Welcome!Exercise programs for people with dementia:

What's the evidence?

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What’s the evidence? Forbes, D., Forbes, S. C., Blake, C. M., Thiessen, E. J., & Forbes, S. (2015). Exercise programs for people with dementia. Cochrane Database of Systematic Reviews, 2015(4), CD006489.http://www.healthevidence.org/view-article.aspx?a=23982

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National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

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Poll Question #4

Dorothy Forbes, PhD, RNProfessor, Faculty of Nursing, University of Alberta

Exercise programs improve health outcomes for people with dementiaA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #5

ReviewForbes, D., Forbes, S. C., Blake, C. M., Thiessen, E. J., & Forbes, S. (2015). Exercise programs for people with dementia. Cochrane Database of Systematic Reviews, 2015(4), CD006489.

Review Team

• Dorothy Forbes, University of Alberta• Scott C. Forbes, Okanagan College • Catherine M. Blake, University of

Western Ontario• Emily J. Thiessen, University of Alberta• Sean Forbes, University of Florida

Background• In 2012, WHO declared dementia a public health priority.

• In the coming decades, with the aging of the population, the number of individuals living with dementia in our communities will rise dramatically, affecting their quality of life.

• In addition, the burden on family caregivers, community care, and residential care services will increase.

• Exercise is among the potential protective lifestyle factors identified as a strategy for treating the symptoms of dementia or delaying its progression.

Review Questions• Do exercise programs for older persons

with dementia: – improve cognition, activities of daily living

(ADLs), neuropsychiatric symptoms, depression, and mortality?

– have an indirect impact on family caregivers’ burden, quality of life, and mortality?

– reduce the use of health care services (e.g. visits to the emergency department) by persons with dementias and their family caregivers?

Approach• Selection of studies:

– Studies were identified from searching the ALOIS, the Cochrane Dementia & Cognitive Improvement Group’s specialized register.

– All relevant RCTs in which older adults with dementia were allocated to either exercise programs or control groups (usual care or social contact/activities) were included.

– At least two reviewers independently assessed retrieved articles for inclusion, assessed methodological quality, and extracted data.

Analyses• We calculated mean differences or

standardized mean differences for continuous data.

• Data for each outcome were synthesized using a fixed effects model, unless there was substantial heterogeneity between studies, then a random effects model was applied.

• We also evaluated adverse events.

Analyses• Subgroup analysis and investigation of

heterogeneity:

– Severity and type of dementia

– Type, frequency, and duration of exercise program

Results of Search & Screening

5241 titles/abstracts located

542 abstracts screened for inclusion

18 articles (17 trials) met criteria and were included

69 articles retrieved and rated

Studies/Participants• Trials published between 1997-2012

• Conducted in USA=4, Netherlands=3, Australia=2, France=2, Belgium=1, Brazil=1, Italy=1, South Korea=1, Spain=1, Sweden=1

• Participants (N=1067) were residents of nursing homes, graduated residential care, psychiatric facilities, day care centres, and in their own home settings.

Exercise Programs • Program length varied from two weeks to 18

months

• Programs ranged from twice/week to daily and from 20 to 75 minutes per session

• Exercises were combinations of aerobic, strength, and balance

• Control groups were usual care or social contact

Risk of Bias of Included Studies

Results

Exercise & Cognition• Nine trials (409 participants) examined the

effect of exercise on cognition• The meta-analysis revealed no clear evidence of

benefit from exercise on cognitive functioning• Estimated standardized mean difference

between exercise and control groups was 0.43 (95% CL -0.05 to 0.92, P value 0.08)

• There was substantial heterogeneity in this analysis (I2 value 80%) and quality of evidence was very low

Exercise & ADLs • We found a benefit of exercise programs on the

ability of people with dementia to perform ADLs (six trials, 289 participants)

• Estimated standardized mean difference between exercise and control groups was 0.68 ( 95% CL -0.08 to 1.27, P value 0.02)

• There was substantial unexplained heterogeneity in this analysis (I2 value 77%) and quality of evidence was very low

Other Outcomes• One study suggested that caregiving

burden may be reduced by supporting the person with dementia to participate in an exercise program

• There was no clear evidence of benefit of exercise on neuropsychiatric symptoms or depression in persons with dementia

Other Outcomes (cont’d)• The remaining outcomes could not be

examined because appropriate data were not reported:– Quality of Life– Mortality– Health Care Costs

Summary• This review included 17 trials with 1067

participants

• The exercise programs varied greatly

• The review suggests that exercise may improve the ability to perform ADLs

• There was no clear evidence of benefit from exercise on cognitive functioning, neuropsychiatric symptoms, or depression

Recommendations to Improve Methodological Quality • In several cases useable data for inclusion

in the meta-analysis were not provided by the authors

• Authors should include:– Means and SDs for end point measures– Change from baseline to final measurement

scores in published reports, or– Be willing to provide these data on request

Quality of the Evidence • Many authors did not adequately report

the random sequence generation and allocation concealment processes

• Several authors did not report the outcome data for each main outcome

• Some authors failed to report on the blinding of outcome assessors

Implications for Practice• No trials reported adverse events related to the exercise

programs

• Health care providers should feel confident in promoting physical activity to persons with dementia

• Decreasing the progression of dependence in ADLs will have clear benefits for the persons with dementia and their caregivers and possibly delay the need for placement in long term care settings

• Encouraging caregivers to participate in exercise may have a beneficial impact on their quality of life

Implications for Research• Setting of intervention (home or institution) should be

considered in future

• There were insufficient trials to conduct subgroup analyses to determine which type of exercise (aerobic, strength training, or a combination), at what frequency and duration, is most beneficial for specific types and severity of dementia

• Further research is needed to develop best practice guidelines for health care providers to advise persons with dementia living in institutional and community settings

ReferenceProtocol first published in 2007, regular updates since then

Forbes D, Forbes SC, Blake CM, Thiessen EJ, & Forbes S. Exercise programs for people with dementia. (Review). Cochrane Database of Systematic Reviews 2015;4.

For further information contact dorothy.forbes@ualberta.ca

Exercise programs improve health outcomes for people with dementiaA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #6

Poll Question #7Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Questions?

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

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