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Understanding Dementia: Etiology, Communication, and Exercise Intervention

Rone-Adams, Shari PT, DBA1; Stern, Debra F. PT, DPT, DBA1; Olivier, Traci W. MS2; Blodgett, Michelle Gagnon PsyD2,3,4

Strength & Conditioning Journal: August 2013 - Volume 35 - Issue 4 - p 88–98
doi: 10.1519/SSC.0b013e31829ed301


1Physical Therapy Program, College of Health Care Science, Nova Southeastern University, Fort Lauderdale, Florida;

2Nova Southeastern University Counseling Center for Older Adults, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Florida; and

3Geriatric Clinical Services, Health Professions Division and

4Department of Geriatrics, College of Osteopathic Medicine, Fort Lauderdale, Florida

Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding.



Shari Rone-Adams is associate professor and the director of the Entry-Level Doctor of Physical Therapy Program at Nova Southeastern University.



Debra F. Stern is associate professor and director of Clinical Education for the Physical Therapy Program at Nova Southeastern University.



Traci W. Olivier is a clinical psychology doctoral student (neuropsychology concentration) at Nova Southeastern University's Center for Psychological Studies who is currently serving as co-coordinator of the Nova Southeastern University Counseling Center for Older Adults.



Michelle Gagnon Blodgett is a clinical psychologist specializing in geropsychology whose roles at Nova Southeastern University include Coordinator of Geriatric Clinical Services and Clinical Assistant Professor in the Department of Geriatrics, College of Osteopathic Medicine, Director of the Nova Southeastern University Counseling Center for Older Adults, and adjunct faculty in the Center for Psychological Studies.

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Dementia is defined by the American Psychiatric Association as a "loss of intellectual abilities (medically called cognitive function) of sufficient severity to interfere with social or occupational functioning" (7). Dementia is a progressive deterioration of cognitive abilities and executive functioning, which results in progressive social and functional impairments with resultant loss of independence (29,39,55). Approximately 100 types of dementia (reversible and irreversible) are known, the most common types being Alzheimer's disease, which accounts for approximately 50–70% of the cases, and vascular dementia, which accounts for approximately 18–20% of the cases (8,23,27). The likelihood of having some form of dementia increases with age, the incidence doubling every 5 years after the age of 65 years (62). With the aging of the population and the increased life expectancy, the incidence of dementia is expected to rise significantly over the next century. Global prevalence of dementia is estimated to be approximately 35.6 million people, with this number expected to double by 2030 and triple by 2050 (62). It has been estimated that 5–6 million Americans, over the age of 65 years, have some type of dementia (4,21).

As the population ages and the incidence of dementia increases, it is imperative that professionals understand the risk factors, are able to recognize potential symptoms in those that may be undiagnosed, are knowledgeable about how to work effectively with individuals with dementia, and understand the benefits of exercise. Increasing numbers of professionals (individuals licensed to practice within a specific profession, recognized with an educational specialized degree as defined by the Federal Government, or having specialized training to work with a defined population of individuals) will be working with older adults (aged 65 years and older) who have some form of dementia within their career. Early detection and treatment are important to slow or delay progression and improve the likelihood of recovery in cases of reversible types of dementia. This article will provide the strength and conditioning professional with an overview of the etiology, risk factors, and signs and symptoms of dementia; practical tips for communicating with older adults with dementia; and exercise considerations.

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Dementia is a generic term that includes a variety of disorders affecting the functioning of the brain cells resulting in the loss of function or death. The death or loss of function of cells results in changes in memory and behavior. The etiologies for dementia include both progressive, irreversible causes and reversible causes that can be resolved with the treatment of the underlying disease processes. Most causes of dementia are unfortunately progressive with only approximately 9–11% of dementias being of the reversible type (20,30). Causes of reversible dementias include drug and alcohol toxicity, depression, nutritional deficiencies, metabolic diseases, normal pressure hydrocephalus, central nervous system infections, intracranial tumors, and others (13,25,55). The most frequent causes of reversible dementia are drug toxicity and depression (20,59) and with treatment are likely to result in full recovery. Other causes of reversible dementia, such as metabolic disorders, alcohol toxicity, and others, may improve significantly with treatment of the underlying cause but may not reverse completely.

The increasing incidence of dementia has resulted in much research dedicated to the understanding of the disease processes. Research during the mid to late 20th century resulted in the classification of irreversible causes of dementia into groupings (4,9,13,21):

  • Alzheimer's disease
  • vascular dementia (e.g., multi-infarct)
  • frontotemporal dementia (e.g., Pick's disease and progressive supranuclear palsy)
  • dementia with Lewy bodies (e.g., Parkinson's disease) and
  • mixed dementias (e.g., Alzheimer's in association with another type of dementia, often vascular dementia)

These classifications have led to more targeted research resulting in a more complete understanding of the risk factors and underlying pathologies, leading to more advanced diagnosis, treatment, and management. Table 1 lists various diagnoses associated with dementia and common early symptoms.

Table 1

Table 1

Over the recent years, dementia related to chronic traumatic encephalopathy (CTE) has received increasing attention. CTE is a progressive neurodegenerative disease associated with closed head injuries, in athletes who participate in contact sports, such as boxing, football, wrestling, soccer, and others (41,51). Research indicates that CTE is most associated with the sport of boxing (41). Risk factors include repetitive concussions, often resulting in mild traumatic brain injuries (51), and specific apolipoprotein E markers. The first symptoms of CTE are decreased attention, memory deficits, and disorientation (41). With progressive deterioration, symptoms such as overt dementia and progressive movement dysfunction occur. Symptoms usually become more apparent as the athlete ages. CTE is an irreversible condition that can only be diagnosed through postmortem autopsy. Differential diagnoses often include Alzheimer's disease, frontotemporal dementia, and closed head injury.

Currently, no treatments are available that stop the progression of irreversible dementias. Active medical management is recommended to maintain health at an optimal state through management of comorbidities. There are several medications in the market, promoted to temporarily improve symptoms or slow the progression of the disease process.

The Alzheimer's Disease Association recommends 5 steps in the management of older adults with progressive dementia (4):

  • appropriate use of available treatment options
  • management of coexisting conditions,
  • coordination of care among health care professionals
  • active participation in activities and adult day care programs and
  • participation in support groups and other support services
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Risk factors for dementia are divided into genetic and nongenetic factors. The only nongenetic risk factor universally accepted is age. The incidence of dementia doubles every 5 years after the age of 65 years (40), with approximately 50% of the population over the age of 82 years having some form of dementia (39). As a person ages, the ability of the brain to repair itself decreases but varies highly from person to person. Additionally, aging also increases the likelihood of other risk factors associated with dementia, such as cardiovascular disease and diabetes (14,35).

Accounting for the fact that women live longer than men, research does show that women are affected more often than men with two-thirds of the cases involving women (60). The increased incidence in women is attributed to hormonal effects, particularly the role of estrogen. Some research suggests that estrogen may protect the brain from age-related changes that lead to cognitive impairment and that hormone replacement therapy produces a significant reduction in risk for women (60).

Cardiovascular disease associated with obesity, high blood pressure, and high cholesterol and diabetes are associated with vascular dementias and Alzheimer's disease (16). The risk of dementia has been found to be highest in people with peripheral artery disease, resulting in insufficient blood flow to the brain (8,35,40). The blood and oxygen nourish the brain, and any effect on blood flow affects brain function and activity.

Lower levels of formal education have been shown to increase the likelihood of dementia. Theories about this phenomenon focus both on the lack of brain stimulation at critical periods and the association with an unhealthier lifestyle accounting for more risk factors (8,35,40). Some theories promote that more highly educated individuals have a greater cognitive reserve making it easier to preserve function as cognitive changes occur.

Exposure to heavy metals, such as lead, manganese, and aluminum, are also associated with an increased risk for dementia. Persons, with dementia, are often found to have a higher absorption of these metals.

Genetic risk factors for dementia include family history of degenerative dementia, Down syndrome, and other gene mutations on specific chromosomes. The area of epigenetics is currently being explored in the literature, focusing on the interaction between genes and environmental factors. Although both genetic and nongenetic factors are attributed to the development of dementia, many researchers suggest that combinations of genetic and nongenetic factors are the best predictors of which individuals will develop dementia and dementia-related symptoms (9,48). The complex interaction between genes and other nonmodifiable risk factors such as age, family history, and heredity is most likely at play.

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The signs and symptoms of dementia are insidious, progress gradually (4,13,23), and are often mistaken for normal changes of aging by older adults, family members, and caregivers. The most commonly known symptom is loss of memory. Older adults, family members, and caregivers often do not recognize the early signs of dementia and often attribute any memory loss to normal aging. Older adults with recent memory lapses often are able to provide rational reasons for such lapses, for example, changes in regular schedule, lack of sleep, medication effects, etc.

Dementia affects the areas of intellectual capacity and executive functions that include areas such as memory, orientation, language, judgment, and behavior (29,39,49). Changes in these areas are often referred to as changes in cognition (44). Executive function is an umbrella term referring to cognitive processes such as problem solving, verbal reasoning, and task switching (44). Mild cognitive changes have been considered an intermediate stage between normal aging and the development of dementia (10,15). Symptoms, such as problems in the areas of memory, language, problem solving, and judgment that are greater than normal age-related changes, are considered to be mild cognitive changes and may indicate progression onto dementia. Older adults are often the first to recognize their mental function has declined, but these changes are often not severe enough to interfere with day-to-day activities (44,49). Table 2 shows a comparison between normal age-related changes and signs of dementia.

Table 2

Table 2

As clinicians, we are often the first to discuss signs of cognitive change with the older adult and their family or caregivers. The signs are often corroborated by the older adult, family members, and caregivers once a change in cognitive function is brought to their attention. Early signs of dementia often show problems in the areas of intellectual capacity, including memory, orientation, language, judgment, and behavior. Table 3 lists examples of early signs of dementia in each of these areas.

Table 3

Table 3

Some of the common symptoms associated with dementia are also associated with depression such as changes in memory and attention (58,63). The misdiagnosis of dementia as depression and vice versa is common in the early stages. In the older adults, depression often presents as cognitive loss in addition to the sadness that we commonly associate with depression. Dementia may be masked by the onset of depression in the early stages (14,58,63). The use of medications to treat depression can have a further declining effect on the individual as these medications may worsen confusion and memory. Oftentimes, an underlying depression exists in older adults with dementia as they realize their memory is failing. One key difference between depression and dementia is with depression, changes in language and motor skills are not commonly seen (14,45). Distinguishing between depression and dementia is critical in the early stages to assure that proper treatment is initiated.

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Professionals may find communication with the older adult suffering from dementia difficult. Dementia is characterized by a number of different symptoms, including memory impairment, language impairment, spatial deficits, and executive functioning deficits (7,27,43). Although each of these deficits can severely affect the quality and effectiveness of communication with patients with dementia, memory, language, and executive impairments are most relevant to communicating with older adults. Because of the numerous challenges with which clients present, communicating with them can be difficult and overwhelming for professionals, but there are certain strategies that may be used to overcome some of these barriers.

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Loss of memory can be one of the most frustrating aspects of dementia for both the patient and the professional. Memory impairments are often one of the first symptoms of dementia to manifest, and inability to learn new information is one of the classic memory impairments exhibited in the dementing processes (27,33). In addition, memory impairments may manifest as deficits in auditory (verbal) memory or visual memory. Patients may present with one modality as more impaired than another. For example, an individual may find it particularly difficult to remember information that is spoken to them (e.g., auditory memory deficit) or presented to them on paper (e.g., visual memory deficit).

Although memory loss may become functionally debilitating, there are ways in which to compensate for deficits, especially in the early stages of dementia. When attempting to discuss novel information with a patient with dementia, such as how to implement a new exercise regimen, identifying the patient's preferred method of learning may be helpful. The professional may first endeavor to ask the patient directly how he or she best learns. Some patients have an adequate degree of insight regarding their deficits and may be able to convey this information. Other individuals, such as those whose decline is more advanced, may not be able to indicate their preferred method of learning. In these cases, asking the caregiver or an individual close to the patient may be helpful. Additionally, inquiring about the person's educational background and previous work to get an idea of what knowledge and skills are better developed may provide insight into an individual's cognitive strengths or well-practiced skills.

For individuals whose auditory (verbal) memory is more preserved than their visual memory, information presented verbally will be more likely to be retained. That is, speaking to these patients may be more helpful than presenting written information to them, such as handouts or brochures. Although these materials may be presented in addition to verbal information, someone, such as the professional or the caregiver, should thoroughly read the information to the patient, in addition to using frequent, verbal reminders.

When patients have profound auditory memory deficits (i.e., verbal memory more intact), verbal information will not be retained as well as visual information (provided that the latter system is still relatively intact). In these instances, written information will be quite useful, and spoken information may be easily forgotten. Written reminders (e.g., sticky notes, calendars, journals) may also prove helpful. Asking clients how they kept track of appointments and other important information in the past (e.g., work, family) can be beneficial. Such strategies would be well learned and could prove more easy and effective to adopt with health-related activities and directives.

When dementia has significantly progressed, both auditory and visual memory systems may be impaired. Short-term memory loss may also be evident. In such cases, enlisting the help of the caregiver will be more useful than relying solely on the patient. If the patient's physical systems are intact, the caregiver can assist the patient in carrying out an exercise regimen; but it may be futile to expect that the patient will do so out of his or her own volition. As memory loss progresses, even reminders (whether verbal or visual) may not be useful because of the degree of impairment; yet, research has demonstrated that frequent reminders from other individuals may be effective in improving adherence (14,17).

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Executive functioning is an umbrella term that encompasses cognitive functions, such as planning, initiation, shifting, higher level abstraction, working memory, and efficient execution of tasks, and these skills are often impaired in individuals with dementia. Additionally, research has demonstrated a link between executive functioning declines and declines in activities of daily living (33,47). Communicating with individuals who experience executive functioning declines may be quite difficult. Even if they are able to retain the information conveyed to them, they may have difficulty carrying out the instructions. For example, a patient who has executive functioning deficits may initially seem to understand the exercise regimen presented by the professional. Yet, even something as seemingly simple as exercise requires a great amount of executive functioning. The patient must first be able to remember the instructions and figure out how to incorporate them into his or her daily life, which requires working memory and planning skills. Then, he or she must be able to effectively plan and execute the instructions. Apathy or lack of volition, which often accompanies the dementing process, can complicate matters by further hindering compliance. Additionally, executive dysfunction is usually superimposed on preexisting memory deficits, which can further impair the patient. In communicating with such patients, it will be helpful for the professional to be mindful of the cognitive load that is necessary to follow through with fitness recommendations. Accommodations for deficits, such as presenting the patient with a written plan that has the recommendations broken into small, easy to understand elements (e.g., "chunking" information), and enlisting the help of the caregiver to assist the patient in following through with intended plans are often effective.

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Older patients often have unique sets of care needs because of the numerous impairments and difficulties that they may face. In addition, they often have preconceived notions and preferences as to how these needs should be addressed (18). If a patient does not have the cognitive or emotional capacity to address their needs and care preferences with their professional verbally, they may do so through nonverbal methods of communication. Therefore, professionals should be aware of basic emotional responses that may be exhibited nonverbally. Ruckdeschel and Van Haitsma (50) indicate that care providers can gain valuable information that can guide treatment by being aware of "emotional indicators," which can be especially important in communicating with patients who have dementia and may primarily respond emotionally. The authors explain,

“By tuning in to people's emotions, staff can tell whether the (patients) are satisfied or whether something should be changed in their environment or in the way care is being provided to help minimize negative feelings and maximize positive ones. Information monitoring of emotions also helps determine what might be provoking a positive or negative emotional reaction. For example, staff may detect triggers for agitation or catastrophic reactions, or identify activities or care approaches to which the person will respond with pleasure or interest” (50).

Both obvious and subtle indicators will become valuable in detecting how the patient is feeling. Negative emotions or discontent may be manifested through facial grimaces, averting eye contact, or tensing muscles, indicating that something may not sit well with the patient. Conversely, positive signs, such as smiles, openness, eye contact, and physically turning toward the professional, may indicate the patient is comfortable and content with the nature of the material being discussed.

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Deficits, such as those discussed above, can severely affect the quality of a patient's life, and accommodations to overcome cognitive barriers may prove helpful. Perhaps, the most useful skill a professional may employ in communicating with patients with dementia, however, is simply establishing rapport and using a patient-centered approach instead of focusing on goal attainment, such as a treatment plan (1). Research has demonstrated focusing on the patient as a unique individual and being an active, empathic listener can increase well-being in patients with dementia (50). This may be particularly useful when attempting to convey the importance of adhering to an exercise regimen to a patient with dementia. With the ever-increasing demands of time and performance, professionals may find themselves eager to present the "bottom line" to patients; yet, the literature indicates that this may not be an effective approach in gaining treatment adherence. Patients are more likely to respond to treatment recommendations when they believe their voices have been heard. This is especially applicable to the older adult population with dementia who may be experiencing numerous barriers to physical and cognitive health. Perhaps, the most important strategy is to use a patient-centered approach. In such an approach, empathy and rapport building are highly valued and goal attainment is considered secondary. Research indicates that older adults respond better when they feel valued and understood by the professional (1,50,54).

Table 4 provides an overview of tips on communicating with patients who have dementia.

Table 4

Table 4

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Much literature exists regarding the effects of physical fitness on health and wellness. Exercise is intimately linked with both physical and cognitive health (57). There is no literature that provides evidence of a fail-safe way to prevent or cure dementia. Literature does, however, support exercise as a way to improve health overall, facilitate neuroplasticity, and improve cardiovascular status, thereby ameliorating the effects of dementia or delay onset, regardless of the type or cause (2,3,6,12,26,34). Studies out of the Mayo clinic indicate exercise may decrease the risk of dementia and slow the progression (2,3,53). This presents a positive argument for promoting physical activity in aging individuals as a way of delaying the onset of dementia and for therapeutic management, assuming the individual can actively participate in the activity. Ahlskog et al. (3) reviewed over 1,000 publications and concluded that exercise, especially aerobic exercise, improved cognition in older adults, which was supported by a variety of measures, including functional magnetic resonance imaging. A meta-analysis done by Heyn et al. (31) concluded that a variety of exercises were beneficial for individuals with cognitive deficits, including dementia. A randomized trial to determine the impact of a supervised, multicomponent exercise program (aerobic and strengthening exercises) on a population with older adults with minimal cognitive impairment was conducted by Suzuki et al. (56) at the National Center for Geriatrics and Gerontology in Japan. Findings from the study indicated that cognitive functions, including immediate memory and language ability, were shown to improve in the exercise group as compared with a group that received education only.

The overall benefits of exercise are well known and according to the Centers for Disease Control (CDC) and the World Health Organization (WHO) include (19,61) the following:

  • weight control
  • reduced risk for type 2 diabetes and metabolic syndrome
  • reduced risk of some cancers
  • strengthening of bones and muscles
  • increased chances of living longer
  • reduced risk of cardiovascular disease
  • improved ability to do daily activities and prevent falls in older adults and
  • improvement of mental health and mood

According to Landi et al. (32) and the CDC, exercise decreases the risk of early cognitive decline and delays further progression while improving mood and positive well-being (45). Evidence exists that biomarkers for cognitive dysfunction are higher in individuals who do not exercise regularly (34,36). Professionals, with the knowledge and skills of managing movement disorders with or without comorbidities and cognitive impairment, are in a position to determine appropriate exercise. By instituting effective exercise programs and improving overall health, the ability for an individual with impaired cognition to function optimally (in the absence of illness or pathology) can be facilitated (3,12,22,34). According to the Geriatric Section of the American Physical Therapy Association, the evidence supports the benefits of exercise in the aging adult with and without cognitive decline (24).

The overall combination of the effects that exercise has on health and well-being contribute to the role in the management of dementia. The WHO considers exercise for adults 65 years and older, a subcategory of physical activity, and specifically references the benefits in improving cognitive decline and other health benefits. General exercise principles appropriate to the management of aging adults are indicated for individuals with dementia, including both aerobic and strengthening exercises to maximize physical fitness (28,37,38,42). It has been purported that aging adults have historically been underexercised. Exercise levels should be adequate to obtain the benefits attributable to exercise while maintaining safety. As dementia is most commonly identified in aging adults, the principles applicable to the aging population should be considered in both the presence and absence of dementia. In individuals with cognitive impairment, closer monitoring of exercise may be indicated from both safety and effectiveness perspectives.

Before starting any type of exercise program for an older adult, the National Strength and Conditioning Association (NSCA) recommends the following (11):

  • clearance from a physician (depending on comorbidities and pathology)
  • complete medical history with comorbidities and risk assessment
  • medication assessment
  • assessment of preexisting conditions, including cognition and nutritional status
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The introduction of exercise, especially aerobic, which improves cardiovascular status and circulation in large and small vessels, is indicated. Aerobic exercise is defined by The American College of Sports Medicine as activities that use large group muscles, is rhythmic, and can be maintained (5,42). Aerobic exercise, to be effective, should elevate the heart rate, increasing the need for increased oxygen uptake. Table 5 shows the recommendations of various organizations relative to the amount and intensity of aerobic exercise that is recommended for older adults. Recommendations for frequency of regular exercise vary from 3 to 5 times a week, depending on the source. Sessions can be broken down into 10-minute sessions several times a day, as recommended by the American College of Sports Medicine (5). In the presence of dementia, this may work better than longer sessions based on attention span and cognitive status.

Table 5

Table 5

Assessing aerobic capacity before initiating aerobic exercise is indicated. Treadmill testing, if deemed safe, is a commonly used assessment in determining aerobic baselines and then as an aerobic exercise tool. The 6-Minute Walk Test, Sitting Step Test, and Step Test are simple to administer, especially in individuals with impaired cognition (24,52). Vital signs, including blood pressure, heart rate (pulse), and respiratory rate, should be monitored initially and on a regular basis at the beginning, during, and after completion of a session. If a client is on medication such as beta blockers that regulate pulse rate and prevent normal elevation responses, the individual should be instructed in a self-rating scale such as the Rating of Perceived Exertion (52), if the cognitive level allows for understanding. If not, it becomes more critical to monitor the objective measurements, such as heart rate and blood pressure. In some cases, it may be easier to monitor oxygen saturation using a finger-type pulse oximeter.

For general aerobic exercise to be effective, the American College of Sports Medicine recommends an intensity of 50–85% of maximum heart rate, at 20–60 minutes duration (5). However, in unconditioned older adults, it is preferable to start at a lower intensity and progress over time.

There is a variety of equipment that can be used for aerobic exercise, such as exercise cycles, recumbent or upright; ellipticals; steppers; and treadmills. Walking at a brisk enough pace to raise the heart rate has also been found to be effective under a variety of conditions. Repeatedly walking up and down stairs is effective, as are intervals of walking and running. Bicycling, if considered safe, or swimming when weather permits is also suggested. Participation in exercise classes may offer the additional benefit of socialization and motivation through group participation.

Regardless of the type of exercise selected, the individual should be able to talk while exercising to stay in safe ranges. If it is possible to teach a caregiver or the individual to monitor the radial pulse once a target heart rate is established, this can also facilitate safe and effective exercise levels. The same is true if the cognitive status is adequate to learn and report on the Rating of Perceived Exertion Scale (52).

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Although the literature stresses the effectiveness of aerobic exercise for cognitively impaired individuals for its cardiovascular benefits, recent studies suggest, as in the general population, a combination of aerobic and strengthening exercises are most beneficial. Aging does not impair the body's ability to adapt to strengthening exercise (11). To establish a baseline for beginning a strengthening program, a 1 repetition maximum (1RM) test can be used for assessment and establishment of a baseline (11,24,52). Unconditioned individuals should be started at low intensity, regardless of the activity selected, stressing proper technique and posturing to prevent soreness and injury. Proper breathing should also be incorporated with avoidance of the Valsalva maneuver, which can stress the cardiac system. The individual should work within a pain-free range of motion and any limitations noted.

The NSCA recommends mastering basic resistance exercise before higher intensity workouts (11). A warm-up period is indicated of generally 5–10 minutes. Recommended NSCA progression is "from 1 set of 8–12 reps at relatively low intensity ∼40–50% 1RM to 3 sets at 60–80% of 1RM" (11).

The WHO recommendations include strengthening of large muscle groups at least twice weekly (63). The NSCA also recommends twice weekly especially in the early stages of initiating a program to promote appropriate recovery in older persons (11). For cases in which formalized exercise cannot be performed because of the level of cognitive or physical impairment, minimizing sedentary activities and prolonged sitting will provide positive health benefits, although not to the extent of more structured, regimented programs. Taking small walks around the house, performing light housekeeping, walking in the grocery store, standing while watching TV, parking the car a distance away from a destination, extending and flexing the knees, alternating foot tapping or ankle circles will contribute to facilitating function. For individuals with limited mobility, the WHO suggests engagement in physical activity at a tolerable level at least 3 d/wk, in an effort to prevent falls and facilitate improved function (61).

Strengthening can be accomplished by activities such as lifting free weights, lifting body weight, resistance machines, using weighted medicine balls, and resistance exercise bands. Simple functional activities such as carrying grocery bags and laundry in the absence of equipment or ability for an individual to safely manipulate equipment are also indicated. The more cognitive impairment present the less complex the exercise choice should be, with emphasis on the major muscle groups needed for function, such as rising from a chair, stair climbing, and negotiating inclines.

Aging individuals with dementia can benefit from strength training and aerobic exercise (31,46). The choice of specific exercise, aerobic, strengthening, or combination, should be determined based on client ability to understand and participate, resources available, overall health status, client preference, access, safety, and potential to continue on a regular basis. The literature supports that a combination of both aerobic and strengthening exercises may be the most effective for overall health and wellness for adults with and without cognitive decline.

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With the aging of the baby boomers, the number of older adults is increasing. One of the pathologies associated with aging is dementia, regardless of type. Increasing numbers of professionals will be working with older adults with some form of dementia within their careers. To effectively work with these aging adults with dementia, practitioners must understand the disease process and the communication challenges that are associated with dementia. Individuals with dementia are often impaired in many domains of cognitive and physical functioning; they are likely to exhibit, among other deficits, memory impairment, executive dysfunction, and impairment in activities of daily living. Because of the numerous challenges with which these patients present, communicating with them can be difficult and overwhelming for practitioners, but there are certain strategies that may be used to overcome some of these barriers. Research indicates that empathy and rapport building where clients feel valued and understood are strategies that are effective when working with older adults with dementia.

Increasing evidence indicates that exercise is a vital component in the overall medical management of cognitive impairment, as a method to delay the onset of dementia, slow the progression, and in some cases improve cognitive function. Professionals should understand the benefits of exercise for individuals with dementia and have the skills to effectively communicate with the client and the caregivers for safe engagement and emphasis on the benefits.

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dementia; communication; exercise; Alzheimer's disease

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