Psychogeriatrics - 2023 - Lok - Effect of Physical Activity Program Applied To Patients With Alzheimer S Disease On

doi:10.1111/psyg.
13010 PSYCHOGERIATRICS 2023; 23: 856–863
ORIGINAL ARTICLE
Effect of physical activity program applied to patients

with Alzheimer’s disease on cognitive functions and
depression level: a randomised controlled study
Neslihan LOK ,1 Alime Selçuk TOSUN ,2 Sefa LOK ,3 Veysel TEMEL 4
and Zekiye AYDIN 5
Department of 1Psychiatric Nursing and 2Public Abstract

Health Nursing, Selcuk University Faculty of
Nursing, 3Department of Coaching Education, Background: In this study, it was aimed to evaluate the effect of a physical
Selcuk University Faculty of Sports Sciences and activity program applied to Alzheimer’s disease patients on cognitive func-
5
Department of Nursing, Selcuk University Health tions and depression.
Sciences Institute, Konya and 4Karamanoglu Method: This study is a randomised controlled study designed in a pre-test
Mehmetbey University Faculty of Sports Sciences,
post-test design. It was conducted with 72 patients in total, 36 of whom
Karaman, Turkey
were interventions and 36 were controls, at the Alzheimer’s Day Life Centre.
Correspondence: Reasearch Fellow, Zekiye Aydın,
Selcuk University Health Sciences Institute, In data collection, a personal information form prepared by the researchers,
Department of Nursing, 42130, Konya, Turkey. questioning the socio-demographic characteristics of individuals, Mini Men-
Email: [email protected] tal Test and Cornell Dementia Depression Scale were used. In the analysis
Selcuk University Scientific Research Projects of the data, the homogeneity between the groups in terms of independent
Coordinatorship variables was evaluated by performing a Chi-square analysis. In the evalua-
Received 31 May 2023; revision received 3 July 2023; tion of cognitive functions and depression levels of the experimental and
accepted 6 July 2023. control groups, t-test was used in the dependent and independent groups.
Statistical significance level was accepted as P < 0.05.
Results: In the study, the cognitive functions of the experimental group, in
which a 12-week physical activity program was applied, were higher than
the control group and the difference was significant (P < 0.05). Similarly, the
depression scale mean score of the experimental group was found to be
better than the depression level of the individuals in the control group, and
the difference was significant (P < 0.05).
Conclusion: The 12-week physical activity program applied to Alzheimer’s
Key words: Alzheimer, cognitive functions, disease patients improved cognitive functions and depression levels of
depression, physical activity. individuals.
Pharmacological interventions in AD have only a

INTRODUCTION
More than 55 million people worldwide have demen- limited effect on symptoms, and it has been reported
tia, and around 10 million new cases are detected that there is no cure to date.4 Therefore, it is stated
each year. Alzheimer’s disease (AD) is stated as the that palliative measures including drug5 and non-drug
most common type of dementia, accounting for strategies (cognitive education, music therapy and
60%–70% of all cases.1 It is stated that the disease physical exercise) can be applied for AD.6 In a meta-
is characterised by a progressive deterioration in epi- analysis study evaluating non-pharmacological inter-
sodic (autobiographical) semantic memory, cognitive ventions, it was reported that exercise intervention
dysfunction, regression in language function, and has the preliminary potential to improve activities of
changes in both affect and behaviour. AD may be daily living and cognitive level.6 Today, there is evi-
associated with genetics,2 tobacco, sugary drinks, dence evaluating the effectiveness of aerobic,
obesity, diabetes, sedentary lifestyle, hypertension strength, flexibility and balance exercises in individ-
and cardiovascular diseases.3 uals with AD.7–9
856 © 2023 Japanese Psychogeriatric Society.

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In a systematic review study evaluating the METHODS

effectiveness of physical activity on AD, it was Design and setting
reported that aerobic physical exercise alone or in This study is a randomised controlled study designed
combination with a multimodal program including in a pre-test and post-test design. It was carried out
strength and balance exercise may be beneficial to at the Alzheimer’s Day Living Centre, which was
improve or maintain physical functional capacity and established to ensure that individuals with a diagno-
cognitive performance.10 In another systematic and sis of AD have a pleasant and quality time.
meta-analysis study, it was stated that physical exer-
cise positively affects cognitive performance in
Participants
elderly individuals with AD.11 Physical activity and
A total of 147 individuals with a diagnosis of AD reg-
exercise in mild cognitive impairment and dementia,
istered with the Alzheimer’s Day Living Centre formed
and physical activity/exercise supported by very low
the population of the study. The sample size was cal-
to moderate certainty of evidence in research exam-
culated using the ‘G Power-3.1.9.4’ program at 95%
ining intervention and observational studies, has
confidence level. According to Lanza et al.,17 taking
been reported to have a positive effect on a variety of
into account the Mini Mental Test (MMT) score aver-
cognitive and non-cognitive outcomes in people with
age, with an effect size of 0.8654198 a total of 72 par-
mild cognitive impairment and dementia.12,13 In a
ticipants were required (Fig. 1). Participants were
meta-analysis study of randomised controlled trials
divided into two groups as experimental (n = 36) and
(RCTs), it was stated that physical exercise improves
control (n = 36) using the block randomisation
quality of life, depressive symptoms and cognition in
method.
chronic brain disorders. In the same study, it was
Inclusion criteria of the study were having been
reported that meta-regression showed a dose–
diagnosed with AD, MMT result being in the range
response effect on depressive symptoms for exercise
of 23–24 points, getting eight points or more from
duration (min/week).14 Song et al.15 reported that
the Cornell Dementia Depression Scale and using
depressive symptoms decreased with a moderate-
regular antidementia drugs. Exclusion criteria were
intensity exercise program.
having any sensory disability and having any physi-
When the literature is examined, it is seen that
cal illness or disability that would affect participation
physical exercise potentially improves cognitive
in the sessions, having a heart condition that would
function and reduces depressive symptoms in indi-
prevent them from exercising and that s/he attended
viduals with mild cognitive impairment and AD. At
fewer than two sessions of the physical activity pro-
the same time, it is stated in the relevant literature
gram, or had any physical or psychological discom-
that there is still a need for RCTs with low risk of
fort that developed during the application of the
bias and confusion, taking into account the types,
program.
frequency, intensity or duration of physical activity
Dependent variables were ccognitive functions,
that may be protective against AD.13,16 For these
depression level.
reasons, in this study, it was aimed to evaluate the
Independent variable was the physical activity
effect of a physical activity program applied to indi-
program.
viduals with AD on cognitive functions and
Control variables were age, gender, marital status,
depression.
educational status.
Research hypotheses Randomisation

Individuals with a diagnosis of AD were randomly
1 Cognitive functions of individuals with a diagnosis assigned to the experimental and control groups. In
of AD who underwent physical activity are better order to reduce the selection bias and to control the
than the control group. variables that may have an effect on the outcome vari-
2 Depression level of individuals with a diagnosis of ables, the researchers assigned the experimental and
AD and applied physical activity is better than the control groups with the block randomisation method.18
control group. The created lists were numbered and then two groups
© 2023 Japanese Psychogeriatric Society. 857

N. Lok et al.
Enrollment Assessed for eligibility (n:147)
Extracted (n:62)
Not agree to participate in the
work (n:13)
Non-compliant (n:49)
*Mini mental test score not
suitable (31)
*Depression score not suitable
(18)
Randomized (n:85)
Allocation
Allocated to physical activity Allocated to control group (n:36)

program (n:36) Received allocated control group
Received allocated intervention (n:36)
(n:36)
Analysis
Analyzed (n:36) Analyzed (n:36)

Figure 1 Consolidated Standards
of Reporting Trials (CONSORT)
schema.
were created online on a computer using the random of exercise, 10 min of cool-down) 3 days a week and
sequence generator at www.random.org.19 40 min of walking 2 days a week.
Musical rhythmic exercise, warm-up (10 mins)
included light physical and mental activities performed
Physical activity program at the beginning of the exercise session to prepare the
The 12-week physical activity program was prepared muscles, joints, respiratory and circulatory system for
by researchers in accordance with the literature.20–22 active exercise. Rhythmic exercise with music
The program was designed in accordance with the (20 mins) is the stage where the exercise program is
ergonomics of the elderly with mild cognitive impair- implemented. In order to accelerate the work of the
ment. After the program was created, expert opinion respiratory, circulatory and movement systems, activi-
was taken from five faculty members who are experts ties that include 22 simple movements of moderate
in the field. The program was finalised in line with the intensity (3–6 metabolic equivalents) were selected
comments received.23 The 12-week physical activity and started with correct breathing first, followed by
program, which was prepared in accordance with the endurance, strengthening, stretching and balance
literature, was applied 5 days a week, in the form of exercises (four or with more repetitions per muscle
30 min of musical exercise (10 min warm-up, 20 min group). Cool-down (10 mins): the exercises were

finished after 10 min of low-intensity exercise. All exer- was developed by Alexopoulos et al.27 The Turkish
cise sessions were conducted in company with the validity and reliability study of the scale was con-
researchers and special attention was paid to the par- ducted by Amuk et al.28 and the Cronbach α value of
ticipation of the entire experimental group. No weekly the scale is 0.864.28 In our study, the Cronbach alpha
evaluation was made for the performances of the value of the depression scale in dementia was calcu-
elderly regarding exercises, but the effect of a lated as 0.76.
12-week physical activity program on cognitive func-
tions and depression was examined. Evaluation of data
Walking exercise (40 min): a suitable area was The data of the study were computerised using SPSS
chosen in a way to walk with normal steps, balanced 25 statistical program, and the number, percentage,
and easy, and it was done at the appropriate time, mean and standard deviation for descriptive statis-
except for the appropriate time for the elderly, when tics, and scale score averages were compared
the weather conditions are suitable, 2 h after meals according to the control and experimental groups.
and the environmental conditions are at suitable The homogeneity between the groups (experimental
temperature. and control groups) was evaluated with Chi-square
Researchers actively participated in the physical and t-test for independent groups analyses. Wilcoxon
activity program and had the elderly practice all the analysis was used to compare the mean scores
movements. During the walking exercise, each between the pre-test and post-test measurements,
elderly person was fitted with a pedometer and their since the data did not fit the normal distribution. In all
steps were checked using the pedometer. Since the analyses, a P-value of 0.05 was considered statisti-
exercise to be applied per week for the elderly could cally significant.
be planned for a total of at least 75 min and a maxi-
mum of 300 min,24 it was applied as 40 min 5 days Ethical dimension
a week. Ethics permission was obtained from the Selcuk Uni-
versity Faculty of Sport Sciences Non-Interventional
Data collection Clinical Researches Ethics Committee for this
The data were collected by the researcher by face- research (Decision no: 178) and. The study was
to-face interview method in two stages as pre-test preregistered with ClinicalTrials.gov (NCT00123456).
and post-test. Before giving the forms to be used in
the research, necessary explanations were made
orally, and then written consent was obtained from RESULTS
the patients, since the disability rate due to the dis- Participants included in the study were compared
ease was below 40% (mild stage AD). A quiet envi- according to age, gender, marital status and educa-
ronment with little stimulus was created during the tional status, and it was found that there was no sta-
application. tistically significant difference between the groups
(P > 0.05). The mean age of the experimental group
Data collection tools included in the study was 72.80 3.99; the mean
Forms prepared by the researchers included personal age of the control group was 73.88 4.85. Individ-
information form that questioned the socio- uals in the experimental and control groups had a
demographic characteristics of individuals, MMT and similar distribution in terms of descriptive characteris-
Cornell Dementia Depression Scale. The MMT is tics (Table 1).
used to assess the cognitive status of elderly people. When the experimental and control groups of the
The SMMT was developed by Folstein et al.,25 and participants included in the study were compared
Güngen et al.26 conducted its validity and reliability in according to time, when the cognitive level averages
the Turkish population. The scale’s cutoff value was of the patients in the experimental group and the pre-
set at 23/24, with a specificity of 0.95 and a sensitiv- test and post-test measurement point averages were
ity of 0.91 (r: 0.99, K value: 0.92).26 In our study, the compared, there was a significant difference between
Cronbach alpha coefficient of the MMT was calcu- the two measurements (P < 0.05, Table 2). It was
lated as 0.82. Cornell Dementia Depression Scale determined that there was no significant difference

N. Lok et al.
Table 1 Comparison of the distribution of individuals in the experimental and control groups according to their descriptive characteristics
Experimental group (n: 36) Control group (n: 36)
Features n % n % χ2 P
a
Gender
Female 18 50.0 19 52.8 0.561 (SD: 1) 0.815
Male 18 50.0 17 47.2
Marital statusa
Single 17 47.2 18 50.0 0.045 0.844
Married 19 52.8 18 50.0
Education statusa
Primary/middle school 19 52.8 17 47.2 2.272 (SD: 1) 0.453
High school and university 17 47.2 19 52.8
Experimental group (n: 36) Control group (n: 36)

Mean SD Mean SD t P
Age
72.80 3.99 73.88 4.85 1.278 0.63
Abbreviations: t, t-test for independent groups; SD, standard deviation; χ , Chi-square test. Yates corrected Chi-square test was performed since the observa-
2 a
tion had an observed number of less than 25.
between the mean scores of the pre-test and control groups were compared according to time, a
post-test measurements of the individuals in the con- significant difference was found between the two
trol group (P > 0.05, Table 2). measurements when the depression level of the
When the mean cognitive level of the patients in patients in the experimental group was compared
the experimental group was compared with the mean with the mean score of the pre-test and post-test
scores of the pre-test and post-test measurements, it measurements (P < 0.05). It was determined that
was found that there was a significant difference there was no significant difference between the mean
between the two measurements (P < 0.05, Table 2). scores of the pre-test and post-test measurements
In the control group, there was no significant differ- of the individuals in the control group (P > 0.05,
ence between the mean scores of the initial pre-test Table 3).
and post-test measurements (P > 0.05, Table 2). When the mean depression level of the patients in
When the depression level averages of individuals the experimental group was compared with the mean
with a diagnosis of AD in the experimental and score of the measurement after the experiment, it
Table 2 Comparison of cognitive levels of individuals with a diagnosis of Alzheimer’s disease in the experimental and control groups
Mini Mental Test Experimental group (n: 36) mean SD Control group (n: 36) mean SD Statistical analysis P
Beginning 23.36 0.48 23.50 0.50 t: 2.883 0.721
Post-experiment 25.50 0.73 23.27 0.45 t: 0.348 0.02*
Z* 1.092 4.073
P 0.02* 0.723
Abbreviations: SD, standard deviation; t, t-test for independent groups; Z, Wilcoxon test. * P < 0.05. Statistically significance is highlighted in bold.
Table 3 Comparison of depression levels of individuals with a diagnosis of Alzheimer’s disease in the experimental and control groups
Cornell depression in Experimental group (n: 36) Control group (n: 36) Statistical
dementia mean SD mean SD analysis P
Beginning 8.97 1.13 9.22 1.39 t:0.796 0.084
Post-experiment 6.00 0.75 10.01 1.29 t:4.507 0.001*
Z* 2.745 0.759
P 0.001* 0.481
Abbreviations: SD, standard deviation; t, t-test for independent groups; Z, Wilcoxon test. * P < 0.05. Statistically significance is highlighted in bold.

was found that there was a significant difference studies have reported that exercise activities reduce
between the two measurements (P < 0.05). In the the depressive symptoms of individuals with a diag-
control group, there was no significant difference nosis of AD.35 The findings of the studies were similar
between the mean scores of the pre-test and post- to our study. However, in the study by Hoffman
test measurements (P > 0.05, Table 3). et al.,31 it was reported that a physical exercise pro-
gram improved neuropsychiatric symptoms in the
intervention group, but there was no change in the
DISCUSSION level of depression. In some similar studies, it was
This study was conducted to investigate the effect of reported that physical exercise applied to individuals
a physical activity program applied to individuals with with a diagnosis of AD had no effect on depression
a diagnosis of AD on cognitive functions and depres- symptoms compared to the control group who did
sion level. In this study, the cognitive functions score not exercise.30,36,37 These different results can be
of the patients in the intervention group participating explained by the differences in the aetiology of
in the program (25.50 0.0.73) increased compared depression due to organic brain damage in individ-
to the control group, and their cognitive functions uals with AD and the low level of depression in the
improved. Venturelli et al.29 applied a 6 month walk- intervention groups in which exercise was applied. In
ing program to individuals with a diagnosis of AD and addition, there are studies that prevent and reduce
reported that the cognitive functions of the interven- the symptoms of depression in different ways by
tion group significantly increased. Vreugdenhil et al.30 increasing the hormonal changes in individuals or the
found that the cognitive functions of individuals with functional capacity of individuals.38,39 It shows that
a diagnosis of AD increased after the community- the physical activity program can be an effective
based exercise program. Hoffman et al.31 applied treatment for depressive symptoms in individuals
moderate and high-intensity physical exercise pro- with a diagnosis of AD. Therefore, it is important to
grams to individuals with a diagnosis of AD. They identify depression in individuals with a diagnosis of
reported there was a significant difference in the cog- AD and to implement physical activity interventions.
nitive functions of the experimental group partici-
pants. In other similar studies, it has been reported
Limitations
that physical exercise positively affects the cognitive
Since this study was conducted with elderly people
functions of individuals with a diagnosis of AD.9,32
with AD who came to a centre, the sample was lim-
The similarity of our study with other studies can be
ited. The results of the study cannot be generalised
explained by the fact that the exercise program was
because external validity cannot be achieved, but it
supervised, the experimental group was dependent
can contribute to generalisation.
on the exercise intervention, and the group had
social interaction. In line with the findings obtained
from the other studies and the findings obtained from
this study, it is revealed that the practices that sup- CONCLUSION
port the physical activity of individuals with a diagno- Our findings suggest that a regular physical activity
sis of AD positively affect the cognitive process. program should be considered for inclusion as rou-
In this study, the depression level of the patients tine care for the improvement of cognitive functions
in the intervention group participating in the program and depressive symptoms in elderly people with
decreased compared to the control group AD. Individuals with a diagnosis of AD who undertook
(6.00 0.75), and the patients’ depression symptoms the 12-week physical activity program had their cog-
improved. Stella et al.33 reported that individuals with nitive functions and depression levels improved.
a diagnosis of AD and their caregivers who partici- Older people with individual worker nurses and other
pated in the physical exercise program improved senior professionals in chronic diseases may help
their depression levels after the intervention. protect AD patients and provide a better quality of life
Nascimento et al.34 found that depression symptoms and meet their requirements and it is recommended
regressed in the exercise program they applied to that physical activity programs be routine in their
individuals with a diagnosis of AD. Other similar schedule.

N. Lok et al.
ACKNOWLEDGMENT 9 Sobol NA, Dall CH, Høgh P et al. Change in fitness and the
relation to change in cognition and neuropsychiatric symptoms
We thank Selcuk University Scientific Research
after aerobic exercise in patients with mild Alzheimer’s disease.
Projects Coordinatorship for financial support for this J Alzheimers Dis 2018; 65: 137–145. https://doi.org/10.3233/
study [Project number 23401035]. JAD-180253.
10 Camara-Calmaestra R, Martínez-Amat A, Aibar-Almaza n A,
Hita-Contreras F, de Miguel Hernando N, Achalandabaso-
Ochoa A. Effectiveness of physical exercise on alzheimer’s
FUNDING INFORMATION disease. A systematic review. J Prev Alzheimers Dis 2022; 9:
601–616. https://doi.org/10.14283/jpad.2022.57.
This study was supported by Selcuk University Sci-
11 Liu W, Zhang J, Wang Y, Li J, Chang J, Jia Q. Effect of physical
entific Research Projects Coordinatorship [Project exercise on cognitive function of Alzheimer’s disease patients:
number 23401035]. The funding source had no role a systematic review and meta-analysis of randomized con-
in the design, practise or analysis of this study. trolled trial. Front Psych 2022; 13: 927128. https://doi.org/10.
3389/fpsyt.2022.927128.
12 Lök S, Lök N. Kronik psikiyatri hastalarına uygulanan fiziksel
egsersiz programlarının etkinliği: sistematik derleme.
Psikiyatride Güncel Yaklaşımlar. 2016;8:354‐366. (in Turkish).
DISCLOSURE 13 Demurtas J, Schoene D, Torbahn G et al. Physical activity and
The authors declare they have no conflicts of interest exercise in mild cognitive empire and dementia: an umbrella
in the research. review of intervention and observational studies. J Am Med Dir
Assoc 2020; 21: 1415–1422.e6. https://doi.org/10.1016/j.
jamda.2020.08.0
DATA AVAILABILITY STATEMENT 14 Dauwan M, Begemann MJH, Slot MIE, Lee EHM,
The data that support the findings of this study are Scheltens P, Sommer IEC. Physical exercise improves quality
of life, depressive symptoms, and cognition across chronicle
available from the corresponding author upon rea- brain disorders: a transdiagnostic systematic review and
sonable request. meta- analysis of randomized controlled trials. J Neurol
2021; 268: 1222–1246. https://doi.org/10.1007/s00415-019-
09493-9.
15 Song D, Yu WSF. Effects of a moderate-intensity aerobic
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doi:10.1111/psyg.

13010 PSYCHOGERIATRICS 2023; 23: 856–863

Effect of physical activity program applied to patients

Department of 1Psychiatric Nursing and 2Public Abstract

Pharmacological interventions in AD have only a

856 © 2023 Japanese Psychogeriatric Society.

In a systematic review study evaluating the METHODS

Research hypotheses Randomisation

© 2023 Japanese Psychogeriatric Society. 857

Enrollment Assessed for eligibility (n:147)

Allocated to physical activity Allocated to control group (n:36)

Analyzed (n:36) Analyzed (n:36)

858 © 2023 Japanese Psychogeriatric Society.

© 2023 Japanese Psychogeriatric Society. 859

Experimental group (n: 36) Control group (n: 36)

tion had an observed number of less than 25.

860 © 2023 Japanese Psychogeriatric Society.

© 2023 Japanese Psychogeriatric Society. 861

862 © 2023 Japanese Psychogeriatric Society.

© 2023 Japanese Psychogeriatric Society. 863

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