Exercise could ease Alzheimer’s disease complications
This year alone, Alzheimer’s and related dementias will cost the United States more than $250 billion, according to data from Alzheimer’s Association. Experts predict these costs, as well as the occurrence of the disease will go up in the future, due to the influx of U.S. residents already in, or about to enter, middle age.
“With the baby boomers entering retirement and beyond and the life expectancy of the entire population increasing, the burden of Alzheimer's disease grows alarmingly greater,” Daniel D. Christensen, MD, an adjunct psychiatry professor at the University of Utah School of Medicine, wrote in the Journal of Family Practice.
“There are 5.7 million Americans with Alzheimer’s today, a number that could triple by 2050. The U.S. will spend $277 billion a year treating those aged 65 years and older with Alzheimer’s in 2018, and that number could increase to $1.1 trillion by 2050,” James Hendrix, PhD, the Alzheimer’s Association director for global science initiatives and medical and scientific relations, told Healio Family Medicine. “Alzheimer’s disease is a huge problem that is only going to get bigger if we don’t have a way to stop, slow or cure the disease.”
In recognition of June as Alzheimer’s and Brain Awareness Month, Healio Family Medicine discussed the state of research and treatment options for the neurological condition with a range of experts in the field. A future installment will review the challenges in finding a pharmacologic option. Today’s article reviews what PCPs can discuss with patients.
Alzheimer’s Association explores combined intervention
The Alzheimer’s Association will launch the Protect Brain Health Through Lifestyle Intervention to Reduce Risk, or POINTER, trial later this year, according to Hendrix.
The 2-year study will examine whether combining exercise, diet, social and intellectual challenges and better management of other health conditions can stave off cognitive decline in those who are at most risk for Alzheimer’s, according to the association. The program is based on the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability, or FINGER trial, he said, but with one notable difference.
“The group in Finland was homogenous. We want to see what we can learn from a more diverse population,” Hendrix said in the interview.
Hendrix said he has not lost hope that a drug that can prevent or stave off Alzheimer’s disease can be found, but not to encourage the strategies being studied in POINTER while waiting for such a treatment would potentially withhold improved quality of life from thousands of patients.
“Researchers have made tremendous strides in the last few years. I’m optimistic we’re on the right track and we’ll start to see new therapies approved,” he said. “In the meantime, though, we believe that strategies, such as exercise, could help keep people healthier longer, keep their brain healthier longer as a way of at least preventing or maybe slowing down the progression of Alzheimer’s disease.”
The Alzheimer’s disease – exercise connection
Other experts discussed the benefits of physical activity.
“There does seem to be a correlation in improving cognition, executive function, speed of processing in people who exercise,” Sharon A. Brangman, MD, of the geriatrics department at Upstate Medical University in New York and a Center for Excellence for Alzheimer’s Disease, told Healio Family Medicine.
“This may be explained by the effect of exercise on our bodies — benefits such as how it lowers blood pressure and helps your body handle glucose metabolism better and how it may reduce stress hormones. These are all things that, without exercise, can make cognitive function more impaired,” she said.
“There are some nerve growth factors that are circulating in the body and get into the central nervous system and help your brain when you exercise, so there’s a lot of different ways exercise can help brain function,” Brangman added.
Additionally, an expert panel in Canada composed of experts from the fields of neurology, exercise, epidemiology, aging, Alzheimer’s disease, physical activity, behavior changes, and dementia reviewed 27 studies on the relationship between these subject matters to develop a consensus statement, which they published in BMC Public Health in 2017.
“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,” they wrote.
The statement received a favorable ranking by a sample of physicians who treat Alzheimer’s disease in terms of its appropriateness, clarity and use, the panel from Canada wrote
Examining the evidence
Data from studies that Healio Family Medicine found in PubMed suggest exercise produces cognitive benefits that are as varied as the manifestation of the disease.
A 2009 prospective cohort study published in JAMA showed that those who adhered to a Mediterranean diet and participated in activities such as aerobic dancing, jogging, playing handball, cycling, swimming, hiking, tennis, walking, dancing, calisthenics, golfing, bowling, gardening, and horseback riding had a lower risk for Alzheimer’s disease than those who did not report modifying their diet and engaging physical activity.
“Confidence in our findings is strengthened by the following factors,” Nikoloas Scarmeas, MD, of the department of neurology at Columbia University, and colleagues wrote in JAMA.
“The study is community-based and the population is multiethnic, increasing the external validity of the findings. Assessment instruments that have been previously validated and widely used in epidemiological studies were applied. The diagnosis of [Alzheimer’s disease] took place in a university hospital with expertise in dementia and was based on comprehensive assessments and standard research criteria. The patients were followed up prospectively at relatively short intervals.”
“[In addition], measures for multiple potential confounders were carefully recorded and adjusted for in the analyses,” Scarmeas and colleagues continued. “Using a variety of sensitivity analyses, including conservative propensity analyses methods, the results were similar.”
Further, a 2015 study published in CNS & Neurological Disorders Drug Targets examined more modest exercise levels than those that meet the HHS-recommended 150 minutes of moderate activity, or 75 minutes of moderate and vigorous activity during a week. The participants, all from China, cycled 40 minutes a day, three times a week at 70% of maximum intensity.
Study participants’ Minimum Mental State Examination score significantly increased, and Alzheimer's Disease Assessment Scale-cognition scores significantly decreased in the 3 months before and after the intervention began. Conversely, the control group after 3 months saw no significant difference in Alzheimer's Disease Assessment Scale-cognition scores and the Minimum Mental State Examination scores decreased significantly.
In another report published in Dementia and Geriatric Cognitive Disorders in 2015, investigators randomly assigned participants in South Korea to a single multicomponent therapy session consisting of music, art, horticulture, handicraft, recreational, stretching, and laughing therapies, or a regimen that combined these therapies with exercise sessions comprising 15 minutes of warm-up and stretching, 30 minutes of lower-limb aerobic exercise and 15 minutes of cool-down and relaxation. This occurred two times a day, five times a week for 6 months.
Researchers found that after 6 months, there were significant within-group differences for the Alzheimer's Disease Assessment Scale-cognition scores, but not for the Minimum Mental State Examination scores in those who received the combination therapy. Conversely, there were no significant differences in all cognitive measures over the 6 months of the intervention in the group that did not exercise.
How much physical activity?
The multiple different findings regarding exercise’s benefit on Alzheimer’s disease suggest there is no one approach to physical activity that is better than the others. Hendrix said primary care physicians should tell their patients to exercise at a level that makes them comfortable, and that it’s also never too early or too late in life to start exercising.
“I’m often asked, ‘How much exercise should I do’? And my answer is quite simple. It’s the exercise you will do, not the one that your friend across the street who runs marathons does. Do the exercise you will stick with,” he said. “Patients need to do what they enjoy so that it becomes part of their lifestyle. If they miss a day here and there, that’s not a big deal. But if the patient is only exercising one day a month, that probably is not going to improve cognitive function.”
Brangman said that patients should be told that even small financial and physical investments in physical fitness can make a difference.
“There’s no downside to exercising if they can physically manage themselves with the other medical conditions they may have. And it doesn’t even look like you need fancy equipment. It could be something as simple as walking every day for about 30 minutes,” she said in the interview. “Exercise is usually very helpful in the scheme of options that we offer patients.”
Getting patients to exercise
Acknowledging that not everyone likes to exercise, Brangman offered ways that primary care physicians can help their patients connect the dots between physical activity and brain function.
“Exercising helps lower blood pressure and we know that high blood pressure can have a negative impact on the brain and how it functions. In addition, exercising helps our bodies metabolize sugar better and we know that if you have diabetes or trouble metabolizing sugar, that can put a stress on the brain,” she said. “Exercising also decreases the stress hormones in the body that can have a negative effect on brain function. There are some nerve growth factors circulating in the body that can get into the central nervous system and help our brains when we exercise.”
Discussing Alzheimer’s disease with patients
Until scientists find a pharmacological cure, Brangman offered suggestions on how primary care physicians can answer their patients and their caregivers’ questions about how to prevent or stave off Alzheimer’s disease.
“Tell them to work on the things that they can control. If they have hypertension, get it treated. If they have high blood sugar, get it under control. Tell them to watch their lipids and in light of the increasing evidence that suggests people who don’t get at least 7 hours of sleep may actually be increasing their risk for dementia, tell them to get a good night’s sleep. Advise patients to look at the things that they can impact,” she said.
Barry Reisberg, MD, director of the Fisher Alzheimer’s Disease Education and Resources Program at the New York University’s Alzheimer’s Disease Center, told Healio Family Medicine that PCPs must be transparent when discussing the disease.
“If patients and family members know more about the disease and there is information about the course of the disease, and if the doctors aren’t afraid to share that information with the family members, then the family members won’t become as disturbed with every new change in the disease,” he said. “By educating these people about what the disease is it makes the disease more tolerable because people understand what is going on.” – by Janel Miller
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Disclosures: None of the contributors to this article report any relevant financial disclosures.