This is not the most recent version of the article. View current version (15 APR 2015)

Intervention Review

You have free access to this content

Exercise programs for people with dementia

  1. Dorothy Forbes1,
  2. Emily J Thiessen1,
  3. Catherine M Blake2,*,
  4. Scott C Forbes3,
  5. Sean Forbes4

Editorial Group: Cochrane Dementia and Cognitive Improvement Group

Published Online: 4 DEC 2013

Assessed as up-to-date: 13 AUG 2012

DOI: 10.1002/14651858.CD006489.pub3


How to Cite

Forbes D, Thiessen EJ, Blake CM, Forbes SC, Forbes S. Exercise programs for people with dementia. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD006489. DOI: 10.1002/14651858.CD006489.pub3.

Author Information

  1. 1

    University of Alberta, Faculty of Nursing, Edmonton, Alberta, Canada

  2. 2

    University of Western Ontario, School of Nursing, Health Sciences Addition H022, London, Ontario, Canada

  3. 3

    University of Alberta, Faculty of Physical Education and Recreation, Edmonton, Alberta, Canada

  4. 4

    University of Florida, Department of Physical Therapy, Gainesville, FL, USA

*Catherine M Blake, School of Nursing, Health Sciences Addition H022, University of Western Ontario, 1151 Richmond Street, London, Ontario, N6A 3K7, Canada. cmblake@uwo.ca.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 4 DEC 2013

SEARCH

This is not the most recent version of the article. View current version (15 APR 2015)

 
Characteristics of included studies [ordered by study ID]
Christofoletti 2008

Methods6-month RCT


ParticipantsCountry: Brazil

Centre: long-term psychiatric institution

Diagnosis: moderate stage mixed dementia

Participants: 54 at baseline, and 41 completed

Baseline: 54 (37 women and 17 men), mean age (SD) = 74.3 years (1.4), mean years of education (SD) = 4.8 (0.7)

Three groups: Group 1 was an interdisciplinary program, group 2 was physiotherapy, group 3 was control. Of the two experimental groups, only group 2 was included in this review.

Experimental Group:  n = 17, mean MMSE (SD)  = 12.7 (2.1)

Control Group: n = 20, mean MMSE (SD)  = 14.6 (1.2)

Inclusion criteria: "primary diagnosis of dementia" using ICD-10 criteria and confirmed by MMSE and Katz ADL score, medically fit for participation in intervention, resident of psychiatric institution

Exclusion criteria: cognitive impairment associated with other neuropsychiatric conditions or neurological diagnosis; antidepressant prescriptions with sedative or anticholinergic actions; impairment of cognition or balance related to drugs


InterventionsExperimental Group: physiotherapy kinesiotherapeutic exercises (strength, balance, memory, and recognition exercise using balls, elastic ribbons, and proprioceptive plates), provided by physiotherapist

Type of physical activity: strength, balance

Frequency: 3 times a week, exercise duration = 1 h

Time period: 6 months

Control Group: received usual care

Time period: 6 months


OutcomesCognition outcomes:

1.      Mini-Mental State Examination

2.      Brief Cognitive Screening Battery


NotesThe participants' medications were kept the same throughout the study. If a change in medication was required the participant was removed from the study


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskUnclear process of randomization: "A sealed envelope with an identification number was assigned to each subject, each one filled with a slip giving the group. When a patient was registered and given a number, the appropriate envelope was opened"

Allocation concealment (selection bias)Low riskSealed envelope used, but did not specify whether envelopes were opaque or non-opaque

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated: "As a common bias presented on most rehabilitation trials, it was not possible to 'blind' the subjects regarding the treatments"

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
High riskStudy attrition rate was 24.1%

Attrition rate for each group:

Experimental Group: 29.4%

Control Group: 15.0%

 

Reasons for attrition given, however, not specified according to group

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskAttendance and adherence not stated

Conradsson 2010

Methods6-month cluster-RCT


ParticipantsNote: Conradsson 2010 and Littbrand 2009 articles report on the same trial. Conradsson 2010 reports on depression and Littbrand 2009 reports on ADL

Country: Sweden

Multicentre: 9 residential facilities

Diagnosis: 100 of 191 participants diagnosed with mild to moderate dementia (type of dementia unspecified)

Participants: 191 (139 women and 52 men), mean age (SD) = 84.7 years (6.5), mean MMSE (SD) = 17.8 (5.1).  Baseline age, education, and MMSE, not reported for dementia subgroup

Of the 100 participants with dementia, 91 completed

Experimental Group: n = 47; Control Group: n = 53

Inclusion criteria: 65 years or older, MMSE score ≥ 10, dependent for assistance with at least 1 ADL as per Katz index, able to stand from arm chair with help from no more than 1 person, resident physician approval

Exclusion criteria: none stated


InterventionsExperimental Group: the high-intensity group exercise (3-9 participants per exercise group) focused on weight bearing and progressively increased in difficulty. Activity consisted of strength and balance exercises including walking, squats and trunk exercises

Type of physical activity: strength, balance, aerobic

Frequency: 5 sessions every 2 weeks, exercise duration = 45 minutes

Time period: 13 weeks

Control Group: social contact plus seated activities provided by occupational therapists, e.g. watching films, singing, reading, conversation

Frequency: 5 sessions every 2 weeks, activity duration = 45 minutes

Time period: 13 weeks


OutcomesDepression outcome (Conradsson 2010): Geriatric Depression Scale 15-item

Psychological well-being outcome (Conradsson 2010): Philadelphia Geriatric Centre Morale Scale

Activity of Daily Living outcome (Littbrand 2009): Barthel ADL Index


NotesWe used only data specific to people with dementia in the analysis


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskProcess of random selection not described

Allocation concealment (selection bias)Low risk"Researchers not involved in this study performed the randomization using lots in sealed non-transparent envelopes" Conradsson 2010

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"The assessors of the outcome measures were blinded to group allocation and previous test results" Conradsson 2010.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe attrition rate for the Experimental Group was 14.3%, and that of the Control Group 9.0%. Trial authors specified reasons for attrition in each group. ITT principles used in analyses

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Eggermont 2009a

Methods12-week RCT


ParticipantsCountry: Netherlands

Multicentre: 23 nursing homes

Diagnosis: mild to moderate dementia (type of dementia not specified)

Participants: 103* (79 women and 18 men), mean age (SD)  = 85.4 years, mean MMSE (SD)  = 17.7. Information about level of education not provided

* 6 did not complete study protocol so number who actually took part in the study = 97

Experimental Group: n = 51; Control Group: n = 46

Inclusion criteria: age > 70 years; diagnosis of dementia; able to walk for short distances with or without a walking aid; written consent from participants and relatives

Exclusion criteria: MMSE score of < 10 or > 24; visual disturbances; hearing difficulties; history of alcoholism; personality disorders; cerebral trauma; hydrocephalus; neoplasm; or disturbances of consciousness


InterventionsExperimental Group: walking group, walks occurred on unit wards and in public places

Frequency: 5 days a week, exercise duration = 30 minutes

Type of physical activity: aerobic

Time period: 6 weeks

Control Group: social contact

Frequency: 5 days a week, social visit duration = 30 minutes

Time period: 6 weeks


OutcomesExecutive function, memory and cognitive domains outcomes:

1. Rivermead Behavioural Memory Test

2. Wechsler Memory Scale-revised


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low risk"By tossing a coin subjects were randomly allocated to either an experimental or control group."

Allocation concealment (selection bias)Unclear riskNot described

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome measures were evaluated by a trained psychology student blinded to the participants’ intervention

Incomplete outcome data (attrition bias)
All outcomes
Low riskStudy attrition rate 5.8%. Trial authors did not report group attrition rates, or reasons for attrition. ITT used in analysis

Selective reporting (reporting bias)Low riskUsed 2 rating scales to measure executive function, memory, and cognitive domains.  Components of both scales were reported elsewhere: "The following tests were administered (details are published elsewhere)"

Other biasLow riskAttendance and adherence not stated

Eggermont 2009b

Methods6-week clustered-RCT


ParticipantsCountry: Netherlands

Multicentre: 10 nursing homes

Diagnosis: mild to moderate dementia (subtype unknown), diagnosed with dementia using the DSMIV criteria

Participants: 66 at baseline, and 61 completed; mean age = 84.6 years;

Experimental Group: n = 30, mean MMSE (SD) = 15.8 (5.0); Control Group: n = 31, mean MMSE (SD): 84.2 (4.6)


InterventionsExperimental Group: hand movement activity group performing activities such as "finger movement, pinching a soft ball, or handling a rubber ring"

Type of physical activity: hand movement

Frequency: 5 days a week, duration = 30 minutes

Time period: 6 weeks

Control Group; social contact plus read out loud program

Frequency: 5 days a week, duration = 30 minutes

Time period: 6 weeks


OutcomesCognition: MMSE (at baseline)

Memory: examined using the face recognition test from the Rivermead Behavioural Memory Test and the Eight Word Test

Executive function: tested using the stop signal task, attention network test, and the digit span subset from the Weschsler Memory Scale-Revised

Mood: examined using the Geriatric Depression Scale (a Dutch version)

Actigraphy data: rest and activity domain

All outcomes were measured at baseline, after 6 weeks and 12 weeks


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskUnclear process of randomization

Allocation concealment (selection bias)Unclear riskUnclear process of allocation concealment

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants or personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskReasons for attrition provided

Used ITT analysis

Per-protocol analysis included participants that attend 80% of the sessions

Selective reporting (reporting bias)Low riskReported all outcomes measured

Other biasLow riskNone apparent

Francese 1997

Methods7-week RCT


ParticipantsCountry: USA

Centre: long-term care facility

Diagnosis: severe AD

Participants: 12 participants at baseline, and 11 completed

Completed: 11 (gender not specified), age, years of education, and baseline MMSE not provided

Experimental Group: n = 6; Control Group: n = 5

Inclusion criteria: documentation in chart of late stage Alzheimer-type dementia, could understand English, considered medically fit, require assistance from 1 or 2 care providers to transfer, informed consent obtained by family member or legal guardian

Exclusion criteria: none stated


InterventionsExperimental Group: exercises targeting strength and function that included the use of music, various types of exercise balls and parachute leg weights; participants provided with snack

Type of physical activity: strength, balance

Frequency: 3 times a week, duration = 20 minutes

Time period: 7 weeks

Control Group: social contact plus sing-along group that watched music videos; participants provided with snack.

Frequency: 3 times a week, duration of social activity = 20 minutes

Time period: 7 weeks


OutcomesFunction (particularly ADL) outcomes

Changes in Advanced Dementia Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskMethods of randomization not described

Allocation concealment (selection bias)Unclear riskMethods used to conceal allocation not described

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding of the outcome assessors not described

Incomplete outcome data (attrition bias)
All outcomes
Low riskStudy attrition was 8%, one participant dropped out of Control Group as "had a major CVA and was confined to bed" p 125 Francese, 1997

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskAttendance and adherence not stated

Holliman 2001

Methods2-week, quasi-experimental design


ParticipantsCountry: USA

Centre: geriatric psychiatric facility

Diagnosis: dementia

Participants: 14 at baseline, and 12 completed

- 14 (12 women and 2 men), age range: 65-89 years, education: 1-16 years, mean MMSE (SD) = 4.57 (4.88).

Number of participants in Experimental Group and Control Group not specified

Inclusion criteria:  primary diagnosis of dementia, living with in psychiatric facility for at least 3 weeks, not scheduled to be discharged until after study completed

Exclusion criteria: participating in another research trial at same time

All participants were pronounced to be a danger to themselves or others


InterventionsExperimental Group: activity targeted gross and fine motor skills, and movement in a way that was meaningful and appropriate for participants. Snack provided

Type of physical activity: aerobic and balance

Frequency: 3 times per week, duration = 30 minutes

Time period: 2 weeks

Control Group: activities not described


OutcomesBehaviour outcomes:

1. Psychogeriatric Dependency Rating Scale

2. Patient Behaviour Rating Sheet (PBRS). (PBRS measure used in the Experimental Group only)


NotesThe following statement was made In the published article, "the sample was not fully randomly assigned due to patient availability, informed consent matters, and institutional procedures" (p 67). Email messages clarified the process of randomization. "Randomly assigned eligible residents a number. In order to assign each resident to either the control or treatment group, copies of these numbers were made and put into an envelope and the numbers were then drawn from the envelope" (personal communication on 5 June 2007 and 5 July 2007)

All exercises completed while sitting in chair, as majority of the participants in wheelchairs


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNumbers used, but review authors unaware of where they originated

Allocation concealment (selection bias)Unclear riskUsed envelopes

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessors were blinded to group allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rate was 14.29% and "all participants were active almost all the time". Reason for attrition provided, but unclear within which group the attrition occurred

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskAttendance and adherence not stated

Control group activity not described

Hwang 2010

Methods8-week trial with random assignment to experiment and control groups


ParticipantsCountry: Korea

Centre: nursing home

Diagnosis: mild-severe dementia (type of dementia unspecified)

Participants: 28 at baseline, and 18 completed

Baseline: 28 (all women)

Experimental Group: n = 14; mean age =  81.30 years (5.4); mean education years (SD) = 3.3 (0.95); mean MMSE-KC (SD) = 11.6 (3.47)

Control Group: n = 14, mean age (SD) = 81.75 years (8.86), mean education years (SD) = 3.0 (1.07), mean MMSE-KC (SD) = 13.88 (5.06)

Inclusion criteria: aged 65 or older, from nursing home residence; agreement of family; recommended by head of facility; dementia confirmed by MMSE-KC score, based on age, years of schooling, and gender; and capable of taking part in intervention activity

Exclusion criteria: none stated


InterventionsExperimental Group: a dance program consisting mainly of upper body exercises, with a 10-minute warm-up and warm-down.

Type of physical activity: strength, balance

Frequency: 3 times a week, duration = 50 minutes

Time period: 8 weeks

Control Group: usual care


OutcomesCognitive outcome: Cognitive Memory Performance Measuring Tool in the Korean version (CERAD-K)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomization process not described. Emailed 13 March 2012, 10 April 2012 and 9 May 2012 to clarify randomization, no response received

Allocation concealment (selection bias)Unclear riskNo description of methods used to conceal allocation

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding of outcome assessors not described

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rate: study = 35.7%: Experimental Group = 28.6%; Control Group = 42.9%

Reason for attrition: "10 subjects quit due to personal affairs and health issues, and the materials that were used for the final analysis were those of 18 subjects in total".  Contacted by email for details 10 April 2012 and 9 May 2012, but no response received

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskAttendance and adherence not stated. The Control Group activity was not described, and participants were recommended by head of facility

Kemoun 2010

Methods19-week RCT


ParticipantsCountry: France

Centre: nursing home

Diagnosis: mild to severe AD

Participants: 38 at baseline, and 31 completed (23 women and 8 men)

Experimental Group: n = 20, mean age (SD) = 82.0 years (5.8), mean MMSE (SD) = 12.6 (range = 7-20)

Control Group: n = 18, mean age (SD) = 81.7 years (5.1), mean MMSE = 12.9

Information about education level of participants not provided

Inclusion criteria: diagnosis of Alzheimer dementia using DSM IV criteria, MMSE < 23, able to walk 10 m without technical assistance

Exclusion criteria: none stated


InterventionsExperimental Group: the exercise program included three different sessions each week, i.e. 1) walking, 2) stamina exercise and 3) a combination of walking, stamina, and balance exercises. For the first 2 weeks of the program participants prepared for the routine program with specific muscles and joint exercises

Type of physical exercise: aerobic, balance

Frequency: 3 times a week, duration = 1 h

Time period: 15 weeks

Control Group: usual care


OutcomesCognition outcome: Rapid Evaluation of Cognitive Functions test (ERFC, French Version)


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomization process not described.  Email correspondence, Kemoun, 13 May 2012, description was as follows "The process of randomization was conducted by the randomization manager of the clinical investigation centre of the university hospital of Poitiers.  Each randomization number was given for each patient after he had been included in the study by the principal investigator."

Allocation concealment (selection bias)Unclear risk"Subjects were randomized into two groups using a permutation table".  Methods used to conceal allocation not described

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessor blinded

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rate was 18.4%: 4 participants lost from Experimental Group and 3 from Control Group. Reasons for attrition provided

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Rolland 2007

Methods12-month RCT, 2-week enrolment, single-blinded


ParticipantsCountry: France

Multicentre: 5 nursing homes

Diagnosis: mild to severe AD

Participants: 134 at baseline, and 110 completed

Baseline: 134 (101 women and 33 men), mean age (SD) = 83 years (7.4); mean ADL = 3.1 (1.3); mean MMSE (SD) = 8.8 (6.6)

Experimental Group: n = 67; mean age (SD) = 82.8 years (7.8); mean ADL = 3.2 (1.3); mean MMSE (SD) = 9.7 (6.8)

Control Group: n = 67; mean age (SD) = 83.1 years (7.0); mean ADL (SD) = 3.1 (1.3); mean MMSE (SD) = 7.9 (6.4)

Inclusion criteria: diagnosis in chart of AD or MMSE < 25, diagnosis of AD confirmed by trained geriatrician, met criteria for Alzheimer Disease of National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association, had resided in nursing home for at least 2 months, could transfer from chair and walk 6 m without assistance from people

Exclusion criteria: evidence of Parkinson’s disease or vascular dementia, life expectancy < 6 months due to terminal illness, cardiac condition that could worsen with exercise, planned transfer from nursing home for surgery within the next year


InterventionsExperimental Group: aerobic (walking), strength (lower extremity), flexibility and balance training, gradually increased in intensity, (2-7 participants per group). Music with sessions

Type of physical activity: aerobic, strength, balance

Frequency: 2 times per week, duration = 1 h

Time period: 1 year

Control Group: usual care


OutcomesADL outcome: Katz Index of ADLs

Behaviour disturbance outcome: Neuropsychiatric Inventory

Depression outcome: Montgomery-Asberg Depression Rating Scale


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskUsed lottery draw

Allocation concealment (selection bias)Low riskPublished in Forbes 2007

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskGeriatrician outcome assessor was blinded to group allocation, data analysts also blinded

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition rate of 18%, however 100% were included in ITT analysis (Forbes 2007); reasons for attrition provided

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Santana-Sosa 2008

Methods12-week randomized, block-controlled design


ParticipantsCountry: Spain

Centre: nursing home

Diagnosis: mild AD

Participants: 16 at baseline, all of whom completed

- 16 (10 women and 6 men); information about mean education level not provided

Experimental Group: n = 8; mean age (SD) = 76 years (4); mean MMSE (SD) = 20.1 (2.3)

Control Group: n = 8; mean age (SD) = 73 years (4); mean MMSE (SD) = 19.9 (1.7)

Inclusion criteria: consent of closest relative and geriatrician; diagnosis of AD by geriatrician; MMSE between 18-23 in Spanish validated MMSE; resided in nursing home for at least 4 months

Exclusion criteria: vision, muscle, cardio-respiratory, or neurological disorder (other than AD)


InterventionsExperimental Group: individualized exercise with walking, stretching, joint mobility, resistance and co-ordination exercises (with music)

Type of physical activity: aerobic, strength

Frequency: 3 times a week, duration = 75 minutes

Time period: 12 weeks

Control Group: usual care


OutcomesADL outcome: Katz ADL score, Barthel ADL index


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomly assigned with a block design according to gender. Email correspondence 10 May 2012 with Alejandro Lucia: "Participants were randomly assigned to either the control or training group with a block on gender based on a randomization sequence."

Allocation concealment (selection bias)Unclear riskMethods used to conceal allocation not described

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome measure assessors blinded

Incomplete outcome data (attrition bias)
All outcomes
Low risk100% of participants completed the trial. Adherence to trained program averaged at 98.8%

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Steinberg 2009

Methods12-week randomly-assigned experimental trial


ParticipantsCountry: USA

Location: home

Diagnosis: mild to moderate AD

Participants: 27 at baseline (19 women and 8 men) all of whom completed; information about education level not provided

Experimental Group: n = 14; mean age (SD) = 76.5 years (3.9); mean MMSE (SD) = 20.1 (5.1)

Control Group: n = 13; mean age (SD) = 74.0 years (8.1); mean MMSE (SD) = 15.5 (5.4)

Inclusion criteria: probable AlD using Alzheimer Disease of National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria; MMSE ≥ 10; residing in community; stable health and medical history; caregiver that was spending a minimum of 10 hours per week with the person with AD.

Exclusion criteria: residing in assisted-living facility


InterventionsExperimental Group: exercise program consisting of aerobic, strength, balance, and flexibility training

Type of physical activity: aerobic, strength, balance

Frequency: daily, exercise duration not specified. Participants were given points for each activity performed. The weekly exercise goal was obtained when the participant collected 6 aerobic points, and 4 strength and balance points

Time period: 12 weeks

Control Group: social contact, e.g. received home safety assessment that included 2 home visits. In addition, participants recorded 3 activities they performed regularly at home


OutcomesCognition outcome: 1-h cognitive battery that included the Boston Naming Test, MMSE, and Hopkins Verbal Learning Test

Depression outcomes:

1. Neuropsychiatric Inventory

2. Cornell Scale for Depression in Dementia

Caregiver Burden outcome: Screen for Caregiver Burden


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskStratified randomization by age and gender.  Emailed 13 March 2012, 10 April 2012, and 9 May 2012, to clarify randomization, but no answer received

Allocation concealment (selection bias)Unclear riskNo description of methods used to conceal allocation

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"All tests were administered by the same rater, who was masked as to treatment assignment"

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskAttrition not reported. Requested attrition data 13 March 2012, 10 April 2012, 9 May 2012, and 3 July 2012, but data not provided

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Stevens 2006

Methods12 week, pre- and post-test RCT


ParticipantsCountry: Australia

Multicentre:  6 aged-care facilities, nursing homes

Diagnosis: mild to moderate dementia (type of dementia not specified)

Participants: 120 at baseline, and 75 completed

Completed: 75 (56 women and 19 men), mean age = 80.5 years; mean MMSE not provided

Three groups: Group 1 received no intervention, group 2 received a social visit, and group 3 was the exercise program. Of the two control groups, only group 1 was included in this review.

Experimental Group: n = 24, mean age = 79 years

Control Group: n = 30, mean age = 81 years

Inclusion criteria:  mild to moderate dementia as assessed by local Aged Care Assessment Team; those with confirmed diagnosis of dementia, or MMSE < 23 were considered to have dementia; lived in aged-care facility; capable of providing informed consent legally and competently, or consent obtained from legal guardian; able to respond verbally and appropriately to majority of questions; assessed by Age Care Facility as being physically able to complete exercise

Exclusion criteria:  severe dementia with MMSE of 0-9


InterventionsExperimental Group: activity was based on joint and large muscle group movement with the intention of creating gentle aerobic exertion

Type of physical activity: aerobic

Frequency: 3 times per week, duration = 30 minutes

Time period: 3 months

Control Group: usual care


OutcomesBehaviour outcome: Revised Elderly Persons Disability Scale

Cognitive Symptoms outcome: Clock-drawing test


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskLottery method

Allocation concealment (selection bias)Unclear riskSimply stated that subjects were randomly allocated by a lottery method

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessors blinded to group allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskAttrition rate was 37.5%; reason(s) for attrition not provided

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Van de Winckel 2004

Methods3-month RCT


ParticipantsCountry: Belgium

Centre: public psychiatric hospital

Diagnosis: moderate to severe multiple infarct dementia (3 participants) and Alzheimer's disease (22 participants)

Participants: 25 at baseline, and 24 completed

Baseline: 25 (all women)

Experimental Group: n = 15; mean age (SD) = 81.33 years (4.24); mean MMSE (SD) = 12.87 (5.01)

Control Group: n = 10 mean age (SD)  = 81.90 years (4.18); mean MMSE (SD) = 10.8 (5.01)

Inclusion criteria: diagnosed with probable AD using NINCDS-ARDRA criteria or multiple infarct dementia; MMSE < 24; able to follow verbal and visual commands; mimic movements; and hear music. Medically cleared by physician; consent signed by family

Exclusion criteria:  unable to sit in chair for 30 minutes; apathetic; would require change in medication during intervention


InterventionsExperimental Group: intervention focused on strength training, balance, trunk movements and flexibility. Exercise routine supported with music

Type of physical activity: strength, balance

Frequency: daily, duration = 30 minutes

Time period: 3 months

Control Group: social contact 1-on-1 conversation with therapist

Frequency: daily, activity duration = 30 minutes

Time period: 3 months


OutcomesBehaviour outcome: Beoordelingsschaal voor Oudere Patienten/Evaluation Scale for Elderly Patients

Cognitive Function outcomes:

1. MMSE

2. Amsterdam Dementia Screening Test 6


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskCoin flipping

Allocation concealment (selection bias)Unclear riskNo description of methods used to conceal allocation

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot possible to blind participants and the personnel to the intervention allocated.

Blinding of outcome assessment (detection bias)
All outcomes
High risk"The physiotherapist who was conducting both treatments evaluated the patients on cognition. However, the nurses who scored the patients on behaviour were all blind to the group assignment"

Incomplete outcome data (attrition bias)
All outcomes
Low risk1 participant in control group unable to complete 3-month MMSE and ADS 6 due to hip fracture

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskAttendance and adherence not stated

Venturelli 2011

Methods6-month, randomly assigned experimental trial


ParticipantsCountry: Italy

Centre: nursing home, specifically Alzheimer care unit

Diagnosis: moderate to severe AD

Participants: 24 at baseline, 21 completed

Baseline: 24 (all women)

Experimental Group: n = 12; mean age (SD) = 83 years (6)

Control Group: n = 12; mean age (SD) = 85 years (5)

Inclusion criteria: 65 years or older; dependent on assistance in 2 or more personal ADLs according to the Barthel index; Mini-Mental State Examination (MMSE) maximum score of 15 and minimum of 5; absence of mobility limitations, minimum score of 23, according to the Performance Oriented Mobility Assessment (POMA) index; and constant oxygen saturation during walking (SpO2 > 85%).  According to the clinical dementia rating scale, all nursing home residents had to be in the later stages (CDR3-CDR4) of AD

Exclusion criteria:  none stated


InterventionsExperimental Group: a minimum of 30 minutes of moderate walking 4 times a week for 6 months

Type of physical activity: aerobic

Control group: usual care at the home, which consisted of bingo, sewing, music therapy


OutcomesCognitive function outcomes: MMSE

Activities of daily living outcome: Barthel Index for ADLs


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskMethod of random selection not described

Allocation concealment (selection bias)Low risk"The head nurse of the ACU (not involved in the residents assessments) did the participants’ randomization using StatsPlus for Macintosh"

Blinding (performance bias and detection bias)
All outcomes
Low risk" . . . members of the research team did not know to which group each participant had been assigned . . . No one on the research team was present during the walking exercise"

Blinding of outcome assessment (detection bias)
All outcomes
Unclear risk"Evaluation was done before and after the experiment period in a blind way" - not described well

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition: Experimental Group = 1 (8.4%); Control Group = 2 (16.7%)

Reasons for attrition stated for each group

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Vreugdenhil 2012

Methods4-month RCT


ParticipantsCountry: Australia

Location: home

Diagnosis: mild to moderate AD

Participants: 40 at baseline (24 women and 16 men), all of whom completed; mean age = 74.1 years

Experimental Group: n = 20; mean age 73.5 years; mean education = 10.1 years; mean MMSE (SD) = 22.9 (5.0)

Control Group: n = 20; mean age 74.7 years; mean education = 10.3 years;  mean MMSE (SD) = 21.0 (6.3)

Inclusion criteria:  diagnosed with dementia using DSM IV criteria; diagnosed with AD with NINCDS-ARDRA criteria; from outpatient memory disorder clinic; community dwelling with live-in care provider or caregiver that could visit daily

Exclusion criteria: physical condition that could prevent participation; evidence of neurodegenerative disorder (other than AD); already in exercise program more than once a week (resistance or aerobic training); started dementia medications in last three months


InterventionsExperimental Group: exercises progressively became more challenging, and targeted strength and balance. Also included brisk walking

Type of physical activity: aerobic, strength, balance

Frequency: daily, with 10 simple exercises and 30 minutes of brisk walking

Time period: 4 months

Control Group: usual care


OutcomesCognition outcomes:

1.      Alzheimer's Disease Assessment Scale

2.      MMSE

ADL outcome: Barthel Index of ADLs

Depression outcome: Geriatric Depression Scale

Caregiver burden outcome: Zarit Burden Interview


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskUsed computer-generated random allocation sequence

Allocation concealment (selection bias)Low riskSequentially-numbered, sealed opaque envelopes

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcomes assessors blinded

Incomplete outcome data (attrition bias)
All outcomes
Low risk100% of participants completed the trial

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

Williams 2008

Methods16-week, quasi-experimental design, randomly assigned trial


ParticipantsCountry: USA

Multicentre: 8 long-term care facilities

Diagnosis: moderate to severe AD

Participants: 45 at baseline, all of whom completed (89% female); mean age= 87.9 years (5.95); mean MMSE (SD) = 7.3 (6.19)

Experimental Group 1: n = 16

Experimental Group 2: n = 17

Control Group 3:  n = 12

Inclusion criteria: live in long-term care facility; evidence of AD as per NINCDS-ARDRA  criteria;  able to walk with assistance; CSDD score ≥ 7; dependent in at least 1 of the following: transfers, balance or gait, bed mobility

Exclusion criteria: ability to walk unaided for 30 minutes or more


InterventionsExperimental Group 1: exercise focusing on strength, flexibility, and balance. In addition participants walked each session.

Type of physical activity: aerobic, strength, balance

Frequency: 5 days per week, exercise duration gradually increased to 30 minutes (20 minutes of exercise session was spent walking)

Time period: 16 weeks

Experimental Group 2: supervised walking

Frequency: 5 days per week, exercise duration gradually increased to 30 minutes

Time period: 16 weeks

Control Group 3: social contact-conversation

Frequency: 5 days per week, activity duration equivalent to experimental groups

Time period: 16 weeks


OutcomesDepression outcome: Cornell Scale for Depression in Dementia


NotesThose who could walk 30 minutes or more without assistance were excluded from the trial


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear risk"Participants were assigned a code number, which was drawn by a research assistant who had no access to pre-test results"

Allocation concealment (selection bias)Unclear riskMethods used to conceal allocation not described

Blinding (performance bias and detection bias)
All outcomes
High riskNot possible to blind participants and the personnel to the intervention allocated

Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Raters were blinded to treatment group allocation"

Incomplete outcome data (attrition bias)
All outcomes
Low riskAttrition rate 20%, details provided, differences in drop-outs between groups were not significant. ITT analysis

Selective reporting (reporting bias)Low riskAll outcomes reported

Other biasLow riskNone apparent

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Aman 2009No randomization

Anon 1986Participants not diagnosed with dementia (residents of senior citizens' housing)

Arcoverde 2008No randomization

Batman 1999Unknown study design (may not be RCT), unknown age of participants, not able to contact author

Burgener 2008Treatment included more than exercise (i.e. cognitive behavioural therapy and support group)

Christofoletti 2011Not a true randomization

Heyn 2008Compared cognitively-impaired with normal older adults

Kerse 2008Participants were not diagnosed with dementia

Kwak 2008Participants do not appear to have been randomly assigned to groups

Littbrand 2006Participants not diagnosed with dementia (older, dependent people)

Littbrand 2011Did not assess any of the primary or secondary outcomes of this review

Netz 1994Participants not diagnosed with dementia (cognitive deterioration and/or depression)

Netz 2007Did not assess any of the primary or secondary outcomes of this review

Obisesan 2011Control group was stretch exercise

Onor 2007Treatment was not physical activity

Oswald 2007Treatment was combined cognitive and physical activity

Powell 1974Participants not diagnosed with dementia (geriatric mental patients)

Rodgers 2002Participants not diagnosed with dementia (elderly veterans)

Scherder 2005Participants not diagnosed with dementia (mild cognitive impairment)

Tappen 2000Outcome measured was mobility and not ADLs

van Uffelen 2005Participants not diagnosed with dementia (mild cognitive impairment)

Viscogliosi 2000Participants not diagnosed with dementia (mild cognitive impairment)

Williams 2007This article examined mood and affect and not depression

Yagüez 2011Intervention was non-aerobic "Brain Gym". Outcome measures were sustained attention, visual memory, and working memory

 
Characteristics of studies awaiting assessment [ordered by study ID]
Hasselbalch 2012

Methods

Participants

Interventions

Outcomes

Notes

NCT01935024

MethodsBenefits of Exercise in Alzheimer's Disease, Date Accessed 6 Nov 2013

Participants

Interventions

Outcomes

Notes

Volkers 2011

Methods

Participants

Interventions

Outcomes

Notes

 
Characteristics of ongoing studies [ordered by study ID]
Cerga-Pashoja 2010

Trial name or titleEvaluation of exercise on individuals with dementia and their carers: a randomized controlled trial

Trials 11, 53. 2010. PUBMED 20465799

MethodsRandomized, single-blind controlled trial

ParticipantsAiming to recruit 146 people with dementia and their carers

InterventionsParticipants will be randomized into 2 groups: 1 trained in a structured, tailored walking program, while the other continues with usual treatment

OutcomesNot known

Starting dateNot known

Contact informationacerga-pashoja@nhs.net

CNWL NHS Foundation Trust

Stephenson House

75 Hampstead Road

London England NW1 2PL

Tel: 020 3214 5886

NotesCurrently at recruitment stage

Cyarto 2010

Trial name or titleThe fitness for the Ageing Brain Study II (FABS II): protocol for a randomized controlled clinical trial evaluating the effect of physical activity on cognitive function in patients with Alzheimer's disease 

Trials 11, 120. 2010. PUBMED 21143943

MethodsParticipants will be randomly allocated to 2 treatment groups: usual care group or 24-week home-based program

ParticipantsThe study will recruit 230 community-dwelling participants diagnosed with Alzheimer's disease

InterventionsA 24-week home-based program consisting of 150 minutes per week of tailored moderate physical activity

OutcomesNot known

Starting dateNot known

Contact informatione.cyarto@nari.unimelb.edu.au

NotesCurrently at recruitment stage

Gennep van 2011

Trial name or titleEffects of a program combining walking and cognitive training on memory and behaviour of older persons with dementia

http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3121

MethodsMulticentre, randomized, controlled single-blind study

ParticipantsTarget number of participants is 164

InterventionsParticipants will be randomized to 1 of 4 interventions:
1. Combined intervention: walking and cognitive training (face-name learning)
2. Cognitive training (face-name learning)
3. Walking
4. Social visits

OutcomesNot known

Starting dateNot known

Contact informationGennep van, Martin, Netherlands

NotesCurrently enrolling participants, expect to complete in 2014

Laks 2012

Trial name or titlePhysical exercise as an additional treatment for Alzheimer disease http://clinicaltrials.gov/ct2/show/NCT01515982

Date accessed 6 Nov 2013

MethodsRandomized controlled trial, double-blinded, with 16-week follow-up

ParticipantsEstimated enrolment is 60 elderly people with Alzheimer disease

InterventionsParticipants will be randomly assigned to an exercise group (on a treadmill) and a control group

OutcomesNot known

Starting dateNot known

Contact informationjlaks@centroin.com.br

Federal University of Rio de Janeiro

NotesTrial ongoing until December 2013

Lamb 2011

Trial name or titlePhysical activity programs for community dwelling people with mild to moderate dementia (DAPA – Dementia And Physical Activity): a multi-centre, randomized controlled trial

http://www.controlled-trials.com/ISRCTN32612072/

MethodsParticipants will be randomly allocated to 2 treatment groups: usual care group, or 4-month exercise program with follow-up at 6 and 12 months

ParticipantsParticipants must meet the following criteria:
1. Have probable dementia of mild to moderate severity
2. Be able to participate in a structured exercise program:
a) able to walk 10 feet without human assistance
b) have no serious unstable illness (e.g. unstable angina)
3. Live in the community, either alone or with a relative, friend or carer, or in sheltered accommodation

InterventionsThe trial has 2 groups; 1 group (half the participants) will continue with their current treatment, while the other group (half the participants) will take part in the DAPA exercise program as well as their current treatment. The exercise intervention will be delivered in a group format, with up to 14 participants in each group. The program will be provided in 2, 1-hour sessions per week for 4 months, supplemented with between-session at-home exercises of at least 1 hour per week.

OutcomesNot known

Starting dateNovember 2011

Contact informationS.Lamb@warwick.ac.uk

Warwick Clinical Trials Unit at the University of Warwick

NotesTrial ongoing until May 2016

Logsdon 2012

Trial name or titleTwo interventions for early stage dementia: a comparative efficacy trial

http://clinicaltrials.gov/ct2/show/NCT01550718 Date accessed 6 Nov 2013

MethodsRandomized, single blind

ParticipantsEstimated enrolment is 240

Interventions3 groups: 2 intervention groups (physical activity, and social activity), and 1 usual care control group

OutcomesNot known

Starting dateNot known

Contact informationlogsdon@u.washington.edu

University of Washington

NotesTrial ongoing until Dec 2013

Pitkala 2010

Trial name or title

MethodsRandomized

Participants210 patients randomized into 3 groups (70 per arm)

InterventionsParticipants randomized into three arms:

1) tailored home-based exercise twice weekly;

2) group-based exercise twice weekly in rehabilitation centre;

3) control group with usual care and information about exercise and nutrition

OutcomesNot known

Starting date

Contact information

NotesAnalysing results

Potemkowski 2011

Trial name or titleInfluence of physical activity on cognitive dysfunction in patients with mild and moderate Alzheimer dementia Neurodegenerative Diseases

Conference: 10th International Conference AD/PD - Alzheimer's and Parkinson's Diseases: Advances, Concepts and New Challenges Barcelona Spain. Conference Start: 20110309 Conference End: 20110313

Conference Publication 8. 2011

MethodsNot known

Participants240 participants recruited

Interventions4 groups: study group with mild dementia, study group with moderate dementia, control group with mild dementia, control group with moderate dementia

OutcomesNot known

Starting dateNot known

Contact informationandrzej.potemkowski@wp.pl

NotesStudy ongoing

Rosendahl 2012

Trial name or titleA high-intensity functional exercise program for older people with dementia and living in residential care facilities (The Umeå Dementia and Exercise Study)

ISRCTN: http://isrctn.org/ISRCTN31767087 Date accessed 6 Nov 2013

MethodsCluster-randomized controlled trial

ParticipantsOlder people with dementia living in residential care facilities; target number of participants = 183

InterventionsTwo groups: exercise, and control (activities while sitting)

OutcomesNot known

Starting dateNot known

Contact informationerik.rosendahl@physiother.umu.se

NotesStill collecting data

 
Comparison 1. Exercise vs usual care: cognition

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Cognition8Std. Mean Difference (IV, Random, 95% CI)Subtotals only

    1.1 Cognition: all trials
8329Std. Mean Difference (IV, Random, 95% CI)0.55 [0.02, 1.09]

    1.2 Cognition: excluded moderate-severe dementia
7308Std. Mean Difference (IV, Random, 95% CI)0.31 [-0.11, 0.74]

 
Comparison 2. Exercise vs usual care: Activities of Daily Living (ADL)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Comparison of ADL6289Std. Mean Difference (IV, Random, 95% CI)0.68 [0.08, 1.27]

    1.1 ADL: all trials
6289Std. Mean Difference (IV, Random, 95% CI)0.68 [0.08, 1.27]

 
Comparison 3. Exercise vs usual care: depression

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Depression5341Std. Mean Difference (IV, Random, 95% CI)0.14 [-0.07, 0.36]