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Dementia is a common syndrome in the geriatric population. Subsequent impairment of cognitive functioning impacts the patient’s mobility, ADLs, and IADLs. It is suggested that older persons with lower levels of cognition are less likely to achieve independence in ADLs and ambulation (1–2). Frequently, nursing home residents are viewed as too frail or cognitively impaired to benefit from exercise rehabilitation. Often, persons with Mini Mental State Score (MMSE) score below 25 are excluded from physical rehabilitation programs. However, Diamond (3) and Goldstein (4) concluded that geriatric patients with mild to moderate cognitive impairment were just as likely as cognitively intact patients to improve in functional abilities as a result of participation in exercise rehabilitation programs.
The objective of this study is to compare, through a meta-analysis endurance and strength outcomes of Cognitively Impaired (MMSE <23) and Cognitively Intact (MMSE >24) older adults who participate in similar exercise programs.
Published articles were identified by using electronic and manual searches. Key search words included exercise, training, strength, endurance, rehabilitation, cognitive impairment, cognition, Mini Mental State Exam (MMSE), older adult, aged, and geriatrics. Articles were included if the were from RCTs or well-designed control studies.
A total of 41 manuscripts met the inclusion criteria. We examined 21 exercise trials with cognitively impaired individuals (CI=1411) and 20 exercise trials with cognitively intact individuals (IN=1510). Degree of cognitive impairment is based on the reported MMSE score. Moderate to large effect sizes (ES = dwi, Hedges gi) were found for strength and endurance outcomes for the CI groups (dwi = .51, 95% CI=. 42–.60), and for the IN groups (dwi =. 49, 95% CI=. 40 –.58). No statistically significant difference in ES was found between the CI and IN studies on strength (t=1.675, DF= 8, P=.132), endurance (t=1.904, DF= 14, P=.078), and combined strength and endurance effects (t=1.434, DF= 56, P=. 263).
These results suggest that cognitively impaired older adults who participate in exercise rehabilitation programs have similar strength and endurance training outcomes as age and gender matched cognitively intact older participants and therefore impaired individuals should not be excluded from exercise rehabilitation programs.
PMCID: PMC2853480  PMID: 18548179
Older adult; cognition; physical rehabilitation; strength; endurance; training
2.  Physical Exercise as a Preventive or Disease-Modifying Treatment of Dementia and Brain Aging 
Mayo Clinic Proceedings  2011;86(9):876-884.
A rapidly growing literature strongly suggests that exercise, specifically aerobic exercise, may attenuate cognitive impairment and reduce dementia risk. We used PubMed (keywords exercise and cognition) and manuscript bibliographies to examine the published evidence of a cognitive neuroprotective effect of exercise. Meta-analyses of prospective studies documented a significantly reduced risk of dementia associated with midlife exercise; similarly, midlife exercise significantly reduced later risks of mild cognitive impairment in several studies. Among patients with dementia or mild cognitive impairment, randomized controlled trials (RCTs) documented better cognitive scores after 6 to 12 months of exercise compared with sedentary controls. Meta-analyses of RCTs of aerobic exercise in healthy adults were also associated with significantly improved cognitive scores. One year of aerobic exercise in a large RCT of seniors was associated with significantly larger hippocampal volumes and better spatial memory; other RCTs in seniors documented attenuation of age-related gray matter volume loss with aerobic exercise. Cross-sectional studies similarly reported significantly larger hippocampal or gray matter volumes among physically fit seniors compared with unfit seniors. Brain cognitive networks studied with functional magnetic resonance imaging display improved connectivity after 6 to 12 months of exercise. Animal studies indicate that exercise facilitates neuroplasticity via a variety of biomechanisms, with improved learning outcomes. Induction of brain neurotrophic factors by exercise has been confirmed in multiple animal studies, with indirect evidence for this process in humans. Besides a brain neuroprotective effect, physical exercise may also attenuate cognitive decline via mitigation of cerebrovascular risk, including the contribution of small vessel disease to dementia. Exercise should not be overlooked as an important therapeutic strategy.
PMCID: PMC3258000  PMID: 21878600
3.  Structured Exercise Does Not Stabilize Cognitive Function in Individuals with Mild Cognitive Impairment Residing in a Structured Living Facility 
Exercise has been shown to have positive effects on the brain and cognition in healthy older adults, though no study has directly examined possible cognitive benefits of formal exercise programs in persons with mild cognitive impairment (MCI) living in structured facilities. Thirty one participants completed neuropsychological testing and measures of cardiovascular fitness at baseline and after 6 months of a structured exercise program that included aerobic and resistance training. While exercise improved cardiovascular fitness in persons with mild cognitive impairment, there was no improvement in cognitive function. Rather, mild cognitive impairment patients in this sample declined in performance on several tests sensitive to Alzheimer’s disease. Examined in the context of past work, it appears exercise may be beneficial prior to the onset of MCI, though less helpful after its onset.
PMCID: PMC3079361  PMID: 21244306
mild cognitive impairment; exercise; cognitive functioning; older adults; neuropsychology; cardiovascular fitness
4.  Exercise rehabilitation on home-dwelling patients with Alzheimer's disease - a randomized, controlled trial. Study protocol 
Trials  2010;11:92.
Besides cognitive decline, Alzheimer's disease (AD) leads to physical disability, need for help and permanent institutional care. The trials investigating effects of exercise rehabilitation on physical functioning of home-dwelling older dementia patients are still scarce. The aim of this study is to investigate the effectiveness of intensive exercise rehabilitation lasting for one year on mobility and physical functioning of home-dwelling patients with AD.
During years 2008-2010, patients with AD (n = 210) living with their spousal caregiver in community are recruited using central AD registers in Finland, and they are offered exercise rehabilitation lasting for one year. The patients are randomized into three arms: 1) tailored home-based exercise twice weekly 2) group-based exercise twice weekly in rehabilitation center 3) control group with usual care and information of exercise and nutrition. Main outcome measures will be Guralnik's mobility and balance tests and FIM-test to assess physical functioning. Secondary measures will be cognition, neuropsychiatric symptoms according to the Neuropsychiatric Inventory, caregivers' burden, depression and health-related quality of life (RAND-36). Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two year follow-up.
To our knowledge this is the first large scale trial exploring whether home-dwelling patients with AD will benefit from intense and long-lasting exercise rehabilitation in respect to their mobility and physical functioning. It will also provide data on cost-effectiveness of the intervention.
Trial registration
PMCID: PMC2978202  PMID: 20925948
5.  The Effects of Cognitive Activity Combined with Active Extremity Exercise on Balance, Walking Activity, Memory Level and Quality of Life of an Older Adult Sample with Dementia 
Journal of Physical Therapy Science  2014;25(12):1601-1604.
[Purpose] The purpose of this study was to compare the effectiveness of cognitive activity combined with active physical exercise for a sample of older adults with dementia. [Subjects] A convenience sample of 30 patients with dementia (Mini-Mental State Examination score between 16 and 23) was used. Participants were randomly allocated to one of two groups: cognitive activity combined with physical exercise CAE, n=11), and only cognitive activity CA, n=9). [Methods] Both groups participated in a therapeutic exercise program for 30 minutes, three days a week for 12 weeks. The CAE group performed an additional exercise for 30 minutes a day, three days a week for 12 weeks. A Wii Balance Board (WBB, Nintendo, Japan) was used to evaluate postural sway as an assessment of balance. The Berg Balance Scale (BBS) and Modified Falls Efficacy Scale (MFES) were used to assess dynamic balance abilities. The Timed Up-and-Go test (TUG) was used to assess gait, and the Digit Span Test (DST) and 7 Minute Screening Test (7MST) were used to measure memory performance. The Mini-Mental Status Exam-Korean version (MMSE-K), Kenny Self-Care Evaluation (KSCE), and Short Geriatric Depression Scale (GDS) were used to assess quality of life (QOL). [Results] There were significant beneficial effects of the therapeutic program on balance (velocity in EOWB, path length in ECNB, BBS, and MMFE), QOL (MMSE-KC, GDS, KSCE), and memory performance (DSB) in the CAE group compared to CA group, and between pre-test and post-test. [Conclusion] A 12-week CAE program resulted in improvements in balance, memory and QOL. Therefore, some older adults with dementia have the ability to acquire effective skills relevant to daily living.
PMCID: PMC3885848  PMID: 24409029
Dementia; Elderly; Gait
6.  Can Lifestyle Modification Improve Neurocognition? Rationale and Design of the ENLIGHTEN Clinical Trial 
Contemporary clinical trials  2012;34(1):60-69.
Risk factors for cardiovascular disease (CVD) not only increase the risk for clinical CVD events, but also are associated with a cascade of neurophysiologic and neuroanatomic changes that increase the risk of cognitive impairment and dementia. Although epidemiological studies have shown that exercise and diet are associated with lower CVD risk and reduced incidence of dementia, no randomized controlled trial (RCT) has examined the independent effects of exercise and diet on neurocognitive function among individuals at risk for dementia. The ENLIGHTEN trial is a RCT of patients with CVD risk factors who also are characterized by subjective cognitive complaints and objective evidence of neurocognitive impairment without dementia (CIND)
Study Design
A 2 by 2 design will examine the independent and combined effects of diet and exercise on neurocognition. 160 participants diagnosed with CIND will be randomly assigned to 6 months of aerobic exercise, the DASH diet, or a combination of both exercise and diet; a (control) group will receive health education but otherwise will maintain their usual dietary and activity habits. Participants will complete comprehensive assessments of neurocognitive functioning along with biomarkers of CVD risk including measures of blood pressure, glucose, endothelial function, and arterial stiffness.
The ENLIGHTEN trial will (a) evaluate the effectiveness of aerobic exercise and the DASH diet in improving neurocognitive functioning in CIND patients with CVD risk factors; (b) examine possible mechanisms by which exercise and diet improve neurocognition; and (c) consider potential moderators of treatment, including subclinical CVD.
PMCID: PMC3800162  PMID: 23000080
Neurocognition; Cognitive impairment; Dementia; Aerobic exercise; Nutrition; DASH diet; CIND; Randomized Clinical Trial
7.  Exercise and Early-Onset Alzheimer's Disease: Theoretical Considerations 
Although studies show a negative relationship between physical activity and the risk for cognitive impairment and late-onset Alzheimer's disease, studies concerning early-onset Alzheimer's disease (EOAD) are lacking. This review aims to justify the value of exercise interventions in EOAD by providing theoretical considerations that include neurobiological processes.
A literature search on key words related to early-onset dementia, exercise, imaging, neurobiological mechanisms, and cognitive reserve was performed. Results/Conclusion: Brain regions and neurobiological processes contributing to the positive effects of exercise are affected in EOAD and, thus, provide theoretical support for exercise interventions in EOAD. Finally, we present the design of a randomized controlled trial currently being conducted in early-onset dementia patients.
PMCID: PMC3347875  PMID: 22590474
Dementia; Early-onset Alzheimer's disease; Early-onset dementia; Intervention; Physical activity; Presenile dementia
8.  Study protocol: a randomised controlled trial of the effects of a multi-modal exercise program on cognition and physical functioning in older women 
BMC Geriatrics  2012;12:60.
Intervention studies testing the efficacy of cardiorespiratory exercise have shown some promise in terms of improving cognitive function in later life. Recent developments suggest that a multi-modal exercise intervention that includes motor as well as physical training and requires sustained attention and concentration, may better elicit the actual potency of exercise to enhance cognitive performance. This study will test the effect of a multi-modal exercise program, for older women, on cognitive and physical functioning.
This randomised controlled trial involves community dwelling women, without cognitive impairment, aged 65–75 years. Participants are randomised to exercise intervention or non-exercise control groups, for 16 weeks. The intervention consists of twice weekly, 60 minute, exercise classes incorporating aerobic, strength, balance, flexibility, co-ordination and agility training. Primary outcomes are measures of cognitive function and secondary outcomes include physical functioning and a neurocognitive biomarker (brain derived neurotrophic factor). Measures are taken at baseline and 16 weeks later and qualitative data related to the experience and acceptability of the program are collected from a sub-sample of the intervention group.
If this randomised controlled trial demonstrates that multimodal exercise (that includes motor fitness training) can improve cognitive performance in later life, the benefits will be two-fold. First, an inexpensive, effective strategy will have been developed that could ameliorate the increased prevalence of age-related cognitive impairment predicted to accompany population ageing. Second, more robust evidence will have been provided about the mechanisms that link exercise to cognitive improvement allowing future research to be better focused and potentially more productive.
Trial registration
Australian and New Zealand Clinical Trial Registration Number: ANZCTR12612000451808
PMCID: PMC3503610  PMID: 23009189
Exercise; Cognition; Aged; Multi-modal exercise; Brain derived neurotrophic factor
9.  The Effect of a Self Exercise Program in Cardiac Rehabilitation for Patients with Coronary Artery Disease 
Annals of Rehabilitation Medicine  2011;35(3):381-387.
To investigate the effect of self exercise in cardiac rehabilitation on cardiopulmonary exercise capacity for selected patients with coronary artery disease.
The subjects of this study were patients who received percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery and who participated in a cardiac rehabilitation program. The supervised exercise group participated in 6-8 weeks of aerobic exercise training with telemetry ECG monitoring in hospital. The self exercise group, whose exercise risk was low, was instructed to participiate in self exercise training in a community exercise environment according to the exercise tolerance test (ETT) using a modified Bruce protocol. Both groups underwent ETTs before and 6 months after initiation of the cardiac rehabilitation program. We compared the supervised group with the self exercise groups on exercise capacity.
After 6 months, the supervised exercise group showed significant changes in maximum oxygen consumption, maximal heart rate, resting heart rate, and submaximal rate pressure product. The self exercise group also showed significant improvement of maximum oxygen consumption and submaximal rate pressure product. However, the changing rate of maximum oxygen consumption was significantly higher in the supervised exercise group than the self exercise group.
Both the supervised and self exercise groups showed similar improvement of cardiopulmonary exercise capacity after 6 months' participation in the cardiac rehabilitation program. However, the changing rate of maximum oxygen consumption, maximal heart rate, and resting heart rate were significantly higher in the supervised exercise group than the self exercise group.
PMCID: PMC3309221  PMID: 22506148
Coronary artery disease; Exercise; Rehabilitation; Self
10.  Effect of Cognitive and Aerobic Training Intervention on Older Adults with Mild or No Cognitive Impairment: A Derivative Study of the Nakajima Project 
An increasing elderly population in Japan requires effective cognitive intervention programs for dementia. This study demonstrates the effectiveness of such programs for older adults.
The participants were local community-dwelling non-demented older adults and adults with mild cognitive impairment who underwent executive function and group aerobic training. In addition, a non-intervention group participated in activity sessions involving handicraft, Skutt ball matches, and cooking. The four criteria for assessment were cognitive function, instrumental activities of daily living, human relationships, and physical function.
The participants in both intervention groups showed a significant improvement in their memory function compared with the non-intervention group.
Early rehabilitation intervention using executive function and aerobic training programs may improve memory.
PMCID: PMC3350345  PMID: 22619662
Community-based study; Dementia; Cognitive rehabilitation; Aerobic exercise; Non-pharmacological therapies; Reasoning; Memory performance/appraisal
11.  Can aerobic exercise protect against dementia? 
There are more than 36 million people in the US over the age of 65, and all of them are impacted by the cognitive decline and brain atrophy associated with normal aging and dementia-causing conditions like Alzheimer's disease, Lewy body disease, and vascular dementia. Recently, moderate exercise and improved fitness have been shown to enhance cognition in cognitively normal older persons as well as in individuals who complain of memory difficulty. Additionally, fitness correlates with brain volume in persons who are cognitively normal and those with Alzheimer's disease. Exercise in mouse models causes neurogenesis in the dentate gyrus. This review will discuss animal experiments, epidemiology, limited prospective studies, and biomarker data that make the case that prospective blinded studies are urgently needed to evaluate the role of aerobic exercise in protecting against dementia.
PMCID: PMC3109415  PMID: 21392412
12.  The Effects of a Multimodal Intervention on Outcomes of Persons With Early-Stage Dementia 
Theories supporting the existence of a use-dependent neuroplasticity in the older brain were used to guide this pilot study. A repeated-measures randomized design was used to test the effectiveness of a multimodal (Taiji exercises, cognitive-behavioral therapies, support group) intervention on cognitive functioning, physical functioning, and behavioral outcomes in persons with dementia. The treatment group (n = 24 persons with dementia) participated in a 40-week intervention, with outcomes assessed at 20 and 40 weeks to assess optimal treatment length. Control group subjects (n = 19 persons with dementia) received attention-control educational programs. At 20 weeks, differences between groups were found for mental ability and self-esteem, with gains in balance being evident. Also, stability in depression and physical health were evident at 20 and 40 weeks for treatment group subjects. Continued improvement in outcomes was not observed at 40 weeks. However, findings support further testing of the intervention along with potential for achieving positive outcomes in early-stage dementia.
PMCID: PMC3014218  PMID: 18453642
multimodal intervention; Taiji exercises; randomized design; cognition; balance
13.  Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer's or vascular type: a review 
Cognitive impairments, and particularly memory deficits, are a defining feature of the early stages of Alzheimer's disease and vascular dementia. Interventions that target these cognitive deficits and the associated difficulties with activities of daily living are the subject of ever-growing interest. Cognitive training and cognitive rehabilitation are specific forms of non-pharmacological intervention to address cognitive and non-cognitive outcomes. The present review is an abridged version of a Cochrane Review and aims to systematically evaluate the evidence for these forms of intervention in people with mild Alzheimer's disease or vascular dementia. Randomized controlled trials (RCTs), published in English, comparing cognitive rehabilitation or cognitive training interventions with control conditions and reporting relevant outcomes for the person with dementia or the family caregiver (or both), were considered for inclusion. Eleven RCTs reporting cognitive training interventions were included in the review. A large number of measures were used in the different studies, and meta-analysis could be conducted for several primary and secondary outcomes of interest. Several outcomes were not measured in any of the studies. Overall estimates of the treatment effect were calculated by using a fixed-effects model, and statistical heterogeneity was measured by using a standard chi-squared statistic. One RCT of cognitive rehabilitation was identified, allowing the examination of effect sizes, but no meta-analysis could be conducted. Cognitive training was not associated with positive or negative effects in relation to any of the reported outcomes. The overall quality of the trials was low to moderate. The single RCT of cognitive rehabilitation found promising results in relation to some patient and caregiver outcomes and was generally of high quality. The available evidence regarding cognitive training remains limited, and the quality of the evidence needs to improve. However, there is still no indication of any significant benefits from cognitive training. Trial reports indicate that some gains resulting from intervention may not be captured adequately by available standardized outcome measures. The results of the single RCT of cognitive rehabilitation show promise but are preliminary in nature. Further well-designed studies of cognitive training and cognitive rehabilitation are required to provide more definitive evidence. Researchers should describe and classify their interventions appropriately by using the available terminology.
PMCID: PMC3979126  PMID: 23924584
14.  Increased Risk of Dementia When Spouse Has Dementia? The Cache County Study 
Chronic psychosocial stress in caregivers can lead to adverse health outcomes including depression, anxiety, and cognitive decline. We examined the effects of having a spouse with dementia on one’s own risk for incident dementia.
Population-based study of incident dementia in spouses of persons with dementia.
Rural county in northern Utah.
2,442 subjects (1,221 married couples) aged 65 and older.
Incident dementia was diagnosed in 255 subjects, with onset defined as age when subject met DSM-III-R criteria for dementia. Cox proportional hazards regression tested the effect of time-dependent exposure to dementia in one’s spouse, adjusted for potential confounders.
A subject whose spouse experienced incident dementia onset had a six-fold increase in the hazard for incident dementia compared to subjects whose spouses were dementia free [Hazard Rate Ratio (HRR)=6.0, 95% CI: 2.2–16.2 (p<.001)]. In sex-specific analyses, husbands had higher risks (HRR=11.9, 95% CI: 1.7–85.5, p=.014) compared to wives (HRR=3.7, 95% CI: 1.2–11.6, p=.028).
The chronic and often severe stress associated with dementia caregiving may exert substantial risk for the development of dementia in spouse caregivers. Additional (not mutually exclusive) explanations for findings are discussed.
PMCID: PMC2945313  PMID: 20722820
dementia; caregiving; stress
15.  Physical exercise and cognitive performance in the elderly: current perspectives 
In an aging population with increasing incidence of dementia and cognitive impairment, strategies are needed to slow age-related decline and reduce disease-related cognitive impairment in older adults. Physical exercise that targets modifiable risk factors and neuroprotective mechanisms may reduce declines in cognitive performance attributed to the normal aging process and protect against changes related to neurodegenerative diseases such as Alzheimer’s disease and other types of dementia. In this review we summarize the role of exercise in neuroprotection and cognitive performance, and provide information related to implementation of physical exercise programs for older adults. Evidence from both animal and human studies supports the role of physical exercise in modifying metabolic, structural, and functional dimensions of the brain and preserving cognitive performance in older adults. The results of observational studies support a dose-dependent neuroprotective relationship between physical exercise and cognitive performance in older adults. Although some clinical trials of exercise interventions demonstrate positive effects of exercise on cognitive performance, other trials show minimal to no effect. Although further research is needed, physical exercise interventions aimed at improving brain health through neuroprotective mechanisms show promise for preserving cognitive performance. Exercise programs that are structured, individualized, higher intensity, longer duration, and multicomponent show promise for preserving cognitive performance in older adults.
PMCID: PMC3872007  PMID: 24379659
aging; neurodegeneration; dementia; brain; physical activity
16.  Effects of multicomponent exercise on cognitive function in older adults with amnestic mild cognitive impairment: a randomized controlled trial 
BMC Neurology  2012;12:128.
To examine the effects of a multicomponent exercise program on the cognitive function of older adults with amnestic mild cognitive impairment (aMCI).
Design: Twelve months, randomized controlled trial; Setting: Community center in Japan; Participants: Fifty older adults (27 men) with aMCI ranging in age from 65 to 93 years (mean age, 75 years); Intervention: Subjects were randomized into either a multicomponent exercise (n = 25) or an education control group (n = 25). Subjects in the multicomponent exercise group exercised under the supervision of physiotherapists for 90 min/d, 2 d/wk, for a total of 80 times over 12 months. The exercises included aerobic exercises, muscle strength training, and postural balance retraining, and were conducted using multiple conditions to stimulate cognitive functions. Subjects in the control group attended three education classes regarding health during the 12-month period. Measurements were administered before, after the 6-month, and after the 12-month intervention period; Measurements: The performance measures included the mini-mental state examination, logical memory subtest of the Wechsler memory scale-revised, digit symbol coding test, letter and categorical verbal fluency test, and the Stroop color word test.
The mean adherence to the exercise program was 79.2%. Improvements of cognitive function following multicomponent exercise were superior at treatment end (group × time interactions for the mini-mental state examination (P = 0.04), logical memory of immediate recall (P = 0.03), and letter verbal fluency test (P = 0.02)). The logical memory of delayed recall, digit symbol coding, and Stroop color word test showed main effects of time, although there were no group × time interactions.
This study indicates that exercise improves or supports, at least partly, cognitive performance in older adults with aMCI.
PMCID: PMC3534485  PMID: 23113898
Aerobic exercise; MCI; Elderly; Alzheimer’s disease; Prevention
17.  How do persons with dementia participate in decision making related to health and daily care? A multi-case study 
Many countries have passed laws giving patients the right to participate in decisions about health care. People with dementia cannot be assumed to be incapable of making decisions on their diagnosis alone as they may have retained cognitive abilities.
The purpose of this study was to gain a better understanding of how persons with dementia participated in making decisions about health care and how their family carers and professional caregivers influenced decision making.
This Norwegian study had a qualitative multi-case design. The triad in each of the ten cases consisted of the person with dementia, the family carer and the professional caregiver, in all 30 participants. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2, moderate dementia; (3) able to communicate verbally. The family carers and professional caregivers were then asked to participate.
A semi-structured interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day centre. How the professional caregivers facilitated decision making was the focus of the observations that varied in length from 30 to 90 minutes. The data were analyzed using framework analysis combined with a hermeneutical interpretive approach.
Professional caregivers based their assessment of mental competence on experience and not on standardized tests. Persons with dementia demonstrated variability in how they participated in decision making. Pseudo-autonomous decision making and delegating decision making were new categories that emerged. Autonomous decision making did occur but shared decision making was the most typical pattern. Reduced mental capacity, lack of available choices or not being given the opportunity to participate led to non-involvement. Not all decisions were based on logic; personal values and relationships were also considered.
Persons with moderate dementia demonstrated variability in how they participated in decision making. Optimal involvement was facilitated by positioning them as capable of influencing decisions, assessing decision-specific competence, clarifying values and understanding the significance of relationships and context.
PMCID: PMC3475075  PMID: 22870952
18.  Outcomes of Older Cognitively Impaired Individuals With Current and Past Depression in the NCODE Study 
We examined the frequency and course of cognitive impairment, no dementia among a group of older patients enrolled in a longitudinal study of depression. Among 230 participants, 29 with baseline dementia diagnosis were excluded from further analyses. Among the remaining 201 participants, 69 were classified with cognitive impairment, no dementia—broadly defined (34.3%) and 28 (13.9%) with cognitive impairment, no dementia—narrowly defined. At 2-year follow-up, individuals with cognitive impairment, no dementia either narrowly or broadly defined had varied outcomes including (1) improvement to normal cognition, (2) continued cognitive impairment, and (3) progression to dementia. Patients with cognitive impairment, no dementia were more likely to be assigned a later diagnosis of dementia. Our results characterize the concept of cognitive impairment, no dementia as a risk factor for dementia among older individuals with current and past depression; however, just as with the general population, the course of this condition is heterogeneous.
PMCID: PMC2745319  PMID: 19196631
depression; cognitive impairment; cognitive decline
19.  Endurance Exercise Training in Older Patients with Heart Failure: Results from a Randomized, Controlled, Single-Blind Trial 
To test the hypothesis that exercise training (ET) improves exercise capacity and other clinical outcomes in older persons with heart failure with reduced ejection fraction (HfrEF).
Randomized, controlled, single-blind trial.
Outpatient cardiac rehabilitation program.
Fifty-nine patients aged 60 and older with HFrEF recruited from hospital records and referring physicians were randomly assigned to a 16-week supervised ET program (n = 30) or an attention-control, nonexercise, usual care control group (n = 29).
Sixteen-week supervised ET program of endurance exercise (walking and stationary cycling) three times per week for 30 to 40 minutes at moderate intensity regulated according to heart rate and perceived exertion.
Individuals blinded to group assignment assessed four domains pivotal to HFrEF pathophysiology: exercise performance, left ventricular (LV) function, neuroendocrine activation, and health-related quality of life (QOL).
At follow-up, the ET group had significantly greater exercise time and workload than the control group, but there were no significant differences between the groups for the primary outcomes: peak exercise oxygen consumption (VO2 peak), ventilatory anaerobic threshold (VAT), 6-minute walk distance, QOL, LV volumes, EF, or diastolic filling. Other than serum aldosterone, there were no significant differences after ET in other neuroendocrine measurements. Despite a lack of a group “training” effect, a subset (26%) of individuals increased VO2 peak by 10% or more and improved other clinical variables as well.
In older patients with HFrEF, ET failed to produce consistent benefits in any of the four pivotal domains of HF that were examined, although the heterogeneous response of older patients with HFrEF to ET requires further investigation to better determine which patients with HFrEF will respond favorably to ET.
PMCID: PMC2950161  PMID: 20121952
rehabilitation; functional capacity; exercise physiology; cardiac function
20.  Evaluation of a computer-assisted errorless learning-based memory training program for patients with early Alzheimer’s disease in Hong Kong: a pilot study 
Improving the situation in older adults with cognitive decline and evidence of cognitive rehabilitation is considered crucial in long-term care of the elderly. The objective of this study was to implement a computerized errorless learning-based memory training program (CELP) for persons with early Alzheimer’s disease, and to compare the training outcomes of a CELP group with those of a therapist-led errorless learning program (TELP) group and a waiting-list control group.
A randomized controlled trial with a single-blind research design was used in the study. Chinese patients with early Alzheimer’s disease screened by the Clinical Dementia Rating (score of 1) were recruited. The subjects were randomly assigned to CELP (n = 6), TELP (n = 6), and waiting-list control (n = 7) groups. Evaluation of subjects before and after testing, and at three-month follow-up was achieved using primary outcomes on the Chinese Mini-Mental State Examination, Chinese Dementia Rating Scale, Hong Kong List Learning Test, and the Brief Assessment of Prospective Memory-Short Form. Secondary outcomes were the Modified Barthel Index, Hong Kong Lawton Instrumental Activities of Daily Living Scale, and Geriatric Depression Scale-Short Form. The data were analyzed using Friedman’s test for time effect and the Kruskal-Wallis test for treatment effect.
Positive treatment effects on cognition were found in two errorless learning-based memory groups (ie, computer-assisted and therapist-led). Remarkable changes were shown in cognitive function for subjects receiving CELP and emotional/daily functions in those receiving TELP.
Positive changes in the cognitive function of Chinese patients with early Alzheimer’s disease were initially found after errorless training through CELP. Further enhancement of the training program is recommended.
PMCID: PMC3679968  PMID: 23766638
Alzheimer’s disease; memory training; errorless learning; computerized; early dementia
21.  Exercise Interventions for Dementia and Cognitive Impairment: The Seattle Protocols 
Research evidence strongly suggests that increased physical exercise may not only improve physical function in older adults but may also improve mood and slow the progression of cognitive decline. This paper describes a series of evidence-based interventions grounded in social-learning and gerontological theory that were designed to increase physical activity in persons with dementia and mild cognitive impairment. These programs, part of a collective termed the Seattle Protocols, are systematic, evidence-based approaches that are unique 1) in their focus on the importance of making regular exercise a pleasant activity, and 2) in teaching both cognitively impaired participants and their caregivers behavioral and problem-solving strategies for successfully establishing and maintaining realistic and pleasant exercise goals. While additional research is needed, initial findings from randomized controlled clinical trials are quite promising and suggest that the Seattle Protocols are both feasible and beneficial for community-residing individuals with a range of cognitive abilities and impairments.
PMCID: PMC2518041  PMID: 18548177
AD; Behavioral Treatment; Caregiver training; Depression; Physical Activity; Behavioral problems; Exercise
22.  Exercise and cognition: Results from the National Long Term Care Survey 
Age remains a robust risk factor for Alzheimer’s disease as well as other dementias. Therefore, the aging of the population in the United States will result in dramatic increases in the prevalence of dementia if preventative interventions are not identified. The aim of this study was to examine potential associations between exercise and lowering the risk of cognitive impairment.
National Long Term Care Survey (NLTCS) data were used. Level of exercise participation was measured at baseline (1994) and cognitive impairment status was measured at baseline and 5- and 10-year follow-up. Linear regression was performed, controlling for age, sex, education, baseline score on cognitive test, diabetes and hypertension.
At 10-year follow-up, the number of different types of exercises performed was inversely associated with the onset of cognitive impairment (p=0.002) as was the number of exercise sessions lasting at least 20 minutes (p=0.007).
Study results from NLTCS data provide evidence supporting the potential for exercise to lower the risk of dementia.
PMCID: PMC2983109  PMID: 21044775
exercise; physical activity(ies); cognitive impairment; cognition; dementia
23.  Exercise Program to Enhance Physical Performance and Quality of Life of Older Hemodialysis Patients: A Feasibility Study 
International urology and nephrology  2010;42(4):1125-1130.
Evaluate the feasibility of implementing a combined in-hospital and home-based exercise program in older hemodialysis (HD) patients.
A prospective longitudinal 12-week pilot study.
A university hospital HD unit and patients’ homes.
A convenience sample of 9 older (>55years) patients undergoing HD.
An individualized exercise program performed on HD days (3/week) and at home (2–3/week), including aerobic, flexibility, strength exercises and patient education.
Main Outcome Measures
Feasibility measures: patient participation and satisfaction. Exercise performance: Duke Activity Status Index (DASI); 2-minute walk test (2MWT); Timed-up-and-go (TUG). Quality of life: The Illness Intrusiveness Ratings Scale (IIRS); The Kidney Disease Quality of Life questionnaire (KDQOL).
The mean (SD) age of the patients was 68.1 (7.1). Participation in the in-hospital supervised exercise program was high, with patients exercising during 89% of HD sessions, but was lower for the unsupervised home-based component (56% exercised ≥ 2 times/week). Patients showed a gradual increase in the amount of exercise performed over 12 weeks. The 2MWT, TUG, IIRS and the KDQOL physical composite score demonstrated moderate responsiveness, while the DASI score exhibited only limited responsiveness.
This exercise program and the outcome measures were feasible for older HD patients: inhospital participation was high and physical performance and QOL measures exhibited moderate levels of responsiveness. Future, larger studies are needed to demonstrate whether intra-dialysis exercise, with or without home exercise, can lead to improved outcomes in this population.
PMCID: PMC3252390  PMID: 20213292 CAMSID: cams2045
Aged; Exercise; Physical fitness; Quality of Life; Renal Dialysis
24.  Development and Feasibility of a Smartphone, ECG and GPS Based System for Remotely Monitoring Exercise in Cardiac Rehabilitation 
PLoS ONE  2011;6(2):e14669.
Despite its efficacy and cost-effectiveness, exercise-based cardiac rehabilitation is undertaken by less than one-third of clinically eligible cardiac patients in every country for which data is available. Reasons for non-participation include the unavailability of hospital-based rehabilitation programs, or excessive travel time and distance. For this reason, there have been calls for the development of more flexible alternatives.
Methodology and Principal Findings
We developed a system to enable walking-based cardiac rehabilitation in which the patient's single-lead ECG, heart rate, GPS-based speed and location are transmitted by a programmed smartphone to a secure server for real-time monitoring by a qualified exercise scientist. The feasibility of this approach was evaluated in 134 remotely-monitored exercise assessment and exercise sessions in cardiac patients unable to undertake hospital-based rehabilitation. Completion rates, rates of technical problems, detection of ECG changes, pre- and post-intervention six minute walk test (6 MWT), cardiac depression and Quality of Life (QOL) were key measures. The system was rated as easy and quick to use. It allowed participants to complete six weeks of exercise-based rehabilitation near their homes, worksites, or when travelling. The majority of sessions were completed without any technical problems, although periodic signal loss in areas of poor coverage was an occasional limitation. Several exercise and post-exercise ECG changes were detected. Participants showed improvements comparable to those reported for hospital-based programs, walking significantly further on the post-intervention 6 MWT, 637 m (95% CI: 565–726), than on the pre-test, 524 m (95% CI: 420–655), and reporting significantly reduced levels of cardiac depression and significantly improved physical health-related QOL.
Conclusions and Significance
The system provided a feasible and very flexible alternative form of supervised cardiac rehabilitation for those unable to access hospital-based programs, with the potential to address a well-recognised deficiency in health care provision in many countries. Future research should assess its longer-term efficacy, cost-effectiveness and safety in larger samples representing the spectrum of cardiac morbidity and severity.
PMCID: PMC3036581  PMID: 21347403
25.  Return to Full Functioning after Graded Exercise Assessment and Progressive Exercise Treatment of Postconcussion Syndrome 
Exercise assessment and aerobic exercise training for postconcussion syndrome (PCS) may reduce concussion-related physiological dysfunction and symptoms by restoring autonomic balance and improving cerebral blood flow autoregulation. In a descriptive pilot study of 91 patients referred to a university clinic for treatment of PCS, a subset of 63 patients were contacted by telephone for assessment of symptoms and return to full daily functioning. Those who experienced symptoms during a graded exercise treadmill test (physiologic PCS, n = 40) were compared to those who could exercise to capacity (PCS, n = 23). Both groups had been offered progressive exercise rehabilitation. Overall 41 of 57 (72%) who participated in the exercise rehabilitation program returned to full daily functioning. This included 27 of 35 (77%) from the physiologic PCS group, and 14 of 22 (64%) from the PCS group. Only 1 of the 6 patients who declined exercise rehabilitation returned to full functioning. Interpretation of these results is limited by the descriptive nature of the study, the small sample size, and the relatively few patients who declined exercise treatment. Nonetheless, exercise assessment indicates that approximately one third of those examined did not have physiologic PCS.
PMCID: PMC3265107  PMID: 22292122

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