Paired Integrative Home Exercise for Seniors With Dementia and Their Caregivers

Alzheimer's dementia (AD) is a major public health challenge for our century. Research into pharmaceutical therapies has been disappointing and not provided any safe medications that can halt the disease's trajectory of decline in the cognitive, functional, emotional and social capabilities of the affected individuals. For non-pharmacological approaches, multi-domain exercise programs that address several of these capabilities in an integrated way have shown strong promise for their ability to slow the decline. The team of investigators has systematically developed one such program-the Preventing Loss of Independence through Exercise (PLIÉ) program-an integrative exercise program that uses procedural memory (memory for movements without explicit recall), can be taught at and integrated into senior day care centers and has been pilot-tested by our team with encouraging results for functional, cognitive and social outcomes (see Table 1).

However, (1) most people in the community do not have access to a day care center, are concerned about the stigma associated with day care or are unable to afford it. This was endorsed by semi-structured interviews conducted with caregivers and community-based organizations in preparation for a larger study of the PLIÉ program. There is a huge need for innovative programs to assist individuals with dementia and their caregivers in the community. Irrespective of having access to day care or not, motivated caregivers, who are aware of the benefits of exercises for their loved ones and spend hours alone with them at home, ask: "What can we do with our [e.g. mother]?" They point out a major lack of guidance for caregivers in the community to be able to use a regular exercise practice on a long-term basis at home. Caregivers and seniors with dementia living together in the community are dyads in need of a paired exercise program. (2) How exercise may delay cognitive and functional decline is unknown. One hypothetical mechanism of action is an improved brain oxygenation related to exercise. Near-Infrared Spectroscopy (NIRS) is a non-invasive method to assess regional cortical oxygenation levels, has been suggested for the early diagnosis of Alzheimer's dementia, but has never been applied to longitudinal studies in this population.

Paired home exercise programs for seniors with dementia and their primary caregivers have rarely been studied. A pilot study that used 6 'sticky hands' movement variations based on Tai Chi, music and exercise incentives found improvements in 2 outcome measures considered to be important in fall prevention (sit-to-stand time, one-legged stance time). However, movements were limited to tai chi and outcomes to fall-related function, leaving out cognitive function for which the PLIÉ program had shown such promising results.

The group of investigators is an established collaboration between the Osher Center for Integrative Medicine and the Department of Psychiatry at UCSF and has recently pioneered a novel, 45-minute, multi-domain program called Preventing Loss of Independence through Exercise (PLIÉ) that integrates physical activity (training of procedural memory for basic daily activities such as sitting and standing), cognitive stimulation (mindful body awareness), social engagement (group movement and sharing of in-the-moment experiences), and caregiver education (monthly home-visit). The investigators pilot-tested PLIÉ in 11 individuals with mild to moderate dementia who were attending an adult day program at the Institute of Aging in San Francisco, CA (ClinicalTrials.gov registered NCT01371214), and found (Table 1) preliminary evidence of medium to large, clinically meaningful effect sizes com-pared to usual care (UC; 45 minutes of usual chair-based exercises at the day care center) across a wide range of out-comes including measures of quality of life (0.83), cognitive function (0.76), physical performance (0.34) and caregiver burden (0.49).7,11 That study methodologically mimicked a drug study by including measures that are commonly used in dementia medication trials, which enabled comparison of the magnitude of our results to currently available dementia medications.. The investigators are now completing data collection for a second implementation of the PLIÉ program at an adult day program in San Rafael, CA (Senior Access). The intervention of the current proposal will be similar to PLIÉ in using the same principles6 and taught by instructors trained in the PLIÉ program. However, it will differ in its format: instead of a day-care center-based group program taught by professional exercise instructors, it uses a dyadic approach, introduced through caregiver support groups to pairs of individuals with dementia and their caregivers, initially using a group class format, but taught to enable caregivers to practice independently at home. To allow for wide-spread long-term routine application, it will be brief (20 minutes), use personalized music associated with positive affect memories, and be supported by video instructions.

2 papers have been published about the study.