JAMDA 16 (2015) 638e639
JAMDA journal homepage: www.jamda.com
Editorial
Get Up and Go Eric G. Tangalos MD * Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
In this issue of JAMDA, Espeland et al1 have taken on the task of measuring ankle brachial index to study cognitive function in a sedentary elderly population that is neither demented nor in a nursing home but that has significant functional limitations. The authors have been careful not to overstep their results, but the conclusions suggest that lower baseline ankle brachial index was independently correlated with cognitive function and associated with a tiered risk for progression to mild cognitive impairment or probable dementia. Thus, better vascular health means better cognitive health. The authors have described their cohort, and it is a fairly typical population of elders. Although their evidence cannot take them beyond the suggestion that exercise might improve cognition, it would appear that improvements in vascular health do make a difference. Studies on hippocampal volume2,3 have shown size improvements with exercise. Along with socialization, there also may be a direct impact on improved cognition. Practitioners in the nursing home need to get our patients up, active, and walking, as well as engaged. Individuals who do this on their own remain more physically healthy, whereas those who are physically impaired end up cognitively frail as well. The study does help to validate the evidence that the way to reduce cognitive decline is with improved vascular health. The authors were wise not to overreach in their conclusions, but the assumption is that if you stay physically fit, you will stay mentally fit as well. There is nothing wrong with this construct, given that we have so few interventions that limit or forestall cognitive decline. As it stands, all of our current interventions are intended to reduce the opportunities for functional decline and limit transitions in care. Gait speed as a surrogate for function now appears to be one of the strongest predictors of cognitive decline.4 Preventive strategies to preserve cognitive function tend to focus on cardiovascular health, socialization, and exercise. There is not much else that has captured our attention or provided a worthwhile signal to pursue. A direct link between vascular health and Alzheimer disease also may exist.5 Whether there is a stronger component of vascular and white matter disease in contributing to Alzheimer disease is less well understood. Control of blood pressure and improved cardiac function may directly improve functional impairment in Alzheimer disease.
DOI of original article: http://dx.doi.org/10.1016/j.jamda.2015.03.010 * Address correspondence to Eric G. Tangalos, MD, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.04.011 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Finnish investigators conducted a randomized controlled trial to investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with Alzheimer disease and to explore its effect on the use and cost of health and social services.6 Their publication has received a fair amount of notoriety in the public domain, with titles such as “Exercise May Help People with Alzheimer’s Disease Avoid Nursing Homes.7” The authors used functional outcome measures, looked at the use and cost of social and health services, and found that the intervention group showed beneficial effects on the physical functioning of patients with Alzheimer disease without increasing the total cost of health and social services or causing any significant adverse effects. The intervention group also had significantly fewer falls than the control group during the year of follow-up. Additional controlled studies have shown that aerobic exercise increases hippocampal volume in patients with probable mild cognitive impairment.3 That particular group was all women, with the assumption that exercise would be beneficial to both sexes. One of the oldest studies is the Systolic Hypertension in Europe (Syst-Eur) trial published in 1998.8 This particular study found that elderly people with isolated systolic hypertension who were treated vigorously for their antihypertensive therapy had a lower incidence of dementia. The conclusion was that if 1000 hypertensive patients were treated with antihypertensive drugs for 5 years, 19 cases of dementia might be prevented. Additional studies have suggested that hypertension is, in fact, a risk factor for dementia.9 Another study suggests that exercise training increases hippocampal volume by 2%, leading to improvement in spatial memory.2 Nursing homes have had a smattering of research activities related to dementia and exercise. One randomized controlled trial looked at 134 ambulatory patients with mild to severe Alzheimer disease who came from 5 different nursing homes.10 They were randomly assigned to either exercise or routine care, and at the 6- and 12-month intervals, activities of daily living (ADL) scores declined significantly in both groups, but mean ADL score reduction was significantly lower in the exercisers than the routine care group. The exercise program participants declined approximately one-third as much as the routine medical care patients, and significant improvements in walking speed were observed in the exercise group at 6 and 12 months. There is not much to lose in promoting fitness in an environment that supports socialization and self-actualization. Any activity that encourages physical activity appears to bring on benefit. Yoga, Thai Chi, and water aerobics have all produced positive results.11 Get up and go should not refer to a test. It should refer to a series of instructions on how to stay healthy in the face of physical and cognitive
Editorial / JAMDA 16 (2015) 638e639
decline. Cognitive and physical frailty become all the more entwined in the aged nursing home population; exercise and vascular health seem to help.
5.
6.
References 1. Espeland MA, Newman AB, Sink K, et al. Associations between ankle-brachial index and cognitive function: Results from the Lifestyle Interventions and Independence for Elders Trial. J Am Med Dir Assoc 2015;16:682e689. 2. Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 2011;108: 3017e3022. 3. Ten Brinke LF, Bolandzadeh N, Nagamatsu LS, et al. Aerobic exercise increases hippocampal volume in older women with probable mild cognitive impairment: A 6-month randomised controlled trial. Br J Sports Med 2015;49: 248e254. 4. Schoon Y, Bongers K, Van Kempen J, et al. Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value
7.
8.
9. 10.
11.
639
compared to step length and chair rise time. Eur J Phys Rehabil Med 2014;50: 693e701. Kivipelto M, Helkala EL, Laakso MP, et al. Midlife vascular risk factors and Alzheimer’s disease in later life: Longitudinal, population based study. BMJ 2001;322:1447e1451. Pitkala KH, Pöysti MM, Laakkonen ML, et al. Effects of the Finnish Alzheimer disease exercise trial (FINALEX): A randomized controlled trial. JAMA Intern Med 2013;173:894e901. HealthDay. Exercise May Help People With Alzheimer’s Avoid Nursing Homes. Available at: http://consumer.healthday.com/cognitive-and-neuro logical-health-information-26/alzheimer-s-news-20/exercise-may-help-peoplewith-alzheimer-s-avoid-nursing-homes-675459.html. Accessed May 28, 2015. Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet 1998;352:1347e1351. Nagai M, Hoshide S, Kario K. Hypertension and dementia. Am J Hypertens 2010;23:116e124. Rolland Y, Pillard F, Klapouszczak A, et al. Exercise program for nursing home residents with Alzheimer’s disease: A 1-year randomized, controlled trial. J Am Geriatr Soc 2007;55:158e165. Jahnke R, Larkey L, Rogers C, et al. A comprehensive review of health benefits of qigong and tai chi. Am J Health Promot 2010;24:e1ee25.
JAMDA journal homepage: www.jamda.com
Editorial
Get Up and Go Eric G. Tangalos MD * Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
In this issue of JAMDA, Espeland et al1 have taken on the task of measuring ankle brachial index to study cognitive function in a sedentary elderly population that is neither demented nor in a nursing home but that has significant functional limitations. The authors have been careful not to overstep their results, but the conclusions suggest that lower baseline ankle brachial index was independently correlated with cognitive function and associated with a tiered risk for progression to mild cognitive impairment or probable dementia. Thus, better vascular health means better cognitive health. The authors have described their cohort, and it is a fairly typical population of elders. Although their evidence cannot take them beyond the suggestion that exercise might improve cognition, it would appear that improvements in vascular health do make a difference. Studies on hippocampal volume2,3 have shown size improvements with exercise. Along with socialization, there also may be a direct impact on improved cognition. Practitioners in the nursing home need to get our patients up, active, and walking, as well as engaged. Individuals who do this on their own remain more physically healthy, whereas those who are physically impaired end up cognitively frail as well. The study does help to validate the evidence that the way to reduce cognitive decline is with improved vascular health. The authors were wise not to overreach in their conclusions, but the assumption is that if you stay physically fit, you will stay mentally fit as well. There is nothing wrong with this construct, given that we have so few interventions that limit or forestall cognitive decline. As it stands, all of our current interventions are intended to reduce the opportunities for functional decline and limit transitions in care. Gait speed as a surrogate for function now appears to be one of the strongest predictors of cognitive decline.4 Preventive strategies to preserve cognitive function tend to focus on cardiovascular health, socialization, and exercise. There is not much else that has captured our attention or provided a worthwhile signal to pursue. A direct link between vascular health and Alzheimer disease also may exist.5 Whether there is a stronger component of vascular and white matter disease in contributing to Alzheimer disease is less well understood. Control of blood pressure and improved cardiac function may directly improve functional impairment in Alzheimer disease.
DOI of original article: http://dx.doi.org/10.1016/j.jamda.2015.03.010 * Address correspondence to Eric G. Tangalos, MD, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.04.011 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Finnish investigators conducted a randomized controlled trial to investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with Alzheimer disease and to explore its effect on the use and cost of health and social services.6 Their publication has received a fair amount of notoriety in the public domain, with titles such as “Exercise May Help People with Alzheimer’s Disease Avoid Nursing Homes.7” The authors used functional outcome measures, looked at the use and cost of social and health services, and found that the intervention group showed beneficial effects on the physical functioning of patients with Alzheimer disease without increasing the total cost of health and social services or causing any significant adverse effects. The intervention group also had significantly fewer falls than the control group during the year of follow-up. Additional controlled studies have shown that aerobic exercise increases hippocampal volume in patients with probable mild cognitive impairment.3 That particular group was all women, with the assumption that exercise would be beneficial to both sexes. One of the oldest studies is the Systolic Hypertension in Europe (Syst-Eur) trial published in 1998.8 This particular study found that elderly people with isolated systolic hypertension who were treated vigorously for their antihypertensive therapy had a lower incidence of dementia. The conclusion was that if 1000 hypertensive patients were treated with antihypertensive drugs for 5 years, 19 cases of dementia might be prevented. Additional studies have suggested that hypertension is, in fact, a risk factor for dementia.9 Another study suggests that exercise training increases hippocampal volume by 2%, leading to improvement in spatial memory.2 Nursing homes have had a smattering of research activities related to dementia and exercise. One randomized controlled trial looked at 134 ambulatory patients with mild to severe Alzheimer disease who came from 5 different nursing homes.10 They were randomly assigned to either exercise or routine care, and at the 6- and 12-month intervals, activities of daily living (ADL) scores declined significantly in both groups, but mean ADL score reduction was significantly lower in the exercisers than the routine care group. The exercise program participants declined approximately one-third as much as the routine medical care patients, and significant improvements in walking speed were observed in the exercise group at 6 and 12 months. There is not much to lose in promoting fitness in an environment that supports socialization and self-actualization. Any activity that encourages physical activity appears to bring on benefit. Yoga, Thai Chi, and water aerobics have all produced positive results.11 Get up and go should not refer to a test. It should refer to a series of instructions on how to stay healthy in the face of physical and cognitive
Editorial / JAMDA 16 (2015) 638e639
decline. Cognitive and physical frailty become all the more entwined in the aged nursing home population; exercise and vascular health seem to help.
5.
6.
References 1. Espeland MA, Newman AB, Sink K, et al. Associations between ankle-brachial index and cognitive function: Results from the Lifestyle Interventions and Independence for Elders Trial. J Am Med Dir Assoc 2015;16:682e689. 2. Erickson KI, Voss MW, Prakash RS, et al. Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 2011;108: 3017e3022. 3. Ten Brinke LF, Bolandzadeh N, Nagamatsu LS, et al. Aerobic exercise increases hippocampal volume in older women with probable mild cognitive impairment: A 6-month randomised controlled trial. Br J Sports Med 2015;49: 248e254. 4. Schoon Y, Bongers K, Van Kempen J, et al. Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value
7.
8.
9. 10.
11.
639
compared to step length and chair rise time. Eur J Phys Rehabil Med 2014;50: 693e701. Kivipelto M, Helkala EL, Laakso MP, et al. Midlife vascular risk factors and Alzheimer’s disease in later life: Longitudinal, population based study. BMJ 2001;322:1447e1451. Pitkala KH, Pöysti MM, Laakkonen ML, et al. Effects of the Finnish Alzheimer disease exercise trial (FINALEX): A randomized controlled trial. JAMA Intern Med 2013;173:894e901. HealthDay. Exercise May Help People With Alzheimer’s Avoid Nursing Homes. Available at: http://consumer.healthday.com/cognitive-and-neuro logical-health-information-26/alzheimer-s-news-20/exercise-may-help-peoplewith-alzheimer-s-avoid-nursing-homes-675459.html. Accessed May 28, 2015. Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet 1998;352:1347e1351. Nagai M, Hoshide S, Kario K. Hypertension and dementia. Am J Hypertens 2010;23:116e124. Rolland Y, Pillard F, Klapouszczak A, et al. Exercise program for nursing home residents with Alzheimer’s disease: A 1-year randomized, controlled trial. J Am Geriatr Soc 2007;55:158e165. Jahnke R, Larkey L, Rogers C, et al. A comprehensive review of health benefits of qigong and tai chi. Am J Health Promot 2010;24:e1ee25.
