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senior-couple-walking

The Walking Games

/13 December 2023/ All MFN blog/

Walking is the most readily available form of physical activity that most people can do regularly.  As the days turn darker and the temperatures drop, the innate enjoyment of walking outdoors can make regular walking harder as we spend more time indoors. 

The solution? Walking Games. 

These are strategies to bring enjoyment and engagement to indoor physical activity.  Further, these strategies also sneak in some added of brain health benefit with added cognitive challenge and an emotionally enhanced experience beyond what people expect from “walking.”

Brain games alone are not enough.  They can provide some cognitive benefit, but for most of human history, we solved intensely meaningful problems directly related to survival while moving, not sitting on a couch playing a low-stakes brain game or working on a crossword puzzle. 

Likewise, any exercise is good for brain health.  But when you add cognitive challenge to exercise, the benefits multiply.  Conceptually, it’s as simple as considering the difference between the treadmill and a trail for walking.  The latter requires using sensory information to consciously choose where and how to take each step.  

The strategies below are designed to create a “think and move” experience, all while enhancing the emotional response to movement. 

Walking Game 1:  Alphabet Walk

  • Mark off a rectangular or oval space with cones, water bottles, shoes, pillows, or anything else readily available.
  • Within the space, walk to trace letters on the floor with your feet.  Use names of favorite movies, books, musical artists or names of friends, family, or pets or perhaps names of travel destinations.  

The highly variable direction of movement makes the walking more beneficial and the use of letters of cherished names adds cognitive benefit and enhances the emotional state while walking by keeping favorite pop culture offerings or loved ones front-of-mind while moving. 

Walking Game 2:  Balloon Tap Walk

  • Blow up a balloon and gently tap it as you walk to keep it up by “air dribbling.”  

The need to track the unpredictable action of the balloon will result in variable walking speeds and co-coordination of eye-hand movements. 

Walking Game 3:  Balloon Wall Dribble

  • Blow up a balloon and face a wall. 
  • Tap the balloon into the wall and keep tapping it into the wall, adjusting body position slightly side-to-side to move with the balloon.  

Optional add-on for balloon exercises: Use a light-colored balloon and a dark-colored marker. Write letters or numbers on the balloon.  Use it to perform any of the following (in increasing order of difficulty):

  • Call out the letter or number most visible when tapping the balloon.  
  • Call out words in the same categories introduced above in “Alphabet Walk”
  • Using the numbers, designate a left and right hand for even and odd numbers, then tap the balloon with the corresponding hand. Or, perform simple math like addition or subtraction.
  • Combine use of letters and numbers. For example, call out favorite musical artists for letters and use the left-right/even-odd hand tap for numbers.

Walking Game 4:  Bounce, Catch…or Fetch

This can be done strolling slowly through any indoor space or standing still.  Use a ball, a pet’s toy, a pillow, or any object which you can bounce and/or toss and catch.  Bonus brain points for using something without an “easy” shape as it requires more manual dexterity to catch.  And if you drop the object, you get some extra essential life skill movement by fetching it from the floor.  

Wrap Up 

The reason people become less active when spending more time indoors is that the usual ways of moving more indoors are boring – no one is realistically going to take a walk around their house.  However, moving consistently is important to our physiology and our brain health regardless of the weather or season.  

Using these and other similar strategies that you think of can make staying active when spending more time inside more appealing, and that is the key to making it happen more regularly.  You can be an inspired leader to the people you serve when you make things enjoyable, more engaging, and as a result easier to do (so they no longer have to force themselves to do them.)

Brain Health Education for Fit Pros

All physical activity is good for the brain, but the inclusion of specific elements such as coordination, reactivity, partner interaction, attention and memory challenges integrated with physical activity make it even more beneficial. MedFit Classroom’s Alzheimer’s Disease Fitness Specialist course blends current science with common sense to present cutting-edge ideas to optimize the impact that fitness can have in the lives of those you serve who are concerned about or diagnosed with Alzheimer’s.

Article originally printed in canfitpro magazine.

His “800 Pounds of Parents” directly inspired Jonathan’s prolific fitness career. He is a multiple Personal Trainer of the Year Award-Winner (ACE, IDEA, and PFP Magazine), master trainer for the American Council on Exercise (ACE), creator of Funtensity, brain fitness visionary, blogger, international speaker and author. He is the author of MedFit’s Alzheimer’s Disease Fitness Specialist online course.

Senior-and-Trainer

Dementia Doesn’t Invalidate Exercise Needs

/8 June 2021/ All MFN blog/

With careful capability assessment and appropriate program design, exercise regimens can improve walking, balance, and flexibility and reduce falls in patients with dementia.

“Ruth, sit down! Don’t get up on your own.”
Who is that? Why is she yelling at me? I need to get up. My legs are stiff and I want to go for a walk.

“Ruth, stop getting up. You’re going to fall.”
Stop yelling at me. Who are these people? I feel so anxious. All I want to do is go for a walk. Why can’t I just go for a walk? I have walked by myself my whole life.

In working with older adults, many of us have witnessed circumstances similar to this. Often staff wish to maintain the safety and security of individuals living with dementia by limiting their independent mobility and ambulation. But are we truly protecting these individuals who are at risk? What are the ramifications of our actions? Movement and mobility are important foundations to maintaining strength, balance, flexibility, and continence; reducing anxiety and depression; and maintaining social relationships.

To this point, the positive impact of exercise in older adults is well documented in the literature. Exercise programs have been found to result in more favorable physical, social, and emotional health status and fewer activities of daily living impairments in the elderly.(1) These optimistic results provide support for older adults’ exercise groups to improve quality of life and reduce the burden of care for at-risk populations, including those with dementia.

While many focus on the cognitive effects of dementia, the physical aspects are also pronounced. Frequently noted are gait changes including a decrease in step length, step height, and reduction in cadence. These are compounded by balance deficits associated with a reduction in coordination, proprioception, and vision. To further aggravate the situation, the physical effects also can result in expressive and receptive communication deficits. As a result, patients living with dementia can have difficulty communicating these issues, as well as pain.

Effects of Exercise on Individuals With Dementia

Randomized controlled trials of patients with dementia or mild cognitive impairment have indicated improved cognitive scores after six to 12 months of aerobic exercise when compared with a sedentary population.(2) Other benefits associated with aerobic activity include the reduction of osteoporosis and fracture risk,(3) as well as a reduction in mortality risk.(4) Aerobic activity has also been noted to have other beneficial effects on secondary diagnoses associated with dementia including depression,5 anxiety,6 and behavior management.(7)

While the exact causative reasons for these beneficial outcomes are not fully understood, many studies favor the view that the cerebrovascular benefits exercise has on other body systems can be applied to the neurodegenerative process of dementia. Furthermore, evidence exists that aerobic exercise reduces the progression of the neurodegenerative process through facilitation of neuroprotective factors and neuroplasticity.(8)

The positive effects of exercise have also been found in individuals living with dementia who are already experiencing negative physical outcomes. Toulotte et al studied the effects of physical training on frail patients with dementia with a history of falls.(9) The training group was noted to have improved walking, flexibility, and balance, and a reduction in falls. Furthermore, Huusko et al evaluated the impact with hip fracture patients who also had mild/moderate dementia. Those who received intensive rehab were found to have shorter lengths of hospital stay and greater ability to return to the community than those in the control group.(10)

Developing an Exercise Prescription

Regardless of the reasons behind the beneficial effects of exercise on individuals with dementia, it’s necessary to evaluate each patient individually before initiating an exercise program. This includes an interdisciplinary review of an individual’s age, prior exercise involvement, and comorbid medical conditions. Based on the findings, an appropriate exercise program can then be initiated using the American Heart Association’s recommendation of 150 minutes per week of moderately strenuous physical activity.(11) These minutes of exercise can be divided over any number of days per week and with any number of sessions per day. For patient tolerance purposes, these sessions are often kept to between 15 and 30 minutes.

What type of exercise is appropriate for a patient to perform? For individuals with dementia, similar to those without, it is important to focus on their interests. Understanding these interest levels requires investigation. For some patients, this investigation may be complicated by apathy, aggressive behaviors, pain, and communication difficulties.

Depending on the severity of the disease, a focused understanding of a patient’s short- and long-term memory recall is necessary. While older adults without dementia may have a strong recall of their short- and long-term interests, this may not be true of an individual with dementia. Therefore, for those with intact long-term memory, we need to obtain the relevant information. Maybe interests include running, ballroom dancing, bowling, bicycling, gardening, or swimming. If patients can’t physically perform these activities, should we just give up? Of course not. We need to improvise. For example, ballroom dancing may now require walkers, or bicycling may need to be on stationary recumbent bikes with scenery posted around the bicycle.

Case Study

Ms. T is a 53-year-old female who presented to the Hebrew Home at Riverdale skilled nursing facility with a diagnosis including vascular dementia. Prior to initiating a therapy-based warm water program, Ms. T required intermittent assistance walking with a rollator. Her cognition was limited to the point that she could not participate in interviews on the Minimum Data Set (MDS). Despite significant staff efforts to minimize any emotional or environmental disturbances, she experienced periods of agitation. She completed a standardized assessment of her mobility, utilizing the Timed Up and Go (TUG) assessment, completing it in 32 seconds.

At that time, a land- and water-based exercise program with a three-days-per-week frequency was initiated with a physical therapist and dance movement therapist. The hypothesis behind this program was that through the use of multiple therapeutic modalities, gains in strength, balance, cognition, emotional support, and socialization would be achieved. Strength, balance, and functional tasks including ambulation with buoyancy in multiple planes, rotational activities, plyometrics, and resistive activities were implemented. For cognition, behavioral management, and emotional support purposes, music, singing, mental imagery, and floatation were incorporated into individual sessions.

After two months of participating in this innovative program, Ms. T was walking independently without an assistive device. She had also demonstrated an improvement in TUG assessment, completing the test in 10 fewer seconds. Additionally, Ms. T was noted to have experienced an improvement in her cognition, as she was now able to participate in interviews for the MDS. Most meaningful was that Ms. T rediscovered her smile. Tenaya Cowsill, MS, R-DMT, LCAT-P, reported that “this program has been an incredibly meaningful source of joy, autonomy, and pride” for Ms. T.

The Power of Dance

Dance/movement therapy (DMT) is an evidence-based movement approach to psychosocial health and well-being. The American Dance Therapy Association defines DMT as “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual.”(12) Therapists are board-certified licensed mental health professionals who use movement as a tool to explore, support, and strengthen clients’ emotional needs and coping mechanisms.

DMT can result in both positive physical and emotional outcomes, including a “sense of community, decreasing the experience of emotional isolation, and enriched relational interaction.”(13) Because this modality comprises both verbal and nonverbal interventions, it is especially appropriate for older adults with memory loss who are affected by the expressive and receptive communication difficulties.

The American Dance Therapy Association describes the emotional benefits and processes in treatment for older adults. “Individuals’ capacities and incapacities are explored, and accompanying feelings are expressed. Mourning, frustration, joy, and laughter can be ritualized in group movement, allowing for emotional release and group bonding.”(14)

The physical benefits of exercise and movement have been detailed in previous sections of this article. DMT, which places a focus on mental and emotional health, provides additional benefits as its holistic process includes “physical activity or exercise [and also] … learning, attention, memory, emotion, rhythmic motor coordination, balance, gait, visuospatial ability, acoustic stimulation, imagination, improvisation, and social interaction.”(15)

Older adults, especially those living with memory loss, may struggle with coordinated movement due to changes in brain functioning. Dance therapy welcomes all levels of functioning, encouraging engagement from an individual’s baseline, wherever that may be.

The creative, fluid, psychodynamic process allows for relatedness and engagement with multiple levels of functioning. A primary practice of a dance/movement therapist is one of embodied mirroring defined as the “somatic attunement of the therapist in face-to-face engaged interaction,”(13) which physically communicates to individuals living with memory loss that they are seen and understood. In a time when communication is often impaired, embodied mirroring provides an important tool for validating a patient’s experience.(15) As clinician Kalila B. Homann, MA, LPC-S, BC-DMT, wrote, “Mirroring is practiced by the therapist in DMT as a way to enhance emotional resonance between a therapist and patient … when a therapist mirrors the client’s emotional movements, the therapist is communicating this understanding and acceptance nonverbally.”

On a neurological level this intervention activates the brain’s mirror neuron system. From the neuroscience lens, mirror neurons are thought to be the determining factor in our capacity for empathy and interrelatedness.(13,16) This neurophysiological process “coordinates auditory and visual perception of nonverbal communication by tracking movement and expression in others—replicating the patterns of activation in the brain of the observer.” A resident with memory loss thus experiences validation on a neurobiological level. In dementia, because of the changes in communication that often occur due to brain deterioration, the benefits of emotional attunement from a therapist cannot be overstated. This need for witnessing and validation is a basic human need that does not change with dementia.

Case Study

Ms. M was a 92-year-old woman living in a skilled nursing neighborhood at the Hebrew Home at Riverdale. She carried a diagnosis of mild memory impairment and was a vibrant and active member of the community. She expressed and demonstrated a love for music. She would ambulate throughout the home with her walker, attending a wide variety of programs and actively socializing.

After suffering a stroke, her life shifted. She became reliant on a wheelchair for mobility, and her speech, gait, balance, and cognition were all impaired. This medical event also triggered an exacerbation of major depression, something she had lived with throughout her life. Through working with the rehabilitation team, she demonstrated improvements in functioning; however, major depression remained an impediment to treatment. As her therapy was reaching completion, she was transitioned via a warm handoff to DMT twice weekly from her wheelchair.

During group sessions, she presented with bright affect and eye contact, which was supported and validated by the therapist facilitating the group. In the therapeutic group space, Ms. M was able to both verbally and nonverbally express her grief and frustration with her condition. She spoke about her depression and was able to verbally and physically process her feelings through creative expression within the therapeutic alliance. Ms. M was able to “engage physiological processes related to emotion and make them more available to the conscious mind,” as Homann’s writings suggest. Through increased awareness Ms. M was able to more fully process and express her depressive symptoms, enabling her to further her treatment.

As dance therapy progressed, Ms. M began to increase her interpersonal relatedness, making eye contact with peers, sharing memories and physical gestures of connection. Ali Schechter, LCAT, R-DMT, her dance/movement therapist, states: “[Ms. M’s] movement generates vitality which results in expression.” Through the therapeutic alliance, this expression was validated, supporting Ms. M’s improved mood state.

As her mood state improved through DMT, Ms. M expressed the desire to begin standing and walking again. In addition to mood state support, DMT focused on movement of the spine, core, and hips, aiding in body strengthening for standing. The interdisciplinary team referred her for further physical therapy, and she began standing and, at times, walking with her walker for short periods. She continues to be an active participant in DMT sessions.

Blending Therapy Modalities

Maintaining and improving fitness and well-being remains an important evidence-based practice in our society. This is further magnified for older adults, especially those living with dementia. While the benefits of fitness programs remain the same for this population, the prescription for achievement may require a blended approach. Therapies, inclusive of physical and dance/movement, share many common strengths and goals. Therefore, the ability of these modalities to partner provides opportunities for improved mental, physical, and emotional health. The goal in all treatment is the well-being of residents, and care teams should use interdisciplinary tools and modalities toward that goal.

Get a Free Subscription to Today’s Geriatric Medicine

This article was featured in Today’s Geriatric Medicine.

Today’s Geriatric Medicine is a bimonthly trade publication offering news and insights for professionals in elder care.

Get a Free Subscription to Today’s Geriatric Medicine

 

This article was featured in the March/April 2018 issue of Today’s Geriatric Medicine (Vol. 11 No. 2 P. 14). Written by David Siegelman and Mary Farkas.

 David Siegelman, PT, RAC-CT, is the vice president of rehabilitation at the Hebrew Home at Riverdale in Bronx, New York. In this role he oversees the operation of the short-term rehabilitation units, clinical documentation and reimbursement department, and rehabilitation department. Having entered the field as a physical therapist, he has demonstrated expertise in clinical and systems management in acute care hospitals and skilled nursing facilities over the past 20 years.

Mary Farkas, RDT, LCAT, CDP, is the director of therapeutic arts and enrichment programs at the Hebrew Home at Riverdale. She is a licensed creative arts therapist who specializes in the intersection of dementia, end-of-life care, and mental health.

 

References

  1. Hamar B, Coberley CR, Pope JE, Rula EY. Impact of a senior fitness program on measures of physical and emotional health and functioning. Popul Health Manag. 2013;16(6):364-372.
  2. Smith PJ, Blumenthal JA, Hoffman BM, et al. Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials. Psychosom Med. 2010;72(3):239-252.
  3. Rizzoli R, Bruyere O, Cannata-Andia JB, et al. Management of osteoporosis in the elderly. Curr Med Res Opin. 2009;25(10):2373-2387.
  4. Lee DC, Artero EG, Sui X, Blair SN. Mortality trends in the general population: the importance of cardiorespiratory fitness. J Psychopharmacol. 2010;24(4 Suppl):27-35.
  5. Conn VS. Depressive symptom outcomes of physical activity interventions: meta-analysis findings. Ann Behav Med. 2010;39(2):128-138.
  6. Dunn AL. Review: exercise programmes reduce anxiety symptoms in sedentary patients with chronic illnesses. Evid Based Ment Health. 2010;13(3):95.
  7. Teri L, Gibbons LE, McCurry SM, et al. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. JAMA. 2003;290(15):2015-2022.
  8. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884.
  9. Toulotte C, Fabre C, Dangremont B, Lensel G, Thévenon A. Effects of physical training on the physical capacity of frail, demented patients with a history of falling: a randomised controlled trial. Age Aging. 2003;32(1):67-73.
  10. Huusko T, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ. 2000;321(7269):1107-1111.
  11. Nelson ME, Rejeski WT, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094-1105.
  12. What is dance/movement therapy? American Dance Therapy Association website. https://adta.org/. Retrieved January 7, 2018.
  13. Homann KB. Embodied concepts of neurobiology in dance/movement therapy practice. Am J Dance Ther. 2010;32(2):80-99.
  14. American Dance Therapy Association. Dance/movement therapy & the older adult. https://adta.org/wp-content/uploads/2015/12/DMT-with-the-Elderly.pdf. Accessed January 7, 2018.
  15. Kshytriya S, Barnstaple R, Rabinovich DB, DeSouza JFX. Dance and aging: a critical review of findings in neuroscience. Am J Dance Ther. 2015;37(2):81-112.
  16. Iacoboni M. Mirroring People: The New Science of How We Connect With Others. New York, NY: Farrar, Strauss and Giroux; 2008.
fitness-dumbells-exercise

Exercise and Dementia — Does Physical Activity Provide Cognitive Benefits?

/14 April 2021/ All MFN blog/

The World Health Organization recommends regular physical exercise—both aerobic and strength training—for older individuals as a means of reducing cognitive decline.1 However, studies on the effects of exercise on cognitive function in individuals with dementia have produced mixed results. While some research indicates a positive effect, other studies have failed to find clear benefits. Thus, the question remains: Is exercise actually effective at slowing down cognitive decline in individuals with dementia?

Evidence in Favor: Cognitive Benefits in Dementia

Repeated randomized controlled trials have found that various types of exercise programs produce cognitive benefits in dementia over a three- to four-month period. For example, one trial of 40 community-dwelling adults with mild to moderate dementia examined the impact of a four-month home-based exercise intervention consisting of strength and balance training exercises plus daily walking. Those in the exercise group showed improved scores on the Mini-Mental State Examination (MMSE) over baseline as compared with controls. (2) Similarly, a Belgian trial of 25 patients with moderate to severe dementia found that a program of daily physical exercises supported by music produced significant improvements in cognition on both the MMSE and the fluency subtest of the Amsterdam Dementia Screening Test 6 compared with controls. (3) Multiple other trials have produced similar results. (4-7)

A weakness of most randomized controlled trials showing a cognitive benefit of exercise in dementia is that the study populations have been small. One 2016 trial, however, tested a moderate- to high-intensity exercise intervention in a larger sample: 200 community-dwelling patients with mild Alzheimer’s disease (AD). Participants were randomized to either a supervised exercise group (one-hour sessions three times per week for four months) or to a control group. The study found no effect on cognition in the exercise group as a whole; however, in an exploratory analysis, the researchers found a possible beneficial impact on cognition among those who were most consistent in attending exercise sessions and who exercised at the greatest intensity, suggesting a dose-response relationship between exercise and cognition. (8)

Evidence Against: No Cognitive Benefits in Dementia

Although a range of studies suggest that exercise has a benefit for dementia treatment, other studies have found no such benefit. Such was the case, for example, with a 2017 Swedish trial of nearly 200 individuals with dementia in a nursing home setting. Participants were randomized either to a four-month high-intensity exercise intervention or to a seated attention control activity. The exercise intervention had no benefit for either global cognition or executive function over control, relative to baseline measures. This was true regardless of the sex of the participants, their forms of dementia, and their cognitive levels at baseline. (9)

In the case of the Swedish trial, the researchers hypothesized that the lack of benefit could be due to the fact that the exercise intervention focused on strength training rather than aerobic exercise. But a 2018 randomized control trial from British researchers produced no better results with aerobic exercise. In this large, carefully designed trial of almost 500 participants with mild to moderate dementia, participants were assigned to either an exercise group (which included both aerobic exercise and strength training) or to a usual-care group. Not only did exercise fail to produce cognitive benefits, but those in the exercise group actually demonstrated slightly worse cognition at the end of 12 months than did those in the usual care group. (10)

Mixed Results From Meta-Analyses and Systematic Reviews

The mixed results in individual randomized trials mirror the contradictory findings of several recent meta-analyses and systematic reviews.

Specifically, a 2015 systematic review of 17 randomized controlled trials found only very limited benefits of exercise in dementia—namely, researchers concluded that exercise programs may improve ability to do activities of daily living in dementia, but that exercise provides no benefits for cognition, neuropsychiatric symptoms, or depression. (11)

By contrast, however, two other recent meta-analyses reached the opposite conclusion and have affirmed the benefits of exercise—especially aerobic exercise—for cognition in dementia. The first of these meta-analyses, published in 2016, found that exercise has a positive benefit on cognition in both AD and other dementias and that both high-frequency and low-frequency exercise programs are beneficial. (12)

The second meta-analysis with a positive result, published in 2018, included 19 randomized controlled trials involving patients with AD as well as those at high risk of AD. This meta-analysis found that exercise interventions appear to slow cognitive decline in both groups—in those who have AD as well as in those at risk of the disease. (13)

Resolving the Inconsistencies

To make sense of the inconsistencies, a first point of note is that the research on exercise and its impact on cognition in dementia is still in its infancy. “There are a relatively small amount of studies that examine this relationship and there are still many unknowns due to limitations of the current literature,” says Gregory Panza, MS, an exercise physiologist at Connecticut’s Hartford Hospital and lead author of the 2018 meta-analysis referenced previously that found a positive benefit of aerobic exercise on cognition in dementia.

Not only are there a limited number of studies, but many of those that are available have been small and of relatively poor methodological quality. In fact, the authors of the 2015 systematic review that found no cognitive benefits of exercise in dementia explicitly noted that there was considerable unexplained heterogeneity in the analysis, and that the quality of the evidence was “very low.” (11)

With respect to meta-analyses in particular, Panza, a doctoral candidate in the department of kinesiology and the Human Performance Laboratory at the University of Connecticut, notes a major weakness of several analyses that have found a lack of impact of exercise on cognition: Namely, they have included mixed samples of people with multiple types of dementia (AD, vascular dementia, and other types of dementia) and analyzed them all together as one sample, rather than examining each group separately. “This is an issue because there are several physiological differences among the different types, and as a result, exercise may be affecting each type of dementia differently,” Panza says. Additionally, previous meta-analyses usually have failed to examine moderators such as age and gender. It’s important to examine moderators, he says, “because it gives you valuable information on which variables may be influencing the impact that the exercise is having on cognitive function.”

To address these limitations of previous research, Panza and his coauthors adhered to high-quality methodological reporting standards in their own 2018 meta-analysis, suggesting that their group’s finding of a positive cognitive benefit of exercise in dementia may carry more weight than the negative findings of some previous analyses. In their study, Panza and his colleagues also conducted within-group analyses (in which they compared cognitive changes both before and after the intervention for both the exercise and control groups), rather than merely conducting a between-group analysis as had previous meta-analyses. The within-group analysis allowed the group to take into account the cognitive decline that occurs naturally with untreated disease in the control group, and this analysis revealed the novel finding that exercise could improve cognition among controls. Overall, then, the Panza’s meta-analysis offers important support to the hypothesis that exercise can indeed slow cognitive decline in dementia.

Exercise in Midlife Protects Against Dementia

In addition to the evidence about the effect of exercise on cognition in individuals who already have dementia, there’s also a body of research on the effects of mid- to late-life exercise on future risk of cognitive impairment. (14) For instance, in a longitudinal study of women spanning 44 years, high levels of physical fitness were associated with a significantly reduced risk of dementia several decades later as compared with medium levels of physical fitness; in fact, high levels of physical fitness delayed onset of dementia by 9.5 years compared with medium fitness. (15)

Some research suggests that exercise may have especially significant benefits for individuals at highest genetic risk for dementia. A 2014 study, for instance, examined a group of 97 cognitively normal adults and compared how high vs low levels of physical activity correlated with each group’s hippocampal volume over the following 18 months. Researchers found that exercise had no apparent impact on hippocampal volume in those without genetic risk. But in those at genetic risk (that is, carriers of the APOE-E4 allele), low levels of physical activity were associated with a decline in hippocampal volume. This same group of less-active, higher-risk individuals was also more likely to show both cognitive and functional decline over the study period. (16)

According to Stephen Rao, PhD, Ralph and Luci Schey Endowed Chair at the Cleveland Clinic Lou Ruvo Center for Brain Health, a main mechanism by which exercise is thought to affect dementia risk is by affecting inflammation. “What exercise seems to be doing is reducing the amount of inflammation that ultimately is a very important factor in the progression of the disease. The disease is going on for 10 to 15 years prior to its diagnosis. So anything you can do to alter processes like inflammation can make a big dent in the rate of progression of the disease.”

To be clear, not all research shows a protective benefit of exercise against dementia: One 2018 systematic review and meta-analysis found that randomized controlled trials on exercise for dementia prevention are limited, but that the existing evidence does not show any significant effect of exercise in terms of reducing dementia risk. (17)

However, several other meta-analyses have come to the opposite conclusion. A 2011 meta-analysis of 15 prospective studies that included a total of more than 33,000 subjects without dementia concluded that all levels of physical exercise, from low to high, offer a significant and consistent protective effect (-35% or greater) against cognitive decline. (18) Similarly, a 2016 meta-analysis of 10 high-quality prospective observational cohort studies found that those who were more active had a 35% to 40% lower chance of developing AD than did those who were less active. (19)

Implications for Providers

According to Panza, there are still significant gaps in the research on exercise and dementia, and there’s a need for considerably more research using neuroimaging and molecular markers to examine the neuropsychological, electrophysiological, and pathophysiological effects that exercise has on dementia. Still, he recommends exercise—especially aerobic exercise—as a valuable treatment option for those who have dementia or are at risk. “Not only is there evidence that exercise can delay the onset of Alzheimer’s disease but the physical benefits of exercise may also help their patients keep their independence longer.”

Rao likewise acknowledges the unknowns, but he too affirms that exercise appears to be an important means of reducing dementia risk. “Exercise is key. It’s never too late. Providers should really encourage their patients to exercise, within reason, within their level of fitness.”

Get a Free Subscription to Today’s Geriatric Medicine

This article was featured in Today’s Geriatric Medicine.

Today’s Geriatric Medicine is a bimonthly trade publication offering news and insights for professionals in elder care.

Get a Free Subscription to Today’s Geriatric Medicine

 

This article was featured in the May/June 2019 issue of Today’s Geriatric Medicine (Vol. 12 No. 3 P. 6). Written by Jamie Santa Cruz, a health and medical writer in the greater Denver area. Reprinted with permission from Today’s Geriatric Medicine.


References

1. Physical activity and older adults. World Health Organization website. http://www.who.int/dietphysicalactivity/factsheet_olderadults/en. Accessed October 30, 2018.

2. Vreugdenhil A, Cannell J, Davies A, Razay G. A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: a randomized controlled trial. Scand J Caring Sci. 2012;26(1):12-19.

3. Van de Winckel A, Feys H, De Weerdt W, Dom R. Cognitive and behavioural effects of music-based exercises in patients with dementia. Clin Rehabil. 2004;18(3):253-260.

4. Kemoun G, Thibaud M, Roumagne N, et al. Effects of a physical training programme on cognitive function and walking efficiency in elderly persons with dementia. Dement Geriatr Cogn Disord. 2010;29(2):109-114.

5. Arcoverde C, Deslandes A, Moraes H, et al. Treadmill training as an augmentation treatment for Alzheimer’s disease: a pilot randomized controlled study. Arq Neuropsiquiatr. 2014;72(3):190-196.

6. Öhman H, Savikko N, Strandberg TE, et al. Effects of exercise on cognition: The Finnish Alzheimer Disease Exercise Trial: a randomized, controlled trial. J Am Geriatr Soc. 2016;64(4):731-738.

7. Cancela JM, Ayán C, Varela S, Seijo M. Effects of a long-term aerobic exercise intervention on institutionalized patients with dementia. J Sci Med Sport. 2016;19(4):293-298.

8. Hoffmann K, Sobol NA, Frederiksen KS, et al. Moderate-to-high intensity physical exercise in patients with Alzheimer’s disease: a randomized controlled trial. J Alzheimers Dis. 2016;50(2):443-453.

9. Toots A, Littbrand H, Boström G, et al. Effects of exercise on cognitive function in older people with dementia: a randomized controlled trial. J Alzheimers Dis. 2017;60(1):323-332.

10. Lamb SE, Sheehan B, Atherton N, et al. Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. BMJ. 2018;361:k1675.

11. Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane Database Syst Rev. 2015;(4):CD006489.

12. Groot C, Hooghiemstra AM, Raijmakers PG, et al. The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing Res Rev. 2016;25:13-23.

13. Panza GA, Taylor BA, MacDonald HV, et al. Can exercise improve cognitive symptoms of Alzheimer’s disease? J Am Geriatr Soc. 2018;66(3):487-495.

14. Defina LF, Willis BL, Radford NB, et al. The association between midlife cardiorespiratory fitness levels and later-life dementia: a cohort study. Ann Intern Med. 2013;158(3):162-168.

15. Hörder H, Johansson L, Guo X, et al. Midlife cardiovascular fitness and dementia: a 44-year longitudinal population study in women. Neurology. 2018;90(15):e1298-e1305.

16. Smith JC, Nielson KA, Woodard JL, et al. Physical activity reduces hippocampal atrophy in elders at genetic risk for Alzheimer’s disease. Front Aging Neurosci. 2014;6:61.

17. de Souto Barreto P, Demougeot L, Vellas B, Rolland Y. Exercise training for preventing dementia, mild cognitive impairment, and clinically meaningful cognitive decline: a systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci. 2018;73(11):1504-1511.

18. Sofi F, Valecchi D, Bacci D, et al. Physical activity and risk of cognitive decline: a meta-analysis of prospective studies. J Intern Med. 2011;269(1):107-117.

19. Santos-Lozano A, Pareja-Galeano H, Sanchis-Gomar F, et al. Physical activity and Alzheimer disease: a protective association. Mayo Clin Proc. 2016;91(8):999-1020.

brain

A Simple Exercise to Stimulate Your Cerebellum and Boost Your Movement Accuracy, Balance, and Coordination

/8 April 2021/ All MFN blog/

While every brain structure has the potential to be a valuable training target for a medical fitness professional, the cerebellum should always be a high priority consideration when trying to help clients and patients accomplish their pain and performance goals. The cerebellum, whose name means “little brain,” is located at the back and bottom of the brain, and while it makes up only 10% of the brain’s volume, it houses 80% of the brain’s total neurons

brain-neurons

Why Fitness Professionals Must Learn to Help Mature Adults with Brain Health

/5 September 2019/ All MFN blog/

Humanity is racing toward a brain-health crisis, according to the World Health Organization. The number of people with dementia is expected to triple in the next three decades.

The helpful news from WHO is this: Exercise plays a key role in fighting cognitive decline and dementia.

So, those of us in the fitness industry have a greater chance than ever to make a big impact by including brain health in our training and interactions with people over 50.

That’s the message of Ryan Glatt, a brain health coach at the Pacific Brain Health Center.  Ryan and the Functional Aging Institute worked together to bring you the Brain Health Trainer Certification. It’s a unique program that teaches about the connections between brain and body health – and about how fitness professionals can help mature adults with both.

“We can play a significant role in delivering exercise interventions for the primary outcome of brain health, and not just as a secondary benefit of exercising,” Ryan says. “We need to do more.”

Fitness professionals have three steps to follow, he says.

  1. Educating the public about the cognitive benefits of exercise.
  2. Referring people with possible cognitive decline to doctors for early intervention – much like physical therapists refer patients to relevant medical professionals.
  3. Building exercise programming to create primary brain-health results.

Trainers need to encourage clients to have a well-rounded exercise routine that includes balance, resistance training, and cardio work. It helps to know how some activities can have specific benefits on memory, attention and other brain functions. That includes, for instance, dance, sports and martial arts, which involve some level of choreography, which is good for the memory.

Even in initial assessments with prospective clients, fitness pros can learn to raise the topic, Ryan says. For example, if a prospect in her 50s says she wants to lose weight, you can bring up the topic of brain health even at that early stage. “There’s a growing body of research that links exercise to brain health,” you might say. “Does that sound like something you’d like to work on, as well?”

That can open the conversation to topics that might indicate a referral is necessary – or help you build a fitness program to address them.

“We like to tell people that exercise will help them be able to play with their grandkids,” Ryan points out. “But we can also help train them so that they also can remember their grandkids’ names better.”

Brain health is a big, rich topic that we’re going to be hearing more about. Any fitness professional helping mature people live well should be educated on how to help with their brain health, too.

Ryan Glatt, FAFS, BSc is a psychometrist and Brain Health Coach at the Brain Health Center in the Pacific Neuroscience Institute. With a strong background in exercise science and human health, Ryan develops curricula specifically targeted towards those with dementia, Parkinson’s disease, Autism Spectrum Disorders (ASD), and traumatic brain injury, coaching individuals towards optimal brain health.