Margaret lives in a nursing facility. She has dementia and believes that the doll in her room is a baby.

Every day she dresses the baby, feeds it, fails to notice that the baby does not swallow the food pooling on the floor, and gets angry if caregivers fail to acknowledge the baby’s existence.

It’s a delicate balance. Nobody knows what side to come down on - truth or profound despair?

Every practitioner who has ever worked with a patient suffering from neurocognitive decline has felt the urgent sense of uselessness. For a season, even physiotherapists gave up the ghost on the cost-effectiveness of skilled therapy (Sifferlin 2016) when working with patients with dementia. ‘What good am I doing?’ we would whisper. ‘She can’t remember a thing I just showed her.’

It’s true. It is challenging to work with patients with cognitive decline. But there isn’t a therapist on the planet who wouldn’t think it worthwhile if research showed such exercises made an actual, measurable, significant difference.

Well, guess what. They do (Tivadar 2017).

Exercise and Cognition

Regular aerobic training can improve aspects of cognitive function; in fact, adding exercise to a weekly regime both reduces the systems of dementia and slows its onset.

The raw truth is that cognitive abilities and physical exercise interact. Patients with exercise added to their rehabilitation program have been shown to have significant reductions in the behavioural and psychological symptoms of dementia (Fleiner et al. 2017).

In fact, by increasing physical activity a mere 10%, individuals are able to significantly reduce the risk of dementia and Alzheimer’s Disease (Tivadar 2017).

Aerobic training would seem to be a natural choice of exercise, but is it the right choice for patients with cognitive restrictions? Well, it depends.

Aerobic exercise, performed at a low intensity, has a beneficial effect on visual-spatial perception and attention. In contrast, a higher intensity physical activity (classified as moderate) seems to work its magic on working memory and attention and verbal memory and attention.

Just like adding any other new intervention, take care to make the transition period as calm as possible. Each patient is different, so it’s important to know their triggers and do your best to avoid them in their exercise routine (Yu et al. 2017).

Truly, professionals are in a bit of a quandary when prescribing physical activity to people with cognitive impairments (Tivadar 2017). Many experts believe higher intensities are necessary for positive results, while others opine that the higher the intensity, the less the patient can attend to the task at hand, resulting in problems with reduced reaction times, problems with selective attention and a reduction in flexibility.

It is no longer enough to decide what kind of exercise training should be performed. It is now necessary for clinicians to fully comprehend the power of training provided in an ‘enriched’ environment. Brains are wired to be mouldable. When neural pathways are blocked or damaged, the brain can create new pathways to get around these restrictions (Grosse 2013). Enriched environments take advantage of this phenomenon to combine cognitive and physical activities to create these new pathways.

So, what does an enriched environment for physical exercise for the patient with cognitive decline look like?

Let’s Go Salsa Dancing

Ever considered breaking out your dancing shoes and swimming suit for rehab?

Researchers have found that adding an extra layer to physical exercises such as a pool or music can work wonders for cognitive function. In fact, patients who exercised with music were found to have more cognitive improvement than those that didn’t (Satoh et al. 2017).

It is also possible to layer physical exercise with the pool environment to deepen these neural connections. Aquatic exercise is in the news for its powerful dementia-reducing powers, improving the psychological wellbeing of patients (Henwood et al. 2017).

With these examples in mind, what does it look like to apply an enriched environment to your interventions with your patients?

Think About It

While the actual exercise chosen is important, adding a cognitive layer is crucial. It is possible to use tools already at your disposal in an exercise intervention to deepen those neural pathways you are helping to build. Here are some of the best tips pulled from Brain Gym (Grosse 2013):

Require Problem-Solving. Stop giving single-step commands. Use directed questions to solve problems. Ask the patient to walk you through what comes next.
Find the Failure Point. Figure out what is challenging about the intervention and design a program around that point. Why spend time on what isn’t hard?
Require Buy-In. Always explain why you are doing what you’re doing and find out which activities create excitement. The patient who is motivated to participate will always gain more.
Add a Cognitive Overlay. Keep minds and bodies working by requiring dual-task processing. Add a mental task to a physical one (e.g. count backwards by 3’s from 30).
Make it Musical. Get bodies moving to the beat of the music! Connecting mind and body with the rhythm (especially familiar songs) will deepen that cognitive connection.
Don’t Simplify. Keep it complex by encouraging patients to use their whole brain. Cross the midline: Can your patient pat his head and rub his stomach? Can he look straight ahead while raising his arms to the side?
Mix It Up. Don’t repeat ad nauseam. Change it up by mixing tasks with different difficulty levels to keep the routine fresh and unpredictable.
Feedback, Feedback, Feedback! Provide tactile and verbal feedback. Feedback is a great way to make memories stick.
Design Part-to-Whole. Divide tasks up by parts; it’s a great way to move from easy to difficult while building up skill. Make sure to divide tasks into natural parts that are easy to discern and make sense to both provider and patient.

Conclusion

For those living with dementia, fundamental daily tasks become overwhelming. These patients struggle with things which were once taken for granted. Memory, attention to tasks, planning and decision-making skills have deteriorated over time, stealing quality of life from patients in small dribs and drabs.

However, you are not powerless. Add a cognitive element to your physical treatment and enjoy the enhanced benefits of your efforts.

References

Firth, J, Carney, R, Pownall, M, French, P, Elliott, R, Cotter, J, & Yung, A R 2017, ‘Challenges in Implementing an Exercise Intervention Within Residential Psychiatric Care: A Mixed Methods Study’, Mental Health and Physical Activity, vol. 12, pp.141-146, viewed 18 September 2020, https://www.sciencedirect.com/science/article/pii/S1755296617300108
Fleiner, T, Leucht, S, Foerstl, H, Zijlstra, W & Haussermann, P 2017, ‘Effects of Short-Term Exercise Interventions on Behavioral and Psychological Symptoms in Patients with Dementia: A Systematic Review’, Journal of Alzheimer’s Disease, vol. 55, no. 4, pp. 1-12, viewed 18 September 2020, https://pubmed.ncbi.nlm.nih.gov/27911304/
Grosse, SJ 2013, ‘Brain Gym in the Pool’, International Journal of Aquatic Research & Education, vol. 7, no. 1, pp. 72-80, viewed 18 September 2020, https://scholarworks.bgsu.edu/ijare/vol7/iss1/7/
Henwood, T, Neville, C, Baguley, C & Beattie, E 2017, ‘Aquatic Exercise for Residential Aged Care Adults With Dementia: Benefits and Barriers to Participation’, International Psychogeriatrics, pp. 1-11, viewed 18 September 2020, https://www.cambridge.org/core/journals/international-psychogeriatrics/article/aquatic-exercise-for-residential-aged-care-adults-with-dementia-benefits-and-barriers-to-participation
Satoh, M, Ogawa, JI, Tokita, T, Nakaguchi, N, Nakao, K, Kida, H & Tomimoto, H 2017, ‘Physical Exercise with Music Maintains Activities of Daily Living in Patients with Dementia: Mihama-Kiho Project Part 21’, Journal of Alzheimer’s Disease, pp. 1-11, viewed 23 June 2017, https://pubmed.ncbi.nlm.nih.gov/28222531/
Sherlock, LA, Hornsby Jr, WG & Rye, J 2013, ‘The Physiological Effects of Aquatic Exercise on Cognitive Function in the Aging Population’, International Journal of Aquatic Research & Education, vol. 7, no. 3, viewed 18 September 2020, https://scholarworks.bgsu.edu/ijare/vol7/iss3/9/
Sifferlin, A 2016, ‘Exercise Keeps the Brain Young: Study’, Time, 30 December, viewed 23 June 2017, https://time.com/4619686/exercise-cognitive-decline/?xid=time_socialflow_twitter
Tivadar, BK 2017, ‘Physical Activity Improves Cognition: Possible Explanations’, Biogerontology, pp. 1-7, viewed 18 September 2020, https://link.springer.com/article/10.1007/s10522-017-9708-6?no-access=true
Yu, F, Greimel, S, Kelly, K & Wyman, JF 2017, ‘Strategies to Engage Older Adults With Behavioral and Psychological Symptoms of Dementia in Exercise: A Multiple Case Study’, Applied Nursing Research, vol. 36, pp. 77-80, https://www.sciencedirect.com/science/article/pii/S0897189716303925

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