Health Evidence hosted a 90 minute webinar examining the effectiveness of exercise programs for people with dementia. Click here for access to the audio recording: https://youtu.be/jC8HhC2XFrE Dorothy Forbes, Professor, Faculty of Nursing, University of Alberta, Edmonton led the session and presented findings from her latest Cochrane review: Forbes, D., Forbes, S. C., Blake, C. M., Thiessen, E. J., & Forbes, S. (2015). Exercise programs for people with dementia. Cochrane Database of Systematic Reviews, 2015(4), CD006489. As the population ages, the number of people suffering with dementia will also rise. Not only will this affect quality of life of people with dementia but will also increase the burden of family caregivers, community care, and residential care services. Exercise interventions have been identified as a potential way of reducing or delaying the progression of dementia and its symptoms. This review examines two questions: do exercise programs for older people with dementia improve cognition, activities of daily living (ADLs), challenging behaviour, depression, and mortality in older people with dementia? and; do exercise programs for older people with dementia have an indirect impact on family caregivers' burden, quality of life, and mortality?

1. Welcome!
Exercise programs for people
with dementia: What's the
evidence?
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3

4. What’s the evidence?
Forbes, D., Forbes, S. C., Blake, C. M.,
Thiessen, E. J., & Forbes, S. (2015).
Exercise programs for people with
dementia. Cochrane Database of
Systematic Reviews, 2015(4),
CD006489.
http://www.healthevidence.org/view-
article.aspx?a=23982

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12. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

13. Stages in the process of Evidence-
Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

14. Poll Question #3
Have you heard of PICO(S) before?
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15. Searchable Questions Think “PICOS”
1. Population (situation)
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3. Comparison (other group)
4. Outcomes
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Poll Question #4

17. Dorothy Forbes,
PhD, RN
Professor, Faculty of Nursing,
University of Alberta

18. Exercise programs improve health outcomes
for people with dementia
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
18
Poll Question #5

19. Review
Forbes, D., Forbes, S. C., Blake, C. M., Thiessen,
E. J., & Forbes, S. (2015). Exercise programs for
people with dementia. Cochrane Database of
Systematic Reviews, 2015(4), CD006489.

20. Review Team
• Dorothy Forbes, University of Alberta
• Scott C. Forbes, Okanagan College
• Catherine M. Blake, University of Western
Ontario
• Emily J. Thiessen, University of Alberta
• Sean Forbes, University of Florida

21. Background
• In 2012, WHO declared dementia a public health priority.
• In the coming decades, with the aging of the population, the
number of individuals living with dementia in our communities
will rise dramatically, affecting their quality of life.
• In addition, the burden on family caregivers, community care,
and residential care services will increase.
• Exercise is among the potential protective lifestyle factors
identified as a strategy for treating the symptoms of dementia
or delaying its progression.

22. Review Questions
• Do exercise programs for older persons with
dementia:
– improve cognition, activities of daily living (ADLs),
neuropsychiatric symptoms, depression, and
mortality?
– have an indirect impact on family caregivers’
burden, quality of life, and mortality?
– reduce the use of health care services (e.g. visits to
the emergency department) by persons with
dementias and their family caregivers?

23. Approach
• Selection of studies:
– Studies were identified from searching the ALOIS,
the Cochrane Dementia & Cognitive Improvement
Group’s specialized register.
– All relevant RCTs in which older adults with
dementia were allocated to either exercise
programs or control groups (usual care or social
contact/activities) were included.
– At least two reviewers independently assessed
retrieved articles for inclusion, assessed
methodological quality, and extracted data.

24. Analyses
• We calculated mean differences or standardized
mean differences for continuous data.
• Data for each outcome were synthesized using a
fixed effects model, unless there was substantial
heterogeneity between studies, then a random
effects model was applied.
• We also evaluated adverse events.

25. Analyses
• Subgroup analysis and investigation of
heterogeneity:
– Severity and type of dementia
– Type, frequency, and duration of exercise program

26. Results of Search &
Screening
5241 titles/abstracts located
542 abstracts screened for inclusion
18 articles (17 trials) met criteria and were included
69 articles retrieved and rated

27. Studies/Participants
• Trials published between 1997-2012
• Conducted in USA=4, Netherlands=3, Australia=2,
France=2, Belgium=1, Brazil=1, Italy=1, South
Korea=1, Spain=1, Sweden=1
• Participants (N=1067) were residents of nursing
homes, graduated residential care, psychiatric
facilities, day care centres, and in their own home
settings.

28. Exercise Programs
• Program length varied from two weeks to 18 months
• Programs ranged from twice/week to daily and from 20
to 75 minutes per session
• Exercises were combinations of aerobic, strength, and
balance
• Control groups were usual care or social contact

29. Risk of Bias of Included
Studies

30. Results

31. Exercise & Cognition
• Nine trials (409 participants) examined the
effect of exercise on cognition
• The meta-analysis revealed no clear
evidence of benefit from exercise on
cognitive functioning
• Estimated standardized mean difference
between exercise and control groups was
0.43 (95% CL -0.05 to 0.92, P value 0.08)
• There was substantial heterogeneity in this
analysis (I2 value 80%) and quality of
evidence was very low

32. Exercise & ADLs
• We found a benefit of exercise programs on the ability
of people with dementia to perform ADLs (six trials,
289 participants)
• Estimated standardized mean difference between
exercise and control groups was 0.68 ( 95% CL -0.08
to 1.27, P value 0.02)
• There was substantial unexplained heterogeneity in
this analysis (I2 value 77%) and quality of evidence
was very low

33. Other Outcomes
• One study suggested that caregiving burden
may be reduced by supporting the person with
dementia to participate in an exercise program
• There was no clear evidence of benefit of
exercise on neuropsychiatric symptoms or
depression in persons with dementia

34. Other Outcomes (cont’d)
• The remaining outcomes could not be examined
because appropriate data were not reported:
– Quality of Life
– Mortality
– Health Care Costs

35. Summary
• This review included 17 trials with 1067 participants
• The exercise programs varied greatly
• The review suggests that exercise may improve the
ability to perform ADLs
• There was no clear evidence of benefit from exercise
on cognitive functioning, neuropsychiatric symptoms,
or depression

36. Recommendations to Improve
Methodological Quality
• In several cases useable data for inclusion in the
meta-analysis were not provided by the authors
• Authors should include:
– Means and SDs for end point measures
– Change from baseline to final measurement scores in
published reports, or
– Be willing to provide these data on request

37. Quality of the Evidence
• Many authors did not adequately report the
random sequence generation and allocation
concealment processes
• Several authors did not report the outcome data
for each main outcome
• Some authors failed to report on the blinding of
outcome assessors

38. Implications for Practice
• No trials reported adverse events related to the exercise
programs
• Health care providers should feel confident in promoting
physical activity to persons with dementia
• Decreasing the progression of dependence in ADLs will
have clear benefits for the persons with dementia and their
caregivers and possibly delay the need for placement in
long term care settings
• Encouraging caregivers to participate in exercise may have
a beneficial impact on their quality of life

39. Implications for Research
• Setting of intervention (home or institution) should be
considered in future
• There were insufficient trials to conduct subgroup
analyses to determine which type of exercise (aerobic,
strength training, or a combination), at what frequency
and duration, is most beneficial for specific types and
severity of dementia
• Further research is needed to develop best practice
guidelines for health care providers to advise persons
with dementia living in institutional and community
settings

40. Reference
Protocol first published in 2007, regular
updates since then
Forbes D, Forbes SC, Blake CM, Thiessen
EJ, & Forbes S. Exercise programs for
people with dementia. (Review). Cochrane
Database of Systematic Reviews 2015;4.
For further information contact
dorothy.forbes@ualberta.ca

41. Exercise programs improve health
outcomes for people with dementia
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree
41
Poll Question #6

42. Poll Question #7
Do you agree with the findings of this
review?
A.Strongly agree
B.Agree
C.Neutral
D.Disagree
E.Strongly disagree

43. Questions?

44. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

45. Supporting awareness and uptake of
cancer prevention knowledge in practice
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Announcing: Implementation of a research project to build capacity among Canadian public health professionals
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