Support was not found for improved executive functioning, with no significant improvement observed by the intervention group on the TMT-B when compared with the comparison group.
IWDs in the intervention group demonstrated significant improvement in lower extremity strength compared with IWDs in the comparison group (t = 3.3, P = .004). Unstandardized regression coefficients show an average of 5.9 more repetitions on the 30-second chair stand test completed by the intervention group.
IWDs in the intervention group demonstrated significant improvement in balance compared with IWDs in the comparison group (t = 4.1, P = .001). Unstandardized regression coefficients show an average of over 4 points improvement on the m-BBS for the intervention group.
No significant improvement was found in the intervention group for comfortable gait speed (t = 0.6, P = .6). However, IWDs in the intervention group demonstrated significantly better fast gait speed than IWDs in the comparison group (t = 2.6, P = .02). Unstandardized regression coefficients showed that an average of 0.3-m/s improvement was found in fast gait speed for intervention group participants.
No significant improvement in self-reported difficulty in completing instrumental and PADL was found.
The current study contributes to the literature by demonstrating that IWDs can participate in and maintain fidelity to a moderate-intensity functional exercise program. In addition, improvements were noted on multiple functional performance measures including balance, lower extremity strength, and fast gait speed. The program consisted of functional lower extremity strength and balance activities and resulted in noteworthy improvements in these areas. Gait speed can be described as a function of strength and balance; therefore, improvements in fast gait speed are most likely due to the contributions of strength and balance gains. These results are in line with previous literature linking exercise to improvements in functional performance in IWDs.11 , 12 , 30 , 62
Although strength, balance, and fast gait speed demonstrated significant improvements, there were no improvements found for cognition or comfortable gait speed, which does not support prior findings.10 , 19 A potential explanation for this discrepancy is the lack of an aerobic component in the current study, whereas several of the prior studies included an aerobic component that found a positive impact on cognition. Although it has been identified that strength training can induce hormonal adaptations that are neuroprotective,25 Kramer et al9 indicate that the best results have been found using strength training and aerobic activity. Therefore, it is possible that addition of a moderate- to high-intensity aerobic activity (eg, running, playing tennis, biking, and gardening) to the current intervention may be required to elicit changes required for improvements in cognition and has been supported by previous research.10 , 19
Another possible explanation for the difference in findings may be that the sample of participants used by Baker et al10 displayed mild cognitive impairment, with MMSE scores of approximately 27 out of 30, whereas the sample in the current study had lower cognitive performance, with an average MMSE score below 21 indicating mild to moderate impairment. The participants in the current study took an average of 4 minutes and 36 seconds to complete the TMT-B test. When compared with normative data for community-dwelling older adults of 86.3 seconds, indicating participants in the current study began with a high level of executive dysfunction. Although Baker et al10 did not report average performance on this measure, making it difficult to compare to the current sample, it is possible that a simpler test of executive function may be more appropriate to use with a sample of more impaired individuals.
Significant changes in perceived ADL/IADL function were not found, which does not support prior findings by Santana-Sosa et al.21 A possible consideration for these nonsignificant findings may stem from the study design that captured the short-term effects of the protocol rather than longer term effects that may require more time to unfold. For example, changes in perceived ADL/IADL functioning may necessitate a longer time to develop in that more time is required to change individual's perceptions about their day-to-day functioning. Another explanation is the need for a diverse multicomponent intervention. For example, Teri et al32 found that Reducing Disability in Alzheimer's Disease (RDAD), a dyadic multicomponent intervention with exercise and behavioral management techniques, significantly improved scores on the physical functioning subscale of the 36-Item Short Form Health Survey (SF-36) as reported by the caregiver. In addition, Judge and colleagues63 , 64 found significant improvements in perceived distress in ADL function following a dyadic intervention (Project ANSWERS) including cognitive rehabilitation and skills training for IWDs and their caregivers. Project ANSWERS did not incorporate any type of physical activity or exercise, but was able to demonstrate improvements in perceived distress in ADL function after only 6 sessions. Incorporating both physical and psychosocial components, possibly through an interdisciplinary approach with clinicians from psychological sciences as well as health sciences, may be the best approach to impact both objective and subjective function. These examples highlight the possibility of requiring psychosocial components to intervene in a more holistic approach to truly affect the illness or disability experience. Assessing symptoms of depression and anxiety as well as quality of life may allow researchers and clinicians to better understand the association between cognitive and physical function, exercise, and overall well-being.
On the basis of these considerations, modifications to the intervention may be warranted in future research, including the addition of an aerobic component to target cognition. This would bring changes to the implementation of the intervention and likely warrant increased participation from the caregiver to monitor completion of daily aerobic exercise. However, with daily session logs and tightly scripted instructions this could be feasible. Furthermore, addition of cognitive rehabilitative skills or behavioral management training may be introduced to determine effects of a more diverse multicomponent intervention that addresses the illness and disability experience.
The Strength-Based Approach was successful as an overarching framework for guiding the development and implementation of the protocol, and extends this framework from social work and counseling settings51 to physical activity and exercise programs. Therefore, it also may be useful in the fields of physical and occupational therapy when working with IWDs. Research has found that rehabilitation participation mediates the relationship between cognitive impairment and rehabilitative outcomes.65 The high adherence level found in the current study indicates that IWDs can actively participate in an exercise protocol using a Strength-Based Approach. Thus, a Strength-Based Approach may be especially important for rehabilitation professionals to implement when working with IWDs, as this population can pose unique challenges.
Another key point from this study is the importance of the proper dosage or intensity. The Physical Stress Theory49 states that overload is required to induce beneficial adaptations in muscle and neurological tissue, producing improvements in strength and balance. The current study found that IWDs were able to benefit from a protocol that induced the proper intensity to elicit changes in strength, balance, and fast gait speed. Protocols with less intense dosages may result in nonsignificant findings. The current study found that maintaining a moderate-intensity exercise intervention (60%-80% of maximum) leads to positive effects along with good tolerance.
Several study limitations should be considered. The current sample was recruited with assistance from a local chapter of the Alzheimer's Association, which introduces a recruitment bias. Although a large emphasis of the study was on testing the efficacy of the protocol, it is possible that treatment adherence and fidelity findings may have been different with a more diverse sample of participants. However, the universal design of the intervention was intended to maximize adherence through using purposeful activity, optimizing accessibility, and individualized tailoring.66
Another limitation is the TMT-B for measuring executive functioning, which may have resulted in floor effects with this sample. Few assessment tools for assessing executive function in IWDs with mild to moderate dementia are available, with the appropriate level of sensitivity needed to observe significant changes. More research is needed to identify or develop valid and reliable tools for use in this line of research. Also, it is possible that the exploratory nature of the current study resulted in reduced power for some of the outcome measures demonstrating a smaller effect size. Future research should include a larger, more heterogeneous sample of IWDs to provide more power and allow for key comparisons regarding effectiveness including possible stratification by gender or type of dementia.
Neither the researcher nor the participants were blinded to group assignment. However, attempts to minimize this bias were made using random assignment and participants in the intervention group were evenly split between exercise practitioners. In addition, the principal researcher was blinded to the baseline performance of the participant at time of the follow-up. The assessment tools used were objective and straight forward (eg, time via stopwatch and repetitions completed) in attempts to limit the subjectivity of the assessor. In further research, it would be ideal for the researcher completing the baseline and follow-up assessments to be blinded to group assignment to remove all potential measurement biases.
The current study reveals the ability of IWDs to participate in a moderate-intensity functional strength and balance program using a Strength-Based Approach to facilitate implementation of exercise activities. In addition, results highlight improvements in lower extremity strength, balance, and fast gait speed following participation in the 12-week intervention. On the basis of these key findings, rehabilitation professionals should consider integration of these techniques into mainstream clinical practice and research with this patient population.
1. Prince M, Bryce R, Albanese E, Wimo A, Ribeiro W, Ferri CP. The global prevalence of dementia
: a systematic review and metaanalysis. Alzheimers Demen. 2013;9(1):63–75.e62.
2. Suttanon P, Hill KD, Said CM, LoGiudice D, Lautenschlager NT, Dodd KJ. Balance and mobility dysfunction and falls risk in older people with mild to moderate Alzheimer disease. Am J Phys Med Rehabil. 2012;91(1):12–23.
3. Munoz VM, van Kan GA, Cantet C, et al Gait and balance impairments in Alzheimer disease patients. Alzheimer Dis Assoc Disord. 2010;24(1):79–84.
4. Seignourel PJ, Kunik ME, Snow L, Wilson N, Stanley M. Anxiety in dementia
: a critical review. Clin Psychol Rev. 2008;28(7):1071–1082.
5. Cohen-Mansfield J. Behavioral and psychological symptoms of dementia
. In: Lichtenberg P, Mast BT, Carpenter BD, Loebach Wetherell J, eds. APA Handbook of Clinical Geropsychology, Vol. 2: Assessment, Treatment, and Issues of Later Life. Washington, DC: American Psychological Association; 2015:271–317.
6. Amieva H, Jacqmin-Gadda H, Orgogozo JM, et al The 9 year cognitive decline before dementia
of the Alzheimer type: a prospective population-based study. Brain. 2005;128(5):1093–1101.
7. Alzheimer's Association. 2015 Alzheimer's disease facts and figures. Alzheimers Dement. 2015;11(3):332.
8. Wimo A, Jönsson L, Bond J, Prince M, Winblad B. The worldwide economic impact of dementia
2010. Alzheimers Dement. 2013;9(1):1–11.e13.
9. Kramer AF, Colcombe SJ, McAuley E, Scalf PE, Erickson KI. Fitness, aging and neurocognitive function. Neurobiol Aging. 2005;26(1):124–127.
10. Baker LD, Frank LL, Foster-Schubert K, et al Effects of aerobic exercise
on mild cognitive impairment: a controlled trial. Arch Neurol. 2010;67(1):71–79.
11. Hauer K, Schwenk M, Zieschang T, Essig M, Becker C, Oster P. Physical training improves motor performance in people with dementia
: a randomized controlled trial. J Am Geriatr Soc. 2012;60(1):8–15.
12. Rosendahl E, Lindelöf N, Littbrand H, et al High-intensity functional exercise
program and proteinenriched energy supplement for older persons dependent in activities of daily living: a randomised controlled trial. Aust J Physiother. 2006;52(2):105–113.
13. Dawson N. Examining the Effects of a Moderate-Intensity Home-Based Functional Exercise
Intervention on Cognition and Function in Individuals With Dementia
[dissertation]. Cleveland, OH: Department of Psychology, Cleveland State University; 2015.
14. Thuné-Boyle I, Iliffe S, Cerga-Pashoja A, Lowery D, Warner J. The effect of exercise
on behavioral and psychological symptoms of dementia
: towards a research agenda. Int Psychogeriatr. 2012;24(7):1046–1057.
15. McGough EL, Logsdon RG, Kelly VE, Teri L. Functional mobility limitations and falls in assisted living residents with dementia
: physical performance assessment and quantitative gait analysis. J Geriatr Phys Ther. 2013;36(2): 78–86.
16. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701–1707.
17. Verghese J, Robbins M, Holtzer R, et al Gait dysfunction in mild cognitive impairment syndromes. J Am Geriatr Soc. 2008;56(7):1244–1251.
18. Hageman PA, Thomas VS. Gait performance in dementia
: the effects of a 6-week resistance training program in an adult day-care setting. Int J Geriatr Psychiatry. 2002;17(4):329–334.
19. 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.
20. Rolland Y, Pillard F, Klapouszczak A, et al Exercise
program for nursing home residents with Alzheimer's disease: a 1-year randomized, controlled trial. J Am Geriatr Soc. 2007;55(2):158–165.
21. Santana-Sosa E, Barriopedro M, López-Mojares LM, Pérez M, Lucia A. Exercise
training is beneficial for Alzheimer's patients. Int J Sport Nutr. 2008;29(10):845–850.
22. Bossers WJ, van der Woude LH, Boersma F, Hortobágyi T, Scherder EJ, van Heuvelen MJ. A 9-week aerobic and strength training program improves cognitive and motor function in patients with dementia
: a randomized, controlled trial. Am J Geriatr Psychiatry. 2015;23(11):1106–1116.
23. Perrochon A, Tchalla AE, Bonis J, Perucaud F, Mandigout S. Effects of a multicomponent exercise
program on spatiotemporal gait parameters, risk of falling and physical activity in dementia
patients. Dement Geriatr Cogn Dis Extra. 2015;5(3):350–360.
24. Kramer AF, Erickson KI, Colcombe SJ. Exercise
, cognition, and the aging brain. J Appl Physiol. 2006;101(4):1237–1242.
25. Ahlskog JE, Geda YE, Graff-Radford NR, Petersen RC. Physical exercise
as a preventive or disease-modifying treatment of dementia
and brain aging. Paper presented at: Mayo Clinic Proceedings; 2011.
26. Marshall GA, Rentz DM, Frey MT, Locascio JJ, Johnson KA, Sperling RA. Executive function and instrumental activities of daily living in mild cognitive impairment and Alzheimer's disease. Alzheimers Dement. 2011;7(3):300–308.
27. Camicioli R, Licis L. Motor impairment predicts falls in specialized Alzheimer care units. Alzheimer Dis Assoc Disord. 2004;18(4):214–218.
28. Kenny AM, Bellantonio S, Fortinsky RH, et al Factors associated with skilled nursing facility transfers in dementia
-specific assisted living. Alzheimer Dis Assoc Disord. 2008;22(3):255–260.
29. Suttanon P, Hill K, Said C, Dodd K. Can balance exercise
programmes improve balance and related physical performance measures in people with dementia
? A systematic review. Eur Rev Aging Phys Act. 2010;7(1):13–25.
30. Netz Y, Axelrad S, Argov E. Group physical activity for demented older adults—feasibility and effectiveness. Clin Rehabil. 2007;21(11):977–986.
31. Burgener SC, Yang Y, Gilbert R, Marsh-Yant S. The effects of a multimodal intervention on outcomes of persons with early-stage dementia
. Am J Alzheimers Dis Other Demen. 2008;23(4):382–394.
32. 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.
33. Dawson N, Menne H. Can interpreting non-significant findings inform the lessons learned from an intervention? Am J Lifestyle Med. 2015;11(4):354–360.
34. Dick JP, Guiloff RJ, Stewart A, et al Mini-mental state examination in neurological patients. J Neurol Neurosurg Psychiatry. 1984;47(5):496–499.
35. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.
36. Judge KS, Yarry SJ, Orsulic-Jeras S. Acceptability and feasibility results of a strength-based skills training program for dementia
caregiving dyads. Gerontologist. 2010;50(3):408–417.
37. Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922–935.
38. Arbuthnott K, Frank J. Trail making test, part B as a measure of executive control: validation using a set-switching paradigm. J Clin Exp Neuropsychol. 2000;22(4):518–528.
39. Lezak MD. Neuropsychological Assessment. 4th ed. New York, NY: Oxford University Press; 2004.
40. Reitan RM. Validity of the Trail Making Test as an indicator of organic brain damage. Percept Mot Skills. 1958;8(3):271–276.
41. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign, IL: Human Kinetics; 2013.
42. Eriksrud O, Bohannon RW. Relationship of knee extension force to independence in sit-to-stand performance in patients receiving acute rehabilitation. Phys Ther. 2003;83(6):544–551.
43. Bohannon RW. Population representative gait speed and its determinants. J Geriatr Phys Ther. 2008;31(2):49–52.
44. Guralnik JM, Simonsick EM, Ferrucci L, et al A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85-M94.
45. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185(12):914–919.
46. Lawton MP, Brody E. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–186.
47. Benjamin Rose Institute. Cleveland Alzheimer's Managed Care Demonstration: Caregiver & Patient Interviews (T1). Cleveland, OH: Benjamin Rose Institute; 1998.
48. Dawson N, Powers SM, Krestar M, Yarry SJ, Judge KS. Predictors of self-reported psychosocial outcomes in individuals with dementia
. Gerontologist. 2013;53(5):748–759.
49. Mueller MJ, Maluf KS. Tissue adaptation to physical stress: a proposed “Physical Stress Theory” to guide physical therapist practice, education, and research. Phys Ther. 2002;82(4):383–403.
50. vanBeveren PJ, Avers D. Exercise
and physical activity for older adults. In: Guccione AA, Avers D, Wong R, eds. Geriatric Physical Therapy. 3rd ed. St Louis, MO: Elsevier Health Sciences; 2012:64–85.
51. Orsulic-Jeras S, Shepherd JB, Britton PJ. Counseling older adults with HIV/AIDS: a strength-based model of treatment. J Ment Health Couns. 2003;25(3):233–244.
52. Littbrand H, Rosendahl E, Lindelöf N, Lundin-Olsson L, Gustafson Y, Nyberg L. A high-intensity functional weight-bearing exercise
program for older people dependent in activities of daily living and living in residential care facilities: evaluation of the applicability with focus on cognitive function. Phys Ther. 2006;86(4):489–498.
53. Avers D, Brown M. White paper: strength training for the older adult. J Geriatr Phys Ther. 2009;32(4):148–158.
54. Dawson N, Judge K. Acceptability and Feasibility of a Moderate-Intensity Home-based Exercise
Intervention for Individuals with Dementia
. Paper presented at: 65th Annual Scientific Meeting, Gerontological Society of America; November 18, 2015, Orlando, FL.
55. Fraser MW, Richman JM, Galinsky MJ, Day SH. Intervention Research: Developing Social Programs. New York, NY: Oxford University Press; 2009.
56. Fraser MW, Galinsky MJ. Steps in intervention research: designing and developing social programs. Res Soc Work Pract. 2010;20(5).
57. Johanson GA, Brooks GP. Initial scale development: sample size for pilot studies. Educ Psychol Meas. 2010;70(3):394–400.
58. Hertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31(2):180–191.
59. Armijo-Olivo S, Warren S, Magee D. Intention to treat analysis, compliance, drop-outs and how to deal with missing data in clinical research: a review. 2009;14(1):36–49.
60. Tabachnick BG, Fidell LS. Using Multivariate Statistics. Boston, MA: Pearson Education; 2007.
61. Judge KS, Yarry SJ, Looman WJ, Bass DM. Improved strain and psychosocial outcomes for caregivers of individuals with dementia
: Findings from project ANSWERS. Gerontologist. 2013;53(2):280–292.
62. Roach KE, Tappen RM, Kirk-Sanchez N, Williams CL, Loewenstein D. A randomized controlled trial of an activity specific exercise
program for individuals with Alzheimer disease in long-term care settings. J Geriatr Phys Ther. 2011;34(2):50.
63. Judge KS, Yarry SJ, Looman W, Orsulic-Jeras S. Improving Coping and Care Management Strategies for Individuals with Dementia
and Their Family Caregivers: Findings from Project ANSWERS. Paper presented at: Annual Meeting of the Gerontologic Society of America; 2009; Atlanta, GA.
64. Judge KS, Menne HL, Whitlatch CJ. Stress process model for individuals with dementia
. Gerontologist. 2010;50(3):294–302.
65. Lenze EJ, Munin MC, Dew MA, et al Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. Int J Geriatr Psychiatry. 2004;19(5):472–478.
66. Costello E, Kafchinski M, Vrazel J, Sullivan P. Motivators, barriers, and beliefs regarding physical activity in an older adult population. J Geriatr Phys Ther. 2011;34(3):138–147.