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Dementia friendly Tai Chi

Dr Samuel Nyman

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This presentation will introduce a newly-funded research project that will offer Tai Chi to community-dwelling older people with dementia.

It will outline the rationale for the study along with the approach taken to delivery of the intervention, with a focus on harnessing participant’s implicit memory and a positive approach to mental capacity.

Outline

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• Issue of falls• Evidence for preventing falls among

people with dementia

• The TACIT Trial• Approach to delivery of the intervention• Positive approach to mental capacity

Outline

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• Frequency

• Severity

• Cost

Issue of falls

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• 1 in 20 A&E patients are adults 60+ with a fall injury

• 2 in 3 patients with dementia fall each year

• Patients with dementia are 3 times more likely to fracture their hip

• 1 in 3 hip fracture patients with dementia die <1 year

Falls and dementia

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Dementia

• Dementia is an umbrella term used for a collection of diseases of the brain that are progressive and terminal in nature.

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Types of dementia

• Prevalence rate of falls and subtype:• No dementia 36%• Alzheimer’s 47%• Vascular 47%• Lewybody 77%• Parkinson’s 90%

Allan et al. (2009)

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Prevention of falls

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Gillespie et al (2012)

• Cochrane review - community• 159 trials with 79,193 participants• Group and home-based exercise, and home safety

interventions reduce rate of falls and risk of falling.• Multifactorial - reduce rate of falls but not risk of

falling. • Vitamin D supplementation does not reduce falls but

may be effective in people who have lower vitamin D levels before treatment.

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Cameron et al (2012)

• Cochrane review - nursing care facilities• 43 trials with 30,373 participants• Vitamin D supplementation reduced rate of falls by

average of 37% but not risk of falling• Exercise was inconsistent

• Might reduce falls in intermediate level facilities, but increase falls in facilities providing high levels of nursing care

• Multifactorial interventions suggested possible benefits, but inconclusive

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Sherrington et al (2008)

• Exercise reduced the rate of falling by 17% (44 trials with 9,603 participants)

• Greater relative effects (42%) are seen in programs that include• Exercises that challenge balance• Use a higher dose of exercise• Do not include a walking program

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Not all exercise helps

• e.g. Voukelatos et al (2015) • 48 week ‘Easy Steps’ programme among inactive• Increased amount of time walking for exercise• But no difference on fall rate

• e.g. Sherrington et al (2014) • Post-hospital discharge, home-exercise programme • 15-20 mins six times weekly for 12 months• Improved mobility, but increased falls (IRR = 1.43)

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Dr Samuel R NymanNIHR Career Development FellowBournemouth University

The TACIT TrialTAi ChI for people with demenTia

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Tai Chi

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Why Tai Chi?

• Impaired postural balance - core risk factor for all older people, which Tai Chi addresses

• Impairments to balance and gait might be main mechanism for other risk factors of falls

• In community-dwelling, single interventions just as effective; may be more acceptable and cost-effective

• Single intervention studies make greater contribution to science as clear mechanism of effect

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Referred from NHS memory clinics

150 dyads (patient with dementia and carer)Baseline measures

Interventionn = 75 dyads

Usual care plus Tai Chi 5 months

Controln = 75 dyads

Usual care5 months

Repeat baseline measures 6 months post-baseline

Phase 2 RCT

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TACIT approach

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• Both PWD & carer to attend (max 7 dyads)• Positive Emotion-Motivated Tai Chi (PEM-

TC) approach initiated in the USA• Teaching will be implicit learning-based

• Repetition of movements • Positive reinforcement• Muscle / kinaesthetic memory

Tai Chi classes

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• PEM-TC: ‘sticky hands’ technique• Avoids reliance on verbal instruction • Uses palm-to-palm contact to physically guide

the movements. • Less cognitively demanding

Tai Chi home-exercises

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Patient adherence

After 16 weeks:- Improved balance- 86% classes attended- 84% home-ex done

Yao et al (2008) pilot study

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• Why are people with dementia in the community a hard-to-reach group?

• Two central narratives of old age (Johnson, 2005)• Ancient

• Positive, benign, associations with authority, sage• Modern

• Shifting trends and panic, apocalyptic demography, politically generated conflict

Dementia

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Mental Capacity Act 2005

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Five Core Principles of theMental Capacity Act 2005

• People with dementia should be encouraged to make as many decisions as possible for themselves using the five core principles of the Mental Capacity Act

1. A person must be assumed to have capacity unless it is established that they lack capacity.

2. A person is not to be treated as unable to make a decision unless all practicable (doable) steps to help them to do so have been taken without success.

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3. A person is not to be treated as unable to make a decision merely because they make an unwise decision.

4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in their best interests.

5. Before the act is done / decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action.

Five Core Principles of theMental Capacity Act 2005

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• Understand information about the decision to be made

• Retain that information in their mind• Use or weigh that information up • Communicate their decision

• A person needs to do all of the above to have capacity

Dementia

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Just because someone has dementia, doesn’t mean they don’t still have a need to live

Dementia

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Andy Baker BUDI Orchestra

mr.andybaker@virgin.net

The BUDI orchestra

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• Falls are a concern for PWD• Evidence-base for preventingfalls among PWD weak, butPromise for Tai Chi

• The TACIT Trial• Approach to delivery: Use of tacit memory• Positive approach to mental capacity

Conclusion

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• Dr Samuel Nyman is funded by a National Institute for Health Research (NIHR) Career Development Fellowship Award.

• This is a summary of independent research funded by the NIHR’s Career Development Fellowship Programme. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

• Tai Chi logo; created by Jems Mayor from Noun Project.

Acknowledgements

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Any questions?

Dr Samuel NymanBournemouth University Dementia Institute and Department of Psychology