THE EFFECT OF EXERCISE ON BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS IN DEMENTIA: A REVIEW OF THE LITERATURE

1. THE EFFECT OF EXERCISE ON BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS IN DEMENTIA: A REVIEW OF THE LITERATURE Dr. Ingela Thuné-Boyle Prof. Steve Iliffe UCL, Department of Primary Care and Population Health Ms. Arlinda Cerga Pashoja Dr. David Lowery Dr. James Warner Central and North West London NHS Foundation Trust

2. Background • BPSD: Anxiety, depression, apathy, agitation, aggression, ‘wandering’, repetitive motor behaviours, sleep, disinhibition, eating, delusions, hallucinations • Up to 80% - changes in mood, personality and behaviour (e.g. Overshott & Burns, 2007) and sleep disruptions (Bradley et al., 2002) • Pharmacological: mood stabilisers, anxiolytics, hypnotic, acetylcholinesterase inhibitors/memantine and antipsychotics • Worsening symptoms and negative side effects (Boeve et al., 2002) • Unclear efficacy & high cost (e.g. Areosa et al., 2005) • Sedation, gait disturbance, falls, dehydration, chest infections, accelerated cognitive decline, stroke and death (Schneider et al., 2006)

3. Background • Guidance directing clinicians to avoid use of anti-psychotics in dementia (e.g. NICE, 2006) – ‘watchful waiting’ approach – symptoms (e.g. agitation) often improve after a 4-6 week period • 40% to 60% of care home residents with dementia currently prescribed antipsychotics • Approx two thirds of prescriptions are inappropriate • Medicated without dealing with the cause of the problem • Non-pharmacological interventions?

4. Background • Benefit of exercise in older adults – Improved physical & psychological outcomes: • Prevention of heart disease, diabetes, stroke, falls etc. • Reduced depression • Improved QoL • Enhanced sleep • In dementia: reviews – different inclusion criteria, different conclusions, different outcomes

5. Aim of review • Does exercise improve BPSD? • How has exercise been conceptualised and do some aspects of it (e.g. type, frequency & duration) provide better results than others? • What are the main limitations and methodological shortcomings of current research in this area?

6. Methodology • Rapid appraisal • Critical interpretive approach (Dixon-Woods et al., 2006) • Inclusion/Exclusion • Efficacy of exercise in improving BPSD • Intervention studies • Reviews & individual papers • Published in peer review journals • Combined interventions excluded • Medline, Embase, Psychinfo & Pubmed • Number of records identified: n = 723…Final number: 10 reviews and 6 individual papers

7. Results • Type of exercise: Walking, flexibility, strength (e.g. weight training) & balance, cycling, chair-based, dance and rhythmic movement, meaning based, sit to stand repetition • Anxiety: Some evidence (chair based and walking) of immediate effect, maintained at 12 weeks • Depression: Mixed. Few short-term effects but after longer duration (e.g. 3 months onwards – walking, strength, flexibility), effect more likely • Apathy: No evidence (one pilot study only)

8. Results • Aggression/Agitation: Evidence of short and long term effects of walking, aerobics, strength & meaningful exercise • Wandering: Some evidence (structural activity) • Repetitive behaviours: No studies • Sleep: Few studies but positive evidence, especially for mild sleep disturbance. Type of exercise not clear but higher frequency = better outcome irrespective of duration

9. Results • What worked? - Walking, chair-based, aerobics, strength & meaningful exercise • Many studies did not mention frequency and duration • Heyn et al. (2004) – unable to demonstrate significant findings • Eggermont & Scherder (2006) – higher frequency = better outcome (sleep) irrespective of duration • May vary depending on symptom in question

10. Methodological shortcomings • Substantial! • Few RCTs (mostly pilot), absence of blinding • Low sample size • Short follow-up periods – some symptoms may take longer to respond • Mixed dementia (2 studies = Alzheimer’s only) • Cause of BPSD rarely discussed (e.g. ‘wandering’ caused by feeling lost or anxious?)

11. Future research agenda • More comprehensive list of BPSD • Adherence/Motivation • Care homes (e.g. apathy) vs. home setting (most conducted within the care home) • Group based vs. individual • Type, frequency and duration in different types and severity of dementia • How does exercise reduce BPSD? (E.g. Reduction in anxiety = reduction in agitation/repetitive action/wandering? Depression = increased confusion = increased anxiety/aggression? )

12. i.thune-boyle@ucl.ac.uk