Authors: E. Leone, A. Deudon, P. Robert
Categories: Article, Physical Activity, Dementia, Eating Disorder, Nursing Home Resident, Informal Caregiver
Source: The Journal of Nutrition, Health & Aging
Doi: 10.1007/BF02982706
Authors: E. Leone, A. Deudon, P. Robert
Neuropsychiatric symptoms also referred as to ‘BPSD’ (Behavioral and Psychological Symptoms of Dementia), are now considered as a major component of the dementia syndrome and are as clinically significant as disorders of cognition. BPSD are present from the early stages of the disease, constitute a marker of disease progression, are responsible for much of the suffering of both patients and caregivers, and strongly determine the care provided to the patient and his lifestyle, both in institutions for the elderly and in the home (1, 2).
The general approach to BPSD includes the to assess causes and consequences; to correct visual and hearing impairment; and to look for physical causes of BPSD such as infection or pain.
There is now a broad consensus insisting that patient care should not be limited to pharmacological treatment but should also include non-pharmacological approaches. These therapies are widely applied in day-care centers, day hospitals, physiotherapy departments, memory centers and speech therapy practices, amounting to a not-inconsiderable economic cost. There are a wide variety of non-pharmacological therapies open to patients suffering from dementia. Some of these therapies adopt a psychosocial approach while others belong to the field of psychotherapy (3). Still more are based on physical or sensory stimulation (4). But of these techniques seek to optimize patient care by targeting, according to the therapy applied, different aspects of the disease such as cognitive abilities, dependence, mood and behavioural disorders or patient well-being. These techniques are extremely varied.
Over the last twenty years, a large number of articles have been published illustrating the benefits of these therapies on Alzheimer’s disease (AD). According to the studies, reported improvements were observed in different measurements. These improvements were reflected in either a reduction of the depressive symptomatology, a slower decline of cognitive performances, a continued autonomy in activities of daily living (ADL), or an improvement in quality of life (5). These results are encouraging inasmuch as they suggest that a global and multi-disciplinary approach (6, 7) of the disease, combining pharmacological and non-pharmacological treatments, is likely to attenuate some symptoms and to contribute to a certain well-being for the patient.
Nevertheless, it is noteworthy that the vast majority of these results were derived from studies evaluating non-pharmacological treatments whose methodology leaves much to be desired, their main weaknesses being the absence of a control group, the absence of randomization, the absence of a procedure for evaluating in blind fashion and insufficient sample sizes (for review see Cochrane Library (8, 9, 10, 11, 12, 13, 14)).
A total of 1,632 studies were identified with regard to BPSD specifically, of which 162 satisfied the inclusion criteria for the review of Livingston et al. (2005) (15). Results showed that specific types of psycho-education for caregivers about managing BPSD were effective treatments whose benefits lasted for months, but other caregiver interventions were not. Cognitive stimulation appears to have lasting effectiveness for the management of BPSD. The authors concluded that lack of evidence regarding other therapies is not evidence of lack of efficacy. According to APA Practice guidelines for the treatment of AD and other dementia (16), there is limited evidence from clinical trials that general psychosocial interventions, stimulation-oriented treatments, such as recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients, improve behavior and mood, or support their use as part of the care of patients.
As we have already said there are many non pharmacological techniques and starting from the results of several studies into preventative therapies (for review see Jedrziewski et al., 2007 (17)) there is also a growing interest in therapeutic programs which include physical activities.
Physical activity can be considered either as a common element of ADL, such as household chores and walking, or can be considered as physical training (e.g. soliciting muscle power, balance or physical force through activities such as jogging, aerobics, and endurance training). These two categories can lead to different types of efficacy criteria.
Table 1 summarizes the major published studies including information on neuropsychiatric symptoms and other areas.Table 1Effect of physical activity in normal aging and dementiaIntervention typeStudiesNPSEffects Functional mobility**CognitionADLPreventionOther impactsNormal Aging :* Physical exercise (aerobics, walking, endurance training, jogging, streching).Barbour et al. (2005) (27)depressionTaylor et al. (2004) (28)depressionKramer et al. (2003) (24)depressionXKramer et al. (1999) (30)XXKramer et al. (2007) (23)XChen et al. (2008) (22)XWeuve et al. (2004) (25)XVan Gelder et al. (2004) (26)XColcombe et al. (2004) (18)XLazowski et al. (1999) (31)XFreid et al. (1998) (19)cardiovascular diseaseBlair et al. (2004) (20)cancerBean et al. (2004) (21)cancerNormal Aging :Multi-domaininterventionAlessi et al. (1999) (40)sleep, agitationFabre et al. (2002) (49)X (memory)Dementia : Physical exercise (aerobics, walking, endurance training, streching).Farina et al. (2002) (44)eating disordersOlazaran et al. (2004) (45)depressionMcRae et al. (1996) (38)XTeri et al. (1998) (39)XLarson et al. (2006) (32)XRovio et al. (2005) (33)XColcombe et al. (2003) (29)X (executive functions)Tanne et al. (2004) (37)XRolland et al. (2007) (48)XPalleschi et al. (1996) (43)XWhite et al. (1997) (42)malnutritionBuchner et al. (1987) (41)fallAbbott et al. (2004) (36)XphysicalLaurin et al. (2001) (34)XXperformance, diabetesLindsay et al. (2002) (35)XDementia : relaxation, massageSnyder et al. (1995) (46)agitationSansone et al. (2000) (47)agitation*Dementia :multi-domaininterventionTeri et al. (2003) (50)depressionphysicalperformance,delayedinstitutionalizationNPS: Neuropsychiatric symptom ADL**: Activities of Daily Living
Physical activity is associated with decreased morbidity in many chronic diseases including cardiovascular disease (18, 19) or cancer (20, 21). For example, Chen et al. (2008) (22) have shown that practicing Tai-Chi for 50 minutes, 3 times a week for 6 months, improved the overall health of elderly men, especially their blood pressure, strength and body flexibility.
Studies that have focused on the relationship between physical fitness and cognitive aging have shown that people who maintain a good overall level of physical health have a less important cognitive decline relative to their age (23, 24). Accordingly, Weuve et al. (2004) (25) and Van Gelder et al. (2004) (26) demonstrated that physical activities such as walking offset cognitive decline in elderly patients and may improve cognitive performance.
Other studies focused on BPSD and demonstrated the positive impact of physical activity especially on depression (27, 28). Eighteen studies have been included in the meta-analysis of Colcombe et al. (2003) (29). They tend to show a beneficial effect of physical exercise on both cognition (especially executive functions) and behavioral disturbances in normal elderly people (see also Kramer et al. (1999) (30)). Other studies found that exercise programs can improve functioning in frail nursing home residents and may be an important and potent protective factor against ADL decline (31).
Even if the link is not always demonstrated, it seems that physical exercise could be a preventative factor of dementia ((32, 33, 34, 35)) and that it should delay its onset. For example, Larson et al. (2006) (32) have shown that regular physical activity was associated with a reduced risk of developing AD. Results obtained by Abbott et al. (2004) (36) also suggest that a simple activity such as walking could have a preventative effect against the disease. Several other studies (37) confirm these findings.
As everybody knows, dementia is one of the most common diseases associated with aging. This major public health problem underscores the need for treatment and prevention strategies. However, research into patients with dementia is limited and mainly concerns the effects of exercise on functional mobility (38, 39) or sleep (40). Abbott et al. (2004) (36) demonstrated the benefits of walking, which had a positive impact on ADL and physical performance, as well as on diabetes.
Studies on patients suffering specifically from AD show that exercise programs may yield benefits in coping with falls (41), malnutrition (42), cognitive functioning or in general health. A review of the literature was recently conducted by Jedrziewski et al. (17) on the associations between physical activity, cognition and physical functioning in AD patients. Running, walking, swimming, aerobics and stretching, resulted in an improvement in cognitive functioning. Some prospective studies such as Laurin et al. (2001) (34) found that physical exercise could decrease both cognitive impairment in elderly people and in demented patients. Furthermore, Palleschi et al. (1996) (43) have, in turn, tested the effect of the practice of physical exercise (such as 20 minutes of exercise on a stationary bicycle, 3 times a week for 3 months). The results evidenced a significant improvement in cognitive functions.
Some other studies focused on the management of BPSD. Farina et al. (2002) (44) demonstrated the positive impact of physical exercise programs on eating disorders. Olazaran et al. (2004) (45) showed an improvement in depressive symptoms. In addition to those physical exercise programs, other studies focused on softer interventions such as relaxation, massage or yoga. For example, Snyder et al. (1995) (46) and Sansone et al. (2000) (47) found that hand massage or therapeutic touch administered before formal care activities reduced the frequency and the intensity of agitated behavior in demented patients.
Finally, Rolland et al. (2007) (48) demonstrated that a global program of physical exercise (e.g. aerobics, walking, stretching) followed for twelve months led to an improvement of ADL in patients with AD.
Along with these programs of physical exercise proposed in isolation, there are more global non-pharmacologic therapies including multi-domains, combining physical exercise with other types of interventions (cognitive stimulation, occupational therapy, mentoring of caregivers). Multi-domain interventions are capital because most important studies on non-pharmacological treatment for BPSD include physical exercise and other strategies. Alessi et al. (1999) (40) associated intensive physical activity during the day with a night-time program and suggested that such intervention improves sleep and decreases agitation in elderly people living in nursing homes. Fabre et al. (2002) (49) showed that the association between cognitive stimulation and practicing aerobics (2 sessions each week for 2 months) enhanced more cognitive functions, especially memory, than any of the interventions taken in isolation.
Teri et al. (2003) (50) have created a method which combines physical exercise for the patient (such as aerobics or stretching) and a guide for the informal caregiver regarding the management of BPSD (e.g. information on dementia and behavioral disorders, identification and modification of behavioral disturbances). They demonstrated a positive impact of their intervention with a significant improvement in physical condition and depression, a decrease in the number of institutionalizations due to BPSD, and a better adherence by informal caregivers.
Physical exercise programs proposed in isolation or in combination with other types of interventions have proved their effectiveness preserving a good overall level of physical and mental health. In this way, it seems that physical exercise could be a preventative factor of dementia and could help to prevent its onset. There is also evidence that physical activity is useful in the care of demented patients having an impact on their behaviors.
Indeed, physical activity improves overall physical health, decreases the risks of morbidity of chronic diseases, and of falls. It also reduces the impairment of ADL, and sustains and stimulates cognitive functions. Available studies underline the positive effect of physical activity, most particularly when it is a component of multi-domain interventions, on depressive symptoms.
It is therefore important to promote research in this area in order to carry out the evaluation of the usefulness of non-pharmacological therapies, especially in the case of AD and related syndromes, and to better understand their mechanisms in order to develop and propose better adapted and global care.