Tuesday, April 16, 2013

At home, twice-a-week, customized exercise helps independence in dementia patients

What is this study? 

Nothing really new, but it's a well-designed, "clean" study.

It confirms what we've all already known about humans: We weren't designed to be still and it's why long-haul truck driver health is notoriously precarious, people get deep vein thrombosis (DVT) after long plane and car trips, and why disabled elderly men and women are more likely to die after a fall-induced hip fracture (17% of women die within the year)....among other examples of why a sedentary lifestyle diminishes the quality of our lives.

And this detrimental stillness only worsens in its deleterious effects the older we are, and the effects on thinking are profound not only in people who retire and stop keeping their minds active, but are even worse among patients with dementia who are now working with less mental reserve than they used to.

So this study from the Journal of the American Medical Association (JAMA) looked at patients with the actual Alzheimer's form of dementia (keep in mind there are other forms of dementia as well).

It was trying to tell us whether or not exercise actually helps reduce the rate of further decline in the patient's ability to self-participate in their own activities of daily living (ADLs)

It looked at 210 patients, all over the age of 65.
They were followed for 1 year.

It divided them into three groups:

1. Twice-a-week hour-long group exercise
2. Twice-a-week hour-long tailored/customized home exercise
3. Usual community-available care

A physical therapist evaluated them using a 0 to 126 point scale, with a higher number meaning they were more functional/needed less help.  Mobility itself was also measured with a formal test (Short Physical Performance Battery).

At one year:
ALL patients had some deterioration in physical functioning based on the above point system.

1. Twice-a-week group exercisers only lost 10.3 points on their 0-126 scale assessment
2. Twice-a-week home exercisers lost only 7.1 points on their 0-126 scale assessment
3. The patients who just took advantage to whatever community infrastructure is already in place dropped the most, losing 14.4 points on their 0-126 scale assessment

So, the people who exercised twice a week with a tailored/customized home exercise program did the best, with less progression of their inability to independently participate in their own activities of daily living.

Interestingly, the yearly cost for the people who just took advantage of what  was already available in the community was $35,121 (the most expensive), but the group who got the customized home exercise program cost the least at $25,112/year. To me that's a big savings for better care and most importantly a better life for the patients.

I mailed a copy of this study to each of the insurance companies we work with and addressed it to their Medical Director.

Here's a longer version of the above if you would like to read it:

Workout Helps with ADL in Alzheimer's

Published: April 2013

An exercise program for people with Alzheimer's disease helped them cope with activities of daily living, without increasing health and social care costs, researchers reported.
In a randomized, controlled trial, supervised exercise, whether at home or at a day care center, slowed physical deterioration, according to Kaisu Pitkälä, MD, PhD, of the University of Helsinki in Finland, and colleagues.
And the costs for patients in the exercise programs were similar or lower than those associated with a control program of usual community care, Pitkälä and colleagues reported online in JAMA Internal Medicine.
The two main characteristics of Alzheimer's disease are cognitive decline and functional deterioration, including progressively greater need for help in daily activities, the researchers noted.
But although there is extensive research on exercise in older people, there are "surprisingly few rigorous studies" looking at exercise in people with dementia, they commented.
To help fill the gap, they enrolled 210 people with Alzheimer's disease (ages 65 and up) who could walk independently and were living at home under the care of a spouse. Participants had to meet one of the following conditions:
  • At least one fall during the past year
  • Decreased walking speed
  • Unintentional weight loss
They were randomly assigned to one of three groups for a year of study – group sessions twice weekly with about an hour of exercise, tailored home-based exercise for an hour twice a week, and a control group getting usual community care.
Physical functioning was assessed using the Functional Independence Measure, a scale that runs from 0 to 126, with higher scores indicating less need for help in daily living. Mobility was measured with the Short Physical Performance Battery.
The researchers retrieved data on the use of health and social services from both government registers and medical records.
After a year, they found, all patients had deteriorating physical function, but those in the exercise programs had slower declines. For instance, the decline on the functional independence measure after a year was 7.1 points for those in the home exercise group, 10.3 points for those taking group exercise, and 14.4 points for those in the control group.
The difference between the home exercise group and the control group reached statistical significance (P=0.004), but those taking group exercise did not differ significantly from the controls.
But in a mixed effects model, the decline was significantly slower in the exercise groups both at 6 months (P=0.003), and at a year (P=0.015).
There was no significant effect on changes in mobility.
On average, the yearly cost for health and social services in the control group was $34,121 compared with $22,066 for those taking group exercise and $25,112 for those in the home exercise cohort.
In a bootstrap-type analysis of covariance, the researchers reported, the difference from controls was significant (P=0.03) for those taking group exercise, but nonsignificant, although lower on average, for those exercising at home.
The study is "very difficult to criticize," commented Paul Schulz, MD, of the University of Texas Health Science Center in Houston.
"It really was randomized, it really was controlled, and it was partly blinded," Schultz told MedPage Today.
An important implication, he said, may be a knock-on effect on cognition. Research in other areas has suggested that exercise improves cognition by reducing other risk factors for dementia, such as heart disease and high blood pressure.
"Getting the Alzheimer's patients to exercise is not only going to improve their activities of daily living, which was the purpose of the study, but it may also help their cognitive status," he said.
Pitkälä and colleagues noted that the findings should be generalized with caution, because volunteers were selected, motivated, and white. Also, the study was relatively small, and nearly a quarter of the patient-caregiver pairs dropped out, owing to death or other reasons.
Nevertheless, the findings are "a welcome addition to (the) scanty literature" on ways to preserve physical abilities in people with Alzheimer's disease, commented A. Mark Clarfield, MD, and Tzvi Dwolatzky, MD, both of Ben-Gurion University of the Negev in Beersheba, Israel.
But they cautioned in their accompanying commentary that participants volunteered for the study, so that the "strength of the conclusions may have been weakened by the healthy volunteer effect."
In addition, the differences between groups in expected declines over the study period are statistically significant but "not very clinically significant, in our minds."
On the positive side, they concluded that the study suggests the "good news" of a benefit from exercise may apply even to people "well into the process of decline."