Exercise Helpful in Home-Dwelling Dementia Patients

Megan Brooks

April 18, 2013

For patients with Alzheimer's disease (AD) living at home, regular exercise can slow deterioration in physical functioning and reduce the risk for falls, according to results of the randomized Finnish Alzheimer Disease Exercise Trial (FINALEX).

"This intervention provides new means of helping patients with dementia and their families maintain their way of life longer without increasing the total use or costs of health and social services," Kaisu H. Pitkälä, MD, University Helsinki, Finland, and colleagues say.

FINALEX, Dr. Pitkälä told Medscape Medical News, "demonstrated that the exercise must be guided (physiotherapist guiding the patient at each session), tailored according to patients' needs in their everyday life, intensive (1 hour twice a week) and long-term (the effectiveness was not shown until they had exercised for a half a year)."

The study was published online April 15 in JAMA Internal Medicine.

FINALEX

FINALEX involved 210 patients with AD living at home with their spousal caregiver and tested 2 types of exercise interventions: home-based exercise (HE) for 1 hour twice weekly, guided by a physiotherapist, and group-based exercise (GE), also guided by a physiotherapist and provided during visits to day care centers twice weekly. Both interventions lasted for 1 year, and results were compared with those from a control group receiving usual community care.

Dr. Kaisu H. Pitkälä

There were 70 patients in each group. Adherence to the exercise interventions was "high," with 92.9% of patients in the HE group and 78.6% in the GE group participating in at least half the sessions, the researchers say.

As expected, all patient groups showed deterioration in functioning during the year after randomization, but deterioration was significantly faster in the control group than in the 2 exercise groups at 6 (P = .003) and 12 (P = .015) months.

Table. Mean Change in Functional Independence Measure

Group 6 Months (95% CI) 12 Months (95% CI)
HE –6.5 (–4.4 to –8.6) –7.1 (–3.7 to –10.5)
GE –8.9 (–6.7 to –11.2) –10.3 (–6.7 to –13.9)
Control –11.8 (–9.7 to –14.0) –14.4 (–10.9 to –18.0)

CI = confidence interval.

The difference between the HE group and the control group was significant at 6 months (P = .001) and 12 months (P = .004), but the difference between the GE group and the control group was not (P = .07 and P = .12, respectively).

The researchers say the average 7-point (6%) difference in the functional independence measure ratings between the HE group and the control group is "clinically meaningful because it indicates less need for help in several daily activity categories."

Fall Prevention

The exercise interventions did not significantly affect mobility, as evidenced by scores on the Short Physical Performance Battery, but the exercise groups had significantly fewer falls than the control group, a key finding, the researchers say.

People with dementia living at home are at high risk for disability and falls, Dr. Pitkälä said. "No previous trial has been able to show that any intervention could reduce the number of falls among people with dementia; this is the first one in this respect. Furthermore, the benefits were gained without increasing the total health and social care costs."

Medscape Medical News invited Klaus Hauer, PhD, Department of Geriatric Research, Bethanien-Hospital and Geriatric Centre, University of Heidelberg, Germany, to comment on these findings.

"I think the merit of this well done study in my perspective is the cost evaluation, the comparison of different training modules/organizations (although with limited between group differences) and the fact that they achieved a reduction of falls," Dr. Hauer said. "Strangely, [the authors] do not put that result more in front. There are hardly any positive fall prevention studies published for demented [patients], although this was not the primary endpoint of the study."

Dr. Pitkälä told Medscape Medical News FINALEX is "unique" because it is believed to be the first randomized clinical trial exploring and demonstrating the value of exercise on physical functioning of home-dwelling people with dementia.

She noted that one previous randomized trial (J Am Geriatr Soc. 2007;55:158-165) showed that intensive exercise may improve functioning of patients with dementia who live in nursing homes.

As reported recently by Medscape Medical News, researchers have shown that an exercise program delivered at an adult day care center and integrating functional movement and mindful body awareness can improve dementia patients' cognitive and physical function and quality of life and reduce caregiver burden compared with usual care, with effect sizes greater than those achieved with dementia medications.

The FINALEX researchers say several reasons probably explain why the home-based intervention was successful. It was individually tailored and performed at home, which is pleasant for older adults; the exercise was intense and long term and included "brain training" exercises; the physiotherapists were specially trained to treat patients with dementia; and adherence was "exceptionally high," unlike in other trials.

Key limitations of the trial include the inclusion of "selected, motivated volunteers, all of whom were white," and the fact that the trial was not blinded. "The strength of our study is that it relies on a single intervention implementable by a single professional group in primary care. It shows that a patient group especially vulnerable to functional decline can benefit from exercise."

FINALEX was supported by the Social Insurance Institution of Finland, the Central Union for the Welfare of the Aged, the Sohlberg Foundation, and King Gustaf V and Queen Victoria's Foundation. Dr. Pitkälä reports relationships with Lundbeck, MSD Finland, Novartis, and Nestle. A complete list of author disclosures is available with the original article.

JAMA Intern Med. Published online April 15, 2013. Abstract

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