Alzheimer’s disease is associated with a decline in cognitive function and memory. The large clinical trials evaluating pharmacological treatments have not found an effective treatment for stopping the development of this debilitating condition. Researchers have begun to look at behavioral changes as a possible way of addressing the cognitive decline associated with Alzheimer’s disease.
This study examined the effects of an exercise and multicomponent cognitive program (including music therapy, art therapy, horticulture therapy, handicraft, recreational therapy, stretching, laughing therapy, and activity therapy in older individuals (average age 81.5 years) with moderate to severe Alzheimer’s disease over a course of 6 months.1 The researchers observed a significant improvement in cognitive function over 6 months in the group that completed both exercise therapy and multicomponent therapy as compared to the group that completed multicomponent therapy alone, indicating that this combined regiment may be valuable in patients with moderate to severe Alzheimer’s disease.
The researchers conducting this study wanted to investigate the effect of 6-month physical exercise with a multicomponent cognitive program on the cognitive function of older adults with moderate to severe Alzheimer’s disease (AD). This single-blind clinical trial was conducted from December 2014 to June 2015 (6 months). Participants included older adults with moderate to severe Alzheimer’s disease who were living in a nursing home in Seoul, Republic of Korea. A total of 119 nursing home residents were contacted, and 50 of them met the inclusion criteria for study entry. However, of these 50, 12 participants (24%) did not meet the inclusion criteria of being diagnosed by a neurologist as having Alzheimer’s disease, living in a nursing home for at least three months, having moderate to severe Alzheimer’s disease as determined by a baseline Mini-Mental State Examination (MMSE) score of <20, and completion of informed consent from participants and their caregivers or legal guardians. In the 12 who did not meet the inclusion criteria, 6 had severe cognitive impairment with loss of communication skills, 2 had vascular dementia, and 4 refused to participate in the study.
Thus, 38 participants were randomized to the study intervention group of 19 who completed the Kohzuki Exercise Program (KEP) with multicomponent cognitive program (MCP) and 19 who were in a single MCP control group. Before and after the 6-month intervention, cognitive outcomes were assessed using the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog), Mini-Mental State Examination, and the Clock Drawing Test. Also, physical performance was evaluated by exercise time, the number of pedal rotations, total load, grip strength, and the Berg Balance Scale.
The KEP included 60 minutes of supervised exercise sessions 5 times a week for 6 months. This was broken-down into 15 minutes of warm-up and stretching, 30 minutes of lower limb aerobic exercise and 15 minutes of cool-down and relaxation. Exercise intensity was a heart rate of 40% to 60% of the maximum.
All participants in the KEP+MCP and MCP groups received the multicomponent intervention that consisted of music therapy, art therapy, horticulture therapy, handicraft, recreational therapy, stretching, laughing therapy, and activity therapy. Each MCP intervention was conducted by professional therapists for 60 min per session twice a day, 5 days per week for 6 months, and was supervised by two caregivers per group. The participation rate was 100%. Each therapy was given equally to the KEP+MCP group and the MCP group quantitatively and qualitatively.
General cognitive function was evaluated as the primary outcome measure, using the Korean version of the Alzheimer’s disease Assessment Scale-Cognitive Subscale (ADAS-cog) and the MMSE. The scoring range for the ADAS-cog is from 0 to 70, with higher scores indicating greater cognitive impairment, while MMSE scores range from 0 to 30, with higher scores indicating greater cognitive function. The Clock Drawing Test was also performed to evaluate executive function on a scoring range from 0 to 10, with higher scores indicating intact executive function. All cognitive measures were administered at baseline and after 6 months.
Physical function was the secondary outcome measure. All physical measures were administered at baseline, after 1 month, after 3 months, and after 6 months. The total load was calculated as follows: (the pedal power (W) × the number of pedal rotation)/exercise time (s). The pedal power consisted of 7 steps from 10 to 70 W, and was based on the Borg scale scores of 11–13. Grip strength was measured in the dominant hand with a standard handgrip dynamometer, over two successive measures taken and the maximum value recoded in kilograms. Finally, balance was assessed using the Berg Balance Scale.
Among the 38 participants initially present, only 33 completed the whole series of initial and final assessments. Five participants withdrew from the MCP group after a few weeks, due to loss of motivation. No significant differences were shown at baseline between the group that received the KEP and MCP and the group that received only the MCP except for the MMSE scores, which were significantly different between the groups at baseline. The mean age ± standard deviation of all participants was 81.5 ± 6.6 years. Sixty-four percent of all participants used a wheelchair, 21% used a walker, and 15% walked independently without any assistive devices.
In cognitive measures (ADAS-cog and MMSE), there were no significant improvements between the two groups after 6 months in the baseline value-adjusted primary analysis. However, the ADAS-cog score was significantly lower between the two groups when adjusted for baseline value, age, sex, and education years. All physical outcomes were significantly higher in the intervention group except for total load compared with baseline measurements.
Due to the small sample size and convenience of the sample group, further research of a larger cohort is warranted. However, the researchers concluded that lower-limb aerobic exercise with a multicomponent cognitive program consisting of music therapy, art therapy, horticulture therapy, handicraft, recreational therapy, stretching, laughing therapy, and activity therapy might be beneficial for individuals with moderate to severe Alzheimer’s disease.
- Kim MJ, Han CW, Min KY, et al. Physical exercise with multicomponent cognitive intervention for older adults with Alzheimer’s disease: a 6-month randomized controlled trial. Dementia and Geriatric Cognitive Disorders Extra. 2016 Jun 10;6(2):222-32.