Exercise programs for people with dementia: What's the evidence?
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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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The Health Evidence Team
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Students:Emily Belita(PhD candidate)
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What is www.healthevidence.org?
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inform
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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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Stages in the process of Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
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Poll Question #3
Have you heard of PICO(S) before?
1.Yes2.No
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Searchable Questions Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting
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How often do you use Systematic Reviews to inform a program/services?
A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is
Poll Question #4
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Dorothy Forbes, PhD, RNProfessor, Faculty of Nursing, University of Alberta
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Exercise programs improve health outcomes for people with dementiaA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
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Poll Question #5
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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.
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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
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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.
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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?
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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.
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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.
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Analyses• Subgroup analysis and investigation of
heterogeneity:
– Severity and type of dementia
– Type, frequency, and duration of exercise program
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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
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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.
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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
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Risk of Bias of Included Studies
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Results
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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
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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
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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
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Other Outcomes (cont’d)• The remaining outcomes could not be
examined because appropriate data were not reported:– Quality of Life– Mortality– Health Care Costs
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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
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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
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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
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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
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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
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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 [email protected]
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Exercise programs improve health outcomes for people with dementiaA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
41
Poll Question #6
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Poll Question #7Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
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Questions?
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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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