Introduction to Alzheimer's Disease and Exercise

Sharon Arkin, PsyD
arkinaz@earthlink.net

Scan the magazine covers at any newsstand. Headlines for articles touting exercise leap out at you. "Exercise to lose weight...to control diabetes and blood pressure...to improve cardiac function...to fight depression and osteoporosis...to reduce cholesterol...to help you quit smoking..." promise the headlines.

You won't find articles in popular magazines that discuss the benefits of exercise for persons with Alzheimer's Disease. In fact, as of February 2001, only two articles in professional journals documented the multiple benefits of physical fitness training for non-institutionalized early- to moderate-stage persons with Alzheimer's Disease. The author's Alzheimer's Disease Rehab by Students program (Arkin, 1999) showed dramatic gains in physical fitness and mood, maintenance of function in multiple language measures, and a slower than typical decline in mental status after a year of exercise. An Italian research group (Palleschi, Vetta, Degennaro, Idone, Sottosanti, Gianni, & Marigliano, 1996) found a significant improvement on four cognitive measures after three months of aerobic exercise.

Yet, persons with Alzheimer's Disease have the same health problems and emotional needs as everybody else and derive the same benefits from a regular exercise program as their peers who do not have the disease. Plus, they can derive a benefit that is unique to their situation: the ability to gain skill and show regular improvement in physical fitness at a time when they are losing skills in every other arena of life. Such a tangible gain can be a tremendous source of pride, both for the person with Alzheimer's and for his or her caregivers.

The recommendations for exercise programming cited in this paper build on the existing extensive body of knowledge about exercise and the elderly by contributing the experience gained in four years of managing an exercise-based rehabilitation program for community-dwelling persons with Alzheimer's Disease at the University of Arizona (www.u.arizona.edu/~sarkin/elderrehab.html).

For a review of published studies on the benefits of exercise programming among nursing home residents with more severe dementia, see Bonner and Cousins (1996). The various studies they cite show that exercise reduces the frequency of unwanted behaviors such as wandering, pulling at clothing, making repetitive noises, swearing, and aggressive acts, as well as improving communication and social participation.

So why aren't all persons with Alzheimer's flocking to our gyms and health clubs? First of all, even during the very early stage of Alzheimer's Disease, many individuals have difficulty initiating and maintaining a new behavior or routine on their own. Even if they could, most of them no longer drive independently, if they drive at all. "What about treadmills or exercise bikes at home?" you ask. If they have such equipment, and only the "young" elderly are likely to have it, like most owners of such equipment, they probably use it to hang clothes on, and resist nagging by a spouse to use it regularly.

So, persons with Alzheimer's need someone to get them into a program and motivate them to stay with it. (Don't we all?) If you are a caregiver for someone with Alzheimer's and are frail or in poor health yourself, you're probably not a good candidate for motivating and maintaining your partner in an exercise program. But such a program could benefit you as much as your spouse. Read on and you'll get some ideas for making such a routine possible for your partner and you.

If you are a son or daughter of a person with dementia, you could be the catalyst for making an exercise regimen part of your parent(s)' life. Instead of (or tacked onto) a weekly meal together or a trip to church or the mall, why not several trips to a fitness center? You and your spouse and parent(s) could all work out together, taking turns spotting each other, and all benefiting from the increased activity. If you really are too busy to make such a commitment, advertise in your local high school or college newspaper and hire a student to do it. Pay them the same or a bit more than the local fast-food restaurants and they'll be happy for a job that brings satisfaction and looks impressive on a resume.

Alzheimer's Disease: Prevalence and Symptoms

Alzheimer's Disease is a progressive (gradually worsening) brain disorder that disproportionately affects older adults, though it has been known to afflict persons in their 30s and 40s. About 5% of persons over 65, 20% of persons between 75 and 84, and 47% of persons over 85 are believed to have it (Cowley, 2000). According to the Alzheimer' s Association, about 4.5 million Americans have Alzheimer's, with the numbers expected to rise dramatically as the baby boomer generation reaches older adulthood.

Alzheimer's Disease begins so subtly and so gradually, that the persons with the condition and family members often cannot accurately state when symptoms were first noticed. Its cause is unknown and there is no cure. As of February 2001, five approved drugs were on the market - Aricept, Cognex, Razadyne, Namenda, and Exelon - that temporarily improve cognitive functioning to a slight extent or slow the rate of decline in a small number of patients. Positive effects are seldom noticeable for more than six months. Some people do not handle the side effects well; others cannot afford the drugs.

Many doctors now routinely prescribe one of these drugs to any person exhibiting signs of dementia. (Dementia is a general term that means a condition characterized by a decline in previously normal mental functioning.) Alzheimer's is the most common cause of dementia and, either alone, or in combination with other conditions, accounts for about 87% of dementia cases (Thal, 2000). According to the Alzheimer's Association (Alzheimer's Assoc. Link), it is present in an estimated 50% of nursing home residents.

There is a common misperception that Alzheimer's Disease, because it is incurable, is also untreatable. Indeed, most people diagnosed with this disorder are not offered treatment, except for the previously mentioned drugs, or possibly, participation in an experimental drug trial. Typically, they will be invited (through their caregiver) to return periodically to see whether and how much their condition has worsened. This is generally determined by a costly battery of neuropsychological tests which measure specific cognitive and language abilities.

The good news is that you don't need a doctor to provide the best available treatment for Alzheimer's Disease: meaningful activity that uses and strengthens remaining skills and abilities, provides a sense of accomplishment, improves mood, and increases overall physical fitness (Arkin, 1999) (Arkin & Mahendra, 2001) (Bonner & Cousins, 1996) (Rimmer, 1997) ( Zgola, 1990). Exercise can benefit persons with Alzheimer's Disease by serving as a means for other social, memory, and language stimulation activities. Examples of these will be given below.

But is it Alzheimer's?

Only your pathologist knows for sure. That's right - the only way to positively diagnose Alzheimer's is by an autopsy of the brain, where the pathologist looks for the abnormal neuritic plaques (sticky wads of a renegade protein substance that damages brain cells) and neurofibrillary tangles (bundles of disintegrating nerve fibers within brain cells) that are the characteristic markers of Alzheimer's Disease. By then, it's too late to intervene with life-enhancing activities.

The usual way of arriving at a tentative diagnosis of "probable" Alzheimer's is by ruling out other dementia-causing conditions that can be spotted (and, in some cases, treated) - by lab tests, brain scans, and other diagnostic procedures. When all the tests and scans come back negative (i.e., no tumors, strokes, vitamin deficiencies, medication overdoses, depression, alcohol or drug abuse, thyroid problems, Parkinson's Disease, Huntington's Disease), what's left is called "probable" or "possible" Alzheimer's if the person's symptoms appear gradually, the behavior pattern and loss of abilities are consistent with known Alzheimer's Disease behavior, and the condition gets progressively worse over time.

Should you worry about Alzheimer's if you misplace your keys, can't find your car in a parking lot, or forget to turn the oven off? If you're over 60, as I am, you probably will worry, though a man or woman of 30 would attribute these memory lapses to being absent-minded, busy, or stressed. Most people forget and lose things all the time. When should you start worrying? The rule of thumb is that when the forgetting and losing things begin to interfere with the competent and independent handling of your life tasks - job, family and household duties, financial responsibilities, community and social obligations - it might be a good time to schedule a diagnostic evaluation.

Here are some scenarios based on the experiences of real people who did end up with a diagnosis of probable Alzheimer's:

1. A 55 year-old man, formerly a top-performing sales manager of a car dealership, has recently missed a number of appointments and has fallen behind in his paperwork. His company referred him to counseling for suspected depression and for stress management training, but his work performance has not improved. Diagnosis: probable Alzheimer's.
2. A neighbor of an 85-year-old woman who lives alone and still drives her car, telephoned the woman's daughter to report that she saw the woman's mother leave for the grocery store four or five hours ago and that she hadn't returned. The daughter quickly drove to her mother's favorite supermarket and found her wandering around in the parking lot in a confused and agitated state. The frozen food items in her grocery bags were thawed and dripping, indicating she'd been out there for several hours. When the daughter brought her home, she found the refrigerator empty, stacks of unwashed dishes in the sink, and dirty laundry strewn about. Her mother had always been a meticulous housekeeper. Diagnosis: probable Alzheimer's.
3. A retired dietitian and homemaker, known for the originality and variety of her gourmet meals, has served chicken and potatoes, baked in the toaster oven, and canned green beans, three or four times a week for the past several weeks. When asked about it, she snaps at her husband and claims that she has been very busy, and suggests that he take over the cooking. Diagnosis: probable Alzheimer's Disease.

The above scenarios illustrate some early-stage symptoms and behaviors. Other common symptoms are forgetting the names of things, trouble remembering recent events and the names of people - even old friends - and learning new information, such as a change of address or phone number or the name of a new doctor. Most early stage patients cannot keep track of the current date and year or the date and time of appointments. They may get lost or disoriented when away from home. The ability to read is preserved, but the rapid forgetting that occurs makes the activity generally unsatisfying. Most can carry on a coherent one-to-one conversation, but will get lost in a complex discussion, particularly if several people are involved. The net result of this constellation of symptoms is a loss of confidence and a withdrawal from former activities and relationships. Persons at this early stage will most certainly benefit from an exercise program from the standpoint of enhancing social stimulation, particularly if provided one-on-one or in a small, supportive group setting.

Persons in the moderate stage of Alzheimer's Disease will experience a worsening of the above-mentioned symptoms. In addition, they may no longer be able to comprehend or respond appropriately to conversation directed at them. They may no longer consistently identify their spouse or children, though they will recognize them as someone close to and loved by them. Confusing spouses with long-deceased parents, or children with siblings is very common. They may become suspicious, accusing a son or daughter-in-law, or long-trusted household worker of stealing their belongings or their spouse of being unfaithful. Frustration engendered by their failing abilities may trigger outbreaks of aggressive behavior. Wandering and sleep disturbances may occur and ability to dress, bathe, shampoo, and brush teeth independently may be lost. There may be occasional incontinence, made more difficult to manage by patient resistance to wearing absorbent products.

Many persons with moderate and moderate-to-severe symptoms remain at home with help from hired part-time caregivers and the use of adult day care centers. Patients at this level are excellent candidates for an exercise program. If your care recipient attends a day care center, insist that he or she include regular exercise in their daily programming. If you have hired help in the home, ask them to take the person for brisk walks and engage them in regular exercise.

Persons in the severe stage of dementia are unable to communicate or recognize family members, may have difficulty swallowing, are incontinent and incapable of any self-care activities, and may be bedridden much of the time. They typically do respond to music, touch, a doll or stuffed animal, the affection of a dog or cat. Any movement they can be encouraged to make will be beneficial to their cardiorespiratory systems and reduce the likelihood of pressure sores and other infections.

Exercise and the Elderly

Previous generations of elderly persons lived far more active lives than most of today's seniors. They did farm chores and strenuous household tasks without much power equipment. They did less driving and more walking, if only to and from a bus stop. They looked after grandchildren who, in earlier times, were at home till they started school, not in day care or after school programs.

Absent chores to do and children to care for, exposed to exaggerated media reports of street crime, and given the seductive attractions of television and computers, drugs and alcohol, microwave and "fast" food, is it any wonder that the majority of today's seniors are, like increasing numbers of their younger counterparts, out-of-shape "couch potatoes?" It has been estimated that fewer than 34% of Americans over 65 are as active as they should be for optimal health (www.census.gov).

The health costs of this inactive and self-indulgent lifestyle are many and serious. All of the normal physical changes associated with increasing age - decreased cardiac efficiency, decreased respiratory capacity, reduced muscle mass, bone density, and flexibility, slowed reaction time - are exaggerated, and the risk of heart attacks, diabetes, stroke, cancer, arthritis, fractures, and, as recent evidence suggests, dementia, is increased. On a more basic level, the ability to perform day-to-day activities declines: to walk without falling, to rise from a chair or get in and out of a car unaided, to carry a bag of groceries, to tie shoes or hook a bra. Depression, a seldom-recognized and under-treated problem among the elderly, is also a common by-product of inactivity. These problems are worsened when accompanied by cognitive loss and make caring for the person quite difficult.

Where to Begin?

Convincing people of the benefits of exercise is an essential first step. Many persons with early-stage Alzheimer's are worried about becoming a burden to their families. Explaining that exercise can help keep them healthy and make care giving easier on their loved ones can be a strong selling point.

Obtain a thorough physical exam by a physician, preferably one that believes in the health benefits of exercise. Such an exam may reveal cardiac, musculoskeletal, or other problems that may impose restrictions on the type and intensity of exercise to be undertaken. If this is the case, request a referral to a physical therapist or cardiac-rehab specialist to work out a beginning regimen that is suitable for the individual.

Ask the person's physician to reinforce his or her exercise recommendation by writing out a prescription that can be shown to the individual periodically. Such an instruction carries more weight than suggestions from a caregiver. Find media articles that cite the benefits of exercise in improving memory or preventing and slowing the effects of Alzheimer's. For example, a CNN Web site that reports a study done at Case Western Reserve University found that regular exercise may reduce the risk of developing Alzheimer's Disease (www.cnn.com).

That study, by Arthur Smith and Robert Friedland (1998), retrospectively examined the exercise habits of 373 people - 126 with Alzheimer's and 247 healthy people. They found that persons with Alzheimer's Disease had lower levels of physical activity earlier in life. (This could be a good selling point for involving son and daughter caregivers in a joint exercise program with their parent(s)).

The key to motivating people to persevere in any program of lifestyle change is social support. Alcoholics Anonymous and other similar organizations depend on one-to-one support and group encouragement to keep its members abstinent. The clinically proven Ornish diet and exercise program stresses the importance of social support in maintaining adherence to lifestyle changes and preventing heart attacks and other serious diseases.

Fitness club membership lists are filled with names of people who rarely come to work out after an initial "honeymoon" period. Many home treadmills, exercise bikes, and other fad equipment are unused after this initial period. Exercise programs for persons with disabilities that are successful, such as the osteoporosis and Alzheimer's (www.arizona.edu) studies at the University of Arizona, the exercise programs for persons with developmental disabilities and multiple disabilities at the University of Illinois at Chicago (Rimmer et al., 2000), are all characterized by the presence of exercise "buddies" or program monitors that provide ongoing supervision and encouragement.

Use yourself, a valued friend, a hired caregiver, or a student volunteer as an example and monitor and make exercising a joint social activity. Better yet, find another Alzheimer's-affected couple and go together. Set short-term achievable goals, such as a 1-minute increase in time on the treadmill and/or bike every two weeks until 30 minutes is reached, or steady increases in RPMs, miles per hour, pounds lifted, or repetitions achieved. Reward progress along the way with stars on a chart, a special T-shirt or badge, a frozen yogurt treat, or, as one Alzheimer's Disease caregiver does, with lunch at Taco Bell. Avoid promises of long-term results, like weight loss, that may not show evidence of progress for a long time.

Activity and Exercise RX for Persons with Alzheimer's

Physical fitness has been defined as the ability to perform activities of daily living with vigor, and possession of a health history and profile (i.e., lifestyle, weight, blood pressure, cholesterol levels) associated with a low risk of largely preventable diseases such as heart disease, diabetes, osteoporosis, and stroke (Caspersen, Powell, & Christenson, 1985).

The achievement of physical fitness is accomplished by having a regular and substantial amount of physical activity and physical exercise in your life. Physical activity is any bodily movement that burns calories, such as gardening, vacuuming, shoveling snow, walking to the store, climbing stairs, or playing ball with your grandchildren. Physical exercise is physical activity that is planned, structured, repetitive, and has the direct aim of improving physical fitness. It is typically of higher intensity than ordinary physical activity (Caspersen, Powell, & Christenson, 1985). Fortunately, improved fitness can be achieved by everyone, regardless of age or physical condition, when an exercise program is followed. In fact, the greatest improvements are often seen among the frailest individuals who are nurtured through an exercise program.

Physical Activities

The easiest, safest, and most readily available physical activity for a person with Alzheimer's Disease is walking. It channels a tendency for restlessness and wandering that is characteristic of the disease into a beneficial activity. It can be combined with a purposeful activity, such as walking a dog, pushing a person in a wheelchair, walking to the store to buy a newspaper or groceries, or picking up trash in the neighborhood.

Many shopping malls have organized "mall-walking" programs that offer structure, incentives, T-shirts, and social opportunities, as well as a safe, climate-controlled, stimulating, and traffic-free environment for walking. Such programs are perfect for an accompanied person with dementia.

Friends and neighbors who know about the Alzheimer's diagnosis may be sympathetic and willing to help out, but may not know what to do. Ask several of them to take regular turns as a walking partner. All will benefit. Make sure the person with Alzheimer's Disease is wearing a MedicAlert (MedicAlert.org: 1-800-432-5378) or Safe Return (Alzheimer's Association Safety Services link; 1-800-272-3900) ID bracelet or medallion or has other identifying information on his or her person, in case he or she gets lost when out walking alone or gets separated from a walking partner. (Many persons with Alzheimer's Disease can take unaccompanied walks in their immediate neighborhood in the early to early-moderate stages of the disease; however, it is wise to notify neighbors along the route and the nearest police and fire station of the person's diagnosis).

Physical Activities Contd...

• Hiking
  Many communities have hiking clubs that sponsor guided walks at various levels of difficulty. Universities have hiking and service clubs whose members may be willing to take a person with Alzheimer's on an individual or group outing.

• Surrey, Tricycle, or Tandem Bike Riding
  A modern-day surrey is a four-wheeled canopied vehicle powered by two or more people pedaling side by side. Steering and braking are in the control of one person, though both have a wheel to hold onto. These vehicles are often available for rent at beach resort towns. However, large bicycle shops may have them for sale or rent. In Tucson, Bargain Basement Bikes lent one to the University of Arizona's Alzheimer Rehab program (www.arizona.edu), which arranged to store the vehicle at a Tucson Parks and Recreation Department (www.ci.tucson.az.us) golf cart parking lot and opened the use of it to any community member who is accompanying a person with a disability. The adjacent recreation center keeps the surrey schedule and signs people up.

  Persons long accustomed to riding a bicycle can continue to do so, though it might be safer for him or her to ride on a tandem bike with a partner in front. If balance is a problem, adult tricycles are a stable option that can be enjoyed with a companion on bike trails or quiet streets. One Alzheimer caregiver, Don, regularly jogs on a paved trail around a park while his wife, Louise, who has early-onset Alzheimer's Disease, follows on her bicycle. They recently enjoyed an RV and bicycling trip to New England together.

  Don and Louise also volunteer together at Habitat for Humanity and are awaiting clearance to serve as "cuddlers" at a local residence for abandoned and abused children. Don took early retirement in order to make the most of the precious time remaining that they can fully enjoy activities together.

• Dancing
  For couples that already know how to dance, this is an enjoyable activity that can be continued. Many senior centers hold afternoon or early evening dance parties geared to the music tastes and abilities of older persons.

  For couples or individuals that don't know how to dance, certain kinds of dancing (i.e., folk dancing and square dancing) can be enjoyed by a person with dementia, as long as his or her companion can follow the instructions and lead the partner.

• Boating
  Rowing side-by-side and pedaling a two-person pedal boat are enjoyable activities for persons with access to such facilities. Be sure to wear life jackets and sun block!

• Gardening
  Persons with dementia who formerly enjoyed gardening will continue to do so, though they may need supervision to stay on task. Raking leaves is an ideal activity for persons who live in a temperate climate. One caregiver regularly bags the leaves her husband rakes and strews them on the lawn again the following day. Using a non-motorized lawnmower is also a good physical activity.

• Household tasks
  Sweeping, mopping, running a carpet sweeper or vacuum cleaner, washing windows, making beds, and folding laundry are all over-learned tasks that can be continued with proper supervision. One individual with Alzheimer's Disease who was a member of a church quilting group and could no longer sew was kept involved by ironing the squares that were to be pieced by other group members. Many nursing homes and Alzheimer special care units now involve their residents in the maintenance of their living quarters. Such real-life tasks are more meaningful and intrinsically satisfying than busywork and games, which may be viewed as childlike and frivolous by persons used to being productive members of society (Zgola, 1990).

Volunteer Work

Many of the activities pictured on this Web site were taken in the course of community volunteer activities engaged in by persons with Alzheimer's Disease in the company of a student companion or a spouse as part of their participation in the University of Arizona Elder Rehab by Students program. (Elder Rehab, rather than Alzheimer's Rehab is the name commonly used to refer to the U of A program, in deference the sensibilities of some participants and caregivers who either deny or prefer not to be publicly identified with an Alzheimer's diagnosis.) www.u.arizona.edu

These volunteer activities include packing food boxes at a local food bank, bringing pets to a nursing home, taking nursing home residents for walks in their wheelchairs, walking dogs at the Humane Society, picking up trash in public places, and reading to and playing with children at a child day care center.

These activities have multiple benefits. They provide physical activity with a social purpose, which results in improvements in mood and self-esteem for participants. An added bonus is that the community, often depicting negative images associated with Alzheimer's Disease, has an opportunity to see people with this disorder making useful social contributions.

Structured Fitness Development

A balanced exercise program for persons with Alzheimer's Disease, as for any population, should include activities that improve flexibility, balance, cardiovascular endurance (aerobic activity), and strength (weight training). For people with Alzheimer's Disease in otherwise good health, a session might start with a 5-minute walk or a series of stretches, followed by 20 minutes of an aerobic activity, 20 to 30 minutes of weight training, and ending with 5 to 10 minutes of stretching (Fiatarone, O'Brien, & Rich, 1995).

An excellent resource for persons who wish to start their care recipient (or themselves) on an exercise program at home is Exercise: A Guide from the National Institute on Aging. This is a comprehensive illustrated manual by a panel of experts with an accompanying video that demonstrates a one-hour workout that includes all four types of exercise cited above. The manual includes charts for recording participants' progress, as well as an order form for a free certificate of achievement for persons who follow the program for more than one month. The manual and video are available from the National Institute on Aging's Public Information Office (www.nia.nih.gov). To order, call 1-800-222-2225 (voice) or 1-800-222-4225 (TTY).

Assessing and Tracking Progress

Beginning aerobic fitness can be assessed by measuring the distance (in feet) a person can walk in 6 minutes. This is a commonly used and reliable measure of fitness in the elderly and persons with disabilities (Tappen, Roach, Buchnor, Barry, & Edelstein, 1997).

Upper- and lower-body strength can be assessed by recording the amount of weight a person can press or lift 10 times on a chest press and a leg press machine, respectively.

If machines aren't available, dumbbells can be used for an upper-body test. For another test of lower-body fitness, count the number of seconds it takes the person to rise from a chair and sit down again 10 times. Persons using any kind of free weights must be closely monitored and should wear sturdy, closed shoes to minimize the risk of injury should a dumbbell be dropped. Balance can be assessed by having the person stand first on one foot and then on the other and recording how many seconds balance can be maintained (Netz & Argov, 1997). It's a good idea to give three trials for each foot and to record the best trial for each. Progress can be measured by retesting and comparing scores after an interval of training, i.e., three and four months.

A "Tried-and-True" Fitness Protocol for Persons with Alzheimer's Disease
The protocol described below has been successfully used with persons with Alzheimer's Disease for four years at the University of Arizona Medical Center's cardio-rehab/employee wellness center. Four participants, the oldest whom is 90 years old, have been following this program for all four years the program has been in operation. Others currently in the program have been following it from one to three and a half years. Their schedule has been twice-weekly workouts for 10 weeks during each academic semester and, for some participants with committed caregivers, once weekly during university vacation periods.

Each workout consists of stretching and balance exercises, 20 to 30 minutes of aerobics (usually achieved by the end of one semester of participation) and 20 to 30 minutes of upper- and lower-body strength training. One of the two weekly workout sessions is supervised by a student, who also administers a variety of memory- and conversation-stimulation activities during and between the various exercises. (Examples of all the activities administered follow this section.) Students are undergraduates and were originally recruited from among speech and hearing, psychology, and exercise physiology students; later, health science majors and honors students from all disciplines were also recruited via mass e-mails (listservs). They are given small-group training on safety procedures and use of the exercise equipment, as well as individual supervision during their first few sessions with their rehab partner.

There are several purposes for these activities. First, they provide practice in memory and language skills that typically deteriorate in Alzheimer's Disease; second, they help pass the time during lengthy sessions on the treadmill and stationary bike; third, they provide a starting place for conversation between the exerciser and the exercise assistant. Persons with Alzheimer's Disease tend to get in a "rut" conversationally, limiting their discourse to safe, familiar topics and anecdotes, and repeating themselves a great deal. Family members who care for someone with Alzheimer's Disease, often misjudge their ability to discuss complex or controversial issues, and limit their conversation to topics related to care-giving, such as meal preferences, appointment reminders, instructions, and admonitions. Introducing novel, provocative topics in the course of an exercise session stimulates the person's mental "lexicon" and improves conversational ability. (See Arkin & Mahendra, 2001 for a detailed description of Alzheimer's discourse analysis and outcomes after one year of exercise plus language interventions).

The second weekly workout is supervised by a family member. There is also one session per week of brisk walking, which is incorporated into some other type of community activity that is supervised by the student assistant. (The student assistants receive university credit for their work as "rehab partners"). The full workout sessions are scheduled so that there is at least one day of rest between sessions to allow for recovery. For a full description of the University of Arizona Elder Rehab program, including a list of the academic requirements for the student participants, see the following Web site: www.u.arizona.edu

General Precautions and Procedures

As with any exercise program, general precautions and safety procedures must be installed before starting the program. During the first session, record the participant's weight and resting pulse. Begin all sessions with a resting pulse below 100, the upper limit for a normal resting pulse. (If your partner's resting pulse is consistently more than 100, check with his or her doctor to determine at what level it is best to begin exercising.)

Observe your partner's gait. If you notice any signs of instability, be extra-vigilant when he or she is moving about.

Use the "talk test." As a rule of thumb, make sure your partner can talk to you comfortably during any exercise. As long as conversation is possible, the danger of over-exertion or fatigue is minimal.

If using machines, establish and record seat adjustments and starting weight levels during the first two orientation visits.

Have subjects drink water at regular intervals and rest between sets and activities. Make sure that there is a restroom close by, since participants who drink extra fluids may require more frequent trips to the restroom.

Session Routine

1. Warm-up Walk
   This is generally accomplished in the Elder Rehab program by walking from the hospital's parking lot to the wellness center. (Deliberately parking the car a certain distance from a destination is an excellent way to increase the amount of walking done by an individual.)
2. Resting Pulse
   After entering the Center, the subject is seated for a few moments and a resting pulse is taken using an electrical pulse monitor. Pulse should normally be below 100, the upper limit of the normal range, before beginning exercise. Consult a physician if a would-be exerciser's resting pulse is consistently higher than that. It could be okay for that individual, or not. During the resting period, participants typically do a picture description activity, using one of a prescribed series of Norman Rockwell calendar pictures, supplemented by a series of prompt questions.
3. Stretches
   Next, the subject is guided through a series of stretches, each one done twice and held for 15 seconds:
   • Neck to the right side, left side, forward, chin touching chest. Arm across chest-right (press upper arm above elbow with opposite hand); arm across chest-left.
   • Hamstring stretch. Sitting at the edge of a chair, bend forward with head facing forward and slide arms down extended right leg towards ankle; repeat along left leg.
   • Calf stretch right, calf stretch left (done facing and holding onto a bar). Front leg is bent, back leg held straight. Participant moves the bent leg forward, feeling the stretch in the opposite leg, which is extended backward.
   • Calf raise: Strengthens calf muscles. Subjects stand straight, holding on to a bar or tabletop and raise themselves slowly up on toes so they feel a stretch all the way along their calves. Start with 10 repetitions and gradually increase. Ankle weights, fastened with velcro straps can be added to increase resistance as the person develops increasing strength.
4. Step Box:
   Provides lower-body strength, aerobic, and balance training and is functionally related to stair climbing. Participant stands alongside a Step box and mounts it with the left foot, brings the right foot alongside it and touches it to the left (without stepping on the box) and then steps back down with the right. This is repeated 10 times. The exercise is repeated with the other foot. Gradually increase the number of step-ups.
5. Balance Practice
   This is the same activity that was described in the assessment section. Facing and holding lightly to a bar or tabletop, participant stands on one foot and, when he or she feels stable, lets go of the bar. Partner counts the number of seconds balance is held. Three trials with each foot are performed.
6. Aerobics
   Two consecutive periods of aerobic exercise are recommended, one on the treadmill and one on a stationary bicycle with no rest period between them. Some individuals may prefer to substitute a rowing machine for the bicycle. If possible, the treadmill should be equipped with a clip-on safety device that stops the machine if the user falls. Exercisers should be spotted at all times by a monitor standing close by. The goal is to attain 20 minutes of fairly continuous aerobic exercise per session by the end of 10 weeks, and 30 minutes by the end of one year. (More than 30 minutes is not recommended, as it makes the total workout session too long. Additional aerobic exercise can be achieved by daily walking.) By offering two different aerobic activities, boredom is kept to a minimum.
   
   1. Treadmill: Most participants can begin at a speed of 1 mph. Elevation is started at 0, with small incremental increases as tolerated by the participant. Five minutes is suggested as a beginning duration, with a one-minute increase per week, as tolerated, up to 15 minutes.
   2. Stationary bicycles: Two types of bicycles can be used:
      
      1. Schwinn Airdyne bicycles, which require users to sit and pedal in an upright position, maintain balance on a rather narrow seat, and work their arms back and forth while pedaling; and
      2. Recumbent bikes, which provide a wide, stable seat, back support, legs only exercise, and pedaling with legs out front.
      The recumbent bike is a more suitable alternative for overweight individuals and persons with balance problems. Some fitness centers have an upper-arm ergometer, a cycle driven by arm motion only. This would be used for a participant with arthritic knees or other lower-body pain. Again, 5 minutes is suggested as a starting duration, with weekly increases of one minute, as tolerated, up to 15 minutes. The average RPM (revolutions per minute) naturally achieved by the participant during the first few sessions should be observed by the exercise assistant, who can then periodically encourage a slightly higher RPM as the participant's fitness level improves over the course of the program.
7. Conversation Stimulation
   Exercise assistants should talk with their partner throughout the program. Activities used to stimulate conversation include having participants associate thoughts and memories to a stimulus word, tell what's good or bad about different things, complete sentence stems, give the ending to a proverb after the first few words are given, name the category that two related objects belong to, name a famous person with a first name that is provided. Large-type song sheets can be used to enable participant to sing old, familiar songs while exercising.
   During the rest period between the aerobic and the weight training session, participants can be encouraged to discuss their opinion on controversial topics such as free prescription drugs for the elderly or current events, i.e., the President's tax plan. These types of discussions do not depend on memory for specific events, which is often reduced in persons with Alzheimer's Disease. Rather, they draw on common sense, personal philosophy, and general life experience, about which persons with early- to moderate-stage dementia can generally communicate. The exercise assistant should contribute to these discussions so that there is a real dialogue.
8. Weight Training
   The weight-training regimen described here uses five different weight-training machines by MedX. MedX equipment is especially suitable for older persons because it can be finely adjusted to body size, has 2-pound (instead of 5-pound) weight increments, and has a shorter lifting distance for the weight stack than other brands (i.e., Nautilus). However, other machines (or free weights) can be used to achieve the same goals. Consult a trainer at the facility you plan to use. The Elder Rehab program emphasizes exercise machines that strengthen large muscle groups:
   
   1. leg press, which strengthens muscles of the upper legs and buttocks;
   2. chest press, which strengthens muscles of the chest and shoulders;
   3. seated row, which strengthens muscles of the arm, shoulder, and upper back;
   4. torso arm (weights pulled down from above to shoulder level), which strengthens muscles of the arm, shoulder, and upper torso; and
   5. overhead press weights pressed upward from just above shoulder level), which strengthens muscles of the chest and shoulders.

   Substitute exercises are prescribed for participants with specific problems such as arthritic knees or shoulder pain.

   At each beginning weight level, participants should be asked to do two sets of 10 repetitions at each machine, with a rest period of least 30 seconds after each set. After two successful workouts at a given weight, increase repetitions to 12 for two workouts, then increase weights. For upper-body machines, increase weight by two pounds. On the leg press, an increase of 10 pounds is usually tolerated.

   If a participant complains or seems to be working too hard, drop back to a lower weight. (Sometimes a complainer can be distracted by a trip to the drinking fountain or bathroom. By the time he or she returns, the complaint is forgotten and exercise can resume!)

   One participant who had shoulder pain could not do exercises with arms raised above shoulder height; bicep and tricep machines were substituted. A woman with arthritic knees skipped the leg press and did wall squats instead. One post-surgical patient did just walking for one semester, then walking and strength and flexibility exercises on a raised mat for a second semester before resuming full participation in all of the program's exercises. This particular individual, Ida, before two falls and multiple fractures, was videotaped, at age 84, pressing 448 pounds 10 times on a MedX leg press machine, while her 21-year-old student partner could only manage three repetitions!

   Another program participant, currently 90 years old, fell and broke a hip at home in January 2000. Within two weeks, with a pin in her hip, she was walking with a cane; soon after that she began water aerobics with her student partner. By the fall 2000 semester, she had resumed full participation in all of the program's exercises, though at a somewhat reduced level of intensity. (She was videotaped pressing 500 pounds on the MedX leg press machine pre-injury!) In February 2001, she covered 960 feet in her six minute walk test, one year post-injury. Her performance had been 1111.5 feet in December 1998, after one semester of participation.

   The speedy and complete recovery of these two very elderly individuals from what are frequently disastrous and permanently disabling injuries is clearly attributable to the strength and stamina developed through regular and vigorous exercise. An amazing fact about Ida's recovery is that her mental status test score, as measured by a commonly used test, the Mini-Mental Status Exam (Folstein, Folstein, & McHugh, 1995), was actually one point higher after one semester of modified program participation with a student after her injury than at the beginning of the program. This occurred despite enormous disruptions in her life, including two surgeries and hospitalizations, a stay at a rehabilitation hospital, and a move from her cherished home of many years to an assisted living facility. Even one such disruption usually triggers a steep and often permanent decline in mental status for a person with dementia.

   Organizations

   1. National Institute on Aging :
      Bethesda , Maryland

   Suppliers

   1. MedicAlert Foundation International :
      Turlock , California

   Books

   1. American College of Sports Medicine, J. Larry Durstine, Geoffrey E. Moore (Eds.). (1997). ACSM's exercise management for persons with chronic diseases and disabilities. Champaign, IL: Human Kinetics.
   2. N. Mace (Eds.). (1990). Dementia Care: Patient, Family, and Community: Therapeutic activity. Baltimore, MD: Johns Hopkins University Press.

   Journals

   1. Arkin, S. (1999). Elder Rehab: A student-supervised exercise program for Alzheimer's patients:. The Gerontologist, 39, 729-735.
   2. Arkin, S., & Mahendra, N. (2001). Discourse analysis of alzheimer's patients before and after intervention: Methodology and outcomes. Aphasiology, 15, 533-569.
   3. Bonner AP, Cousins SO. (1996). Exercise and Alzheimer's disease: Benefits and barriers. Activities, Adaptation and Aging, 20, 21-34.
   4. Caspersen, C.J., Powell, K.E., & Christenson, G.M. (1985). Physical Activity, Exercise, and Physical Fitness: Definitions and Distinctions for Health-Related Research. Public Health Reports, 100, 126-131.
   5. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-Mental State," a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
   6. Kuczmarski, R.J. (1992). Prevalence of Overweight and Weight Gain in the United States. American Journal of Clinical Nutrition, 55, 495S-502S.
   7. Netz, Y. & Argov, E. (1997). Assessment of functional fitness among independent older adults: A preliminary report. Perceptual and Motor Skills, 84, 1059-1074.
   8. Palleschi, L., Vetta, F., deGennaro, E., Idone, G., Sottosanti, G., Gianni, W., & Marigliano, V. (1996). Effects of aerobic training on the cognitive performance of elderly patients with senile dementia of the Alzheimer type. Archives of Gerontology and Geriatrics(Supplement 5), 47-50.
   9. Rimmer, J., Riley, B., Creviston, T., & Nicola, T. (2000). Exercise training in a predominantly African-American group of stroke survivors. Medicine and Science in Sports and Medicine, 32(12).
   10. Vertinsky, P. (1991). Old age, gender, and physical activity: The biomedicalization of aging. Journal of Sport History, 18, 64-80.

   Magazines

   1. Cowley, G. (2000-01-31). Alzheimer's: Unlocking the mystery. Newsweek. 46-51.

   Reports

   1. U.S. Department of Health and Human Services. (1996). Physical Activity and Health. A Report of the Surgeon General.
   2. (1998). Study: Exercise may reduce Alzheimer's risk. .
   
   
   

   This fact sheet was last updated on 01-08-2008.

Add a Fact Sheet Section

Update this Fact Sheet
(edit sheet name, edit organizations, etc.)