#PTonICE Daily Show – Wednesday, November 8th, 2023 – International guidelines for physical activity & exercise for dementia

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses the new international guidelines for physical activity and exercise in the prevention and management of mild cognitive impairment and dementia. With the number of people with dementia projected to double by 2050, increasing levels of physical activity could potentially prevent 3% of these cases. Alex highlights the importance of understanding that dementia does not equal Alzheimer’s disease.

Take a listen to learn how to better serve this population of patients & athletes.

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Hello everyone and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today’s segment of Geri on ICE. My name is Alex Germano, a member of the Older Adult Division.

It is Alzheimer’s Disease Awareness Month so I thought it would be fitting to present some research in the cognitive space of Geri Rehab. So today we will be reviewing those new international guidelines that came out in September for physical activity and exercise, for the prevention and management of mild cognitive impairment and dementia. Now, the number of people with dementia is projected to reach 75.6 million by 2030. This is gonna double by 2050. It’s estimated that 3% of these dementia cases could be prevented by increasing levels of physical activity. That could be millions of people. Now, let’s recognize that dementia does not equal Alzheimer’s disease. Dementia is a symptom, it’s not technically a disease. However, 60 to 80% of dementia cases are thought to be caused by Alzheimer’s. So, just important to note the distinction there.

Now, before we dive into more, I want to give you just a heads-up of what we’re up to in 2023. There are only a few months left here, And I wanted to highlight our upcoming courses. We have a live course in Wappingers Falls, New York, and Westmont, Illinois this upcoming weekend. And then in December, we will be in Chandler, North Carolina. And we will have our first ever MMOA Live in the state of Maine. So we will be in Portland. And there are only a few seats left for that course. It’s already looking big, and wonderful. I’ll have two TAs with me. It’s going to be really high-energy, lots of fun course. So if that’s what you’re looking for, to kind of kick off your holiday season, we would love to have you join us.

Now let’s review this guideline. First, who collaborated on it, and who made it? It is a collaboration between Alzheimer’s Europe, a neuropsychopharmacology group, the European Geriatric Medicine Society, the Council on Aging, osteoporosis, there’s osteoporosis and Osteoarthritis Council, the International Association of Gerontology, the World Psychiatry Association, the European Academy of Neurology. So, This is a pretty stacked team who came together to look at all this research and literature in order to help us determine the strategy. Their goal was to create some type of evidence and expert-based guidelines on prevention and management strategies regarding physical activity, which they define as any type of bodily movement. Okay, so think like decreasing sedentary behavior. and they were looking to see if exercise which is planned structured or repetitive movement could be applicable to those who are healthy and to those with mild cognitive impairment and dementia. Now they were trying to answer three main questions so we’ll dive into each and then let you know about the status of the literature in each section. The first question they were trying to answer was, in people without dementia or mild cognitive impairment, aka healthy older adults, is physical activity and exercise able to delay the onset of dementia and mild cognitive impairment? Could this be considered a preventative strategy? They based their recommendations on two studies, okay? One was this very big meta-analysis of over 250,000 people that in those with higher self-reported physical activity, remember these are not sedentary people, they had a significantly lower risk of dementia, Alzheimer’s disease, vascular dementia, and there tended to be a dose gradient response, so those who were more physically active were at less of a risk. Now they did say that overall this study had a high risk of heterogeneity and it was not powered super well. So there’s that to consider. Now they based their exercise recommendation around one large randomized control trial dealing with the outcome of interest. In this study there were 1,635 community-dwelling older adults who were either put in a moderate-intensity exercise program or within the control group was this health education program. They were supposed to go to these health seminars once or twice a week. Now in this This study, surprisingly, did not result in a lower incidence of mild cognitive impairment or dementia across the groups. So there was no difference in each group. So the guideline, this international guideline, does say that exercise could be comparable to a health education program. And I feel like for us, the Institute of Clinical Excellence, that can feel kind of like a gut punch. So let’s think through why this is and let’s put maybe a giant asterisk next to it. When you dig into the study that they’re referencing, the intervention groups, did 30 minutes of walking, 10 minutes of lower extremity strengthening with ankle weights, and 10 minutes of balance training and flexibility. And what the authors of that paper recognize, and also in my mind, is probably not the best dosage of exercise for this population. And that could absolutely have been a limiting factor. The study group also recognizes that cognitive function, unfortunately, was more of this tertiary outcome. It wasn’t really the main goal of the study. And due to that and the poor dosage and the length of the study and the Cohort, they selected being at just an inherently less risk of cognitive decline because they were like educated wealthy folks this is why health education and Physical exercise were kind of equated as they were being, they were told as being equals in this they could both benefit cognition Now there are some huge positives to the study that are that need to go recognize Particularly that participants that were in the physical exercise group and were over the age of 80 years old and those who had really low levels of physical function to begin with, they had very good benefits in terms of executive functioning as compared with the health education group. So people who were older and not doing as well benefited a ton from the exercise versus just health education. Now cognitive function also remained stable over two years for these participants, so that’s also a huge win. Now this study also had very high retention rates, people really enjoyed it, and the physical activity levels in the intervention group remained, were much higher than the controls. And you know, like we understand the power of exercise, not only for cognitive health but for many other health outcomes and like non-health related outcomes. So we also recognize that exercise doesn’t really have any negative side effects. So there’s almost no reason that we shouldn’t have people engage with exercise. And that’s what the guideline, this international guideline came to the conclusion of. They say that without dementia or mild cognitive impairment, physical activity should be considered for the primary prevention of dementia. However, they recognize that health education may be equal to exercise in this space as well. So if you educate people about their health, they probably go do some health-promoting behaviors and that may help delay or attenuate the decline into mild cognitive impairment and dementia. All right. win for exercise.

Now question two, are our physical activity and exercise able to delay the onset of dementia in people with mild cognitive impairment? This is a very important question for us. We really feel passionate about finding and identifying humans who have mild cognitive impairment because they are kind of in this window where treatment actually may be really effective. So this is what the study was trying to answer. Now currently, physical inactivity or sedentary behavior seems to be an independent risk factor for the conversion of mild cognitive impairment to dementia. However, they weren’t able to find studies that specifically were out there to indicate if exercise or physical activity could directly reduce the risk of dementia. It’s very difficult for studies to capture that exact question. However, they did find research in populations with mild cognitive impairment that did exercise, And that did improve cognitive outcomes. Exercise information in this population, unfortunately, is very heterogeneous, as are many exercise studies, in that the type, duration, frequency, or intensity of the exercise was very different across all the studies. They also recognize in some of the literature that resistance training and mixed aerobic and anaerobic programs have the capacity to improve global cognition. They also saw the benefits of mindfulness-type activities. However, there was no exercise program that came out as superior for preventing or delaying cognitive decline. So the general consensus statement is that 100% of experts agree that we should not discourage exercise in the population with mild cognitive impairment. I know sometimes these vague recommendations are really, hard to hear and if you feel like it doesn’t give you the information you’re looking for we should reframe that and think this actually gives me a ton of good information this means that I don’t have to force Doris who loves to do tai chi to do resistance training that means actually her tai chi may work let’s just get her to the appropriate dosage and intensity and frequency of that activity So this almost removes some of our bumpers and gives us like a lot of space to work with many different humans. And in this population, we’re meeting so many different people who have so many feelings about exercises and histories with exercise and physical activity. So I love it when the bumpers get removed and we can say, hey, really anything is going to work at this point. So keep encouraging exercise in the population of people with mild cognitive impairment.

And then lastly, Can physical activity or exercise improve cognition and disability in those with dementia? So let’s go a step further into the part of the population with even more significant cognitive decline. dementia, and let’s see what the evidence says. Overall, in people with dementia, it came out with mixed physical activity and exercise at a frequency of two times a week for 40 minutes. That was effective in improving global cognition in moderate Alzheimer’s disease. Home-based physical activity interventions in people with a moderate degree of dementia Also stabilized disability and activities of daily living. There were plenty of secondary benefits to exercise, outside of just what it’s doing to cognition. It helps improve depressive symptoms, improve fall risks, and improve the number of falls. The evidence did not decrease the risk of hospitalization, mortality, or quality of life in the studies that they found. So it’s important to know kind of what the benefits of exercise truly are here. And so the recommendation in the international guidelines is that in people with moderate dementia, physical activity and exercise could be considered for maintaining cognition. In people with moderate dementia, exercise could be considered for stabilizing disability. compared to usual care. Interestingly, this is the only time where it was not 100% of them, but 86% of the experts agreed that physical activity and exercise are important for maintaining cognitive reserve and function in people with dementia and that it may have beneficial effects on non-cognitive outcomes such as mood, but these potential benefits should be balanced with the potential side effects. I do not know, and they did not define what potential side effects of exercise and physical activity are, That is something I would love to understand more about because I almost see no downfall in increasing physical activity and exercise for this population. I agree that there are many barriers to doing that once we are in the throes of dementia. So I think that is going to be the biggest hurdle to get over and maybe the demand on what we’re asking caregivers to do. But once again, we have another recommendation saying yes to exercise. Overall, you’re seeing the trend exercise of or physical activity take the win on delaying potentially delaying even the development of mild cognitive impairment for delaying the onset of mild cognitive impairment to dementia and For those with dementia to help maintain a high quality of life now Unfortunately, the evidence is not perfect. It’s not amazing in this space and this article does a really nice job at like a call to action for better quality studies, and more of them, more diverse studies in different populations of dementia. But, you know, there are many reasons why these recommendations kind of remain vague, and it’s because mild cognitive impairment and dementia are multifactorial in nature, and it’s not just due to physical inactivity and exercise, right? Like, these patients have many risk factors that cause them to develop these conditions, and we can’t change that with physical activity and exercise. I can’t exercise my way out of smoking. I cannot exercise my way out of not eating well, and smoking cessation and nutritional impacts are very big in this space. Also, the way that we’re defining exercise and physical activity really is different across the literature. People are using different types of exercise interventions, and getting clear evidence can be difficult. but I really like that the study recognizes that and pushes for better recommendations for the use of exercise across stages of cognitive change. So, you know, don’t feel frustrated by some vague guidelines. I think it’s great to have guidelines like this out there just promoting the benefits of exercise overall for all stages of cognitive change. Think about it as letting the bumpers kind of go and that you can just start anywhere with this population and really just try to dial in dosage and keep increasing intensity That’s what we know really works. Alright, so you guys get out there and start getting those patients moving. Have a really great rest of your week Wednesday. I will pop the link to this article and guidelines in the Instagram chat. Thanks, y’all.

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