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