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PROMOTING MOVEMENT AS MEDICINE FOR THE MIND
Lauren Bechard, BSc Graduate Student (MSc Rehabilitation Science)
University of Toronto | Sunnybrook Research Institute
CCAA Research 2 Action Conference London, ON June 10, 2017
Overview
• The Big Picture on Brain Health
• Physical Activity Behaviours of Older Adults
• Learning from the Experts
• Implications for Community Exercise Advocates
• Questions
THE BIG PICTURE ON BRAIN HEALTH
Healthy Cognitive Aging is a Global Priority
Alzheimer’s Disease International, 2015
The Cognitive Aging Continuum • Dementia is NOT a normal part of aging
• Dementia is NOT just memory problems
• Disease processes can manifest decades before symptoms appear
Sperling et al., 2011
Brain Benefits of Physical Activity: Proposed Mechanisms
↑ Cerebral Perfusion (Tarumi & Zhang, 2014)
↑ Vascular Endothelial Function (Santos-Parker et al., 2014)
↑ Neurogenesis (Dery et al., 2013)
↓ Inflammation (Iyalomhe et al., 2015)
↓ Oxidation (Garcia-Mesa et al., 2016)
Schematic representation of the neurovascular unit (Altman & Rutledge, 2010)
Brain Benefits of Physical Activity: Dementia Prevention • Physical activity is associated with a 30-40% reduced risk of
developing Alzheimer’s Disease (Beckett et al., 2015)
• 13% (4.3M) of AD cases globally attributed to physical inactivity. 25% reduction in this risk factor could prevent almost 1M cases of AD globally (Barnes & Yaffe, 2011)
• Biggest benefits for lifelong exercisers, but better late than never (Middleton et al., 2010)
• Reduced risk of progressing to dementia for people already experiencing cognitive impairments (Grande et al., 2014)
Brain Benefits of Physical Activity: Maintaining Independence • Even people already living with dementia can benefit
from physical activity! • Reduced declines in cognitive domains like executive function*
(Farina et al., 2014) • Maintain ability to complete activities of daily living** (Rao et
al., 2014)
*Executive function – cognitive capacity needed to orient and sequence behaviour to accomplish a goal
** Activities of Daily Living – routine activities that are part of daily life (Basic vs. Instrumental)
EXECUTIVE FUNCTION AND ACTIVITIES OF DAILY LIVING ARE CRITICAL FOR MAINTAINING INDEPENDENCE!
PHYSICAL ACTIVITY BEHAVIOURS OF OLDER ADULTS
Physical Activity Recommendations
Early Years (0-4yo)
•180 min / day
•Varied intensity
•Activities developing movement skills
Youth (5-17yo)
•60 min / day of moderate to vigorous
•>>60 min / day of light activity
•No more than 2 hours of screen time
•Limit sitting for extended periods
Adults (18-64yo)
• 150 min / week moderate to vigorous aerobic exercise
• Minimum 10 min bouts
• Strengthen major muscle groups at least 2 days / week
Older Adults (>64yo)
• 150 minutes / week, minimum 10 minute bouts
• Strengthen major muscle groups at least 2 days / week
• Balance training if at risk of falling
MORE PHYSICAL ACTIVITY PROVIDES GREATER HEALTH BENEFITS!
Guidelines available at http://www.csep.ca/en/guidelines/guidelines-for-other-age-groups
Physical Activity Reality
Data from Statistics Canada CANSIM Table 105-051
2010 2011 2012 2013 2014
12-19 years 71% 72% 71% 71% 70%
20-34 years 56% 58% 57% 60% 57%
35-44 years 50% 51% 52% 52% 52%
45-64 years 49% 51% 51% 51% 51%
65 years and over 42% 44% 46% 48% 48%
35%
40%
45%
50%
55%
60%
65%
70%
75%
Physical activity during leisure-time, moderately active or active (% Active)
Physical Activity Reality
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
18-39 years 40-59 years 60-79 years Males, all ages Females, allages
Total, all ages
19%
13%
11%
17%
13%
15%
Proportion of Canadian Adults Meeting Physical Activity Guidelines (2007-2011)
Data from Canadian Health Measures Survey, 2007-2011
What about people living with dementia?
0%
5%
10%
15%
20%
25%
30%
35%
AerobicFitness
Upper BodyStrength
Lower BodyStrength
DynamicBalance
27%
32%
23%
15%
% Participants Meeting Physical Fitness Requirements for Independent Living
• Under-researched population (Canadian Longitudinal Study in Aging should help!)
• 84% of participants reported no physical activity or levels that failed to meet Canadian guidelines (O’Connell et al., 2015)
• Older adults with MCI and
dementia not meeting physical fitness requirements for independent living (Hesseberg et al., 2016)
So what does all this mean?
• Healthy cognitive aging is a global priority
• Physical activity has many benefits for maintaining cognition and independence in aging
• There’s no “expiration date” on the benefits of physical activity for cognitive aging
• Despite many benefits, older adults with cognitive impairment underutilize this health-promoting behaviour
HOW CAN WE GET OLDER ADULTS MOVING FOR BETTER BRAIN HEALTH?
LEARNING FROM THE EXPERTS
The Research Context
• Voices of persons with dementia historically excluded from research • Ethically “vulnerable” population
• Cognitive symptoms “threaten” validity of data
My [unsolicited] opinion:
Ignorance: refusing to acknowledge something because it’s (a) challenging, (b) difficult, (c) you don’t understand it.
Research Question
How do older adults with MCI and AD and their caregivers perceive and participate in physical
activity?
• Concerning physical activity participation in MCI and AD, describe: • Experiences of physical activity in the community setting • Beliefs of persons with MCI, AD, and their caregivers about
physical activity for health promotion and dementia management
• Perceptions about barriers, facilitators, and unmet needs affecting physical activity participation
Who are the “Experts”? • Care dyads from cognitive neurology clinic at
Sunnybrook Health Sciences Centre • Purposive sampling – maximum variation
• Finish sampling when theoretical saturation achieved
• “Dyads” • 1 older adult (≥65 years) with Mild Cognitive
Impairment (MCI) or mild/moderate Alzheimer’s Disease (AD) (MMSE=18-28)
• 1 adult (≥18 years) spouse or family member providing routine care
Study Design • Qualitative exploratory study
• Thematic Analysis (Braun & Clarke, 2006)
• Semi-structured interview (30-40min, both dyad members) • Dyad members individually interviewed
• Set of pre-determined questions, but follow participant’s lead within these topics
• Field notes taken during interview
• Audio-recorded and transcribed verbatim to generate transcripts
• Physical activity questionnaire (10min, both dyad members)
• Apathy & caregiver distress – Questionnaire (10min, just caregiver)
Characteristics Caregiver (n=10) AD/MCI (n=10)
Sex (% female) 50.0% 60.0%
Age (years) 65.9 (SD=17.4), (23-83) 74.4 (SD=7.5), (66-86)
Diagnosis 60% AD; 40% MCI
MMSE 24.5 (SD=3.0), (20-28)
Dyad Relationship 80% Spouse 10% Child 10% Grandchild
80% Spouse 10% Parent 10% Grandparent
Education > 12 years 100% 100%
Ethnic Diversity (% not Caucasian) 20% 10%
Activity level
High (≥150min MVPA/wk) 60.0% 10.0%
Moderate (100-149min MVPA/wk) 30.0% 30.0%
Low (0-99min MVPA/wk) 10.0% 60.0%
Apathy
Apathy present 70.0%
Apathy Score (/96) 17.7 (SD=13.4) (1-36)
Caregiver distress (/40) 6.0 (SD=3.6) (3-11)
Bechard et al., in preparation
Results – Semi-Structured Interviews
• 20 interviews conducted, 33:11 minutes on average (18:34-46:30).
• Analysis using groups (care partner vs. persons with AD or MCI) and dyads as units of analysis:
Between Groups
1. Meaningful activities over meeting guidelines
2. Feeling over thinking
3. Activity despite dementia Within Dyads
4. Caregivers as enablers
Bechard et al., in preparation
Theme 1: Meaningful activities over meeting guidelines
“I haven't thought about that [guidelines], no. Probably it would be beneficial.” (Participant with MCI) “My mum loves dancing - she always ever did… all the women that worked there would go down on their lunch and learn tap dancing... So she loves dancing. I think she kind of grew up in a German household where there was a lot of polka-ing and all of that.” (Caregiver)
Bechard et al., in preparation
Theme 2: Feeling over thinking
“I can believe that what the book says, what you'll say, what the doctors will say about mental health and physical as being improved by physical activity… I believe that, but I can't prove it” (Participant with MCI)
“I notice that if I’m sitting in one place and don’t exercise or I don't walk… then I feel I am sleepy” (Participant with AD)
“it's really nice to breathe deeply… it's really wonderful to feel your lungs clear, to feel the blood coursing around your body” (Participant with MCI)
Bechard et al., in preparation
Theme 3: Activity despite dementia
“I think every day-regardless of... your mental capacity-I think there should be some effort made for them to have some kind of physical activity just to keep everything moving. I really believe that... Depending on maybe their confusion level-maybe they wouldn't be able to participate in a lot of things, but hopefully they would still be able to walk every day.” (Caregiver)
Bechard et al., in preparation
Theme 4: Caregivers as enablers
“And my wife is on me about this… She's trying to get me to exercise a couple of times a week at least because I can go a whole week without thinking about it. That's memory” (Participant with MCI)
“She doesn't drive, right? She relies on her daughter as a form of transportation if she needs to get anywhere. So that's the reason why she probably exercises just at home or independently.” (Caregiver)
“Even the tandem bike... It's not that I couldn't do it, but I would be worried that I would get another fracture… If I got a fracture, then nobody to look after him” (Caregiver)
Bechard et al., in preparation
Implications • Theme 1 – Emphasize engaging in meaningful activities
in daily life rather than meeting guidelines when promoting physical activity
• Theme 2 – Messaging on physical activity benefits appealing to positive sensations rather than general health benefits.
• Theme 3 – Physical activity is possible in dementia by adapting activities with person-centered approach
• Theme 4 – Caregivers are key enablers of activity, but experience barriers like competing demands, managing their own health concerns, and apathy.
Limitations • Limited generalizability
• Low sample diversity in ethnicity, socioeconomic status, rural vs. urban dwelling
• Small, non-representative sample
• Potential for bias • Interviewer confirmation bias (reflexivity)
• Healthy volunteer bias (maximum variation sampling)
• Social desirability bias (perspectives from both dyad members)
Conclusions
1) The way we talk about physical activity for health promotion doesn’t match the beliefs and perceptions of older adults with MCI and AD about physical activity.
Conclusions
2) Older adults with MCI and AD value and enjoy physical activity, but participation requires navigating barriers at the intersection of aging and cognition.
Conclusions
3) Changing the way we promote physical activity for this population and creating more dementia-friendly programs that meet the needs of both persons with dementia and their care partners could help improve PA participation.
IMPLICATIONS FOR COMMUNITY EXERCISE
ADVOCATES
Older Adults with Dementia & Caregivers • Theme 1 – Make it meaningful
• Are any activities a part of their identity? • Physical activity history?
• Theme 2 – Go by feel for benefits • Everyone already knows physical activity is healthy – focus on
emphasizing the positive sensations of exercise • Can you incorporate outdoor activity?
• Theme 3 – Be aware of symptoms • Not everyone has the same abilities – provide multiple options, get
creative!
• Theme 4 – Incorporate the care network • Get friends and family to join – make it a social event! • Talk to friends and family about how they can be supportive, and
supported
Community Health Promotion
• Theme 1 • Do we need to rethink how we structure our physical activity
guidelines?
• Theme 2 • Focus on the feeling, not just the stats
• Theme 3 • How can we leverage existing resources and community
programs to be more accessible to people with dementia?
• Theme 4 • How can we support caregivers more in enabling physical
activity opportunities for their care partners?
Acknowledgements
First and foremost, thank-you to our research participants!
Funding Acknowledgements: Sunnybrook Research Institute University of Toronto Faculty of Medicine Dalton Whitebread Scholarship Fund Leon & Blossom Wigdor Award for Studies in
Aging
Research Partners: Canadian Partnership for Stroke Recovery Sunnbrook Research Institute • LC Campbell Cognitive Neurology Research
Unit Program Advisory Committee Members
Dr. Sandra Black, MD (Supervisor) Dr. Dorcas Beaton, BScOT, PhD Dr. Katherine S. McGilton, RN, PhD Dr. Carmela Tartaglia, MD
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