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Gait speed and physical exercise in people with dementia
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Gånghastighet och fysisk träning bland personer med demenssjukdom (Swedish)
Abstract [en]

The aim of the thesis was to investigate the importance of physical function for survival in very old people, and furthermore, whether physical exercise could influence physical function, cognitive function, and dependence in activities of daily living (ADLs) in older people with dementia living in nursing homes.

The world’s population is ageing. Given the age-related increase in chronic disease such as dementia   and compounded by physical inactivity, the prevalence in need for assistance and are in daily activities in older people is expected to increase in the near future. Gait speed, a measure of physical function, has been shown to be associated with health and survival. However, studies of the  oldest  people  in  the  population,  including  those  dependent  in ADLs,  living  in  nursing  homes  and  with  dementia,  are  few.  Moreover,  in people  with  dementia  physical  exercise  may  improve  physical and  cognitive function and  reduce  dependence  in  ADLs.  Further large studies with high methodological quality and with designs incorporating attention control groups are needed in this population. In addition, no study has compared exercise effects between dementia types.

The association between gait speed and survival was investigated in a population based cohort study of 772 people aged 85 years and over. Usual gait speed was assessed over 2.4 metres and mortality followed for five years. Cox proportional hazard regression models adjusted for potential confounders were used in analyses. Effects of physical exercise in people with dementia were investigated in a randomised controlled trial that included 186 participants with various dementia types living in nursing homes. Participants were allocated to the High-Intensity Functional Exercise  (HIFE) program or a seated control activity, which both lasted 45 minutes and held five times  fortnightly for four months. Dependence in ADLs was assessed with Functional Independence Measure and Barthel ADL Index, and balance with Berg Balance Scale. Usual gait speed was evaluated over 4.0 metres in two tests; first using habitual walking aid if any, and thereafter without walking aid and with minimum living support. Global cognitive function was assessed using the Mini-Mental State Examination, the Alzheimer’s Disease Assessment Scale-Cognitive subscale, and   executive function using Verbal fluency. Blinded testers performed assessments at baseline, four (directly after intervention completion) and seven months. Analyses used linear mixed models in agreement with the intention-to-treat principle.

Gait speed was found to be an independent predictor of five-year all-cause mortality, where inability to complete the gait test or a gait speed below 0.5 iv meters per second (m/s) was associated with higher mortality risk. In analyses of exercise effects on ADLs there was no difference between groups in the complete sample. Interaction analyses showed a difference in exercise effect according to dementia type at seven months. Positive between-group exercise effects were found for dependence   in ADLs in participants with non-Alzheimer’s type of dementia (non-AD) at four and seven months. In balance, a difference between groups was found at four but not at seven months in the complete  sample, and interaction analyses indicated a difference in effect according to dementia type at four and seven months. Positive between-group exercise effects were found in participants with non-AD.  No difference between groups in gait speed was found in the complete sample, where the majority habitually walked with a walking aid. In interaction analyses exercise effects differed according to walking aid use. Positive between-group exercise effects in gait speed were found in participants that walked unsupported at four and seven months. No difference between groups in cognitive function was found in the complete sample. The effects of exercise on gait speed and cognitive function did not differ according to sex, cognitive level, or dementia type.

In conclusion, among people aged 85 or older, including those dependent in ADLs and with dementia, gait speed seems to be a useful clinical indicator of health status. Inability to complete the gait test or a gait speed below 0.5 m/s appears to be associated with higher five-year mortality risk. In older people with mild to moderate dementia living in nursing homes, a four-month high-intensity functional exercise program appeared to attenuate loss of dependence in ADLs and improve balance, albeit only in participants with non-AD type of dementia. Further studies are needed to validate this result. Furthermore, exercise had positive effects on gait speed when tested unsupported, in contrast to when walking aids or minimum support were used. The result implies that the use of walking aids in the gait speed test may conceal exercise effects. The exercise program had no superior effects on global cognition or executive function when compared with an attention control activity. This thesis suggests that, in older people with dementia, exercise effects on physical function rather than cognitive function may explain effects on dependence in ADLs.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2016. , p. 70
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1866
Keywords [en]
Exercise, dementia, residential facilities, postural balance, activities of daily living, cognitive function, mobility limitation, Alzheimer's disease, rehabilitation, frail elderly, gait speed, mortality, aged 80 and older
National Category
Physiotherapy Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-128733ISBN: 978-91-7601-616-9 (print)OAI: oai:DiVA.org:umu-128733DiVA, id: diva2:1056005
Public defence
2017-01-13, Hörsal Betula, Byggnad 6M, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-12-16 Created: 2016-12-13 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Usual gait speed independently predicts mortality in very old people: a population-based study
Open this publication in new window or tab >>Usual gait speed independently predicts mortality in very old people: a population-based study
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2013 (English)In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 14, no 7, p. 529.e1-529.e6Article in journal (Refereed) Published
Abstract [en]

Objectives: In older people, usual gait speed has been shown to independently predict mortality; however, less is known about whether usual gait speed is as informative in very old populations, in which prevalence of multimorbidity and disability is high. The aim of this study was to investigate if usual gait speed can independently predict all-cause mortality in very old people, and whether the prediction is influenced by dementia disorder, dependency in activities of daily living (ADL), or use of walking aids in the gait speed test.

Design: Prospective cohort study. Setting: Population-based study in northern Sweden and Finland (the Umea 85+/GERDA Study).

Participants: A total of 772 participants with a mean age of 89.6 years, 70% women, 33% with dementia disorders, 54% with ADL dependency, and 39% living in residential care facilities.

Measurements: Usual gait speed assessed over 2.4 meters and mortality followed-up for 5 years. Results: The mean +/- SD gait speed was 0.52 +/- 0.21 m/s for the 620 (80%) participants able to complete the gait speed test. Cox proportional hazard regression analyses adjusted for potential confounders were performed. Compared with the fastest gait speed group (>= 0.64 m/s), the hazard ratio for mortality was for the following groups: unable = 2.27 (P < .001), <= 0.36 m/s = 1.97 (P = .001), 0.37 to 0.49 m/s = 1.99 (P < .001), 0.50 to 0.63 m/s = 1.11 (P = .604). No interaction effects were found between gait speed and age, sex, dementia disorder, dependency in ADLs, or use of walking aids.

Conclusion: Among people aged 85 or older, including people dependent in ADLs and with dementia disorders, usual gait speed was an independent predictor of 5-year all-cause mortality. Inability to complete the gait test or gait speeds slower than 0.5 m/s appears to be associated with higher mortality risk. Gait speed might be a useful clinical indicator of health status among very old people.

Keywords
Gait speed, mortality, aged 80 and older, dementia
National Category
Physiotherapy Geriatrics
Identifiers
urn:nbn:se:umu:diva-79265 (URN)10.1016/j.jamda.2013.04.006 (DOI)000321491400017 ()23706405 (PubMedID)
Available from: 2013-09-05 Created: 2013-08-13 Last updated: 2018-06-08Bibliographically approved
2. Effects of a High-Intensity Functional Exercise Program on Dependence in Activities of Daily Living and Balance in Older Adults with Dementia
Open this publication in new window or tab >>Effects of a High-Intensity Functional Exercise Program on Dependence in Activities of Daily Living and Balance in Older Adults with Dementia
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2016 (English)In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 64, no 1, p. 55-64Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To investigate the effects of a high-intensity functional exercise program on independence in activities of  daily living (ADLs) and balance in older people with dementia and whether exercise effects differed between dementia types.

DESIGN: Cluster-randomized controlled trial: Umeå Dementia and Exercise (UMDEX) study.

SETTING: Residential care facilities, Umeå, Sweden.

PARTICIPANTS: Individuals aged 65 and older with a dementia diagnosis, a Mini-Mental State Examination score of 10 or greater, and dependence in ADLs (N = 186).

INTERVENTION: Ninety-three participants each were allocated to the high-intensity functional exercise program, comprising lower limb strength and balance exercises, and 93 to a seated control activity.

MEASUREMENTS: Blinded assessors measured ADL independence using the Functional Independence Measure (FIM) and Barthel Index (BI) and balance using the Berg Balance Scale (BBS) at baseline and 4 (directly after intervention completion) and 7 months.

RESULTS: Linear mixed models showed no between-group effect on ADL independence at 4 (FIM=1.3, 95% confidence interval (CI)=-1.6-4.3; BI=0.6, 95% CI=-0.2-1.4) or 7 (FIM=0.8, 95% CI=-2.2-3.8; BI=0.6, 95% CI=-0.3-1.4) months. A significant between-group effect on balance favoring exercise was observed at 4 months (BBS=4.2, 95% CI=1.8-6.6). In interaction analyses, exercise effects differed significantly between dementia types. Positive between-group exercise effects were found in participants with non-Alzheimer's dementia according to the FIM at 7 months and BI and BBS at 4 and 7 months.

CONCLUSION: In older people with mild to moderate dementia living in residential care facilities, a 4-month high-intensity functional exercise program appears to slow decline in ADL independence and improve balance, albeit only in participants with non-Alzheimer's dementia.

Keywords
activities of daily living, dementia, exercise, postural balance, residential facilities
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-116818 (URN)10.1111/jgs.13880 (DOI)000371157900009 ()26782852 (PubMedID)
Funder
Swedish Research Council, K2009-69P-21298-01-4Swedish Research Council, K2009-69X-21299-01-1Swedish Research Council, K2009-69P-21298-04-4Swedish Research Council, K2014-99X-22610-01-6
Available from: 2016-02-12 Created: 2016-02-12 Last updated: 2018-06-07Bibliographically approved
3. Walking aids moderate exercise effects on gait speed in people with dementia: a randomized controlled trial
Open this publication in new window or tab >>Walking aids moderate exercise effects on gait speed in people with dementia: a randomized controlled trial
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2017 (English)In: Journal of the American Medical Directors Association, ISSN 1525-8610, E-ISSN 1538-9375, Vol. 18, no 3, p. 227-233Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To investigate the effects of exercise on gait speed, when tested using walking aids and without, and whether effects differed according to amount of support in the test.

DESIGN: A cluster-randomized controlled trial.

SETTING: The Umeå Dementia and Exercise (UMDEX) study was set in 16 nursing homes in Umeå, Sweden.

PARTICIPANTS: One hundred forty-one women and 45 men (mean age 85 years) with dementia, of whom 145 (78%) habitually used walking aids.

INTERVENTION: Participants were randomized to the high-intensity functional exercise program or a seated attention control activity.

MEASUREMENTS: Blinded assessors measured 4-m usual gait speed with walking aids if any gait speed (GS), and without walking aids and with minimum amount of support, at baseline, 4 months (on intervention completion), and 7 months.

RESULTS: Linear mixed models showed no between-group effect in either gait speed test at 4 or 7 months. In interaction analyses exercise effects differed significantly between participants who walked unsupported compared with when walking aids or minimum support was used. Positive between-group exercise effects on gait speed (m/s) were found in subgroups that walked unsupported at 4 and 7 months (GS: 0.07, P = .009 and 0.13, P < .001; and GS test without walking aids: 0.05, P = .011 and 0.07, P = .029, respectively).

CONCLUSIONS: In people with dementia living in nursing homes exercise had positive effects on gait when tested unsupported compared with when walking aids or minimum support was used. The study suggests that the use of walking aids in gait speed tests may conceal exercise effects.

Keywords
mobility limitations, residential facilities, alzheimer disease, rehabilitation, frail elderly
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-127495 (URN)10.1016/j.jamda.2016.09.003 (DOI)000398943400008 ()27810267 (PubMedID)
Funder
Swedish Research Council, K2009-69P-21298-01-4Swedish Research Council, K2009-69X-21299-01-1Swedish Research Council, K2009-69P-21298-04-4Swedish Research Council, K2014-99X-22610-01-6Forte, Swedish Research Council for Health, Working Life and Welfare, 2012-0775
Available from: 2016-11-14 Created: 2016-11-14 Last updated: 2018-06-09Bibliographically approved
4. Effects of exercise on cognitive function in older people with dementia: a randomized controlled trial
Open this publication in new window or tab >>Effects of exercise on cognitive function in older people with dementia: a randomized controlled trial
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2017 (English)In: Journal of alzheimers disease, ISSN 1387-2877, Vol. 60, no 1, p. 323-332Article in journal (Refereed) Published
Abstract [en]

Background: Although physical exercise has been suggested to influence cognitive function, previous exercise studies show inconsistent results in people with dementia. Objectives: To investigate effects of exercise on cognitive function in people with dementia. Method: The Umea a Dementia and Exercise (UMDEX) study, a cluster-randomized controlled trial, was set in 16 nursing homes in Umea, Sweden. One hundred-and-forty-one women and 45 men with dementia; mean age of 85 y and mean MiniMental State Examination (MMSE) score of 15, were randomized to a High-Intensity Functional Exercise program or a seated attention control activity. Blinded assessors measured global cognitive function using the MMSE and the Alzheimer's disease Assessment Scale -Cognitive subscale (ADAS-Cog), and executive function using Verbal fluency (VF) at baseline and 4 months (directly after intervention completion), and MMSE and VF at 7 months. Results: Linear mixed models showed no between-group effects in mean difference from baseline (95% confidence intervals, CI) at 4 months in MMSE (-0.27; 95% CI -1.4 to 0.87, p = 0.644), ADAS-Cog (-1.04, 95% CI -4 to 1.92, p = 0.491), or VF (-0.53, 95% CI -1.42 to 0.35, p = 0.241) or at 7 months in MMSE (-1.15, 95% CI -2.32 to 0.03, p = 0.056) or VF (-0.18, 95% CI -1.09 to 0.74, p = 0.707). Conclusion: A 4-month, high-intensity functional exercise program had no superior effects on global cognition or executive function in people with dementia living in nursing homes when compared with an attention control activity.

Place, publisher, year, edition, pages
IOS Press, 2017
Keywords
Cognition, dementia, exercise, residential facilities
National Category
Physiotherapy Geriatrics
Identifiers
urn:nbn:se:umu:diva-128727 (URN)10.3233/JAD-170014 (DOI)000408582800026 ()28800328 (PubMedID)
Note

Originally published in manuscript form with title [Effects of exercise on cognitive function in older people with dementia: a randomized controlled study]

Available from: 2016-12-13 Created: 2016-12-13 Last updated: 2018-06-09Bibliographically approved

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