. 16, 2014
- Radak Z, Hart N, Sarga L, Koltai E, Atalay M, Ohno H, Boldogh I., Exercise plays a preventive role against Alzheimer’s disease. J Alzheimers Dis. 2010;20(3):777-83. doi: 10.3233/JAD-2010-091531. http://www.ncbi.nlm.nih.gov/pubmed/20182027
- Yves Rolland, Fabien Pillard, Adrian Klapouszczak, Emma Reynish, David Thomas, Sandrine Andrieu, Daniel Rivie`re, Bruno Vellas. Exercise Program for Nursing Home Residents with Alzheimer’s Disease: A 1-Year Randomized, Controlled Trial. J Am Geriatr Soc 55:158–165, 2007. http://www.researchgate.net/profile/Emma_Reynish/publication/6502137_Exercise_program_for_nursing_home_residents_with_Alzheimer’s_disease_A_1-year_randomized_controlled_trial/links/0c96052e22e097a764000000.pdf
- http://www.webmd.com/alzheimers/guide/alzheimers-exercise. June 28, 2014, reviewed by Neil Lava, MD