June 2018 Issue

Focus on Fitness: Alzheimer's Disease and Exercise
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 6, P. 52

Physical activity can improve quality of life and help manage comorbidities.

June is Alzheimer's and Brain Awareness Month, when the Alzheimer's Association urges us to "Go Purple" to promote awareness, honor loved ones with the disease, and fundraise for Alzheimer's research (www.alz.org/abam/#takeAction).

Alzheimer's disease is a progressive and irreversible neurodegenerative disorder involving loss of memory and cognitive skills and, eventually, simple daily living tasks and basic communication. Those with severe Alzheimer's are completely dependent on others for care. Alzheimer's disease is the most common cause of dementia in older adults, and symptoms generally first appear around age 65. A small percentage of Alzheimer's cases are early-onset cases, with symptoms and brain deterioration beginning before age 65—sometimes as young as age 30. According to the Alzheimer's Association, Alzheimer's disease is the sixth-leading cause of death overall, and the fifth-leading cause of death in adults older than 65. Currently, 5.7 million Americans have Alzheimer's disease; that number is expected to increase to 9 million by 2030.1

Alzheimer's is the only disease in the top 10 leading causes of death that cannot be cured, prevented, or its progression slowed, according to the Alzheimer's Association. Its exact cause is unknown, but it's speculated that a combination of genetic, lifestyle, and environmental factors contribute to its development. Research on whether regular physical exercise throughout life can reduce the risk of Alzheimer's disease, as it does for heart disease and diabetes, is ongoing but currently inconclusive.

Although exercise for Alzheimer's disease prevention is a worthwhile topic, I'm focusing here on the benefits of exercise for those with Alzheimer's disease. Recent research on exercising to reduce symptoms of Alzheimer's disease appears to be more conclusive, demonstrating that certain types of exercise can benefit those living with the disease. While most studies are small and have resulted in lower-quality evidence, positive results suggest that exercise should be a part of Alzheimer's disease management whenever possible.

Regular exercise often is neglected as part of Alzheimer's disease management, simply because caregivers and medical professionals are more focused on the progressive loss of brain tissue and associated symptoms. With the primary focus on memory loss and cognitive decline, the physical health of those with Alzheimer's usually is neglected. Older adults with Alzheimer's disease must cope with the same age-related physical health issues as older adults without the disease, including cardiovascular and respiratory disease, osteoporosis, and increased risk of falls. Regardless of its effects on Alzheimer's disease symptoms, exercise is important to maintain the health of the rest of the body and help prevent age-related physical decline.

Management strategies for Alzheimer's patients involve a combination of pharmacologic and nonpharmacologic therapies. Exercise, which is considered a nonpharmacologic adjunctive or alternative therapy for managing the stages and symptoms of Alzheimer's disease, is aimed at slowing cognitive and physical decline and improving or maintaining quality of life.2

Brain benefits associated with low- to moderate-intensity exercise are thought to result from increased blood flow to the brain and changes in brain metabolism that increase neural activation.1 Various types of exercise, including aerobic and resistance exercises as well as yoga, are being studied in those with Alzheimer's disease. Systematic reviews have concluded that exercise—specifically sessions that include aerobic, strength, balance, coordination, and flexibility—improves the following symptoms of Alzheimer's disease2-4:

• cognitive functioning, such as attention, memory, and executive functioning;

• behavioral disturbances, such as agitation, wandering, repetitive noises, and aggression; and

• psychological conditions, such as depression, mood fluctuations, anxiety, and delusions.

In addition, regular comprehensive exercise programs improve physical functioning; this is especially important because they increase the ability to perform activities of daily living and decrease the decline in performing such tasks.4

Smaller studies focused on yoga also reported benefits for those with Alzheimer's disease. Eight weeks of a chair yoga program improved physical functioning, gait, and balance in older adults (mean age 83 years) with moderate to severe Alzheimer's disease.5 A randomized controlled trial compared kundalini yoga (a style that combines poses with meditative chanting) with memory enhancement training (considered a gold standard in Alzheimer's management) in older adults with mild cognitive impairment, considered a precursor to Alzheimer's disease. Memory was significantly improved in all trial participants, but only the yoga group showed significant improvements in both executive functioning and depression.6

No clinical guidelines have been published specifically addressing exercising with Alzheimer's disease. Authors of the systematic reviews recommend multimodal or comprehensive exercise programs that include aerobic and strength conditioning, balance and coordination, and flexibility over a lone activity (eg, walking or strength training) because studies have shown that such programs provide maximum benefits related to maintaining or improving both physical and cognitive functioning.2-4

It should be noted that adherence to exercise was very high in almost all the studies of Alzheimer's disease and exercise, given that participants were supervised by specialists (eg, occupational therapists), long term care staff, or caregivers. Positive results and adherence were reported in a range of settings, including long term care facilities, community locations (eg, senior centers), and homes.4 These study results suggest that location and caregiver type may not be barriers to starting and maintaining an exercise program for an individual with Alzheimer's disease.

For those in the early stages of Alzheimer's disease, exercise guidelines and recommendations for older adults in general are appropriate in most cases. In patients with more serious disease, exercise will need to be adjusted for the individual, depending on their frailty, Alzheimer's symptoms, and medications.2,3 Those with more advanced Alzheimer's memory loss often respond positively to familiar activities. Incorporating activities enjoyed when younger can facilitate exercise sessions. For example, a client with Alzheimer's who was an avid basketball player may respond better to exercises performed with an inflated resistance ball than to strength training with weights. Clients who enjoyed dancing may derive more benefit from dance-based exercise set to favorite music.2

Positive results reported in these reviews and smaller studies indicate that exercise does have a role in Alzheimer's disease management. Several related research studies are ongoing, and future research findings will hopefully provide the foundation for establishing clinical guidelines for exercise in the Alzheimer's population.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. Barnes JN. Exercise, cognitive function, and aging. Adv Physiol Educ. 2015;39(2):55-62.

2. Pérez CA, Cancela Carral JM. Benefits of physical exercise for older adults with Alzheimer's disease. Geriatr Nurs. 2008;29(6):384-391.

3. Hernández SS, Sandreschi PF, da Silva FC, et al. What are the benefits of exercise for Alzheimer's disease? A systematic review of the past 10 years. J Aging Phys Act. 2015;23(4):659-668.

4. Rao AK, Chou A, Bursley B, Smulofsky J, Jezequel J. Systematic review of the effects of exercise on activities of daily living in people with Alzheimer's disease. Am J Occup Ther. 2014;68(1):50-56.

5. McCaffrey R, Park J, Newman D, Hagen D. The effect of chair yoga in older adults with moderate and severe Alzheimer's disease. Res Gerontol Nurs. 2014;7(4):171-177.

6. Eyre HA, Siddarth P, Acevedo B, et al. A randomized controlled trial of Kundalini yoga in mild cognitive impairment. Int Psychogeriatr. 2017;29(4):557-567.