Minnesota Nursing magazine
Can exercise delay dementia symptoms?
After reading studies that showed that aerobic exercise can improve cognition in healthy adults, School of Nursing researcher Fang Yu, PhD, RN, GNP, FGSA, FAAN, wondered how exercise could affect people with Alzheimer’s disease and other dementias.
For the last 15 years, Yu has explored that question from a variety of perspectives and she is encouraged about what she’s found.
More than 5.7 million people in the United States are diagnosed with Alzheimer’s disease and that number is expected to increase to 14 million by 2050. There are few approved drugs to treat Alzheimer’s disease symptoms, and none of them prevent or slow the progression of the disease.
Yu, who recently was named the holder of the Long-Term Care Professorship, thinks non-pharmacological treatments hold promise for slowing the progression of the disease.
‘New energy, more vitality’
Bruce Erickson, who participated in one of Yu’s more recent studies, hopes the scans and the other data collected about him help others understand the disease better, but he already knows he benefitted from the exercise program.
“I’d gotten to the point where I just didn’t feel like doing anything,” said Erickson, who was diagnosed with Alzheimer’s disease 14 years ago. “The exercise gave me new energy and more vitality.”
He looked forward to his exercise sessions on a recumbent bike, knowing he could banter with Study Coordinator Sue Greimel and Exercise Interventionist Kaitlin Kelly. “You know, I’d never forget them,” he said.
The exercise sessions, three times a week for six months, were also a time to spend with his good friend Jerry Parks, who he met years ago at an Alzheimer’s meeting. The two would sing old songs during the car ride to the gym and could finish each other’s sentences if one needed help remembering what he was about to say. Parks, who was diagnosed in 2006, agrees with Erickson that it felt good having purpose again and knowing he was doing something useful. “After I was diagnosed I decided I wanted to help as many people as I could,” said Parks.
Both Erickson and Parks, after the initial anger and sadness that came with the diagnosis, committed to helping others understand the disease, whether it’s through participating in research, speaking at conferences or even singing in the choir Giving Voice with others who have dementia. “It’s a disease that I’ve been living with for 14 years,” said Erickson. “It’s possible to live with the disease. Even though I don’t want anyone to have to.”
They say they’ve gotten plenty out of the participation, but, ultimately, they’re not participating for what they get out of it. “It’s not for me, as much as for the future — for our siblings, for our grandchildren and greatgrandchildren,” said Erickson.
Yu’s research trajectory
Yu’s early research asked if there was anything about having a cognitive impairment that prevented safe aerobic exercise. While conducting pilot studies, she determined how to standardize the intensity of the exercise. Eventually she discovered an individualized dosage that is determined by heart rate reserve, subjective rating of exertion and monitoring symptoms that indicate intensity measures, like sweating patterns, skin color, ability to talk and breathing patterns.
Pilot studies showed that exercise was feasible for people with Alzheimer’s disease and adherence to exercise protocols was more than 75 percent, which is significantly higher than many exercise studies. Perhaps most exciting, the pilot studies showed preliminary benefits, suggesting that exercise could delay cognitive decline.
With successful pilot studies, Yu was awarded $3.4 million from the National Institute on Aging to conduct a randomized control trial to determine both the immediate and mid-term cognitive effects of exercise on people with Alzheimer’s disease. The study is assessing 96 participants’ cognition every three months over a year and brain structural changes at three points in time: prior to starting the exercise program, at its conclusion and six months after conclusion. MRIs measure hippocampal volume in the brain, which is thought to be responsible for spatial memory, direction and navigation.
Exercise Interventionist Kaitlin Kelly takes Bruce Erickson's blood pressure to ensure he is exercising at the prescribed level.
With the FIT-AD Trial underway, Yu saw that studies were showing that the most promising preventative interventions were cognitive treatment and exercise therapy. “Seeing that physical exercise and cognitive training were so promising, I wondered if combining them would have a synergistic effect, leading to results even better than doing just one or the other,” she said.
This led to the ACT Trial, a fiveyear, $3.8 million study investigating the effects of aerobic exercise and cognitive training in participants with mild cognitive impairment (MCI). MCI is an intermediate stage between the expected memory loss of normal aging and the more serious diagnosis of dementia. Approximately 15 to 20 percent of people 65 years old and older have MCI. Since MCI can be an early stage of Alzheimer’s, understanding how exercise and cognitive training effect it could help understand how to prevent Alzheimer’s disease.
Yu was awarded funding by the National Institute on Aging and is partnering with Feng Vankee Lin, PhD, RN, University of Rochester in New York, on this project.
The program involves 128 participants ages 65 and older who have MCI. Each participant will be evaluated for memory, brain function and physical ability over the course of a year and a half, and a brain scan will be conducted at various intervals using MRI.
Selected participants will also have PET scans of their brains to determine their level of amyloid. “We want to see whether or not this combined intervention can reduce the accumulation of amyloid, which is a key feature of Alzheimer’s disease,” said Yu.
Research with a clinical application
While work continues on the two trials, Yu isn’t going to wait until results are published to encourage people with dementia to safely exercise. Instead she’s working to obtain funding for a pragmatic trial, which is research with a clinical application. “The research I have been doing so far is very confined with rigorous control. We have strict criteria participants have to meet and then we have staff deliver those interventions,” said Yu. On the pragmatic trial, she’ll be working directly in the community.
“There are very few people who are educationally prepared to work with people who have Alzheimer’s in aerobic exercise,” said Yu. She’s developing a FIT-AD certificate program so that professionals like exercise physiologists and personal trainers can receive training on how to encourage safe exercise.
Yu is working with exercise physiologist Dereck Salisbury, PhD, School of Nursing assistant professor, to develop the content. The two have worked together in Yu’s previous studies, as Salisbury writes the exercise prescription for each participant based on individualized test results.
The certificate program consists of four modules, with information about the disease, how to assess individuals to determine the appropriate level of exercise and how to engage them to meet that level. The last module explains the declining trajectory of the disease and how to modify an exercise regimen over time.
“There is so much promise in nonpharmacological treatments, like exercise and cognitive training,” said Yu. “Ultimately, I want people with cognitive impairment to live longer in the community, with a better quality of life.”