Presentation by Dr Samuel Nyman for the ESRC Seminar Series on Ageing and Physical Activity - "Physical activity among hard to reach groups: Issues for research, policy and practice"

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Dementia friendly Tai Chi
Dr Samuel Nyman

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This presentation will introduce a newly-funded
research project that will offer Tai Chi to community-
dwelling older people with dementia.
It will outline the rationale for the study along with the
approach taken to delivery of the intervention, with a
focus on harnessing participant’s implicit memory and
a positive approach to mental capacity.
Outline

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• Issue of falls
• Evidence for preventing falls among
people with dementia
• The TACIT Trial
• Approach to delivery of the intervention
• Positive approach to mental capacity
Outline

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• Frequency
• Severity
• Cost
Issue of falls

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• 1 in 20 A&E patients are adults 60+ with a fall injury
• 2 in 3 patients with dementia fall each year
• Patients with dementia are 3 times more likely to
fracture their hip
• 1 in 3 hip fracture patients with dementia die <1 year
Falls and dementia

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Dementia
• Dementia is an
umbrella term used
for a collection of
diseases of the brain
that are progressive
and terminal in
nature.

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Types of dementia
• Prevalence rate of falls and subtype:
• No dementia 36%
• Alzheimer’s 47%
• Vascular 47%
• Lewybody 77%
• Parkinson’s 90%
Allan et al. (2009)

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Prevention of falls

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Gillespie et al (2012)
• Cochrane review - community
• 159 trials with 79,193 participants
• Group and home-based exercise, and home safety
interventions reduce rate of falls and risk of falling.
• Multifactorial - reduce rate of falls but not risk of
falling.
• Vitamin D supplementation does not reduce falls but
may be effective in people who have lower vitamin D
levels before treatment.

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Cameron et al (2012)
• Cochrane review - nursing care facilities
• 43 trials with 30,373 participants
• Vitamin D supplementation reduced rate of falls by
average of 37% but not risk of falling
• Exercise was inconsistent
• Might reduce falls in intermediate level
facilities, but increase falls in facilities
providing high levels of nursing care
• Multifactorial interventions suggested possible
benefits, but inconclusive

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Sherrington et al (2008)
• Exercise reduced the rate of falling by
17% (44 trials with 9,603 participants)
• Greater relative effects (42%) are seen in
programs that include
• Exercises that challenge balance
• Use a higher dose of exercise
• Do not include a walking program

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Not all exercise helps
• e.g. Voukelatos et al (2015)
• 48 week ‘Easy Steps’ programme among inactive
• Increased amount of time walking for exercise
• But no difference on fall rate
• e.g. Sherrington et al (2014)
• Post-hospital discharge, home-exercise programme
• 15-20 mins six times weekly for 12 months
• Improved mobility, but increased falls (IRR = 1.43)

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Dr Samuel R Nyman
NIHR Career Development Fellow
Bournemouth University
The TACIT Trial
TAi ChI for people
with demenTia

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Tai Chi

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Why Tai Chi?
• Impaired postural balance - core risk factor for all older
people, which Tai Chi addresses
• Impairments to balance and gait might be main
mechanism for other risk factors of falls
• In community-dwelling, single interventions just as
effective; may be more acceptable and cost-effective
• Single intervention studies make greater contribution to
science as clear mechanism of effect

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Referred from NHS memory clinics
150 dyads (patient with dementia and carer)
Baseline measures
Intervention
n = 75 dyads
Usual care plus Tai Chi
5 months
Control
n = 75 dyads
Usual care
5 months
Repeat baseline measures 6 months post-baseline
Phase 2 RCT

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TACIT approach

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• Both PWD & carer to attend (max 7 dyads)
• Positive Emotion-Motivated Tai Chi (PEM-
TC) approach initiated in the USA
• Teaching will be implicit learning-based
• Repetition of movements
• Positive reinforcement
• Muscle / kinaesthetic memory
Tai Chi classes

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• PEM-TC: ‘sticky hands’ technique
• Avoids reliance on verbal instruction
• Uses palm-to-palm contact to physically guide
the movements.
• Less cognitively demanding
Tai Chi home-exercises

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Patient adherence
After 16 weeks:
- Improved balance
- 86% classes attended
- 84% home-ex done
Yao et al (2008) pilot study

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• Why are people with dementia in the
community a hard-to-reach group?
• Two central narratives of old age
(Johnson, 2005)
• Ancient
• Positive, benign, associations with authority, sage
• Modern
• Shifting trends and panic, apocalyptic demography,
politically generated conflict
Dementia

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Mental Capacity Act 2005

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Five Core Principles of the
Mental Capacity Act 2005
• People with dementia should be encouraged to make as
many decisions as possible for themselves using the five
core principles of the Mental Capacity Act
1. A person must be assumed to have capacity unless it is
established that they lack capacity.
2. A person is not to be treated as unable to make a decision
unless all practicable (doable) steps to help them to do so
have been taken without success.

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3. A person is not to be treated as unable to make a
decision merely because they make an unwise decision.
4. An act done, or decision made, under this Act for or on
behalf of a person who lacks capacity must be done, or
made, in their best interests.
5. Before the act is done / decision is made, regard must
be had to whether the purpose for which it is needed
can be as effectively achieved in a way that is less
restrictive of the person’s rights and freedom of action.
Five Core Principles of the
Mental Capacity Act 2005

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• Understand information about the
decision to be made
• Retain that information in their mind
• Use or weigh that information up
• Communicate their decision
• A person needs to do all of the above to
have capacity
Dementia

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Just because
someone
has dementia,
doesn’t mean they
don’t still have
a need to live
Dementia

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Andy Baker
BUDI Orchestra
mr.andybaker@virgin.net
The BUDI orchestra

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• Falls are a concern for PWD
• Evidence-base for preventing
falls among PWD weak, but
Promise for Tai Chi
• The TACIT Trial
• Approach to delivery: Use of tacit memory
• Positive approach to mental capacity
Conclusion

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• Dr Samuel Nyman is funded by a National Institute for
Health Research (NIHR) Career Development
Fellowship Award.
• This is a summary of independent research funded by
the NIHR’s Career Development Fellowship Programme.
The views expressed are those of the author(s) and not
necessarily those of the NHS, the NIHR or the
Department of Health.
• Tai Chi logo; created by Jems Mayor from Noun Project.
Acknowledgements

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Any questions?
Dr Samuel Nyman
Bournemouth University Dementia Institute and
Department of Psychology