FEATURE ARTICLE

Benefits of Physical Exercise for Older

Adults With Alzheimer’s Disease
Carlos Ayán Pérez, PhD
J. M. Cancela Carral, PhD

The physical and mental benefits of exercise evidence on the benefits of exercise on the health
are widely known but seldom available to per- and functioning of older adults with cognitive dis-
sons suffering from Alzheimer’s disease (AD). orders, the available literature lacks clinical evi-
This article presents information on the po- dence that supports recommendations for
tential benefits of physical exercise for people exercise guidelines in people with AD.5 This arti-
with AD, discussing some of the metabolic cle describes the main symptoms of AD and the
and neuropathological changes regarded as possible benefits of exercise for this disease. It
underlying causes of AD, as well as some of also reviews the major studies that have exam-
the psychological and organic abnormalities ined the influence of exercise in patients with
that can be modified through exercise. The AD and provides basic exercise guidelines for
extent to which physical exercise programs older adults with dementia.
can play a role in the treatment of AD is ad-
dressed in the second part of the article, de-
scribing the most relevant clinical studies in Potential Benefits of Physical
this field. Finally, the article provides informa- Exercise in Alzheimer’s Disease
tion about how to prescribe physical exercise
for AD patients, mainly by giving examples of Benefits of exercise in AD patients can be ex-
structured physical programs designed for plained through 3 pathways. First, some meta-
older adults with dementia. (Geriatr Nurs bolic and neuropathological changes, regarded
2008;29:384-391) as underlying causes of AD, can be modified in
some way through exercising. Second, some psy-
chological and organic abnormalities that accom-
lzheimer’s disease (AD), the most com-

A mon cause of dementia, is a progressive

and irreversible neurodegenerative dis-
ease characterized by cognitive deficits such as
pany the course of the disease can be
ameliorated. Third, AD patients may take advan-
tage of the same potential benefits of physical ex-
ercise that healthy older people experience.
amnesia, apraxia, agnosia, aphasia, and execu-
tive dysfunction. It is among the leading causes
of death among the elderly.1 Although it may
Metabolic and Neuropathological Effects of
not be possible to prevent or alter the course of
Exercise in AD
the underlying disease, benefits of nonpharmaco-
logical approaches in the management of people ß-amyloid (Aß) is an abnormal protein that is
with AD have been highlighted, especially strate- strongly related to the formation of neuritic
gies aimed at slowing cognitive and physical de- plagues and neurofibrillary tangles that interfere
cline, as well as maintaining or ameliorating with the transmission of information to higher
patients’ quality of life.2 Physical exercise is levels of the brain.6 In this regard, Adlard and col-
regarded as a useful tool in this regard; cross- leagues7 found that 5 months of voluntary exer-
sectional and longitudinal studies have demon- cise resulted in a decrease in extracellular Aß
strated that exercise has beneficial effects, such plaques in the frontal cortex, the cortex at the
as decreasing depression, increasing overall hippocampus level, and the hippocampus in
health, and improving cognitive performance, in transgenic mice genetically engineered to exhibit
older adults.3 Moreover, it has been postulated AD neuropathological changes. Although the po-
that exercise may play a role in reducing the tential mechanism underlying the exercise effect
risk of cognitive decline.4 Despite the growing remains unclear, it is likely due to anatomical,

384 Geriatric Nursing, Volume 29, Number 6

neurochemical, and electrophysiological changes Potential Benefits of Exercise on
related to neuronal plasticity. Complications Related to the Course of AD
Reduced regional cerebral blood flow (CBF)
Loss of body weight, which is common among
has been regarded as a required cofactor in the
AD patients,21 is associated with reduced muscle.
cause of AD. It has been confirmed that aerobic
This contributes to decreased muscular strength
exercises increases CBF in frontal, parietal, and
and increased frequency of falls,22 as well as to
temporal cortices of older adults.8 In addition,
loss of functional independence.21 In this regard,
growth of capillaries and enhanced cerebral per-
multiple studies have demonstrated improve-
fusion has been observed in the primary cortex
ments in falls and balance related to exercise pro-
motor of rats as a result of prolonged exercise.9
grams.23,24 Moreover, there is evidence that
Similarly, low levels of cerebral perfusion have
strength training can offset loss of skeletal mus-
been observed in the frontal and occipital cortex
cle mass, as well as improve cognitive decline.25
in AD, which provides evidence for cerebromi-
The latter effect can also be obtained through
crovascular pathology underlying this disease.10
cardiovascular training.26Therefore, physical
Hypoperfusion below a critical level leads to dys-
exercise may represent a simple and effective
functional upregulation of nitric oxide (NO)
intervention.
levels, which could result in a decrease in tis-
Another benefit associated with exercise for
sue-type plasminogen activator (t-PA) activity.
individuals with AD is the improved mood. De-
This reduction is associated with an increase in
pression is common in AD, affecting between
Aß.11 However, activity of t-PA enhances the pro-
5%–23%, of the patients.27 Previous reports indi-
duction of plasmin, which may degrade Aß. Thus,
cate that people with AD who exercised were
an upregulation of NO could attenuate this dys-
much less likely to be depressed.28 Indeed, aer-
function in AD, an effect that could be achieved
obic activities have been found to reduce physi-
through exercise because physical activity leads
ological response to stress and improve one’s
to enhanced NO release and increases cerebral
sense of well-being through the release of
perfusion12 as well as t-PA activity.13
endorphins.29
Evidence suggests decreased cerebral meta-
Finally, several studies of exercise interven-
bolic rate for glucose14 and a decrease of acetyl-
tions with nursing home residents with dementia
choline in AD patients.15 Because carbohydrate
resulted in reductions of unwanted behaviors
metabolism is important in synthesizing acetyl-
typically related to AD, such as wandering,
choline,16 improving carbohydrate oxidation
pulling at clothes, making of repetitive noises,
could be an appropriate method for increasing
swearing, and aggressive behavior, as well as
acetylcholine brain stores. In this regard, aerobic
improvements in communication and social
exercise (which has been seen to increase signif-
participation.30
icantly the release of acetylcholine in conscious
rats17) improves circulating blood glucose levels
and contributes to the regulation of glucose
Additional Effects of Physical Exercise on
homeostasis.18 Furthermore, exercise stimulates
Dementia
gene expressions of nerve growth factors that
are important for neurogenesis, production, Several potential benefits of exercise shown
and function of neurotransmitters and for for healthy people could play a role in AD treat-
synaptogenesis.2 ment. These include enhanced appetite,31 im-
Dopamine (DA) induces behavioral and physi- proved sleep,32 increased bone density,33 and
ologic changes. Abnormally reduced DAergic improved balance.23 In this regard, it must be
function has been reported in AD, and DA levels noted that secondary risk factors associated
are significantly reduced in the caudate nucleus with AD onset, such as vascular disease,34 inac-
and putamen of AD patients.19 Several studies in- tivity, or hypertension,17 can be ameliorated
dicate that calcium ions (Ca) affect brain func- through aerobic activities.
tion. Exercise increases serum calcium levels, Finally, several studies conducted with trans-
and serum calcium is transported to the brain genic mice have shown that aerobic exercise in-
that simulates DA synthesis. Subsequently, the in- creases the thickness of the motor cortex and
creased DA levels induce behavioral and physio- the expression of growth factor in the brain,35 in-
logic changes.20 ducing angiogenesis in both the cerebellar and

Geriatric Nursing, Volume 29, Number 6 385

386

Table 1.
Physical interventions programs with early to early-moderate AD patients.
Study N Intervention Frequency Volumen/Intensity Interventionist Outcomes

Namazi 11 Mobility (joint Daily sessions for 20 min/8 rpt per Specialized fitness Reduced agitated
et al.38 movements and 7 weeks exercise. instructor behaviors
stretching); Light 20 min/8 rpt per
exercise movement exercise
tasks (walk, sit and
stand, etc.)
Palleschi 15 Aerobic: Cycling Thrice-weekly- 20 min at 70% of Not described Improved attention,
et al.39 on arms only sessions, during maximal heart rate verbal and cognitive
stationary bike 3 months. capabilitites
Arkin30 11 Flexibility (stretching); Twice-weekly- 2 rpt of 15 for 10 min; University Significant
Aerobic (walking on sessions, plus 5 min with weekly students improvements in
treadmill, cycling on a weekly increases of 1 min until aerobic capacity,
stationary bike); volunteer-work reach 20 min (treadmill muscular strength, and
Strength out, during a year set at one mile/hour). 2 mood
(strengthening large sets of
muscle groups using 10-12 rpt, resting
MedX weight 30 min (weights
machines) increased by 2-5
pounds)
Rolland 23 Aerobic: Walking A mean of 7 Main daily duration of Caregivers Improved nutritional
et al.40 and cycling (5-12) weeks exercise was 35 min staturs and cognitive
(10-80 min). Intensity function; Less frequent
Geriatric Nursing, Volume 29, Number 6

individually adapted behavioural problems;

Unchanged patient
autonomy
Teri et al.46 30 Balance (transfer, Three non 10-15 min as warm Caregiver Better mood and
base-of-support and consecutive up or cool down instructed by behavior while
walking exercises); sessions a week, period.Free weight, a professional exercising
Flexibility (stretching); for 3 months 1 set of 12 rpt; Load trainer
Strength (lead shot incremented by 0.5- 5
weights); Endurance pounds; 30 min at
(walking) normal pace, speed
gradually increased
Geriatric Nursing, Volume 29, Number 6

Teri et al.47 76 Same as above Same as above Same as above Same as above Increased levels of
physical activity,
physical function and
health; Decreased
levels of depression
Rolland 56 Aerobic (walking); Twice-weekly- Moderate walking Occupational Slower progressive
et al.48 Strength (callisthenic sessions held in up to 30 min. therapist deterioration in ADLs
movements); groups of 2-7 Individualized
Flexibility(stretching); people for intensity; Total
Balance (small step 12 weeks volume of each
trials) session: 60 min
Arkin49 24 Balance; Flexibility; Two-weekly-sessions, 20-30 min of moderate University Significant fitness and
Aerobic (treadmill plus one voluntary walking/cycling, students/ mood gains; no effect
and stationary bike); session of brisk combined with Family in behavioural
Strength (weight walking, for 2-8 cognitive stimulation; member disturbances,
resistance machines) semesters 20-30 min of upper- depression or
lower body strength on nutritional scores
5 machines
Williams 90* Aerobic group 5 individual sessions Walking at normal Graduate Improvements in affect
and (walking), vs. a week for 16 weeks pace up to 30 min; 30 nursing/ and mood (especially
Tappen50 Comprehensive min; (walking up to Physical in the comprehensive
exercise group: 20 min); therapy exercise group)
Strength (callisthenic 3-9 rpt per exercise students
movements); Balance
(side stepping);
Flexibility; Aerobic
(walking)
* 44% of the sample rated as severely impaired patients.
rpt5repetitions;
ADls5activities of daily living.
387
motor cortices36 and activating endogenous ho- performance.41,42 However, similar interventions
meostatic mechanisms that counteract the ongo- did not confirm this beneficial effect,43,44 and the
ing neurodegenerative process.37 However, issue remains controversial.
although these results are remarkable, the appli- Because AD patients are sometimes cared for
cability of studies using animal models human by family members, teaching caregivers to facili-
conditions is unknown, and further research is tate and supervise exercise activity has been re-
needed. garded as a useful solution.45 In this regard,
a community-based program designed to in-
Clinically Relevant Studies crease balance, flexibility, strength, and endur-
ance in AD patients guided by their caregivers
Despite the growing evidence showing that has shown important and beneficial effects.46
physical exercise can be an appropriate nonphar- Moreover, follow-up research that included a con-
macological strategy in the treatment of AD pa- trol group and tested a larger sample showed that
tients, few studies have focused on the benefits AD patients who trained with their caregivers
of exercise in AD, and some of those available were more active, improved their physical func-
have serious methodological flaws. For instance, tion and affective status, and had fewer depres-
several studies have confirmed the efficacy of sive symptoms.47
aerobic and weight-training sessions in reducing It is important to note, however, that care-
agitated behavior,38 improving cognitive func- givers are sometimes elderly and unlikely to
tion, and reducing the risk of falls,39,40 as well seek out structured exercise programs. There-
as improving mood and fitness level.30 However, fore, it is necessary to include specialized person-
the samples sizes were small, interventions in nel to guide the training sessions or to take part in
some cases were short, and some studies did long-term exercise programs carried out in nurs-
not include a control group (Table 1). ing homes. Clinically relevant studies have
In well-controlled studies (Table 2), walking, shown that following this trend, more complex
whether alone or combined with cognitive exercise training programs, resulting in fitness
stimulation, was shown to be an appropriate and mood improvements, can be carried out
intervention for improving communication with AD patients.48-50

Table 2.
Effects of walking alone or combined with conversation, versus only
conversation in AD patients
Study N (n) Intervention Outcomes Conclusion
41
Friedman et al. 30 Walking for 30 Improvement in A conversation only
minutes, three times communication group, did not get
a week, for 10 weeks skills a higher
improvement
Tappen et al.42 71 (261/212) Walking (assisted1 or Improved adherence Walking while talking,
combined with to exercise sessions is a better
conversation2) for 30 and less functional intervention than
minutes, three times decline in combined assisted walking
a week, for 16 weeks group alone
Sobel43 50 One 20-minute session No effect on language Playing Bingo (20’)
of walking or arm ability and verbal induced a significant
and leg extension recognition improvement than
did physical activiy.
Cott et all.44 74 (30) Talking while walking No significant Walking did no better
in pairs for 30 differences in than talking 5 days
minutes three times communication a week, for 16 weeks
a week for 16 weeks skills

388 Geriatric Nursing, Volume 29, Number 6

Designing Exercise Programs for aerobic exercise, such as walking (particularly
People with AD when combined with conversation) at least 30 min-
utes during most days of the week or cycling 20
From the findings of the clinical studies re- minutes at moderate intensity 3 days per week
viewed, 2 basic guidelines for carrying out exercise seem to be efficient ways to improve attentional,
interventions with AD patients in the early to mod- verbal, and cognitive capabilitites.39,41,42 Second,
erate stages of the disease can be addressed. First, muscular strength by means of lifting low free or

Table 3.
Structure of a typical exercise session designed for demented older adults
Activity Objective Example

General movements Warm-up and kinaesthetic Sitting: hand

of the body work touching nose, knee,
alongside with the rhythm shoulder, etc.
of music (3 min)
Mobility of the upper Range of Motion Sitting: flexion,
joints of the body (3 min) extension and rotation
of joints. Squeeze
or rolling a ball
Resistance exercises (5 min) Muscular strengthening Standing or sitting:
pushing, pulling
and lifting, with
or without implements
(balls, wooden sticks, etc.)
or against
the partner
Fine motricity (5 min) Coordination Standing or sitting:
mobility of the fingers,
right extremity touching
left one and vice
versa; making
balls of paper
Mobility of the lower Range of Motion Standing: rotation
extremities (5 min) of ankles, bending
knees, etc.
Lower extremities Balance and Strength Sitting: pushing
performance (15 min) or lifting lower
extremities; 5 rpt, holding
a ball between the legs;
standing: lifting a leg,
shifting centre of gravity
between legs; walking in
different directions, with
or without obstacles
(steps, benches, etc.)
Playing games (5 min) Socialization Passing rubber
balls, clipping
hands alongside
a rhythm, etc.
Relaxation Cooling down Breathing and exhaling
alongside with stretch
movements
Data from Netz et al.51

Geriatric Nursing, Volume 29, Number 6 389

lead-shot weights or strengthening large muscle early stages of the disease, can likely take advan-
groups using weight machines on 3 nonconsecu- tage of physical training. Clinical guideline rec-
tive days per week can be effective in improving fit- ommendations are scarce, however, because
ness and mood.30 However, comprehensive few studies have been carried out. Thus, more
exercise sessions, rather than walking or strength- research is needed.
ening alone, must be emphasized.50
It is clear that physical exercise guidelines for
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0197-4572/08/$ - see front matter
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Alzheimer’s disease: the TEMP-AD Protocol. J Aging Ó 2008 Mosby, Inc. All rights reserved.
Phys Activity 1994;21:80-92. doi: 10.1016/j.gerinurse.2007.12.002

Geriatric Nursing, Volume 29, Number 6 391