Falls in older adults are a significant contributor to functional decline, institutionalization, and economic burden. Community-dwelling older adults with Alzheimer disease (AD) and other dementias fall 2 to 3 times more than their cognitively intact age-matched peers.1–3 Individuals with AD (IwAD) and other dementias are more likely to be hospitalized for and experience greater morbidity and mortality associated with falls.3–6 The etiology of falls in individuals with dementia is complex and multifactorial. Although balance ability is not the sole determinant of fall risk, it correlates with fall risk in community-dwelling older adults with dementia.7–9 Balance and mobility dysfunction have been demonstrated in IwAD8,9 and increase with the progression of the disease.10–12 Degradation of gait and balance was formerly thought to be a late sequelae of AD, but more recent evidence demonstrates these activity limitations early in the course of the disease.13–16 Balance exercise programs have been shown to be effective in improving balance17 and reducing falls18 in older adults without cognitive deficits but have not been well studied in IwAD.
Historically, IwAD were excluded from research studies because of the assumption that they would not be able to fully participate; however, feasibility of individuals with dementia participating in supervised exercise and/or physical activity programs has now been repeatedly demonstrated both in institutionalized19–21 and community-dwelling older adults.22–24 Early systematic reviews examining the effectiveness of exercise with individuals with dementia suggested that methodological issues forced guarded interpretation of studies with positive findings.25,26 More recent systematic reviews have demonstrated that exercise improves physical function, walking abilities, and activities of daily living.27,28 Physical activity interventions, such as exercise and mobility training, have been effective in maintaining function in IwAD as compared with significant decline in members of control groups.29,30 Two recent randomized controlled trials that investigated the effectiveness of activity-specific training (including balance activities), 1 for IwAD in long-term care settings31 and 1 for community-dwelling individuals with dementia,32 both demonstrated positive results in functional outcome as compared with control groups. Although it has been a component of several studies, balance training has rarely been the primary or sole focus of intervention studies. Recent literature reviews33,34 highlight the promise of balance training in IwAD, offer pragmatic suggestions for implementation of training, and call for further research with a specific focus on balance training for IwAD. For training to be successful, the unique challenges of working with IwAD must be acknowledged and addressed with deliberate integration of appropriate strategies. Skillful communication, high levels of intensity and challenge, and integrating specific motor learning principles to exploit the strengths of IwAD may be key to a program's success. Motor learning tenets relevant to the AD population35–38 include emphasizing implicit motor learning capacity, strategically using constant and blocked practice of skills, focusing on training of specific functional tasks, and recognizing the importance of repetition. Although IwAD may have diminished ability for explicit or declarative learning, implicit learning and memory appear to remain intact,36–39 and through the use of this system, individuals maintain some ability for motor learning and relearning of skills. Individuals with AD learn best under constant, consistent practice conditions, and they train best to specific relevant tasks.35,36,38,39
Group training in the adult day care environment is an ideal arena for a balance program for the following several reasons: (1) participants are a “captive audience”; (2) participants enjoy the socialization; (3) group training is an efficient use of time and resources; (4) group training has been demonstrated as feasible and effective; and (5) day program participants (and their families/caretakers) are motivated to remain safe and active at home and in the community. An exercise program found to be useful in improving balance and mobility and reducing fall risk and falls in this population could positively impact quality of life and delay the need to move from a day care environment to a skilled nursing setting. Maintaining individuals in the least restrictive environment and potentially decreasing morbidity and health care costs related to the sequelae of falls in IwAD can save health care dollars and have a positive effect on a major public health issue.4,5
The primary objective of this study was to examine the immediate effects of a 12-week, functionally oriented, constant, blocked-practice, repetitive-training balance exercise program on measures of balance, mobility, gait, and falls in IwAD and also to determine whether any changes were maintained over time. The intervention encompassed motor learning and communication principles relevant to persons with AD and was successfully trialed in 2 small pilot studies.40,41 We hypothesized that this functional balance training intervention designed specifically for IwAD would significantly improve balance and decrease falls.
This prospective, quasi-experimental, pretest-posttest design study was conducted to assess the impact of a 12-week, twice per week, group balance training program on balance, mobility, and falls in a cohort of IwAD. The study was approved by the Marymount University Institutional Review Board.
Thirty participants were recruited from a sample of convenience from 3 Northern Virginia adult day health care centers in the summer of 2012. Data from pilot studies40,41 demonstrated an effect size of 0.72; with a P value of .05, 26 participants would elicit power of 0.80. Inclusion criteria consisted of attendance at participating facility, physician's diagnosis of probable AD, medical stability (ie, absence of all medical conditions in exclusion criteria and/or successful medical management of all medical issues), the ability to walk without the physical assistance of another person (assistive devices allowable), and the ability to follow 1-step commands (gestures and/or tactile cues allowable). Exclusion criteria included unstable or limiting cardiac disease (eg, angina/chest pain or myocardial infarction/heart attack within previous 6 months); pulmonary condition requiring oxygen supplementation or frequent use of inhalers; neurological diagnosis with residual deficit (eg, stroke and Parkinson disease); severely limiting arthritis, joint instability or back pain; surgical history within previous 6 months for coronary artery bypass graft or other cardiac surgery, thoracotomy, or abdominal surgery; surgical history within previous 3 months for total joint arthroplasty or any other lower extremity orthopedic surgery, spinal surgery; surgery, radiation, or chemotherapy for cancer within previous 6 months; documented physician restriction for exercise components of day program; acute illness on day of testing; new participant to adult day center (within past 3 weeks). Exclusion criteria were intended to eliminate participants with any medical instability, whose fall risk might be increased by diagnoses other than AD, or who may not yet be acclimated to the environment.
Informed consent (with family approval) or guardian informed consent was obtained, and participants were cleared by their physicians to participate in the study. Demographic, personal, social, and medical history were collected, including birth date, age, sex, height, weight, education level, home environment, personal (self and family) history, medical history, and medications. Fall history was obtained through phone or in-person interview with guardian/family member, and contact with family members every 6 weeks throughout the study allowed continued collection of falls data. A fall was operationally defined as uncontrolled and unintentionally coming to rest on the ground, floor, or some other lower level.42 Facility staff provided a Functional Assessment Staging (FAST) tool43,44 rating for each participant as a measure of dementia and this was reassessed at each posttest. The FAST tool is related to functional everyday tasks (rated 1 [normal] to 7 [severe AD]).
Outcome measures included 4 clinical tests to assess balance, mobility, and gait, and the Mini-Mental Status Examination (MMSE)45 as a measure of cognitive function. Although more of a screening tool by design, the MMSE, ranging in scores from 0 to 30 with higher scores indicating higher cognitive functioning, is often used to classify dementia levels and allows for comparison of the level of cognitive function of individuals in this study with other published studies. The clinical tests were given as follows:
- Berg Balance Scale (BBS) 46,47: A widely used 14-item functionally based balance assessment tool, where each item is scored on a 0 to 4 scale for a test high score of 56 indicating good balance and low fall risk. Participants were provided with demonstration and verbal cuing for each item as needed. This test is valid and reliable for use with the older adults,46,48 has been used with older individuals with cognitive deficits,19,40 and has been demonstrated to be reliable with this population.49
- Timed Up and Go (TUG) 50: A timed test of general mobility, where the individual stands from a chair with arm rests, walks 3 m to round a cone, and returns to sit in the chair. Demonstration preceded the test. The use of the 3-dimensional visual cue of a cone versus a 2-dimensional tape mark on the floor50 provides a clearer cue for IwAD and is an adaptation to the test previously used by Steffen et al.51 This test has very high validity and reliability with older adults,50,51 has been used with IwAD,21,40 and has been demonstrated to be reliable with this population.52 Timed Up and Go trials were timed concurrently by 2 testers and times were averaged; mean times of 2 trials were used as the TUG score. Participants were encouraged to perform the task “quickly, but safely.” The only modifications to the TUG were that timing began when the participant's bottom left the chair as opposed to when “go” command was given52 and participants sometimes were given reminder cues (eg, after walking around the cone they were reminded to “sit in the chair”).
- Self-Selected Gait Speed (SSGS) and Fast Gait Speed (FGS) as assessed with the GAITRite System (CIR Systems, Inc, Sparta, NJ): The GAITRite is a portable gait analysis system that requires the participant to walk across a 15 foot sensored walkway (acceleration/deceleration occurs before/after the walkway, such that the mat captures steady-state speed). This tool has excellent validity and reliability for temporal and spatial parameters of gait53,54 and has been shown to be reliable in IwAD.52,55 Gait speed data were means calculated from 3 trials for both SSGS and FGS. Participants observed a demonstration by the tester and were instructed to “walk at your normal, comfortable pace” for SSGS. Cues to “keep walking” were offered if needed. For FGS, participants observed a demonstration and were instructed to “walk fast, but be safe” for FGS. Cues to “walk fast” were offered during the test if needed.
Gait belts were used for all participants during testing and classes; heart rate and blood pressure were monitored before and after testing sessions. Pre- and posttesting were carried out at the adult day care facilities within 2 weeks of the beginning and end, respectively, of the exercise program. Testing was administered by 1 of 2 physical therapist (PT) research staff. These individuals were not involved in supervising the exercise program so that scoring of test performance would not be influenced by knowledge of participants' abilities during class. Practice trials of the TUG, SSGS, and FGS preceded data collection trials.
The 45-minute group balance exercise classes were held 2 mornings per week at each of the facilities for 13 weeks during autumn of 2012. With holidays and weather cancellations, there were a total of 22 sessions at 2 of the facilities and 23 sessions at the third facility. The primary goals of the classes were to maximize balance challenges to each participant and to have all participants up on their feet and engaged as much as possible throughout each session.
Principles of optimal communication were integrated into all components of the study and included establishing a personal connection,56–58 maintaining a low stress, familiar environment,58–61 consciously simplifying communication efforts (eg, simple sentences, yes-no questions, and minimal distractions),56–61 and slow progression of cueing (beginning with verbal instruction with concurrent visual cue, followed by gesturing and/or demonstration, followed by tactile guidance, and finally physical assistance if needed).62 Motor learning principles that have been demonstrated to be effective with IwAD were explicit in the group sessions and were a key area of education for research staff. The tasks in the intervention were functional, relevant, familiar, and designed with appropriate practice conditions to facilitate optimal learning. Another important characteristic of the intervention was the substantive level of challenge to participants. Older adults, even those who are frail, must be sufficiently challenged by an intervention to gain benefit.63,64 Authors of studies and reviews demonstrating positive impact of balance training in individuals with dementia have identified that the intensity and level of challenge to the participants was integral to the programs' success.32,40,65
Balance is defined as maintaining one's center of gravity (COG) over one's base of support (BOS) and is reliant on visual, somatosensory, and vestibular input. Thus, justification for the majority of exercises was related to changes in COG or BOS, or altering sensory input. Exercises may have incidentally impacted strength, coordination, or flexibility, but they were chosen primarily as challenges to balance. Each class had similar structure and included the following components:
- Approximately 5-minute seated warm-up to music (eg, reaching, stretching, and active range of motion of all extremities);
- Approximately 5-minute repetitive sit to stand activities, encouraging decreased reliance on upper extremities, and transfer activities (eg, stand and move to the left or right to sit in a different chair);
- Approximately 10-minute individually focused standing activities in a circle (eg, eyes closed, tandem stance, single limb stance (SLS), heel raises, and standing on foam);
- Approximately 10-minute interactive standing activities in a circle (eg, handing, tossing, bouncing, or kicking balls, and batting balloons);
- Approximately 15- to 20-minute dynamic “relay” activities (eg, obstacle courses, ball play including dribbling, throwing, and catching, alterations in terrain and/or speed, and dual tasking) in which 3 to 4 participants could participate under supervision concurrently;
- Approximately 5- to 10-minute finish with dancing or movement to music.
Table 1 gives examples and justification of exercise activities during each component of the class. The consistency of class structure was purposeful and was borne of pilot studies, giving each session a familiar feel. Progression of sessions was in the form of increasing challenges for individual participants within planned activities as opposed to substantial changes to program content, layout, or tasks. Specific activities within the established class structure were planned and documented by the principal investigator (JR) and shared with research staff prior to each session, and all sites followed the same plan for each scheduled class. Two PT researchers (JR and JH) were present at all classes, allowing for excellent fidelity of the intervention across settings. Initially, JH led warm-ups through standing circle activities and JR led relay and dancing activities; as students became more comfortable, they also took lead responsibilities. The PT oversight proved to be vital to maximizing the level of challenge to participants at all times. At least 2 student research assistants were present at all classes. The ratio of participants to research staff was never higher than 3:1, was usually 2:1, and was 1:1 when a participant was doing an exercise for the first time or was deemed unsafe. The exercises were intended to be challenging but doable; the close supervision of participants allowed for progression of difficulty on an individual basis by modifying parameters of the activity for each participant. For instance, SLS was initially a challenge for all participants; however, as some participants mastered this skill, they were progressed to SLS on foam. An attendance log was kept for each setting and participation in more than half of the activities in a given class earned participants credit for attendance at that session.
Data management and analysis were performed using SPSS version 21 (IBM Corporation, Armonk, NY). Participants who completed the full program (including both posttesting) were compared with those who did not using the independent t tests for parametric data, the Mann-Whitney U test for nonparametric data, and the chi-square test for dichotomous data. Repeated-measures analysis of variances (ANOVAs) (with Greenhouse-Geisser correction) were used to compare pretest performance with immediate and 3-month posttests for all outcome measures, and the a priori paired t tests were used for all outcome measures to analyze immediate effects of the intervention. Raw data were used to observe incidence of falls pre- and postintervention, as the small numbers prohibited effective statistical analysis. Participants with and without history of falls were compared on the basis of demographic characteristics using the independent t tests, the Mann-Whitney U test, and the chi-square test.
A participant flow chart is presented in Figure 1. Thirty participants initiated the protocol and 24 (80%) completed the exercise program, as operationally defined by participation in 55% or more of the total number of classes. Twenty-two of 30 participants participated in at least 1 posttest, giving an overall attrition rate of 26.7%, which is not unusual for this population.12,66 Of those who completed the program and at least 1 posttesting session, average participation was in 84% of the total number of classes (ranged from 55% to 100%).
Comparisons of demographic data of those who completed the program and at least 1 posttesting session (n = 22), as compared with those who did not (n = 8), demonstrated no significant differences between the 2 groups in age, sex, body mass index, polypharmacy, level of dementia, the use of assistive device, 6-month history of falls, or pretest scores on MMSE, BBS, TUG, SSGS, or FGS (Table 2). The groups were significantly different in number of comorbidities, with those completing the program having more comorbidities (
) than those who did not complete the program (
Repeated-measures ANOVA indicated significant findings in analysis of BBS (F = 15.04; df = 1.67/28.40; P = .000), and post hoc pairwise comparisons revealed significant improvement in performance between pretest and immediate posttest (P = .000), significant decline in performance between immediate posttest and 3-month posttest scores (P = .012), and a significant difference between BBS pretest and 3-month posttest scores (P = .032). The TUG and SSGS did not reach statistical significance in analysis with repeated-measures ANOVA (TUG [F = 2.52; df = 1.87/31.80; P = .100] and SSGS [F = 0.24; df = 1.08/18.41; P = .65]). Repeated-measures ANOVA evaluating FGS demonstrated statistically significant differences (F = 6.42; df = 1.63/26.07; P = .008). Post hoc pairwise comparisons revealed no significant change in performance between pretest and immediate posttest (P = .061) or pretest and 3-month posttest (P = .061), but significant decline in performance between immediate and 3-month posttest (P = .008). Graphical representation of group mean performance over time for each of the outcome measures is presented in Figure 2. Because our objective was to assess the immediate effects of the intervention, the paired t tests were performed for each of the outcome measures using pretest and immediate posttest data. Significant findings were revealed for BBS (t = −7.010; df = 20; P = .000), TUG (t = 3.103; df = 20; P = .006), and FGS (t = −2.115; df = 19; P = .048), but not for SSGS (t = −1.456; df = 20; P = .161).
Repeated-measures ANOVA indicated significant findings in analysis of MMSE (F = 5.12; df = 1.73/22.53; P = .018). Post hoc pairwise comparisons revealed no significant change in MMSE between pretest and immediate posttest but did show significant decline in MMSE when comparing immediate posttest with 3-month posttest (P = .038) and pretest with 3-month posttest (P = .019), as shown in Figure 3.
Falls data were collected for a 6-month history of falls prior to the study, and for the 3 months of the intervention and 3 months of follow-up (for a total of 6 months after initiation of the intervention), and is represented in Table 3. Two participants who dropped out of the study did so because of fall injuries at home; both had positive fall histories. No injuries or adverse events during testing or intervention were observed; however, it is important to note that there were frequent losses of balance, as participants were being substantially challenged. No falls occurred, based on our operational definition, although there were 2 incidents during interventions where participants were controlled in a slow descent to the knee by research staff when recovery to upright after loss of balance was not possible. In both cases, participants were assisted to a chair and assessed for vital signs and for musculoskeletal injury. In both incidences, participants were stable and without any injury or discomfort and chose to rejoin the class in progress.
Characteristics that have been shown to be highly correlated with falls in the literature (ie, history of falls, the use of assistive device, the use of psychotropic drugs, age, polypharmacy, and multiple comorbidities) were examined in relation to the study participants. The only variable representing a statistically significant difference between participants with and without a fall in the 6 months prior to the intervention was polypharmacy, with participants with history of falls using an average of 6.9 medications and participants without history of falls an average of 4.7 medications (t = −2.586; df = 28; P = .015). No statistically significant differences were found between participants who fell within 6 months of starting the balance program and those who did not fall on any of the demographic variables.
Gait and balance limitations have been identified as contributors to falls in IwAD.3,7,67,68 In this study, participants demonstrated improved balance immediately following a 3-month intervention as demonstrated by a statistically significant increase in BBS score. Degradation in performance was apparent after the program concluded, although there was some maintained benefit as evidenced by significant improvement between BBS baseline/pretest and 3-month posttest scores. Balance training in IwAD has been a component of several research studies but has rarely been the primary focus, perhaps due to the inherent complexities, as opposed to a more straightforward walking program, or the safety of a seated strengthening program. The adult day center environment is an ideal setting to offer this type of intervention, as these participants are still thriving in the community and stand to gain much if improved balance translates to diminished falls risk. Although balance was the primary focus of our intervention, mobility and gait activities were components of training, and mobility (TUG) and gait (FGS) outcome measures also showed improvement immediately following the intervention.
The mean age of participants who completed our program was 78.6 (SD = 11.3) years, and the mean MMSE score was 14.76 (SD = 6.8). Recently published exercise intervention studies with IwAD in the community (home care or group interventions)23,32,69–71 demonstrate comparable age of participants; however, the mean MMSE scores of participants in all but 1 study66 were greater than 20. Despite the greater cognitive impairment in our participants, our findings suggest that IwAD can benefit from regular, challenging, upright balance training as a standard of care in the adult day care setting. Assumptions that IwAD are “too old” or “too cognitively impaired” to benefit from a structured balance training program were disputed with this study.
Participants in this study showed significant gains in balance; this is in contrast to much of the existing literature, which demonstrates a protective effect of exercise where exercising individuals maintain (versus improve) function.29,30,66,72 The concept of excess disability73 suggests that individuals with dementia often appear more functionally incapacitated than they should, given their actual level of impairment. Excess disability is likely a function of both the individual and the caretaker(s). For instance, when it takes longer and is more tenuous for an IwAD to walk to the car independently versus receive support and guidance from a caretaker to get to the car, the individual often loses the opportunity to practice this skill. The noble intention of the caregiver, to keep the individual safe and get them quickly to their destination, may do a disservice to the IwAD, as they may lose the ability to perform the skills they do not practice. This lost opportunity for challenge works to the detriment of the IwAD. It is likely that the balance training protocol in this study gave participants the opportunity to practice skills they had not been “allowed” to perform for some time. A hallmark of excess disability is reversibility.74
The decline of function after cessation of the program (in all variables except SSGS) is likely multifactorial, representing the loss of the positive impact of the balance intervention, the progressive nature of AD, and the basic functional and neuroplasticity principle of “use it or lose it” associated with motor learning.75 We can conclude that our balance program improved participant balance, and we know that balance deficits contribute to falls in this population,7,67,68 but due to the scarcity of falls data, we cannot make any definitive comment about the impact of our protocol on falls or fall risk. The relationship between fall risk and BBS score has proven to be complex. Simplified use of a BBS score less than 45 to predict falls in older adults47,76 has been disputed,77–79 and likelihood ratios for falls may be more useful but still have limitations.77 McGough et al80 recently found a modified BBS (omission of 3 items) that has potential as a fall predictor in IwAD, but the relationship between BBS scores and falls and/or fall risk in this population requires further study.
Although cognitive benefit has been associated with aerobic activity, more recently, participants with AD in movement and balance training programs have demonstrated some cognitive benefit.30,71,81 In this study, MMSE scores were essentially stable during the 3-month intervention (mean pretest score 14.6 [SD = 6.8], mean immediate posttest score 14.2 [SD = 7.6]) but dropped after the conclusion of the program (mean 3-month posttest score 12.4 [SD = 8.1]), such that there was a significant degradation in performance over the 6 months of the study. Given that AD is a degenerative pathology associated with decline in cognitive and functional status and the relatively short time between testing sessions that could impact reliability of this repeat measure,82 it is difficult to draw conclusions from this data; however, the relative stability for the duration of the intervention suggests a potential cognitive protective effect of the training program.
The major strength of this study is the dedication to a unique and evidence-based intervention. Principles of experience-dependent neural plasticity,75 including activity, repetition, intensity, and salience, were intentionally integrated into the balance program. The research staff was well educated on communication and motor learning principles relevant for this population, and these principles were consciously and consistently integrated throughout all interactions with participants. Lessons learned from pilot studies40,41 and expert advice from other study authors were respected and heeded, resulting in a program that had participants up on their feet as much as possible,24,65 provided appropriate intensity of challenges,12,32 and were individualized as possible12,72 within the confines of a group intervention. When a participant mastered a particular activity, the task or environment was modified to enhance the demand. Although the content of our exercise intervention was well justified, it was the context that provided the key to success. Appropriate communication and motor learning strategies, high intensity of upright activities, and maximizing individual challenges led to improved outcomes. Replication of these principles is likely more important to future successes than exact replication of our protocol.
Although the methods are sound, the major limitations of this study are in its size and the rigor of the research design. Studying the effects of this balance program within a large randomized controlled trial would be the ideal next step. A larger, controlled study would offer more insight into the impact of this intervention on balance, allowing comparisons between and within groups of study participants. In addition, in a larger study, more definitive information on the impact on falls may be gleaned. Despite limitations, the findings of this study support the described balance training program as an effective intervention to improve balance in IwAD.
Many thanks to the participants, their families, the staffs, and administrators of the facilities who participated in this study. Much gratitude to a committed student research team: Jonathan Sarji, Sukhmani Bhogal, Madeline De Freitas, Victoria Flood, José Gil-Figueroa, Mandy Watts, and John Wilkinson. Finally, thanks to Rita Wong, PT, EdD, for consultation on statistics and reading of the manuscript.
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