202360 EHR525 Week 11 Dementia and Alzheimers (DG) (1 Slide).pdf

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of th...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice School of Allied Health, Exercise and Sports Sciences 1 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 1 EHR525 EXERCISE FOR NEUROLOGICAL & MENTAL HEALTH CONDITIONS Dementia and Alzheimer’s Disease Presenter: Jack Cannon School of Allied Health, Exercise and Sports Sciences 2 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 2 What We Will Cover ■ ■ ■ ■ ■ ■ Review Dementia and it’s primary characteristics. Dementia prevalence statistics. Four (4) main causes of dementia. Pathophysiology and risk factors for Alzheimer’s disease. Diagnosis of Alzheimer’s disease. Acute and chronic exercise responses in persons with Alzheimer’s disease. ■ General recommendations and considerations for exercise testing and programming in Alzheimer’s disease. School of Allied Health, Exercise and Sports Sciences 3 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 3 Introduction ■ Dementia: Umbrella term describing a syndrome associated with the progressive and irreversible loss of cognitive function. □ Dementia is a symptom of disease rather than a single disease entity. ■ Characterised by impaired cognition, memory, perception, language, personality, and behaviour. □ Pathological, not normal ageing. ■ Occurs as a consequence of diffuse brain disease primarily affecting the cerebral cortex and hippocampus. ■ Dementia is fatal (7-10 year average) with no known cure. School of Allied Health, Exercise and Sports Sciences 4 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 4 Dementia Statistics ■ Currently more than 410,000 Australians are living with dementia. □ 56% are female and 45% are male. ■ Single biggest cause of disability in person >65 years. ■ Dementia is the second leading cause of death of Australians contributing to 8% of all deaths in 2016. ■ By 2025 the number is expected to increase to >530,000 and >1.1 million by 2056. ■ Total direct and indirect costs in 2016 was $14.25 billion. School of Allied Health, Exercise and Sports Sciences 5 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 5 Main Causes Of Dementia ■ Alzheimer disease: Most common type of dementia (50-75%). □ Characterised by short-term memory loss, apathy, and depression. □ Onset is gradual and progressive decline. □ Predictable course of disease. ■ Vascular dementia: Second most common type of dementia (2030%). □ Caused by cerebrovascular conditions (e.g. stroke). □ Symptoms in the early stages are similar to Alzheimer disease but memory loss is not as great and mood fluctuations are more prominent. □ Physical frailty is also evident. □ Onset can be sudden. School of Allied Health, Exercise and Sports Sciences 6 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 6 Main Causes Of Dementia Less common causes ■ Frontotemporal dementia: Accounts for 5-10% of cases. □ More common in males with a younger onset of dementia. □ Early symptoms include personality and mood changes, disinhibition and language difficulties. ■ Dementia with Lewy bodies: Accounts for <5% of cases. □ Associated with development of abnormal cells, called Lewy bodies, in the brain. □ Characterised by marked fluctuation in cognitive ability and visual hallucinations as well as motor symptoms similar to Parkinson’s disease (e.g. tremor and rigidity). □ Progression tends to be more rapid than Alzheimer disease. School of Allied Health, Exercise and Sports Sciences 7 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 7 Alzheimer’s Disease ■ Most common cause of dementia. ■ Rarely occurs under the age of 45 years. ■ The incidence increases with age. ■ The cause of AD is not known (neurodegenerative). □ Up to 30% of cases are genetic (chromosome 19 and 21). ■ Pathology: Presence of senile plaques and neurofibrillary tangles in the brain. ■ Diagnosis of AD may be established during life by early memory failure, slow progression, and exclusion of other causes. ■ Results in complete dependence and death from other illnesses. School of Allied Health, Exercise and Sports Sciences 8 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 8 Normal Lapses School of Allied Health, Exercise and Sports Sciences Alzheimer’s Disease 9 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 9 Pathophysiology of Alzheimer’s Disease ■ Beta-amyloid plaques clump together to block synaptic transmission. ■ Tau within axons dissociate and cause tubules to disintegrate obstructing nutrient supply causing death. School of Allied Health, Exercise and Sports Sciences 10 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 10 Pathophysiology of Alzheimer’s Disease ■ Transaxial PET images of a normal control subject and a patient with mild AD. ■ Note: severe hypometabolism (yellow and blue cortical regions) in association and limbic cortex in AD. ■ Pattern slowly worsens in parallel with symptoms and is well correlated at autopsy with AD pathologic diagnosis. Note the difference between scans School of Allied Health, Exercise and Sports Sciences 11 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 11 Pathophysiology Of Alzheimer’s Disease ■ Progression of AD usually involves: □ Limbic system: Primarily the hippocampus is damaged first. □ Cerebral cortex. □ Brain stem. ■ The symptoms that occur are a direct result of this sequential damage. ■ Brain stem damage late in AD impairs organ function, including the function of the heart, lungs, and various other bodily processes. AD is ultimately fatal due to brain stem damage School of Allied Health, Exercise and Sports Sciences 12 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 12 Diagnosis Of Alzheimer’s Disease ■ No single or simple test that will definitively diagnose dementia or Alzheimer’s disease. ■ Gather sufficient information about changed behaviours, functional capacity, psychosocial issues and relevant medical conditions to allow for a diagnosis to be made. ■ A wide range of screening tools are available, including the MiniMental State Examination (MMSE), the General Practitioner assessment of Cognition (GPCOG), and the 7-Minute Screen. ■ Other tests, such as radiological and laboratory investigations may be undertaken. School of Allied Health, Exercise and Sports Sciences 13 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 13 Diagnosis of AD - MMSE ■ A Mini-Mental State Examination (MMSE) A M ini-M entalState Exam ination (M M SE)is a setof11 questions healthcare professionals com m only use to check for cognitive im pairm ent (problem s w ith thinking,com m unication,understanding and m em ory) ■ Max score is 30, with a score of ≥25 classed as normal: □ Mild cognitive impairment: 21-24. □ Moderate cognitive impairment: 10-20. □ Severe cognitive impairment: <10. School of Allied Health, Exercise and Sports Sciences 14 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 14 ■. School of Allied Health, Exercise and Sports Sciences 15 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 15 Diagnosis Of AD – GPCOG Test ■ GPCOG test ■ Modified and essentially abridged version of MMSE, testing, recall, attention, visual memory and language ■ https://gpcog.com.au/index/patient-assessment ■ Benefit- online, quick, reproducible and standardised School of Allied Health, Exercise and Sports Sciences 16 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 16 Stages of Alzheimer’s Disease School of Allied Health, Exercise and Sports Sciences 17 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 17 Progression of Alzheimer’s Disease School of Allied Health, Exercise and Sports Sciences 18 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 18 Risk Factors For Alzheimer’s Disease ■ Age (65 yrs= 5%; 75 yrs= 10%; 85 yrs= 20%). ■ Genetics (APOE ε4 genotype; two chromosomal copies x10 risk). ■ Female sex. ■ Mild cognitive impairment. ■ TBI. ■ Cardiovascular health. ■ Physical Activity. ■ Education. School of Allied Health, Exercise and Sports Sciences 19 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 19 Functional Impairment Note effects on functional performance Zidan et al. (2012). Rev Psiq. Clin, 39(5); 161-165. School of Allied Health, Exercise and Sports Sciences 20 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 20 Common Comorbidities in Dementia Mondor et al. (2017). PLOS Medicine, 14(3):e1002249. School of Allied Health, Exercise and Sports Sciences 21 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 21 Common Comorbidities in Dementia ■ The number of comorbid conditions and level of GP care influence the rate of hospitalisations. ■ Multimorbidity is the norm rather than the exception among older adults with dementia in the home care sector. This increased chronic disease burden is associated with a greater likelihood of costly hospital admissions and emergency visits. ■ Therefore, the management of comorbid disease is also essential. Mondor et al. (2017). PLOS Medicine, 14(3):e1002249. School of Allied Health, Exercise and Sports Sciences 22 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 22 Treatments ■ Cholinergics: Work by inhibiting the actions acetylcholinesterase increasing Ach availability for memory formation. □ Tacrine, donepezil and galantamine. ■ Memantine: Inhibits glutamate and prevents too much calcium moving into the brain cells causing damage. Note the medications School of Allied Health, Exercise and Sports Sciences 23 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 23 Acute Exercise Response ■ Individuals with AD demonstrate similar CV responses at rest and during submax exercise as healthy individuals. ■ Differences are apparent at the maximal of effort. ■ Evidence for increased HR variability and slower postural CV adjustments. □ Orthostatic HNT, dizziness, falls, etc. Allan et al. (2017). Arch Phys Med Rehabil, 78; 671-677; Billinger et al. (2011). Arch Phys Med Rehabil, 92(12); 2000-2005. School of Allied Health, Exercise and Sports Sciences 24 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 24 Chronic Exercise Response Cardiovascular ■ Meta-analysis; n= 2020, 30 trials. ■ Many different interventions applied: □ □ □ □ □ □ Functional ex. Aerobic. High-intensity RT. Mobility. In-home. Supervised, etc. Strength Flexibility ■ Positive effects of exercise on health-related fitness components. Heyn et al. (2004). Arch Phys Med Rehabil, 85(10); 1695-1704. School of Allied Health, Exercise and Sports Sciences 25 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 25 Chronic Exercise Response Function ■ Meta-analysis; n= 2020, 30 trials. ■ Positive effects of exercise on function, cognition and behaviours. Cognition Behaviour Heyn et al. (2004). Arch Phys Med Rehabil, 85(10); 1695-1704. School of Allied Health, Exercise and Sports Sciences 26 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 26 Chronic Exercise Response Note the strong effect sizes for exercise Heyn et al. (2004). Arch Phys Med Rehabil, 85(10); 1695-1704. School of Allied Health, Exercise and Sports Sciences 27 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 27 Balance and Mobility Training ■ Intervention involved functional activities with altered sensory input, postural instability, and dual tasking. ■ 12wks, 3d/wk. Ries et al. (2015). J Geriatr Phys Ther, 38; 183-193. School of Allied Health, Exercise and Sports Sciences 28 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 28 Balance and Mobility Training ■ After the intervention: □ MMSE remained stable but decline 3mths post. □ BBS increased (ANOVA and t-test). □ TUG, SSGS and FGS increased (t-test). Ries et al. (2015). J Geriatr Phys Ther, 38; 183-193. School of Allied Health, Exercise and Sports Sciences 29 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 29 Pre-Exercise Screening and Assessment ■ Use the ESSA Adult Pre-Exercise Screening tool to perform a general risk assessment. ■ Careful evaluation for comorbidities is essential. ■ Give careful consideration to the stage of AD, individual symptoms, and implications for safety, communication, and behaviour during exercise. School of Allied Health, Exercise and Sports Sciences 30 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 30 Recommendations For Exercise Testing ■ Depending on the stage of AD lab testing may not be safe, appropriate, or possible to perform. ■ Functional assessments may be more effective: □ 6-min walk. □ Sit-to-stand. ■ Assess postural alignment joint ROM/flexibility. ■ Mobility and balance assessments are important for falls risk. ■ May need to perform multiple assessments for reliability. School of Allied Health, Exercise and Sports Sciences 31 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 31 Recommendations For Exercise Programming ■ 1. Aerobic Exercises: Walking, stationary cycling, and swimming ■ 2. Strength Training: Resistance exercises using light weights or resistance bands can help maintain muscle mass and bone density. ■ 3 Balance and Coordination Exercises: Yoga, tai chi, or specific balance-focused exercises can help reduce the risk of falls. ■ 4. Stretching and Flexibility: Stretching can help maintain flexibility, prevent muscle tightness, and improve the overall range of motion. School of Allied Health, Exercise and Sports Sciences 32 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 32 Recommendations For Exercise Programming ■ 5. Brain-Boosting Activities: Puzzles, word games, and memory exercises can benefit cognitive health. ■ 6. Social Activities ■ 7. Moderation and Supervision. ■ 8. Routine and Consistency: ■ 9. Hydration and Rest. ■ 10. Tailor to Abilities School of Allied Health, Exercise and Sports Sciences 33 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 33 Recommendations For Exercise Programming ■ Goals for exercise training in AD are to reduce the impact of declining physical and mental health: • Increase VO2, maintain muscle mass and strength, and reduce risk factors for cardiometabolic disease and falls. ■ Memory loss an issue in the early stages of disease. ■ Consistency, established routines, enjoyment/encouragement. ■ No consensus on exercise programming guidelines for AD: □ Aerobic and mobility/balance training are important. □ Resistance training for muscle mass, strength, and posture. School of Allied Health, Exercise and Sports Sciences 34 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 34 Recommendations For Exercise Programming ■ Off-script and consider implementing a diverse framework variation of your Therapy to support AD treatment goals. ■ Dance – video https://iview.abc.net.au/show/keep-on-dancing ■ Slo Mo – https://vimeo.com/59749737 School of Allied Health, Exercise and Sports Sciences 35 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 35 Special Considerations For Exercise ■ Exercise supervision is essential for client safety depending on cognitive function and behavioural symptoms. ■ AD clients have a higher level of restlessness, agitation, and negative behaviours at the end of the day with fatigue and tiredness, so morning exercise may be best. ■ A daily walk at home may be an optimal way to establish a structured exercise routine in early stages and the only exercise possible in later stages. □ When ambulation is no longer possible maintaining strength and ROM is critical. ■ Management of behavioural symptoms (motivation, aggression, emotional instability) will increase as disease progresses. School of Allied Health, Exercise and Sports Sciences 36 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 36 Example Aerobic Exercise Program AD Stage Goals Mild   Peak VO2.   Cardiometabolic risk factors.   Functional endurance.      Walking. Stationary cycling. Rowing. Treadmill Group fitness classes for socialisation.   Peak VO2.   Cardiometabolic risk factors.   Functional endurance.      Stationary cycling. Rowing. Treadmill. Walking. Seated exercise.  Focus on enjoyment.  Maintain function.  One-to-one supervision.  Seated exercise. Moderate Severe Mode School of Allied Health, Exercise and Sports Sciences Exercise Programming Progression/ Considerations      40-70%HRR (RPE 10-15/20). 20-60 mins/session. 1 session/day. 5-6 days/week. 10-15 min WU/CD.  As tolerated, increase duration and frequency before intensity.  Build strong routine and emphasise enjoyment.  Intervals.      40-50%HRR (RPE 10-13/20). 20-40 mins/session. 1 session/day. 3-5 days/week. 10-15 min WU/CD.  Focus on maintenance and prevention of functional decline.  Behavioural strategies for compliance.  Intervals.      No intensity (<10/20) 10-20 mins/session 1 sessions/day 2-3 days/week. 10-15 min WU/CD.  Simple exercises, few instructions.  Aim to reduce rate of decline. 37 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 37 Example Resistance Exercise Program AD Stage Goals Mode Exercise Programming Progression/ Considerations Mild   Muscle strength/ muscle mass.   Postural alignment.   Physical function.     Body weight. Machine weights. Circuit training. Group fitness classes for socialisation.  1-3 sets x 8-12RM (RPE 1315/20).  2:1:2 cadence (avoid valsalva)  5-8 whole body exercises.  2-3 days/week  10-15 min WU/CD  As tolerated, reps/sets before load.  Build strong routine and emphasise enjoyment. Moderate   Muscle strength/ muscle mass.   Postural alignment.   Physical function.     Body weight. Machine weights. Circuit training. Therabands.  1-2 sets x 8-10 reps @ 40-60% 1RM (RPE 10-13/20).  2:1:2 cadence (avoid valsalva)  5-8 whole body exercises.  2-3 days/week.  10-15 min WU/CD.  Focus on maintenance and prevention of functional decline.  Focus on areas of weakness.  Behavioural strategies for compliance.  Focus on enjoyment.  Maintain function.  One-to-one supervision.  Seated exercise.  Therabands Severe School of Allied Health, Exercise and Sports Sciences      No intensity (<10/20) 2:1:2 cadence (avoid valsalva) 5-8 exercises. 2 days/week. 10-15 min WU/CD.  Simple exercises, few instructions.  Aim to reduce rate of decline. 38 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 38 Flexibility, Mobility, and Balance Exercises ■ Flexibility exercises: Goal to maintain ROM. □ 3-5 days/wk (before or after aerobic or resistance activities). □ Intensity: Below point of discomfort. □ Progression as tolerated. □ Focus on postural muscles. ■ Mobility and balance: Goal to maintain ambulation and prevent falls. □ 2-5 days/wk. □ Intensity: Challenging. □ Progression as tolerated. School of Allied Health, Exercise and Sports Sciences Ries et al. (2015). J Geriatr Phys Ther, 38; 183-193. 39 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 39 Summary ■ ADDITIONAL RESOURSES https://www.abc.net.au/listen/programs/adelaide-mornings/untold-story-thedementia-patient/8705680 https://www.abc.net.au/listen/programs/healthreport/different-thinking-aboutalzheimers/101742346 https://www.dementia.org.au ■ Check in on YOUR MENTAL HEALTH! School of Allied Health, Exercise and Sports Sciences 40 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 40 Summary ■ Dementia is syndrome associated with declines in cognition and physical function and altered personality and behavior. ■ Alzheimer’s disease is the most common cause of dementia and is characterized by short-term memory loss, apathy, and depression. ■ Exercise interventions can be effective for improving cognition and function during early disease stages and can help to slow the rate of decline in later stages. ■ No clear guidelines for exercise testing and programming exist for Alzheimer’s disease but a comprehensive exercise program that accounts for cognitive decline and behavioural factors in program delivery are recommended. School of Allied Health, Exercise and Sports Sciences 41 SCHOOL OF EXERCISE SCIENCE, SPORT & HEALTH 41