Background
Background and project overview
Methods
Statement scope and purpose
Name | Expertise and Institution | Role(s) |
---|---|---|
Jordan Antflick (PhD) | Knowledge Synthesis, Knowledge Translation, Dissemination: Ontario Brain Institute
| Knowledge Broker |
Chris Ardern (PhD) | Guideline Development, Content (exercise, epidemiology): York University
| Content Expert-Physical Activity Epidemiology |
Christa Costas-Bradstreet | Dissemination: ParticipACTION
| Stakeholder, Dissemination |
Mary Duggan | Knowledge Synthesis, Guideline Development and Dissemination: Canadian Society for Exercise Physiology
| Stakeholder, Dissemination |
Jennifer Heisz (PhD) | Knowledge Synthesis, Content (Alzheimer’s disease, exercise, aging): McMaster University
| Content Expert- Alzheimer’s disease, Aging, Exercise, Cognitive Neuroscience |
Audrey Hicks (PhD) | Knowledge Synthesis, Guideline Development, Content (exercise, aging, practice): McMaster University
| Content Expert-Physiology |
Amy Latimer-Cheung (PhD) | Knowledge Synthesis, Guideline Development, Content (disability, behavior change), Knowledge Translation: Queen’s University
| Content Expert-Exercise Behavior Change |
Hans Messersmith | Knowledge Synthesis, AGREE, Guideline Development: McMaster University
| Panel Chair, Process Advisor |
Kathleen Martin Ginis (PhD) | Knowledge Synthesis, Guideline Development, Content (disability, behavior change), Knowledge Translation: McMaster University
| Leadership, Project Direction |
Laura Middleton (PhD) | Content (exercise, cognition, Alzheimer’s disease, dementia: University of Waterloo
| Content Expert-Exercise, Cognitive Aging and Alzheimer’s disease |
Kirk Nylen (PhD) | Knowledge Synthesis, Knowledge Translation, Dissemination: Ontario Brain Institute
| Knowledge Broker |
Don Paterson (PhD) | Content (exercise, aging): Western University
| Content Expert-Physiology, Aging |
Katherine Rankin (BA) | Dissemination: Dementia Alliance, Alzheimer Societies of Brant, Haldimand Norfolk, Hamilton Halton
| Content Expert – Alzheimer’s disease Stakeholder, Dissemination |
Michael Rotondi (PhD) | Evidence Synthesis, Meta-analysis models: York University
| Content Expert-Biostatistics |
John Spence (PhD) | Knowledge Synthesis, Guideline Development, Content (physical activity, behavior change): University of Alberta
| Content Expert-Exercise Behavior Change |
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Overall statement objective: To provide an evidence-based messaging statement for the use of physical activity (a) to prevent Alzheimer’s disease, and (b) to help manage symptoms and complications of Alzheimer’s disease.
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Clinical questions addressed by the statement: Can physical activity help to prevent Alzheimer’s disease in community-dwelling adults? Can physical activity be beneficial for managing symptoms and complications associated with Alzheimer’s disease (i.e., cognitive, affective, behavioural, sleep, physical, activities of daily living [ADL] and quality of life [QOL] outcomes)?
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Target population: Older adults who wish to prevent Alzheimer’s disease AND older adults with a diagnosis of Alzheimer’s disease.
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Potential users of the statement: a) older adults and their families, (b) primary caregivers of older adults with Alzheimer’s disease, c) health care providers including primary care physicians, physiotherapists, kinesiologists, attendant care providers, certified exercise physiologists, and occupational therapists, and d) local service organizations--such as the Canadian Society for Exercise Physiologists (CSEP) and the Alzheimer Society of Ontario –and public health and physical activity promotional agencies (e.g., ParticipACTION).
Systematic review of systematic reviews
Scope of the review; literature search strategy and screening
Data extraction and assessment of methodological quality
Stakeholder involvement
Health care providers | ||||||
n | M (SD) | Range of responses | ||||
In your opinion, is the toolkit appropriate for all community-dwelling individuals with Alzheimer’s disease? | 5 | 4.40 (.55) | 4–5 | |||
In your opinion, does the toolkit provide useful information for people with Alzheimer’s disease? | 5 | 4.80 (.45) | 4–5 | |||
In your opinion, does the toolkit provide useful information for health care practitioners? | 5 | 4.40 (.55) | 4–5 | |||
How confident are you that a client with Alzheimer’s disease could engage in enough physical activity each week to meet the current physical activity guidelines? | 5 | 3.00 (.71) | 2–4 | |||
If given the opportunity, would you use this statement to recommend physical activity in your practice? | 5 | 4.00 (.71) | 3–5 | |||
Older adults | Caregivers | |||||
n | M (SD) | Range of responses | n | M (SD) | Range of responses | |
Does the statement provide useful information for older adults? | 15 | 4.47 (.52) | 4–5 | 5 | 4.20 (.45) | 4–5 |
Does the statement provide useful information for families and caregivers of people with Alzheimer’s disease? | 15 | 4.47 (.52) | 4–5 | 5 | 4.20 (.45) | 4–5 |
Is the statement clear regarding the benefits of physical activity? | 15 | 4.40 (.63) | 3–5 | 5 | 4.20 (.45) | 4–5 |
In your opinion, is the toolkit appropriate for older adults with Alzheimer’s disease or those who want to prevent Alzheimer’s disease? | 14 | 4.21 (.58) | 3–5 | 5 | 4.20 (.45) | 4–5 |
In your opinion, does the toolkit provide useful information for people with Alzheimer’s disease or those who want to prevent Alzheimer’s disease? | 14 | 4.14 (.53) | 3–5 | 5 | 3.80 (.87) | 3–5 |
In your opinion, does the toolkit provide appropriate information to help older adults become more physically active? | 14 | 4.21 (.43) | 4–5 | 5 | 4.00 (.00) | 4–4 |
In your opinion, does the toolkit provide clear information on the benefits of physical activity for preventing Alzheimer’s disease? | 15 | 4.00 (.65) | 3–5 | 5 | 4.00 (.00) | 4–4 |
In your opinion, does the toolkit provide clear information on the benefits of physical activity for managing Alzheimer’s disease? | 15 | 3.93 (.59) | 3–5 | 5 | 4.20 (.45) | 4–5 |
Consensus meeting
Review | Quality score | # Studies in reviewa
| Type | Characteristics | Outcomes | ||||
---|---|---|---|---|---|---|---|---|---|
Participants | Design | Interventions | Physical | Psycho-logical | ADL and quality of life | ||||
Blankevoort et al., 2010b [26] | 9 | 16 | NR/MA | Elderly (mean age >70 years) with dementia | 10 RCT, 6 case series | Various structured exercise programs |
Physical Function:
↑ Gait Speed, fast (k = 2) ES = 0.14; ↑ Gait speed, normal (k = 6) ES = 0.29; ↑ Endurance (k = 5) ES = 1.08; ↑ Lower extremity strength (k = 7) ES = 0.85 ↑ Functional mobility (k = 6) ES = 0.28
Balance and Falls:
↑ Balance (k = 5) ES = 1.76 | ↑ ADL (k = 4) d = 0.68 | |
Boote et al., 2006 [27] | 8 | 1 | NR | Mod-severe AD | RCT | Group exercise |
Physical Function:
<>Functional ability (0/1), ↑ Physical Therapy Assessment (1/1)
Balance and Falls:
↑ Balance (1/1) | ||
Brett et al., 2015 [12] | 9 | 12 | SR | Dementia living in nursing home | RCT | Any PA |
Physical Function:
↑ Mobility (3/5)
Balance and Falls:
↑ Balance (1/2) |
Cognition:
↑ Cognition (5/7);
Affect:
↑ Mood (3/4); ↓ Agitation (1/1) | ↑ ADL (3/5) |
Burton et al., 2015 [28] | 11 | 4 | SR/MA | Dementia living in the community | 3 RCT and 1 quasi-experi-mental | Strength, balance and mobility exercises |
Balance and Falls:
↓ Falls (k = 2) MD = -1.06*; <>Fall risk (k = 2) MD = -0.1; <>Balance (k = 2) MD = 0.51 | ||
Cooper et al., 2012 [13] | 10 | 1 | NR | Dementia | RCT | Comprehensive exercise program | <>QOL (1/1) | ||
de Souto Barreto et al., 2015 [14] | 8 | 20 | SR/MA | Dementia | RCT | Any exercise |
Affect:
↓ Depression (k = 7) SMD= -0.31*
Behaviours:
<>Behaviours (k = 4) MD= -3.88 | ||
Farina et al., 2014 [15] | 10 | 3 | MA | AD | RCT | Any exercise (min. 4 weeks) |
Cognition:
↑ Global cognition (k = 3) SMD = 0.75* | ||
Forbes et al, 2013 [16] | 11 | 16 | CR | Older adults (>65 years old) with dementia | RCT | Any exercise |
Cognition:
↑ Global cognition (k = 8) SMD = 0.55*
Behaviours:
<>Challenging behaviours (k = 1) SMD=-0.60
Affect:
<> Depression (k = 5) SMD = -0.14 | ↑ ADL (k = 6) SMD = 0.68* | |
Forbes et al, 2015 [17] | 11 | 17 | CR | Older adults (>65 years old) with dementia | RCT | Any exercise |
Cognition:
<>Global cognition (k = 9) SMD = 0.43; [excluding moderate-severe dementia (k = 8) SMD = 0.21]
Affect:
<> Depression (k = 5) SMD = -0.14
Behaviours:
<>Challenging behaviours (k = 1) MD= -0.60 | ↑ ADL (k = 6) SMD = 0.68* | |
Groot et al., 2016 [52] | 9 | 18 | MA | All dementia except those that affect motor system (e.g., Huntington’s, Parkinson’s) | RCT | Any physical activity |
Cognition:
↑ Cognition (k = 16) SMD = 0.42* | ↑ ADL (k = 4) SMD = 1.18* | |
Hermans et al., 2007 [18] | 9 | 0 | CR | Dementia living in domestic setting | RCT | Walking and exercise therapy |
Behaviours:
No studies of wandering met inclusion criteria | ||
Heyn et al., 2004 [19] | 10 | 30 | MA | Older adults (≥65 years) with cognitive impairment (MMSE <26) | RCT | Any exercise |
Physical Fitness:
↑ Health-related physical fitness (k = 40) ES = 0.69*; ↑ Cardiovascular (k = 18) ES = 0.62*; ↑ Strength (k = 17) ES = 0.75*; ↑ Flexibility (k = 4) ES = 0.91*
Physical Function:
↑ Functional performance (k = 20) ES = 0.59* |
Cognition:
↑ Cognition (k = 12) ES = 0.57*
Behaviour:
↑ Behaviour (k = 13) ES = 0.54* | |
Jensen and Padilla, 2011 [29] | 6 | 6 | NR | Dementia | Mixed | Exercise and motor-based interventions for falls prevention (2 group-based; 4 individual) |
Balance and Falls:
↓ Fall risk (3/4) ↑ Balance (1/1) | ||
Littbrand et al., 2011 [20] | 9 | 10; results from 6 low quality studies not reported | NR | Dementia | RCT | Walking and combined exercise |
Physical Function:
↑ Walking performance (2/2); <> Mobility (0/2)
Balance and Falls:
<> Balance (0/1) | ↑ ADL (1/1) | |
O’Connor et al., 2009 [21] | 8 | 1 | NR | Dementia | RCT, RM | Any PA or exercise |
Affect:
↑ Positive affect, (1/2); ↓ Negative affect, (1/2) | ||
Pitkala et al., 2013 [30] | 8 | 20 | NR | Dementia | RCT | Any PA |
Physical Function:
↑ Physical function (16/20); ↑ Mobility or ↓ functional limitations (8/9 moderate-to-high quality studies) | ||
Rao et al., 2014 [22] | 5 | 6 | SR | Ambulatory older adults (>65 years) with AD | RCT with sample size >15 | Aerobic, strength, and balanced or any combination of the three |
Physical Function:
Functional ability (k = 6) ES = 0.53* | ↑ ADL (k = 6) ES = 0.80* | |
Thuné-Boyle et al., 2012 [23] | 6 | 16 | RCIA | Dementia | Exercise inter-vention studies (6) and reviews (10) | Any exercise |
Affect:
↓ Agitation (4/4); ↓ Depression (4/8);
Behavior:
↓ Wandering (1/2); ↑ Night time sleep (3/5) | ||
Yu, 2011 [24] | 6 | 12 | NR | AD | Experi-mental or quasi-experi-mental | Aerobic exercise (alone or combination; >2weeks) |
Physical Fitness:
↑ 6 min walk (1/1); ↑ Strength (1/1);
Physical Performance
↑ Physical performance (4/5) |
Cognition:
↑ Global cognition, MMSE (4/4)
Affect:
↑ Mood (4/6) | ↓ ADL limitations (2/2) |
Yu et al., 2006 [25] | 8 | 18 | NR | AD | Any | Aerobic exercise |
Cognition:
↑ Global cognition (2/2) |
Reference | Quality score | Type | Characteristics of included reviews | Conclusions | |||
---|---|---|---|---|---|---|---|
# of studiesa
| Design | Participants | PA | ||||
Beckett et al. 2015 [4] | 7 | MA | 9 | Prospective cohort studies | Cognitively healthy older adults, ≥65 years | Any PA | PA is associated with a ↓ risk of developing AD in adults 65 years and older. RR of .61, 95% CI 0.52-0.73 for physically active older adults compared to non-active counterparts. |
Barnes et al., 2011 [5] | 4 | NR | 2 | Prospective cohort studies | No dementia diagnosis at baseline | Any PA | Of seven potentially modifiable risk factors examined, physical inactivity contributed to the largest proportion of AD cases in the US and a substantial proportion of cases globally. |
Beydoun et al., 2014 [6] | 7 | MA | 8 | Cohort studies with sample size > 300 | Generally healthy older adults | Any PA | RR of AD = 0.58 (0.49,0.70) for the group reporting the highest PA versus the lowest PA. PAR% = 31.9%, 95% CI 22.7–41.2%. |
Daviglus et al., 2011 [7] | 9 | NR & MA | 12 | Cohort studies with sample size ≥ 300 | General population in developed countries, ≥50 year | Self-reported PA. | NR: 8/12 studies reported a protective effect of moderate to high levels of PA on risk of AD; however, the associations were not always significant after adjusting for confounding factors or when looking across high and moderate activity levels. MA: Across 9 cohort studies, higher PA associated with ↓risk of incident AD (HR = 0.72); however, substantial heterogeneity among studies. |
Hamer et al., 2009 [8] | 11 | MA | 5 | Prospective cohort studies | Diagnosis of dementia/AD | Any PA | PA ↓risk of AD by 45%. RR of AD = 0.55 for the group reporting the highest PA versus the lowest PA |
Patterson et al., 2007 [10] | 6 | NR | 3 | Longitudinal cohort studies | Representative of Canadian demographic, exclusion of dementia at baseline | Any PA or energy expenditure | 3/3 studies provided evidence that regular physical activity is associated with a reduced risk for AD. |
Rolland et al., 2008 [11] | 5 | NR | 24 | Longitudinal epidemiological studies | No dementia diagnosis at baseline, ≥60 year | Any PA or energy expenditure | 20/24 studies suggested a significant and independent preventive effect of physical activity on cognitive decline, or dementia, or AD risk. Physical activity could reduce the incidence of AD. |
Results
Systematic review
Cognition
Affect
Behaviours
Physical outcomes
Physical fitness
Physical performance/function
Balance and falls prevention
Activities of Daily Living (ADL)
Quality of Life (QOL)
The messaging statement
“Regular participation in physical activity is associated with a reduced risk of developing Alzheimer’s disease. Among older adults with Alzheimer’s disease and other dementias, regular physical activity can improve performance of activities of daily living and mobility, and may improve general cognition and balance.” |
Stakeholder feedback
Editorial independence
AGREE-II evaluation
Domain | Score | Areas for improvement in the report | Response/Action |
---|---|---|---|
1. Scope and Purpose | 18/21 | • Include specific outcomes of interest and setting to the clinical question • Additional details about the target population would have increased the rating (e.g., specific age ranges, specifying stage and/or severity of the disease) | • These details were added • These details cannot be provided given the limited research base |
2. Stakeholder Involvement | 19/21 | None | |
3. Rigour of Development | 47/56 | • Provide further details on the search for evidence (e.g., time periods searched, outcomes of interest, etc.) • Eligibility criteria for studies not explicitly stated/listed • Provide an explicit linking/identification of the key evidence underpinning the consensus statement | • Additional details have been added • An explicit statement has been added |
4. Clarity of Presentation | 18/21 | • The inclusion of a section or an appendix with the final consensus statement would make the statement more easily identifiable in the report | • A table/box was added to highlight the final statement |
5. Applicability | 21/28 | • No explicit comments were included in the report concerning potential resource implications of applying the recommendations, nor was a formal assessment undertaken/reported | • Notes from the panel’s discussion of resource implications have been added |
6. Editorial Independence | 8/14 | • An explicit statement regarding the funder was not included, nor was an explicit statement to indicate the views or interests of the funding body did not influence the final consensus statement | • An explicit statement has been added |