the effect of exercise on behavioural and psychological symptoms in dementia: a review of the...

THE EFFECT OF EXERCISE ON BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS IN

DEMENTIA: A REVIEW OF THE LITERATURE

Dr. Ingela Thuné-Boyle

Prof. Steve IliffeUCL, Department of Primary Care and Population Health

Ms. Arlinda Cerga Pashoja

Dr. David Lowery

Dr. James WarnerCentral and North West London NHS Foundation Trust

Background • BPSD: Anxiety, depression, apathy, agitation, aggression, ‘wandering’,

repetitive motor behaviours, sleep, disinhibition, eating, delusions, hallucinations

• Up to 80% - changes in mood, personality and behaviour (e.g. Overshott & Burns, 2007) and sleep disruptions (Bradley et al., 2002)

• Pharmacological: mood stabilisers, anxiolytics, hypnotic, acetylcholinesterase inhibitors/memantine and antipsychotics

• Worsening symptoms and negative side effects (Boeve et al., 2002)• Unclear efficacy & high cost (e.g. Areosa et al., 2005)• Sedation, gait disturbance, falls, dehydration, chest infections,

accelerated cognitive decline, stroke and death (Schneider et al., 2006)

Background

• Guidance directing clinicians to avoid use of anti-psychotics in dementia (e.g. NICE, 2006) – ‘watchful waiting’ approach – symptoms (e.g. agitation) often improve after a 4-6 week period

• 40% to 60% of care home residents with dementia currently prescribed antipsychotics

• Approx two thirds of prescriptions are inappropriate

• Medicated without dealing with the cause of the problem

• Non-pharmacological interventions?

Background

• Benefit of exercise in older adults – Improved physical & psychological outcomes:– Prevention of heart disease, diabetes, stroke, falls etc.– Reduced depression– Improved QoL– Enhanced sleep

• In dementia: reviews – different inclusion criteria, different conclusions, different outcomes

Aim of review

• Does exercise improve BPSD?

• How has exercise been conceptualised and do some aspects of it (e.g. type, frequency & duration) provide better results than others?

• What are the main limitations and methodological shortcomings of current research in this area?

Methodology

• Rapid appraisal

• Critical interpretive approach (Dixon-Woods et al., 2006)

• Inclusion/Exclusion– Efficacy of exercise in improving BPSD– Intervention studies– Reviews & individual papers– Published in peer review journals– Combined interventions excluded

• Medline, Embase, Psychinfo & Pubmed– Number of records identified: n = 723…Final number: 10 reviews

and 6 individual papers

Results

• Type of exercise: Walking, flexibility, strength (e.g. weight training) & balance, cycling, chair-based, dance and rhythmic movement, meaning based, sit to stand repetition

• Anxiety: Some evidence (chair based and walking) of immediate effect, maintained at 12 weeks

• Depression: Mixed. Few short-term effects but after longer duration (e.g. 3 months onwards – walking, strength, flexibility), effect more likely

• Apathy: No evidence (one pilot study only)

Results

• Aggression/Agitation: Evidence of short and long term effects of walking, aerobics, strength & meaningful exercise

• Wandering: Some evidence (structural activity)

• Repetitive behaviours: No studies

• Sleep: Few studies but positive evidence, especially for mild sleep disturbance. Type of exercise not clear but higher frequency = better outcome irrespective of duration

Results

• What worked? - Walking, chair-based, aerobics, strength & meaningful exercise

• Many studies did not mention frequency and duration– Heyn et al. (2004) – unable to demonstrate significant findings– Eggermont & Scherder (2006) – higher frequency = better

outcome (sleep) irrespective of duration– May vary depending on symptom in question

Methodological shortcomings

• Substantial!

• Few RCTs (mostly pilot), absence of blinding

• Low sample size

• Short follow-up periods – some symptoms may take longer to respond

• Mixed dementia (2 studies = Alzheimer’s only)

• Cause of BPSD rarely discussed (e.g. ‘wandering’ caused by feeling lost or anxious?)

Future research agenda

• More comprehensive list of BPSD

• Adherence/Motivation

• Care homes (e.g. apathy) vs. home setting (most conducted within the care home)

• Group based vs. individual

• Type, frequency and duration in different types and severity of dementia

• How does exercise reduce BPSD? (E.g. Reduction in anxiety = reduction in agitation/repetitive action/wandering? Depression = increased confusion = increased anxiety/aggression? )

i.thune-boyle@ucl.ac.uk