How to Create a Dementia Exercise Therapy Program

There is a strong need for non-pharmaceutical approaches to managing the cognitive and physical symptoms of dementias including Alzheimer’s disease. Treating dementia with specially designed exercise therapy programs is an exciting possibility. In this post I outline guiding principles for developing your own dementia exercise program.

Medications for dementia offer modest improvements in cognitive and physical function, but many have negative side effects and do not slow disease progression. While we await more effective medications, there is a clear need for alternatives to help individuals with this debilitating condition. The latest clinical research suggests that exercise therapy is a promising treatment option for addressing the physical AND cognitive symptoms of dementia, as well as improve overall quality of life.

In fact, physical exercise may offer unique benefits for treating the cognitive deficits of dementia. Studies of patients with dementia suggest that while their ability to learn new information is diminished, their ability to learn subconsciously (for example, learning new movement patterns or procedures) may still be robust (discussed in Ref1). So it’s feasible that physical exercise may be useful to exercise patients both physically and cognitively. Furthermore, if designed correctly, physical activity can also be very engaging and emotionally rewarding to participants – thereby increasing participation levels.

3 categories of exercise that show benefit for dementia:

The great news is that almost any type of exercise is valuable, and if performed safely, is virtually free of negative side effects (but please consult a physician before beginning any exercise program). This includes:

1. Traditional exercise practices including resistance training and walking routines will improve strength and physical function in dementia sufferers, thereby aiding them in performing everyday activities. Such exercise may also enhance cognitive function.
2. Alternative exercise practices including yoga, dance therapy, tai chi and more will improve physical function, and studies of adults with cognitive impairment indicate that they also enhance cognitive function and quality of life.
3. Supervised exercise therapy provided by physiotherapists and occupational therapists that is focused on patient-specific goals is shown to improve physical function and quality of life.

Designing an optimal dementia exercise therapy class

Clinical investigators out of the University of California San Francisco recently reported on their newly developed integrative exercise therapy program for treating the physical and cognitive symptoms of dementia (Ref 1, see our review “Treating dementia with physical exercise”). While their study was only an initial pilot study, the authors reported that their experimental group exercise program appeared to substantially improve physical performance, cognitive function, and quality of life of participants with mild to moderate dementia. Additional studies are definitely warranted, and are hopefully underway.

Using the lessons learned by these investigators, below are their guiding principles for designing your own exercise therapy class for treating dementia. While your class may only consist of one participant, significant benefits may be gained by creating a group setting. Please consult a physician before beginning any exercise program.

Guiding principles for designing your own exercise therapy class for dementia

1. Include repetition with variation. Each class should follow the same basic sequence of activities (exercises) and events (introduction, active and rest periods, and closing). This should help participants gain familiarity with the routine and promote subconscious procedural learning. Specific exercises should be varied to encourage participant engagement and to also incorporate their feedback. Exercise approaches well suited to this include yoga, tai chi, and dance therapy, as well as physical exercise including stretching and strengthening movements. Physiotherapists can be helpful in identifying user-specific functional goals and thereby select appropriate progressive exercises with variations.
2. Include functional movements that are progressive. The class should include movement sequences that are functionally related to participants’ daily activities (such as standing from a seated position). Simpler movements should build slowly to more complex ones. Physiotherapy and occupational therapy strategies can be incorporated here.
3. Perform the routine at a slow pace and incorporate step-by-step instruction. Step-by-step instruction with demonstration will make it easier for participants to follow-along (by reducing the cognitive demands asked of them) and help promote procedural learning.
4. Focus on participant goals. An assessment of the physical goals of the participants should be done prior to beginning the program, to help gear the program towards these outcomes.
5. Include mindfulness practices such as body and breathing awareness. Incorporating rest periods between activities provides an opportunity to promote body and breathing awareness. Ask participants to breathe deeply and think about how their bodies feel, and to share this with the group.
6. Include social interaction. For example, include circle-based activities where participants move together holding or touching hands.
7. Promote positive emotions. Encouraging (rather than pressuring), non-judgemental and caring environments are optimal. Encourage participants to do what feels good to them. Include music.

Basic structure of a dementia exercise therapy class

The integrative exercise therapy program investigated by the authors of this study used the following class structure:

1. Welcome greetings (5 minutes)
2. Body awareness warm-up (5 minutes)
3. Seated exercises (15 minutes)
4. Sit-to-stand and standing exercises (15 minutes)
5. Closing and appreciations (5 minutes)

Their class was offered three days per week, in 45 minute sessions. The class was delivered by exercise instructors certified in at least one body-awareness focus method, for example Feldenkrais or Rosen methods.

Conclusions

Not surprisingly, exercise is a valuable tool for improving the physical abilities and quality of life of dementia sufferers. But it’s really exciting to see the evidence building in favour of using physical exercise to improve cognitive performance in these individuals. It’s heartening to see that studies such as the one discussed here are being designed to investigate and optimize the use of exercise therapy for dementia – a potentially powerful and side-effect free treatment tool. I look forward to seeing more!

References

1.       Barnes, D.E., Mehling, W., et al. Preventing Loss of Independence through Exercise (PLIÉ): A Pilot Clinical Trial in Older Adults with Dementia. PLoS One. 2015 Feb 11;10(2).