Exercise Programming and Delivery for People Living with Dementia UNSW PDF

Exercise programming and delivery for people living with dementia Dr Morag Taylor 31 Oct 2022 Outline 1. 2. 3. 4. 5. 6. 7. 8. Incidence and prevalence of dementia Risk factors for dementia (modifiable/non-modifiable) Diagnosing dementia Dementia onset and progression, clinical presentation and pa...

Exercise programming and delivery for people living with dementia Dr Morag Taylor 31 Oct 2022 Outline 1. 2. 3. 4. 5. 6. 7. 8. Incidence and prevalence of dementia Risk factors for dementia (modifiable/non-modifiable) Diagnosing dementia Dementia onset and progression, clinical presentation and pathology Common comorbidities Pharmacological management Exercise programming Case studies Dementia prevalence and incidence https://www.who.int/mental_health/neurology/dementia/infographic_dementia.pdf Brown, L., E. Hansata, and H.A. La, Economic cost of dementia in Australia 2016-2056. 2017, The Institute for Governance and Policy Analysis, University of Canberra: Canberra Risk factors for dementia and risk reduction Prevention better than cure? Livingston, G,., et al. (2020). Dementia prevention, intervention, and care. The Lancet, doi:10.1016/S0140-6736(20)30367-6 Livingston, G,., et al. (2020). Dementia prevention, intervention, and care. The Lancet, doi:10.1016/S0140-6736(20)30367-6 WHO risk reduction of cognitive decline/dementia guidelines (2019) Physical activity Stop smoking (low, conditional) Stop drinking ETOH (moderate, conditional) Cognitive training (very low-low, conditional) Social activity (insufficient evidence) Weight management (mid-life) (low-mod, Nutrition interventions conditional) Mx HT (very low, conditional) Mx diabetes (very low, conditional) Mx dyslipidaemia (mid-life) (low, conditional) Mx depression (insufficient evidence) Hearing loss (insufficient evidence) Note. For many of these risk factors, treatment should be offered to ameliorate their negative impact on health, this is purely a summary of evidence for cognitive decline/dementia Non-modifiable risk factors for dementia • • • • • Age CV risk (some potentially modifiable) Genetic risk Family history Sex • • • • Down syndrome PD/MS Chronic kidney disease Head injury (potentially modifiable) – DLB and VaD men greater than women – AD ?? Females https://qbi.uq.edu.au/brain/dementia/genetic-risk-factors-dementia Diagnosing dementia Dementia (DSM-5: major neurocognitive disorder) • Progressive neurodegenerative disorder affecting cognition and as a result ability to function • Cognitive decline: complex attention, executive function, learning and memory, language, perceptualmotor, or social cognition • Cognitive deficits not better explained by another condition • E.g. delirium, depression https://qbi.uq.edu.au/brain/brain-anatomy/lobes-brain Limbic-predominant age-related TDP43 encephalopathy (LATE) Dementia Major neurocognitive disorder Alzheimer's disease Parkinson’s disease dementia Vascular dementia Mixed aetiology Frontotemporal dementia Hippius, H., & Neundörfer, G. (2003). The discovery of Alzheimer's disease. Dialogues in Clinical Neuroscience, 5, 101-108 Inzitari, D, et al. (2009). Changes in white matter as determinant of global functional decline in older independent outpatients: three year follow-up of LADIS study cohort. BMJ, 339 Wood, H. (2019). Piecing together a consensus on a TDP43-related dementia syndrome. Nature Reviews Neurology, 15(7), 367-367, doi:10.1038/s41582-019-0207-z. Dementia with Lewy bodies Mild Cognitive Impairment (MCI; Mild neurocognitive disorder) • Mild Cognitive Impairment • Activities of daily living (ADLS) preserved • • • Minor issues with complex ADLS Cognitive impairment Cognitive complaints • Amnestic vs non-amnestic • Single vs multidomain Petersen, R.C., Mild cognitive impairment as a diagnostic entity. Journal of Internal Medicine, 2004. 256(3): p. 183-194 Petersen, R.C., MILD COGNITIVE IMPAIRMENT. CONTINUUM: Lifelong Learning in Neurology, 2004. 10(1, Dementia): p. 9-28. Dementia onset and progression, clinical presentation, pathology Disease onset and progression • Differs from individual to individual • Eventually terminal • Alzheimer’s Disease (AD) – Insidious onset and gradual progression • Vascular Dementia (VaD) – Step-wise or may appear gradual – Usually more rapid than AD • Frontotemporal dementia (FTD) – Often younger (50’s – 60’s) – Insidious onset and gradual progression • Dementia with Lewy bodies – Insidious onset and gradual progression https://www.dementia.org.au/information/about-dementia/types-of-dementia https://qbi.uq.edu.au/brain/dementia/types-dementia Presentation and pathology Sen, A., Capelli, V., & Husain, M. (2018). Cognition and dementia in older patients with epilepsy. Brain, 141(6), 1592-1608, doi:10.1093/brain/awy022. • Each type of dementia presents with different clinical features – e.g. AD: early memory and learning impairment, DLB: fluctuating cognition, reduced attention, hallucinations, REM sleep disorder, autonomic dysfunction • Each type of dementia presents with different brain pathology – e.g. AD: neurofibrillary tangles (Tau) and amyloid plaques, FTD: two proteins accumulate: TDP43 and Tau • Mixed pathology is relatively common Physical impairment Measure Cognitively intact (n=276) Cognitively impaired (n=138) OR (95% CI) Hand reaction time, ms 250 ± 51 309 ± 118 1.95 (1.56 – 2.45) Knee extension strength, kg 26 ± 11 21 ± 10 0.59 (0.47 – 0.75) Sway on foam, mm² 1043 ± 962 1912 ± 1508 2.44 (1.89 – 3.15) Coordinated stability 16 ± 13 25 ± 15 1.89 (1.48 – 2.40) Sit-to-stand x5, s 16 ± 5 23 ± 12 1.75 (1.36 – 2.26) Timed up + go, s 10 ± 3 20 ± 12 6.99 (4.51 – 10.87) Taylor, M. E., et al. (2013). Physical impairments in cognitively impaired older people: implications for risk of falls. International Psychogeriatrics, 25, 148-156 Physical decline Tolea, et al. (2016). Trajectory of mobility decline by type of dementia. Alzheimer Disease and Associated Disorders, 30, 60-66 Taylor, M. E., et al. (2019). The role of cognitive function and physical activity in physical decline in older adults across the cognitive spectrum. Aging & Mental Health, 23(7), 863-871 Daily-life activity and gait Activity monitors Taylor ME, et al. Older People with Dementia Have Reduced Daily-Life Activity and Impaired Daily-Life Gait When Compared to Age-Sex Matched Controls. J Alzheimers Dis. 2019;71(s1):S125-s35. Dual task Borges Sde, M., et al. (2015). Functional mobility in a divided attention task in older adults with cognitive impairment. J Mot Behav, 47, 378-385 Wadja 2017 Comorbidities and pharmacological management Comorbidities of dementia • Any comorbidity associated with older age e.g. arthritis, CV • Can depend on dementia sub-type • On average 4 comorbities (c/w 2 in cognitively healthy) Falls and fall-related injury (e.g. fracture and head) Incontinence Depression, Anxiety, Apathy (BPSD) Visual disturbance Behavioural and Psychological Symptoms of Dementia Frailty Stroke Sleep disturbance CVD and HT Seizures/Epilepsy Delirium Weight loss/nutritional issues https://sydneynorthhealthnetwork.org.au/wp-content/uploads/2018/04/39282-Dementia-Book_A5.pdf Behavioural and Psychological Symptoms of Dementia (BPSD) • • • • • Depression 20% Anxiety 16 – 35% Apathy 55 – 90% Agitation/aggression – 60% Psychosis – 25% – Hallucinations – Delusions • fixed, false beliefs that are implausible or untrue – Misidentification • mistakes people or objects for something else • Often a sign of unmet needs Assessment and management of people with BPSD. A handbook for NSW Health clinicians. (2013) NSW Ministry of Health and the Royal Australian and New Zealand College of Pyschiatrists Dementia and falls Percent fall each year 70 60 50 40 30 20 10 0 Fallers Cognitively intact Cognitively impaired Taylor, M. E., et al. (2013). Physical impairments in cognitively impaired older people: implications for risk of falls. International Psychogeriatrics, 25, 148-156 Multiple fallers Dementia and falls Allan et al. 2009. Plos One. Doi: 10.1371/journal.pone.0005521 Pharmacological management • No cure • Aimed at slowing cognitive decline and managing symptoms • Cholinesterase inhibitors • Donepezil (Aricept), Rivastigmine (Exelon patch), Galantamine (Reminyl) • Side effects: diarrhoea, nausea, vomiting, muscle cramps, lowered blood pressure, insomnia, fatigue and loss of appetite • Memantine • Side effects: hallucination, confusion, dizziness, headache and tiredness • BPSD: only when non-pharmacological treatment has failed – SSRI antidepressants: agitation – Antipsychotics for severe BPSD (psychosis and/or agitation/aggression causing significant distress to themselves or others) • Shouldn’t be used in DLB • Increased risk of cerebrovascular events and death Shopping list Sugar Eggs Pumpkin Grapes Crackers Tissues Tomatoes Flour Muesli Rice Garlic Mayonnaise Paper towel Yoghurt Exercise programming Common communication changes • Difficulty in finding a word • Speak fluently, but not make sense • May not be able to understand what you are saying or only be able to grasp part of it • Writing and reading skills may deteriorate • May lose the normal social conventions of conversations and interrupt or ignore a speaker, or fail to respond when spoken to • May have difficulty expressing emotions appropriately https://www.dementia.org.au/national/support-and-services/carers/managing-changes-in-communication Communication • Respect, empathy, listen • Body language (55%) and tone and pitch of voice (38%) • Body position e.g. eye contact • Speak slowly, clearly, no jargon • Short sentences/break down instructions • Allow processing/response time • • • • • Be patient Clarify meaning and understanding Minimise competing noise Hearing and vision aids Use personal references Assessment and management of people with BPSD. A handbook for NSW Health clinicians. (2013) NSW Ministry of Health and the Royal Australian and New Zealand College of Pyschiatrists Carer engagement • Work in partnership and acknowledge their expertise • Source of information • Get to know the person e.g. TOP 5 • Communicate about the person with dementia’s needs • Consider impact of intervention on carer • • • • Education and support for the carer Practical examples Focus on the individuals strengths How to help them keep doing what they can do http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/268215/TOP5-Final-Report.pdf Exercise practical considerations • Supervision and safety • Focus on strengths • Tailored (cognitive and physical) and progressive • Instructions and communication • Co-morbid conditions • Current level of function/activity/fall risk • Achievable • Sustainable • Enjoyment • Environment (noise, set-up) • Group vs individual • Dose/duration/frequency Person-centred care • Care centred around the persons’ needs as an individual • Shared goals based on persons’ values and experiences • Past lived experiences • Likes/dislikes • Cultural and religious beliefs • Precipitants to behaviours • Specific behaviours are often a result of unmet needs • Respect, dignity and compassion Don’t treat others as you would wish to be treated… but as they want to be treated! Kate Swaffer Assessment and management of people with BPSD. A handbook for NSW Health clinicians. (2013) NSW Ministry of Health and the Royal Australian and New Zealand College of Pyschiatrists Exercise selection • Evidence-based • Purpose – – – – – Physical/functional performance Fall prevention Cognitive performance Mood/BPSD Strength, CV, weight control etc • Setting – Community – Residential care – Hospital • Cognitive and physical abilities • Social and socioeconomic situation Problems with the evidence so far • • • • • Often excluded from research Small sample sizes Low methodological quality Lack of follow-up Heterogeneous – Samples – Assessments – Interventions • Setting – community vs hospital vs RACF Exercise and physical/functional performance • Exercise improves: – – – – – – – Activities of daily living (ADLs) Balance Gait performance e.g. speed, step length Functional/mobility performance e.g. STS ability, TUG Dual task performance Endurance e.g. 6-min walk test Strength [30s STS] • Exercise prescription goal – – – – – – Tailored and progressive Mode: supervised, combination of: strength, balance, functional, dual task, aerobic, multimodal Session duration: 60 mins (might be too long for some) Session frequency: 2-3x/week Intervention duration: 3-months = minimum Tailor to desired outcome e.g. strength, higher dose of resistance training (Almeida et al 2019; Blankevoort et al., 2010; Brett et al., 2016; Forbes et al., 2015; Lam et al., 2018; Lewis et al., 2017; Long et al., 2019; McDermott et al., 2019; Pitkälä et al., 2013; Sanders et al. 2020; Wajda et al., 2017; Yeh et al., 2021) Exercise and fall prevention • Moderate certainty evidence exercise can prevent falls – Most evidence: • community-dwelling – Exercise has been used in multicomponent /multifactorial interventions in residential aged care: some successful, some not – Many trials are underpowered and have methodological limitations • Exercise prescription goal: – Tailored and progressive – Mode: Supervised, strength, balance (static and dynamic) and functional training +/- dual task, Tai Chi – Intensity: ? moderate to high challenge balance – Dose: 1-2h per week, >50h – Intervention duration: 6-12 months – ? Utilise caregiver supervision (community) Overall, 23% reduction in rate of falls Disclaimer: not published, not peer reviewed 29% reduction in rate of falls: community Disclaimer: not published, not peer reviewed Exercise and cognitive performance • Exercise probably improves (and delays decline) in cognitive performance (low certainty) – Small to medium effect – Some systematic r/vs and meta-analyses do not support – Evidence suggests best effect on global cognition and executive function/attention • Exercise prescription goal: – Tailored and progressive – Mode: multicomponent or aerobic or aerobic combined with another modality; resistance; DT • May depend on cognitive domain trying to impact – Intensity: moderate – Dose: can aim for 150 mins/week aerobic, but lower dose interventions also work and potentially have greater effect (e.g. ≤2 h/week); >24hrs total – Session duration: short, approx 30-45 mins – Session frequency: 3x/week, resistance 2-3x/week – Intervention duration: > 16 weeks aerobic; < 16 weeks resistance – ? <80 years old (Ali 2022; Almeida et al. 2019; Balbim 2022; Coelho-Junior 2022; Demurtas et al., 2021; Du et al., 2018; Duan et al., 2018; Farina et al., 2014; Groot et al., 2016; Guitar et al., 2018; Huang et al., 2021; Jia et al., 2019; Law et al 2020; Lee et al., 2016; Li et al. 2019; Liang et al., 2018; Öhman et al., 2014; Panza et al., 2018; Park and Cohen, 2018; Pesani 2021; Sanders et al., 2019; Strohle et al., 2015; Wang et al. 2020) Exercise and BPSD • Mood – Moderate certainty evidence exercise improves mood, some mixed findings • Body-mind exercise • May not be as effective in major depressive disorder – Exercise prescription goal: • No clear evidence for people with dementia – 20-60 mins, 2-5 x/week, multicomponent or mind-body e.g. Tai Chi • Evidence from general population – Tailored – May have greater effect in people who have depressive symptoms or are clinically depressed – Mind body/aerobic/resistance/multicomponent, moderate to vigorous, supervised • Global BPSD – Low certainty evidence exercise reduces BPSD – Three recent systematic r’vs: may assist in preventing behavioural problems/improving NPI – Aerobic (Almeida et al 2019; Barreto et al., 2015; Brett et al., 2016; Demurtas et al., 2021; Fleiner et al., 2017; Forbes et al., 2015; Heinzel et al., 2015; Kouloutobani, et al., 2021; Lamotte et al., 2017; Law 2020; Leng et al., 2018; Li et al 2019; Liang et al., 2018; Matura et al., 2016; Miller et al., 2020; Park and Cohen, 2018; Potter et al., 2011; Schuch et al., 2016a; Schuch et al., 2016b; Thuné-Boyle et al., 2012; Watt et al., 2021) MCI: exercise and physical function Functional reach (n=242) Lam 2018 https://doi.org/10.1016/j.jphys.2017.12.001 Step length (n=296) MCI: exercise and physical function Walking speed (n=568) Lam 2018 https://doi.org/10.1016/j.jphys.2017.12.001 TUG (n=606) MCI: exercise and global cognition Dose: 3x/week, 30-60 mins Intensity: vigorous Mode: strengthening, mind body, aerobic Song 2018 https://doi.org/10.1016/j.ijnurstu.2018.01.002. supported by Zhou 2022; Hu 2022 (figure); Chan 2021; Xu 2021; Shao 2022 (dose); MCI: exercise and global cognition Wang 2020 doi: 10.1002/gps.5289 ; Xu 2021 MCI: exercise and global cognition Wang 2020 doi: 10.1002/gps.5289 ; Xu 2021 Summary • Moderate evidence that exercise positively impacts physical / functional performance in people with dementia • Moderate certainty evidence exercise prevents falls in communitydwelling people with dementia • Moderate to strong evidence for physical activity/exercise to prevent cognitive decline/dementia (in cognitively intact) • Moderate certainty exercise improves mood in people with dementia • Preliminary/inconclusive evidence for exercise in people with dementia: – Cognitive performance – BPSD Summary • There are other positive benefits from exercise e.g. cardiovascular, OA • We need more evidence/research involving people living with dementia – Setting specific – ? Dementia subtype – Dementia severity Case study 1: Marjorie • 77 yo, female with moderate AD – OA (knees and L/S), HT, high cholesterol – Lives alone, but has a daughter nearby – Independent BADLs, inactive • Assessment – – – – Slow gait speed Cognitive decline Poor balance 2 falls in the last 6-months, 2 falls in the last 12-months • One fall // # wrist • Design an exercise program • Priority area to address? – Talk to the client/patient +/- caregiver – Falls and balance with recent fall-related injury Case study 1: Marjorie • Location? – Home? • Mode of exercise? – Balance, strength, functional +/- dual task training • Dose? – Aim to reach 1-2 hours/week – Supervision: EP and ?Caregiver/Dter • Program/intervention length? – 6-12 months • Additional considerations? – OA, HT – Previously inactive Case study 2: Jim • 71 yo, male, mild VaD – HT, CVD, increased cholesterol, diabetes – Lives with wife, independent in all ADLs – Inactive, except for a bit of gardening • On assessment: – Cardiovascular risk factors – Cognitive decline • Design an exercise program • Priority area to address? – Talk to the client/patient +/- caregiver – Cognitive decline – CV risk Case study 2: Jim • Location? – Home/gym/park? • Mode of exercise? – Aerobic/multicomponent • Dose? – 2-2.5h/week • Session length? – Aim to reach 30 mins • Program/intervention length? – 4-6 months • Additional considerations? – HT and CV disease: stable/unstable? Medications e.g. β blocker • Talk to GP/Dr (with client/patient permission)? – Diabetes: Type I or II? Medications? Stable BSLs? Plan for a hypoglycaemic event Shopping list Sugar Eggs Pumpkin Grapes Crackers Tissues Tomatoes Flour Muesli Rice Garlic Mayonnaise Paper towel Yoghurt Resources Active and Healthy (NSW Health; can search for appropriate exercise classes in local area) http://www.activeandhealthy.nsw.gov.au/ NSW Falls Prevention Network http://fallsnetwork.neura.edu.au/ Australian and New Zealand Falls Prevention Society (ANZFPS) http://www.anzfallsprevention.org/ Otago Exercise Program training course http://www.aheconnect.com/newahec/cdetail.asp?courseid=cgec3 Life Exercise Program training course http://fallspreventiononlineworkshops.com.au/ Physiotherapy Exercises http://www.physiotherapyexercises.com/ Care of confused hospitalised older persons https://www.aci.health.nsw.gov.au/chops Clinical practice guidelines and principles of care for people with dementia http://sydney.edu.au/medicine/cdpc/documents/resources/CDPC-Dementia-Recommendations_WEB.pdf ACI Allied Health and dementia health/allies-in-dementia https://www.aci.health.nsw.gov.au/resources/aged-health/allied- Assessment and Management of people with BPSD https://www.ranzcp.org/Files/Publications/AHandbook-for-NSW-Health-Clinicians-BPSD_June13_W.aspx CEC fall prevention http://www.cec.health.nsw.gov.au/patient-safety-programs/adult-patient-safety/falls- prevention Pedro (Physiotherapy Evidence Database) https://www.pedro.org.au/ The Australian Commission on Safety and Quality in Healthcare (The Commission) developed the National Safety and Quality Health Service (NSQHS) Standards https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard Reablement guides http://sydney.edu.au/medicine/cdpc/resources/reablement.php Dementia Australia https://www.dementia.org.au/ Full references for exercise programming slides Barreto, P. D., Demougeot, L., Pillard, F., Lapeyre-Mestre, M. and Rolland, Y. (2015). Exercise training for managing behavioral and psychological symptoms in people with dementia: A systematic review and meta-analysis. Ageing Res Rev, 24, 274-285. Blankevoort, C. G., van Heuvelen, M. J. G., Boersma, F., Luning, H., de Jong, J. and Scherder, E. J. A. (2010). Review of effects of physical activity on strength, balance, mobility and ADL performance in elderly subjects with dementia. Dementia & Geriatric Cognitive Disorders, 30, 392-402. Du, Z., Li, Y. W., Li, J. W., Zhou, C. L., Li, F. and Yang, X. G. (2018). Physical activity can improve cognition in patients with Alzheimer's disease: a systematic review and meta-analysis of randomized controlled trials. Clinical interventions in aging, 13, 1593-1603. Duan, Y., et al. (2018). Psychosocial interventions for Alzheimer’s disease cognitive symptoms: a Bayesian network meta-analysis. BMC Geriatrics, 18. Farina, N., Rusted, J. and Tabet, N. (2014). The effect of exercise interventions on cognitive outcome in Alzheimer's disease: a systematic review. Int Psychogeriatr, 26, 9-18. Forbes, D., Forbes, S. C., Blake, C. M., Thiessen, E. J. and Forbes, S. (2015). Exercise programs for people with dementia. Cochrane Database Syst Rev, 4, CD006489. Groot, C., et al. (2016). The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Res Rev, 25, 13-23. Guitar, N. A., Connelly, D. M., Nagamatsu, L. S., Orange, J. B. and Muir-Hunter, S. W. (2018). The effects of physical exercise on executive function in community-dwelling older adults living with Alzheimer's-type dementia: A systematic review. Ageing Res Rev, 47, 159-167. Heinzel, S., Lawrence, J. B., Kallies, G., Rapp, M. A. and Heissel, A. (2015). Using Exercise to Fight Depression in Older Adults: A Systematic Review and Meta-Analysis. GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 28, 149-162. Jia, R.-X., Liang, J.-H., Xu, Y. and Wang, Y.-Q. (2019). Effects of physical activity and exercise on the cognitive function of patients with Alzheimer disease: a meta-analysis. BMC Geriatrics, 19, 181-181. Lam, F. M. H., Huang, M. Z., Liao, L. R., Chung, R. C. K., Kwok, T. C. Y. and Pang, M. Y. C. (2018). Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of Physiotherapy, 64, 4-15. Lamotte, G., Shah, R. C., Lazarov, O. and Corcos, D. M. (2017). Exercise Training for Persons with Alzheimer's Disease and Caregivers: A Review of Dyadic Exercise Interventions. Journal of Motor Behavior, 49, 365-377. Lee, H. S., Park, S. W. and Park, Y. J. (2016). Effects of Physical Activity Programs on the Improvement of Dementia Symptom: A Meta-Analysis. Biomed Research International, 2016, 7. Lewis, M., Peiris, C. L. and Shields, N. (2017). Long-term home and community-based exercise programs improve function in community-dwelling older people with cognitive impairment: a systematic review. J Physiother, 63, 2329. Liang, J. H., Xu, Y., Lin, L., Jia, R. X., Zhang, H. B. and Hang, L. (2018). Comparison of multiple interventions for older adults with Alzheimer disease or mild cognitive impairment: A PRISMA-compliant network meta-analysis. Medicine, 97, 12. Matura, S., Carvalho, A. F., Alves, G. S. and Pantel, J. (2016). Physical Exercise for the Treatment of Neuropsychiatric Disturbances in Alzheimer's Dementia: Possible Mechanisms, Current Evidence and Future Directions. Current Alzheimer Research, 13, 1112-1123. McDermott, O., et al. (2019). Psychosocial interventions for people with dementia: a synthesis of systematic reviews. Aging & Mental Health, 23, 393-403. Öhman, H., Savikko, N., Strandberg, T. E. and Pitkälä, K. H. (2014). Effect of physical exercise on cognitive performance in older adults with mild cognitive impairment or dementia: A systematic review. Dementia and Geriatric Cognitive Disorders, 38, 347-365. Panza, G. A., et al. (2018). Can Exercise Improve Cognitive Symptoms of Alzheimer's Disease? A Meta-Analysis. Journal of the American Geriatrics Society, n/a-n/a. Park, J. and Cohen, I. (2018). Effects of Exercise Interventions in Older Adults with Various Types of Dementia: Systematic Review. Activities, Adaptation & Aging, 1-35. Pitkälä, K., Savikko, N., Poysti, M., Strandberg, T. and Laakkonen, M. L. (2013). Efficacy of physical exercise intervention on mobility and physical functioning in older people with dementia: A systematic review. Experimental gerontology, 48, 85-93. Potter, R., Ellard, D., Rees, K. and Thorogood, M. (2011). A systematic review of the effects of physical activity on physical functioning, quality of life and depression in older people with dementia. International Journal of Geriatric Psychiatry, 26, 1000-1011. Sanders, L. M. J., Hortobagyi, T., la Bastide-van Gemert, S., van der Zee, E. A. and van Heuvelen, M. J. G. (2019). Dose-response relationship between exercise and cognitive function in older adults with and without cognitive impairment: A systematic review and meta-analysis. PLoS ONE, 14, e0210036. Schuch, F. B., Dunn, A. L., Kanitz, A. C., Delevatti, R. S. and Fleck, M. P. (2016a). Moderators of response in exercise treatment for depression: A systematic review. J Affect Disord, 195, 40-49. Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B. and Stubbs, B. (2016b). Exercise as a treatment for depression: A meta-analysis adjusting for publication bias. Journal of Psychiatric Research, 77, 42-51. Strohle, A., et al. (2015). Drug and Exercise Treatment of Alzheimer Disease and Mild Cognitive Impairment: A Systematic Review and Meta-Analysis of Effects on Cognition in Randomized Controlled Trials. American Journal of Geriatric Psychiatry, 23, 1234-1249. Thuné-Boyle, I. C. V., Iliffe, S., Cerga-Pashoja, A., Lowery, D. and Warner, J. (2012). The effect of exercise on behavioral and psychological symptoms of dementia: Towards a research agenda. International Psychogeriatrics, 24, 1046-1057. Wajda, D. A., Mirelman, A., Hausdorff, J. M. and Sosnoff, J. J. (2017). Intervention modalities for targeting cognitive-motor interference in individuals with neurodegenerative disease: a systematic review. Expert review of neurotherapeutics, 17, 251-261.