Exercise programming for patients with Alzheimer's Disease

By James H. Rimmer, PhD, and Donald L. Smith, MS, RCEP

This is an excerpt from ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, Third Edition, from the American College of Sports Medicine and edited by J. Larry Durstine, Geoffrey E. Moore, Patricia L. Painter, and Scott O. Roberts.

Recommendations for Exercise Programming

Exercise training for individuals with AD has three major considerations:

to minimize problems arising from the declining physical and mental health of the participant
to recognize behavioral changes that may cause the client to become agitated with the exercise program or the exercise setting
to support caregivers’ willingness to continue bringing the person to the exercise program as the disease progresses

Thus, a low-intensity program at the client’s usual ADL levels is recommended. For this level of involvement, exercise testing is unnecessary.

During the early stages of AD, most clients should be able to participate in some form of physical activity. One of the most common problems associated with exercise programming for adults with AD is memory loss. Clients may forget to come to the exercise session or may find that they have forgotten how to perform certain activities. Depression is also quite common during the early stage of the disease and may result in the client’s withdrawal from the program. The cornerstones of an exercise program for this population are consistency, patience, and enjoyment. The exercise leader must constantly provide verbal encouragement and support to maintain the client’s interest in the program. During the early stages of exercise training, simple repetitive exercises like walking, riding a stationary bike, or lifting a certain amount of weight on various exercise machines will be easier than more complex routines (see table 48.2).

Table 48.2

Click table below to make larger

Precautions

In the early stages of the condition, participation is extremely important in terms of establishing some sort of regular routine that the client can sustain for as long as possible.
Emotional instability or outbursts may affect the exercise program in the later stages.
Low-intensity exercise should be the main focus, involving activities that the person enjoys and can successfully perform.
Constant supervision during physical activity is necessary during the mid to later stages of Alzheimer’s.

The middle stage of AD presents a different set of challenges for the exercise leader. As the disease progresses, the program should become more simple and the leader should consider what reasonable criteria should be used to terminate the program. One of the major concerns during later stages of AD involves behavior. Because agitation is one of the hallmark symptoms of the disease, it is not unusual for a client to become resistant to continuing the exercise program. A client with good exercise adherence during the early stage may suddenly decide to drop out. Memory loss during this stage is more pronounced than earlier, and the client may need verbal or physical guidance in maintaining the exercise routine.

Extreme outbursts of anger and physical aggression can occur during this stage. Often such behavior will last for only a few minutes and the client will immediately forget that the incident occurred. The exercise leader must remember that this is a symptom of the disease and therefore should not take such outbursts personally. He or she must work through the agitation with the support of the caregiver, who may or may not be present during the exercise session. For some caregivers, the brief period away from their loved one is much desired. However, if the individual has a high level of agitation, it may be necessary to have the caregiver present to work through certain behaviors. In some cases, the caregiver may be in the facility and “on call” but wouldn’t necessarily have to be in the same room. Sometimes music can help the person relax during the exercise session provided that it is not too loud and has a sound that is appealing to the participant.

During the advanced and final stage of the disease, the client will require constant supervision and physical assistance. Language skills will be greatly diminished and language comprehension extremely limited. The exercise program must be guided on an individual basis. Incontinence and limited mobility are common. Range of motion and strength exercises will be the major focus during this stage.

Special Considerations

People with AD commonly have a higher level of restlessness or agitation at the end of the day, which experts have labeled “sundowning.” This increased state of agitation, activity, and negative behaviors is associated with high levels of fatigue and tiredness later in the day. Therefore the exercise program should be scheduled for an earlier time in the day, preferably in the morning, when the client’s agitation level is usually at its lowest and mental cognition is at its highest.

If the client is exercising at home with a family member, a daily walk may be the optimal way to establish a structured routine. However, if the client refuses to exercise at home, attending a day care program once or twice a week may be better. As the disease progresses, walking may be the only exercise the individual is capable of carrying out; and once ambulation is no longer a possibility, because of either the inability to walk or the risk of wandering, maintenance of range of motion becomes crucial.

The hallmark exercise program is one that keeps the client active at various times during the day (e.g., 10 min exercise routines), poses a low risk of injury from falls, and has a strong behavioral component (e.g., effective reinforcement strategies).

When developing the training program be sure to consider the following elements:

Strength Training: Therabands

Strengthen postural muscles.
Focus on areas of weakness (i.e., quadriceps, hip extensors).
Use 10 to 12 reps or less as tolerated.

Aerobic Training: Walking and Chair Aerobic Exercises

Emphasize enjoyment.
Maintain function.

Flexibility Training

Stretch postural muscle groups.
Focus on exercises that can be done on a raised platform (i.e., mat table) or chair; getting down or up from the floor will be difficult.

This is an excerpt from ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities, Third Edition, from the American College of Sports Medicine and edited by J. Larry Durstine, Geoffrey E. Moore, Patricia L. Painter, and Scott O. Roberts.

Some general suggestions:

1. Be guided by a clinician who understands brain function.

2. Presuming there is no jewelry on the affected side, remove wrist watches and rings. Try to make a total illusion.

3. Depending on the pain and disability state, decide on an appropriate activity(ies) to perform with the good hand. This could range from just looking at the mirror image to finger movements, or taking weight through the hand.

4. In general, the more severe the problem (eg. Severe Complex Regional Pain Syndrome), small movements, performed often, may be more appropriate.

5. Feel comfortable with the selected movements(s)’, ie. ‘conquer the movement’ before progressing to a more challenging movement

6. Once you feel comfortable with a movement, try and perform it in a different context. For example, do it with a song in your head, or with altered emotions by thinking of something good or bad. Overall, you will need to repeat movements, grade the movements and then context enriching the movements for best neurone health.

7. Take care. If the hand in the box hurts or sweats, you may have taken the brain exercises too far even though the hand has not been moved.

8. Move the painful hand in the box to the point where it starts to hurt a little and then move the good hand which is outside the box a little bit further.

9. Do it simultaneously or reciprocally.

10. By placing a mirror between the feet, a similar therapy can be performed for the for foot and leg problems.