Effects of a high intensity functional exercise program in nursing home residents with dementia

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Effects of a high intensity functional exercise program in nursing home residents with dementia

Elisabeth Wiken Telenius

Faculty of Medicine University of Oslo

Oslo and Akershus University College of Applied Sciences February 2016

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© Elisabeth Wiken Telenius, 2016

Series of dissertations submitted to the Faculty of Medicine, University of Oslo

ISBN 978-82-8333-229-2

Cover: Hanne Baadsgaard Utigard

Printed in Norway: 07 Media AS – www.07.no

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TAKK!

Dette arbeidet ble utført fra 2012 til 2016 og har vært et samarbeid mellom Høgskolen i Oslo og Akershus og Nasjonal kompetansesenter for Aldring og Helse. Studien ble finansiert av ExtraStiftelsen Helse og Rehabilitering. Prosjektet ville aldri blitt fullført uten hjelp og støtte fra mange personer rundt meg. Først og fremst en stor takk til Professor Astrid Bergland og Professor Knut Engedal som har ledet meg gjennom denne prosessen. Jeg takker hovedveileder Astrid for all entusiastme, støtte, konstruktive tilbakemeldinger, hyggelige veiledningsstunder, stor takhøyde og lav dørterskel disse årene! Medveilder Knut som tok initiativet til prosjektet; takk for uvurderlige, og raske, tilbakemeldinger og for at du deler kunnskapen din med dem rundt deg. Jeg kunne ikke bedt om bedre veiledere og støttespillere!

Takk til alle involverte på sykehjemmene som deltok i studien: Manglerudhjemmet, Lilleborg sykehjem, Sagenehjemmet, Grünerløkka sykehjem, Rødtvet sykehjem, Stovnerskogen sykehjem, Grefsenhjemmet, Bekkelagshjemmet, Langerud sykehjem, Ammerudhjemmet, Furuset sykehjem, Hovseterhjemmet, Sofienbergsenteret, Frogner sykehjem, Bråset bo- og omsorgssenter, Greverud sykehjem, Lillestrøm Bo- og behandlingssenter og Skedsmotun bo- og behandlingssenter! Takk til alle deltagere og ansatte på sykehjemmene; alle som har instuert trening, ledet kontrollgrupper, fylt ut skjemaer, organisert lokaler, motivert deltagere, og forflyttet beboerne. Uten dere hadde det ikke vært mulig å gjennomføre et slikt prosjekt. En stor takk går til engasjerte fysioterapeuter som var villige til å delta, og som i mange sykehjem var primus motor for prosjektet! En spesiell takk til Kristine på Grefsenhjemmet for at hun stilte opp på

”photo sessions” og holdt foredrag på konferansen. Tusen takk til Ingrid og Eirik – mine flinke, trofaste, fleksible og entusiastiske medarbeidere!

Tusen takk til Utviklingssenter for sykehjemmene ved Abildsø Sykehjem som finansierte eksterne fysioterapeuter og treningsutstyr, og også for praktiske råd ved oppstarten av prosjektet.

Takk til Milada Småstuen og Are Hugo Pripp for statistisk rådgivning underveis.

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Takk til alle kolleger på HIOA; alle dere doktorer som disputerte før meg og viste vei, og dere som nettopp har kommet i gang med spennende prosjekter som jeg gleder meg til å følge.

Tusen takk til venner og familie som har oppmuntret meg, og gitt meg verdifulle pauser og hyggelige stunder!

Sist, men ikke minst, takk til Carl Aksel som har vært min personlige IT-support gjennom det hele og den aller viktigste støttespilleren og motivatoren! Cecilie og Kristoffer – takk for gode pusterom i travle perioder og for påminnelse om hva som er viktig her i livet.

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ABBREVIATIONS

AD Alzheimer’s disease ADL Activities of daily living BBS Berg Balance Scale

CG Control group

CST 30-second chair stand test EG Exercise group

EXDEM EXercise for people with DEMentia (name of RCT-study) FTD Frontotemporal dementia

ICF International Classification of Function, Disability and Health

NH Nursing home

NPI Neuropsychiatric inventory NPS Neuropsychiatric symptoms QoL Quality of life

SD Standard deviation VaD Vascular dementia

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SUMMARY

Background: This thesis focuses on the physical function and mental health of nursing home residents with dementia. The world’s population is aging, and the number of people with dementia is increasing. Around 80% of nursing home residents suffer from dementia, which is among the leading causes of functional loss and disability in older people. Exercise improves physical function in healthy old people; however, evidence on the effect of exercise on nursing home residents with dementia is scarce and ambiguous.

Aims: The first aim of the thesis was to describe the quality of life (QoL) of nursing- home residents with mild or moderate dementia and their balance, mobility, muscle strength and daily life activity, as well as to examine the associations between QoL and the physical performace measures including ADL-function. The second aim was to assess the inter-rater reliability between pairs of observers independently rating the same subject with the Berg Balance Scale (BBS), the 30 seconds chair stand test (CST) and the 6 meters walking test. In addition we wanted to investigate the internal consistency of the BBS. The third aim was to investigate the immediate and long-term effect of a high intensity physical exercise program on as well as muscle strength, mobility, activities of daily living, quality of life, neuropsychiatric symptoms, including depression in nursing home residents

Methods: This thesis includes three studies with three different designs, which are reported in four papers. The first study is a cross-sectional observational study (n=170);

the second is an inter-rater reliability study (n=33); and the third is an assessor-blinded randomized controlled trial (RCT), the “EXDEM” trial, (N=163 and 170). The participants in all studies were from a population of 170 nursing home residents living in 18

different nursing homes in, and around, Oslo, Norway. The inclusion criteria were: being over 55 years old; being able to give consent; having mild or moderate dementia as measured by the Clinical Dementia Rating Scale (CDR 1 or 2); being able to stand up alone or with the help of one person; and being able to walk six metres with or without a walking aid. The exclusion criteria were: patients being medically unstable; being psychotic; or having severe communication problems. The RCT intervention consisted of intensive functional exercises performed in small groups twice a week for 12 weeks. The control conditions were leisure activities.

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Measurements: Assessments were carried out at baseline (Paper I), at intervention cessation at 12 weeks (Paper II and Paper III) and at 6 months follow-up (Paper IV). We applied the following physical performance tests in all studies: BBS, CST and 6-metre walking test. In study 1, we used Mini Mental State Examination (MMSE) and the clock drawing test to assess cognition, the Barthel Index (BI) to test ADL-function, Quality of life in late-stage dementia (QUALID) scale to test QoL. In study 3, we used

Neuropsychiatric Inventory (NPI) to assess neuropsychiatric symptoms, and the Cornell Scale for Depression in Dementia to assess depression symptoms in addition to all other measures.

Results: Study 1 demonstrated that a population of nursing home residents with mild and moderate dementia is a heterogeneous group concerning physical function and QoL.

The cross-sectional data revealed an association between better physical function and higher QoL. In study 2, we demonstrated that the intraclass correlation (ICC) for the BBS's sum score was very high (ICC=0.99), and the inter-rater minimal detectable change (MDC) was 2.7. The CST had an ICC of 1, while the 6m walking test ICC score was 0.97 with an MDC of 0.08. In study 3, the exercise group improved their score on the BBS significantly more than the control group during the intervention period. The group difference was still statistically significant at the 6-month follow-up. Immediately after intervention cessation, participants who had exercised more than 12 times scored significantly better on the CST than all other participants, but this effect was lost at follow-up. The level of apathy was reduced in the exercise after intervention, but this effect was lost at follow up. At the 6-month follow-up, the exercise group showed less signs of agitation than the control group.

Conclusions: The results indicate a statistically significant association between physical performance and QoL in nursing home residents with mild and moderate dementia, and the reliability study demonstrated a high inter-rater reliability of the BBS, CST and 6m walking. The results from the RCT indicate that physical exercise can be an efficient method to improve physical function and possibly mental health in nursing home residents with dementia. Further studies are warranted to clarify the effect of physical exercise on neuropsychiatric symptoms in nursing home residents with dementia.

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LIST OF PAPERS

Paper I: Telenius EW, Engedal K & Bergland A. Physical performance and quality of life of nursing-home residents with mild and moderate dementia. Int J Environ Res Public Health. 2013 Dec 2; 10(12): 6672-86. PMID: 24317384

Paper II: Telenius EW, Engedal K & Bergland A. Inter-rater reliability of the Berg Balance Scale, 30s chair stand test and 6m walking test, and construct validity of the Berg Balance Scale in nursing home residents with mild-to-moderate dementia. BMJ Open.

2015 Sep 7; 5(9): e008321. PMID: 26346874

Paper III: Telenius EW, Engedal K & Bergland A. The effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor-blinded randomized controlled trial. PLoS One. 2015 May 14;

10(5): e0126102. PMID: 25974049

Paper IV: Telenius EW, Engedal K & Bergland A. Long-term effects of a 12-week high- intensity functional exercise program on physical function and mental health in nursing home residents with dementia: a single-blinded randomized controlled trial. BMC Geriatr. 2015 Dec 3;15:158. PMID: 26630910

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1. INTRODUCTION

This thesis focuses on physical function and mental health of nursing home residents with dementia. Advances in medical care, healthier lifestyles and increased access to family planning cause the world’s population to age rapidly ^{1 2}. In Norway, the number of persons over the age of 80 is estimated to rise from 221,000 today to more than 900,000 in the year 2100 ³ and, consequently, health and social care services will come under pressure to provide care services for older people ⁴. One of the most important aims of elderly healthcare is to provide support and facilitate home-based care to make it possible for very old people to remain at home as long as possible ⁵. In many countries, when old people are no longer independent in activities of daily living and the assistance and help from professional home care services or family and friends is not sufficient, they get admitted to nursing homes; an around-the-clock provider of care ⁶. Today 15%

of people over the age of 80 stay in long-term wards in nursing homes, making nursing homes Norway’s biggest institutional care service system. There, dementia is the most common main diagnosis among the residents ^{7 8}. Necessary care will be provided for the dependent patients, however dependency itself is known to be negatively related to QoL

9. Nursing home life is associated with lack of participation in activities, passivity ¹⁰ and poor QoL ^11-13

Nursing home residents with dementia are one of the most functionally disabled groups living in nursing homes today, and their care needs are significant ^14-17. Limitations in physical functioning are important to consider because of their link to: (1) poor quality of life; (2) increased risk of disability, falls, fractures and depression; and (3) increased healthcare costs ¹⁸. In older individuals, including those residing in nursing homes, impaired strength, range of motion and balance have been associated with difficulty in performing activities of daily living (ADL) ^19-21. There is vast evidence that physical exercise programs can reduce impairments in strength, flexibility, balance and gait speed in community-dwelling older individuals and cognitively healthy nursing home residents ^{22 23}. However, earlier intervention studies have to a large degree failed to include participants with dementia. Before the start of this PhD project, two reviews ^{24 25} concluded that the evidence for the effectiveness of physical exercise on physical function and mental health among people with dementia was insufficient.

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To handle the rising number of older people with dementia who are dependent on help from the professional healthcare system, and to ensure good quality of care, we need more evidence-based knowledge about modifiable factors related to physical

functioning and mental health in this population. Even though substantial research has shown the benefits of exercise interventions among older people, more research is needed to document the effectiveness of different interventions that may increase the level of physical function and improve mental health among nursing home residents with dementia. This thesis includes four papers that describe the results from three studies. The first study focused on the associations between QoL and levels of physical function in nursing home residents with mild and moderate dementia (Paper I). In the second study, we targeted the same population and tested the inter-rater reliability of performance-based tests of functioning (Paper II); and in study 3, we investigated the effect of intensive exercise on physical function and mental health in the same population (Paper III and Paper IV).

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2. BACKGOUND

Instruction to the various topics of this chapter

To enable the comprehension and evaluation of the project, it is critical to understand the context of the studies (chapter 2.1). The participants in the project are nursing home (NH) residents with mild or moderate dementia. Thus, the topic of chapter 2.2 is dementia. Neuropsychiatric symptoms are common in the described population.

Research indicates an association between neuropsychiatric symptoms (NPS) and physical function ^26-28, and between NPS and QoL. The relationship between impaired cognition and reduced physical function has been repeatedly reported ^{29 30}. For these reasons I have reviewed NPS, cognition and QoL in the NH population of persons with dementia in chapter 2.3. Physical function is a central concept in this thesis, and in chapter 2.4.1 I will introduce WHO’s International Classification of Functioning, Disability and Health (ICF). It is a useful framework for understanding the complex process that can lead to functional decline and disability among older people ³¹. In chapters 2.4.2 and 2.4.3, I will address the topics of balance, mobility and muscle

strength. Furthermore, we know that NH residents with dementia have an increased risk of falling, which is closely related to both balance and muscle strength, and this topic is described in chapter 2.4.4. Functional decline and physical exercise interventions are described in chapter 2.5. The main focus of this thesis is to investigate the effect of a physical exercise intervention on the function of NH residents with dementia. We used a randomized controlled (RCT) design and, therefore, RCT as an experimental design for evaluating complex interventions is a central theoretical focus (chapter 2.6). The RCT design will be evaluated using the PRECIS-2 framework ^{32 33}. PRECIS-2 is a tool that focuses on trial design choices which determine the ability of a trial result to be applied or used in a “real life-situation”. Lastly, at the end of chapter 2, I will present the rationale of the thesis.

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2.1 The nursing home and its residents

The public care of old people in Norway consists of in-home services and services in assisted-living facilities and NHs. The public sector plays an important role in the Norwegian health and social care system. In the 1960s, the first public institutions for old people were established and, at that time, the NHs were the responsibility of the counties. From 1986, the responsibility was transferred to the municipalities, and the institutional management is now regulated by the Municipal Health Services ^{34 35}. This happened at the same time as NHs were described as vital elements in the institutional care of patients with dementia ³⁶. NHs are organized in regular units (RUs),

rehabilitation units, respite units and special care units (SCUs) for persons with dementia ³⁷. People staying in the rehabilitation and respite units stay for a couple of weeks and then move back home. These units are also called short-time stay units. RUs and SCUs are units for permanent stay, and are also called “long-term units”. Usually, people do not move back home from these two units; they die in the nursing home. In 2011, 24% of Norway’s NH beds were in SCUs ³⁸. Ideally, SCUs should be small home- like units for 6-8 residents, staffed by special dementia-trained nursing staff ⁵. The NH is a place of residence for people who require around the clock care and have significant difficulty in performing ADL. The most common main diagnoses in NHs are dementia, cerebrovascular accidents and chronic heart disease ^{7 8 39} and the average age for NH residents in long-term units in Norway is 84 years ⁴⁰. Women are, on average, five years older than the men, and make up more than 70% of the residents in long- term-units ⁴⁰. The duration of permanent stays in NHs varies substantially from individual to individual. To give an average value is not representative. However, more than 40% die during the first 6 months, and 30% stay for two years or more ⁴¹. In 1998, there were 43,166 beds in residential care units in Norway, including: NH beds, beds in homes of the elderly, and beds in other institutions for elderly and disabled persons. In 2011, with 38,000 more people over the age of 67 years than in 1998, the number of beds was reduced by more than 10% to 38,700 ⁴¹. The reduction can mainly be explained by the fact that homes for the elderly have been closed down all over the country as a result of the development of in-home care services. Consequently, there has been a shift forward of admission. Elderly people who are admitted to a permanent place in a NH today are older, sicker, more cognitively impaired and frailer in

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comparison to those who were admitted to nursing homes about 30 years ago 39 40 42 43. Frailty is a geriatric syndrome particularly common in people over 80 years old. In line with the WHO’s definition of health and the ICF, a bio-psychosocial definition of frailty was developed by Gobbens et al. (2010) ⁴⁴: “frailty is a dynamic state affecting an individual who experiences losses in one or more domains of human functioning (physical, physiological, social) that are caused by the influence of a range of variables and which increases the risk of adverse outcomes.” However, it has been demonstrated that the physical components of frailty (unintentional weight loss, low physical activity, exhaustion, slow walking speed and weakness) are most important for the prediction of adverse outcomes ^{45 46}.

2.2 Dementia

According to WHO, nearly 35.6 million people around the world live with dementia ⁴⁷. In Norway, it is estimated that 78,000 people have a dementia disorder ^{48 49}. With the population ageing and no widely effective preventive options and treatment, this number is expected to double by 2030, and more than triple by 2050 ⁵⁰. The largest increase will be seen in middle- and low-income countries in Asia and South-America ⁴⁷

51 52. According to WHO, dementia is “a syndrome – usually of a chronic or progressive nature – in which there is deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from normal ageing.” WHO has a broad definition of dementia, as well as a more specific one as presented in the ICD-10 criteria for research (see in Textbox 1).

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Textbox 1: Diagnostic research criteria for dementia according to the ICD-10

G1 ⁽¹⁾A decline in memory which is most evident in the learning of new information, although in more severe cases, the recall of previously learned information may be also affected.

(2) A decline in other cognitive abilities characterized by deterioration in judgement and thinking, such as planning and organizing, and in the general processing of information.

The degree of cognitive decline must be so severe that it affects the individual’s ability to carry out activities of daily living.

G2 Preserved awareness of the environment.

G3 A decline in emotional control or motivation, or a change in social behaviour, manifested as at least one of the following: (1) emotional lability; (2) irritability; (3) apathy; (4) coarsening of social behaviour.

G4 G4. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the manifest onset is shorter, the diagnosis can only be tentative.

Dementia can be caused by a variety of brain disorders that usually progressively lead to increasing brain damage, and the occurrence of a gradual deterioration of the

individual’s functional capacity and social relations. Clinical symptoms of dementia usually begin after the age of 65, but it may also present in people below this age.

Women are at greater risk than men ^{53 54}. The ICD-10 criteria describe three stages of dementia: mild, moderate and severe (see Textbox 2). The severity of dementia is determined by the cognitive domain with most severe impairment (e.g. mild decline in memory and moderate decline in cognitive abilities indicate a dementia of moderate severity) and dependency.

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Textbox 2: Criteria for severity of dementia according to ICD-10

2.2.1 Dementia disorders

Dementia disorders can be roughly divided into three main types. The most common type is dementia caused by degenerative brain diseases such as Alzheimer´s Disease, dementia with Lewy bodies, frontotemporal lobe dementia, Parkinson´s disease with dementia, and a variety of rare degenerative brain disorders. The second most common type is vascular dementia and the third type is dementia that is secondary to other conditions, such as alcoholism, brain tumours, encephalitis, head trauma or others.

Alzheimer’s disease, vascular dementia and Lewy body dementia are not easily

distinguished from each other on the basis of neuropsychological assessment alone, but can be differentiated more effectively by reference to history, presentation and results of medical examinations, and by the use of spinal fluid biomarkers, magnetic Resonance imaging (MRI), single Photon Emission tomography (SPECT) and Positron emission tomography (PET) ⁵⁵.

Alzheimer’s Disease

The most common cause of dementia is Alzheimer´s Disease (AD), which accounts for 60-70% of cases ^{56 57}. AD is characterized by an increase in amyloid plaques outside the neurons, and neurofibrillary tangles (tau protein damage) inside the neurons that begins in the parahippocampal areas of the medial temporal lobes of the brain. The disease is characterized by these two changes, which in turn lead to dysfunction and loss of neurons and synapses in the cerebral cortex and certain subcortical regions. At a macroscopic level, we can at first observe by MRI examination an atrophy of the medial

Mild degree of dementia: a degree of memory loss or decline in cognitive abilities is sufficient to interfere with everyday activities, though not so severe as to be incompatible with independent living.

Moderate degree of dementia: A degree of memory loss or decline in cognitive abilities, which represents a serious handicap to independent living. The decline makes the individual unable to function without the assistance of another in ADL.

Severe degree of dementia: A degree of memory loss or decline in cognitive abilities, which represents a serious handicap to independent living. The decline is characterized by an absence, or virtual absence, of intelligible ideation.

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temporal lobes of the brain and the whole cortex. The most common early symptom is episodic memory loss, and as the disease progresses, symptoms may include attention deficits, apathy and depression, language problems, mood swings, disorientation, not managing self-care, mobility problems and behavioural challenges ⁵¹. In the further progression of the disease, the patients often withdraw from family and society, and gradually bodily functions are lost, leading to death. The speed of progression varies, nevertheless, life expectancy following AD diagnosis is in most cases three to nine years, although some have a longer life after the diagnosis. Approximately 50% of people with AD exhibit a comorbid pathology that is related to other types of dementias, mostly vascular dementia or Lewy Body dementia, or both, and these are termed mixed dementia ^{51 58}.

Vascular dementia

Vascular dementia (VaD) is caused by either stroke or a severely decreased blood flow in the brain, and is thought to be the second most common dementing disorder after AD

59. Narrowing or blocking of small vessels deep inside the brain (small vessel disease), a single large stroke, or several mini-strokes can cause VaD. It is estimated that at least 20% of AD patients also have VaD ⁶⁰. In VaD, there is usually a history of stepwise progression. Risk factors for vascular disorders, such as hypertension and diabetes, are likely to be present. VaD is often difficult to differentiate from AD when there is no history of stroke, but a comprehensive examination, including imaging techniques such as MRI and PET, can be useful to separate the two disorders from each other ⁵⁵.

Other types of dementia

Lewy Body disease is caused by dysregulation of the synaptic protein α-synuclein known as Lewy bodies and it is an umbrella term for two related diagnosis: dementia by Lewy bodies (DLB) and Parkinson’s disease ⁶¹. DLB is characterized by cognitive impairment, fluctuating consciousness, visual hallucinations, sleep disturbances, and features of parkinsonism (slowness, rigidity, tremor and changes in gait) ⁶². Memory impairment may not be evident in the early stages ⁵¹.

Frontotemporal dementia (FTD) is a rare form of dementia, and refers to several disorders caused by progressive nerve cell loss in the brain’s frontal or temporal lobes.

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The most frequent initial symptoms of FTD are changes in behaviour and personality.

The subtle and insidious onset makes FTD a clinically complex diagnosis, and it normally takes longer to diagnose FTD than AD ⁶³.

2.2.2 Risk factors for dementia

In general, three main risk factors for dementia exist: aging of the individual, genetics and lifestyle factors.

Ageing: Increasing age is the most consistent risk factor for dementia worldwide, and is also the strongest risk factor ^{59 64}. In persons aged between 65 and 69, the prevalence of dementia is less than 1%, whereas in the group above 90 years it is estimated to be about 40% ^{52 65}.

Genetics: Genetic studies have identified mutations on some genes that can be carried onto the next generation with the consequence that as many as 50% of descendants can get the same disease. As of today we know of mutations on three different chromosomes that lead to dominant inheritance of AD: mutations on chromosome no 1 (presenilin 2), on chromosome 14 (presenilin 1) and chromosome 21 (amyloid precursor protein).

Mutations on chromosome 14 are the most common variant, however less than 1% of AD-patients have an inherited gene fault. In FTD it is estimated that 30-40% of cases are caused by dominant inheritance, i.e. congenital mutations ^{64 66}. Furthermore, several genetic variants have been identified with an increased risk of AD. Apolipoprotein E-4 (APOE-4) has been found to be associated with AD ⁶⁷, and it is estimated that the lifetime risk of developing AD increases from 9% to 29% for carriers of one APOE-4 allele ^{68 69}. The APOE-4 allele has been demonstrated to accelerate the onset of AD, but even though it may have a modest effect in predicting cognitive decline in older people, the genotype alone is not a useful predictor in non-demented people ⁷⁰. In addition, several other gene variants have been found to increase the risk of AD.

Lifestyle factors, increased risk: Observational studies have proved to be relatively consistent in suggesting that elevated blood pressure in midlife (40-60) increases the risk of later life cognitive impairment, dementia and AD ^71-73. Observational studies have

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also demonstrated that type 2 diabetes nearly doubles the risk of AD ⁷⁴ and there is an association between midlife-blood lipid values and risk of development of AD. This is supported by studies that have identified several genes involved in cholesterol

metabolism or transport as AD-susceptibility genes, including APOE, and apolipoprotein J ⁷². Increased total homocystein levels predict the risk of all-causes of dementia ⁷⁵. The relationship between metabolic syndrome and AD has also indicated a positive association ^{76 77}. Any association between smoking and AD has not yet been

demonstrated because the results from studies are inconsistent. Smoking may increase the risk of AD via several mechanisms, for instance through increased generation of free radicals leading to high oxidative stress, or by affecting the inflammatory immune system. It may also affect AD risk by promoting cerebrovascular disease.

Lifestyle factors, reduced risk: The Mediterranean diet (high intake of plant-food, fish and olive oil; low intake of red meat and poultry; moderate intake of wine) is associated with a reduced risk of AD and mild cognitive impairment (MCI) independent of physical activity and vascular comorbidity ⁷². Epidemiological studies suggest that physical activity is associated with a reduced risk of dementia ^{78 79}. Possible mechanisms are increased cerebral blood flow, oxygen extraction and glucose utilization, as well as activation of growth factors promoting structural brain changes, such as increase in capillary density. In addition, rodent studies suggest that physical activity decreases the rate of amyloid plaque formation ⁸⁰. The Alzheimer’s Association also believes that there is sufficiently strong evidence to conclude that a healthy diet and lifelong

learning/cognitive training may also reduce the risk of cognitive decline and dementia

81.

2.2.3 Dementia in nursing homes

A criterion for a dementia diagnosis is that the memory loss and decline in cognitive abilities affect the ability of the individual to perform ADL. Consequently, dementia severity is a critical predictor of NH placement. The changes that lead to

institutionalization among those with dementia vary. Both the loss of physical capacity, and the behavioural and psychological symptoms, represent challenges for their family carers, and are significant underlying factors ⁸². Nevertheless, studies indicate that ADL

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function may be a more important reason for institutionalization than behavioural or psychiatric symptoms ^{83 84}. It is estimated that about 40% of people with dementia in Norway live in a NH ⁸⁵. Among those living in a NH, about 80% have dementia ³⁹. Studies from Germany, Italy and Tunisia ^86-88 report a prevalence of around 50%, but the under- diagnosis of dementia in NHs is commonly reported in literature worldwide ^{87 89 90}. In the United States, 75% of individuals ≥80 years old with AD or other dementias will require NH admission, compared with only 4 %of the general population ⁹¹.

2.3 Mental health

Mental health is closely related to mental well-being, and is an integral part of health:

“There is no health without mental health.” ⁹². Mental health is fundamental to our ability to think, express, interact with other people and appreciate life, and it is therefore essential to promote mental well-being in all groups of society. At all ages, mental health is determined by biological, psychological and social factors. In this chapter, I will describe different aspects of mental health that are relevant to the population targeted in this thesis.

2.3.1 Neuropsychiatric symptoms and comorbid psychiatric disease

Neuropsychiatric symptoms (NPS) and behavioural and psychological symptoms of dementia (BPSD) have been defined as terms for the same symptoms often seen in people with dementia. In this thesis I will use the term NPS, described as a

“heterogeneous range of psychological reactions, psychiatric symptoms and behaviours occurring in people with dementia of any aetiology.” ⁹³. The concept includes symptoms such as agitation, apathy, anxiety, depression, disinhibition, euphoria and hallucinations

94. It has been argued that homogeneity in aetiology and treatment of the conditions included in the term NPS is unlikely. Thus, it may be a problem that these symptoms are considered a syndrome when they are caused by an interaction of multiple biological, personal and environmental factors ⁹⁵. The distinction between NPS and psychiatric disorders such as paranoid psychosis, late onset depressive disorder or late onset

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schizophrenia, is challenging. In particular, depression as a reaction to dementia seems to be common in patients with dementia in the early stage, while they still have insight into their impairments ⁶³. In younger patients with dementia, depression as a comorbid disorder is frequently seen, and among NH patients, many will fulfil the criteria of a depressive episode ⁹⁶.

Clinically significant NPS occur in 90% or more of individuals diagnosed with dementia at some time during the course of their illness ^97-100. Longitudinal studies have

demonstrated that almost all patients with dementia in a NH experienced at least one clinically significant NPS over 16 months and 53 months ^{99 100}, but individual symptoms fluctuate. The prevalence of NPS has been found to be similar in AD and VaD ²⁸. The management of these behaviours can be challenging for NH staff, particularly those providing personal care. The disruptive behaviours of residents pose challenges to staff’s QoL, satisfaction, turnover and quality of care ¹⁰¹. Staff may become distressed ¹⁰² and react negatively to aggressive patients ¹⁰³, and this may complicate treatment delivery. Disruptive behaviours require the focused attention of one or more staff members, reducing the number of staff available for other residents. Problem behaviours are treated with psychotropic drugs with sedative effects and physical restraints ^{37 104-108}. These types of medications have been associated with functional decline, sedation, reduced QoL and falls ^109-112, and should thus be avoided, or used only for a short time.

The most prevalent NPS in NH residents with dementia are agitation, apathy and affective symptoms ^{98 113 114}. Agitation has been defined as an “inappropriate verbal, vocal, or motor activity that is not explained by needs or confusion per se.” ¹¹⁵. The causes of agitated behaviour are many, including: psychological, neurological, physical (pain), functional, interpersonal, environmental and restraint factors ^{116 117}. Aggressive behaviour can often be seen together with anxiety, and frequent manifestations are restlessness, pacing, repetitious sentences, requests for attention, complaining and cursing ¹¹⁸. A negative association between physical function and agitation was demonstrated in a study by Yu et al. ¹¹⁹, however, the association was closely related to cognitive status.

Apathy, which is a syndrome of motivational loss ¹²⁰, is believed to be frontally

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mediated, and this symptom increases in severity as dementia progresses ¹⁰⁰. There is evidence that apathy in particular may have significant negative functional

consequences in dementia patients ¹²¹. This association between physical function and apathy has also been demonstrated elsewhere 27 28 122 123, while others have not found this correlation ¹¹⁹.

Affective symptoms include depression and anxiety. Anxiety is common in dementia, however there is a lack of consensus about how to define and conceptualize anxiety in dementia ¹²⁴. Ballard et al. ¹²⁵ argued that there are three main categories of anxiety in dementia: anxiety in the context of depression, anxiety in the context of psychosis, and the group of patients with insight into their condition may suffer from situational anxiety. Depression is more common in older persons than in the young, and is more common in NHs than in the general old population ¹²⁶. Depression is both under- diagnosed and undertreated in NHs ¹²⁷. Reasons for this may be that depression in NHs often coexists with dementia, and because symptoms of depression and dementia overlap ¹²⁸. Worse general medical health and cognitive impairment has been found to be associated with depression in NHs ¹²⁹. Depression is also a predictor of mortality in NHs ^{96 127}.

2.3.2 Cognition and cognitive impairment

To describe cognitive impairment, the understanding of the concept of cognition is important. Stedman’s Medical Dictionary ¹³⁰ defines cognition as the mental activities associated with thinking, learning and memory. Cognition includes general intellectual ability, memory, language, visual-spatial skills, perception and complex problem solving

131. Every action that is performed is influenced by our cognitive abilities and ageing is associated with changes in cognition. “Cognitive aging” is a process of gradual changes that occur as people age, and it is not a disease. Functions in some cognitive domains decrease by age, such as attention, memory, spatial and perceptual ability and executive function, whereas others increase, such as wisdom and knowledge ¹³². It is a highly dynamic process with great variability within and between individuals ¹³³.

A possible transitional state between normal aging and dementia is described as mild

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cognitive impairment (MCI) ¹³⁴. Approximately 50% of individuals with MCI either return to normal cognitive status or have a stable condition that does not develop dementia, whereas the other half develops dementia, mainly AD ¹³⁵. The criteria for mild cognitive impairment according to Winblad et al. ¹³⁶ are: (1) not normal, not demented (does not meet criteria for dementia diagnosis); (2) cognitive decline; and (3) preserved basic activities of daily living/minimal impairment in complex instrumental functions.

The most recent suggested clinical characterization of MCI was put forward by Petersen et al. in 2014 ¹³⁷. They proposed seven criteria: (1) self- or informant-reported memory complaint; (2) self- or informant-reported cognitive complaint; (3) objective memory impairment; (4) objective memory impairment; (5) essentially preserved general cognitive functioning; (6) preserved independence in functional abilities; and (7) no dementia.

Since the participants in the studies described in this thesis have mild or moderate dementia, it is interesting to explore some of the cognitive domains that are relevant for physical function (described in chapter 2.4) in persons with dementia, such as memory, attention, executive function and visuospatial cognition.

Memory is perhaps the best known cognitive domain that is impaired in people with dementia. A decline in memory (especially episodic memory) is a diagnostic criterion of dementia (ICD-10, Textbox 1). Memory is a complex process that involves the ability to sense an object or event, to formulate thought, to retain information and to recall it at will ¹³⁸. Persons with AD typically present with dysnomia (forget words, or have difficulties coming up with specific words they want to use) and severe impairment on both memory recall and recognition. In VaD patients, the memory function is more intact, with some recall deficits but little, or no, recognition problems ^{139 140}. In FTD patients, memory is preserved in the early phase of the disorder. An association has been demonstrated between working memory and balance and mobility in an healthy adult community-dwelling population (with an average age of 69.5 years) ¹⁴¹.

Attention is the conscious and wilful focusing of mental energy on one object or one component of a complex experience and, at the same time, excluding other emotional or thought content; i.e. the act of taking notice or concentrating. Attention is made up of three separate elements: selective attention is the ability to focus on a particular stimuli

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while filtering out other stimuli; divided attention is the ability to share attention resources and shift focus when required; and sustained attention is the ability to sustain focus for as long as necessary ¹⁴². The ability to sustain attention is a fundamental component of the cognitive capacities that is essential for functioning in everyday life

143, and has by some been considered as a core executive function ¹⁴⁴. In persons with AD, selective and divided attention is affected early in the disease progress. Sustained attention is relatively well preserved until the later stages of AD ¹⁴⁵. Divided attention plays an important role in walking and multitasking and has been associated with a higher fall risk ¹⁴⁶.

Executive functions (EF) include high-level cognitive control processes involved in modulating more basic functions, including sensory, motor, cognitive, memory and affective domains. They include the ability to maintain and shift mental sets

appropriately, to take all aspects of a situation into account, and to use that knowledge in setting goals, establishing priorities and formulating a plan. EF are also used in implementing behaviour strategically, and monitoring and modifying responses compliant with shifting environmental demands ¹⁴⁷. Baseline executive dysfunction is a significant and powerful predictor of future functional decline in individuals with VaD

140. Extensive impairments in EF have been demonstrated in persons with mild and moderate AD and VaD, and there is no difference between the two groups ^{139 145}. In FTD, EF is impaired in an early phase of the disorder. EF plays an important role in balance control, as demonstrated in a group of community-dwelling persons with cognitive impairment and AD ¹⁴⁸.

Visuospatial functioning involves the interrelationships between people, objects and space, and it includes visuospatial perception (the mental capacity to perceive and manipulate objects in two- and three-dimensional space) ¹⁴⁷, mental imagery, spatial memory and navigation ¹⁴⁹. Visual perceptual functions predict the instrumental activities of daily living in patients with dementia ¹⁵⁰.

In a study of the trajectory of decline in different types of dementia, it was demonstrated that persons with AD declined in all cognitive domains during four years follow-up, and persons with FTD (behavioural variant) declined the fastest. The persons with VaD declined in EF and attention. DLB also demonstrated a marked decline in most domains,

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except language and global cognition ¹⁵¹ Correlations between physical function (gait, balance and muscle strength) and four cognitive domains (EF, global cognitive function, verbal fluency and processing speed) exist, and have been demonstrated in a group of people with dementia ¹⁵².

2.3.3 Quality of life in nursing home residents with dementia

QoL has emerged as an important topic in dementia research to improve care for these patients ^153-155. It has been interpreted in many ways, with numerous definitions. QoL is a multi-factorial concept, and the WHO Quality of Life Group offers the following definition: ”the individual ‘s perception of his/her position in life in the context of the culture and value system in which he/she lives and in relation to his/her goals,

standards, and concerns.” WHO suggests that QoL can be broken down into four core life domains: physical, psychological, social and environmental ¹⁵⁶.

Lawton’s conceptualization of QoL in dementia includes both subjective and objective factors based on the following four components: behavioural competence, objective environment, psychological well-being and perceived QoL ¹⁵⁴, while the definition by Whitehouse, et al. focuses on an integration of cognitive functioning, activities of daily living, social interactions and psychological well-being ¹⁵⁷. It is evident that the QoL of the elderly in NHs is a determinant of their satisfaction with life, as well as a measure of their general health ^{158 159}.

There is a consensus that the subjective component is important to the concept of QoL;

however, there is uncertainty about the ability of a patient with dementia to communicate reliably about his/her QoL. NH residents with dementia have greater difficulties reporting their perceptions about their own QoL than community-dwelling dementia patients, due to more advanced cognitive impairments. They more often present with communication problems ¹⁶⁰, severe memory problems and have less insight into their own situation ¹⁶¹. NH residents experience a variety of problems that may affect QoL, such as physical disabilities, mental disabilities, cognitive disabilities, self-neglect, and a lack of social and financial support and resources ¹⁶². Consequently, QoL in individuals who live in a dependent state is greatly reduced ^{12 163 164}, and it is

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important to consider this in the planning of care services and as a quality indicator of care in NHs ¹⁶⁵. QoL has been increasingly addressed in the literature concerning patients with dementia ¹⁶⁶. Changes in QoL in people with dementia is mostly associated with changes in NPS ^{12 167-169}. Better cognitive function, as well as functional capacity, predicts better QoL in NH residents with dementia ^169-172.

Crespo et al. ¹⁷⁰ used three rating sources (the resident, staff and family) when they investigated the QoL in NH residents with dementia. They found that the residents themselves scored a significantly higher QoL than both proxy groups. A disagreement between self-rating and proxy-rating has also been demonstrated by others ^171-173. In the study by Crespo et al. ¹⁷⁰, only 49% of the residents were able to complete the QoL-AD- questionnaire, and the results demonstrated that self-reported QoL was mainly affected by their emotional state (level of depression). The strongest predictors for lower QoL, rated by the family and staff was incontinence, a longer length of stay in the NH, having to use a feeding tube, the use of physical restraints, and greater cognitive and functional impairment. Studies in Norwegian NHs that used the QUALID scale demonstrated that NPS, especially affective symptoms such as depression, were associated with poorer QoL

12 174. This concurs with the self-reported findings of Crespo et al. ¹⁷⁰, as well as Bruvik et al. ¹⁷³ and Sands et al. ¹⁷¹. The QoL of NH residents with severe dementia has also been found to relate to environmental factors such as temperature, noise, and lighting ¹⁷⁵. Frail NH residents with and without cognitive impairment reported that QoL was affected by pain, sleep quality, ADL function and risk of falling ¹⁷⁶. Another study from the same population found that pain, lack of family connectedness and decreased cognitive function were associated with lower QoL ¹⁷⁷. An association between performance of physical tests and QoL has also been demonstrated in the general NH population ¹⁷⁸, and in the next chapter I will address physical function, a concept that is central in this thesis

2.4 Function

In this section, I will start with a presentation of the International Classification of Functioning, Disability and Health (ICF). I will then proceed to address three important

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topics in this thesis: balance and mobility (2.4.2), muscle strength (2.4.3) and fall and risk of falling in NH (2.4.4).

2.4.1 ICF and physical function

The ICF is a positive description of the interaction between an individual (with a health condition) and the individual’s environmental and personal contextual factors ³¹, and was developed by WHO in 2001 ^{31 179} (Figure 1). The ICF is based on a bio-psychosocial model that regards the human being as a biological, psychological and social being. Thus, the domains included in the ICF are described from the perspective of the body (body structure and function), the individual (activity), and society (participation) ¹⁸⁰. These are the functional components. The ICF has become the generally accepted framework within which to describe functioning in rehabilitation ¹⁸⁰, and it is a relevant instrument in elderly healthcare, since it allows the healthcare team to assess the older person as a whole. The ICF can help clinicians to define the meaning of improvement in relation to rehabilitation of individuals and to acknowledge the influence of multiple factors on functioning and disability ¹⁸¹.

In the ICF context, a health condition includes diseases, disorders, injury, or trauma, aging, and congenital anomalies that interrelate with the three functioning components mentioned above ¹⁸. The ICF characterizes disability as a problem in one of the three functioning components after contextual factors are considered. Deficits in body function or structure are identified as impairments. Examples of body functions and structures described in this thesis are muscle strength, balance and cognition (dementia). Difficulties with tasks or actions are labelled activity limitations, and problems with social participation are termed participation restrictions. Reduced mobility and ADL-function may limit both activities and participation. Personal factors include, amongst others, age, sex and patterns of behaviour, and environmental factors are related to the physical and social environment in which people live and participate.

The NH can therefore be considered as an environmental factor for the resident. The NH setting may have positive or negative effect on a person´s capacity to perform actions or tasks and on the body structure or function. Providing support and opportunities for the

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elderly to participate in activities may help to keep active interactions and maintain, or even improve, function ¹⁸².

Figure 1: The three levels of human functioning, as classified by ICF

Physical function can be defined as the ability to perform mobility tasks and ADL¹⁸³. Physical function is particularly important for NH residents because it comprises modifiable factors that are related to a variety of important outcomes that may influence QoL ¹⁸⁴. With increasing age, a degeneration of the neuromuscular system can be seen, and this degeneration reduces physical function ¹⁸⁵. Independent of physical illness, there is evidence that cognitive impairment is associated with functional limitation ¹⁸⁶

187, which is defined by WHO as “any health problem that prevents a person from completing a range of tasks, whether simple or complex”. In line with the ICF, functional performance is affected by the interaction of physiological, psychological, social and environmental factors ¹⁸⁸. Even though physiological factors are the most central in this thesis, psychological factors will also be considered. Social and environmental factors are outside the scope of this thesis.

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Cognitive and physical aspects of functionality are closely related. Cognitive

impairments may influence the older adults´ interpretation and reporting of symptoms, leading to delays in identification and treatment of new illnesses or exacerbations of existing diseases. Cognitive impairment may also complicate the use of standard approaches to chronic disease management. Both these factors may influence physical function. In addition, progression of the disease that underlies cognitive impairment may result in changes in physical function ¹⁸⁹. Below, I will present the following issues:

balance and mobility, muscle strength, and fall risk. The potential effects of exercise on physical function will be addressed in chapter 2.5.

2.4.2 Balance and mobility

Balance is a prerequisite for our ability to perform everyday activities in a safe and efficient manner ¹⁹⁰. The inescapable consequence of failing to maintain balance is falling, and so balance is an important topic for physical therapists and other healthcare workers. Balance can be defined as the ability to maintain the body’s centre of mass in relationship to the base of support ¹⁹¹. The human body has a relatively narrow base of support, a high centre of gravity and many moving joints; therefore, it is a demanding task to maintain balance during an upright stance ¹⁹². Balance control can be seen as the ability to regain balance after postural imbalance during movement, and is dependent on anticipatory and reactive balance control ¹⁹³. The complex interaction to achieve balance includes both musculoskeletal and neural systems 191 194 195.

As part of the aging process, elderly people undergo a range of physical changes that influence postural control, and balance function is reduced with increasing age ¹⁹⁶. Studies of elderly subjects without a diagnosable disease have documented deficits in several physiological systems critical for postural control. They include cognitive processing, control of dynamics, orientation in space, sensory strategies, movement strategies and biomechanical restraints (see Figure 2) ¹⁹⁷. These are all important resources that are required for optimal balance function. Disorders in any of these resources, e.g. cognitive disorders such as dementia, may cause reduced postural balance ¹⁹⁸.

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Figure 2. Necessary functions for postural stability and balance ¹⁹⁸

There is a need for accurate coordination between afferent information from the proprioceptive, vestibular and visual systems, and the descending motor program for the adjustments of posture during all functional activities ¹⁹⁵. All aspects of balance control deteriorate with the increasing severity of dementia, and executive function in particular plays an important role in balance control ¹⁴⁸. For this reason, balance is especially interesting and important in relation to persons with dementia.

Mobility is defined as the ability to independently and safely move from one place to another ¹⁹¹. Mobility activities include transfers (e.g. rising from a chair or getting into bed), walking, or other types of recreational activities, such as dancing or sports ¹⁹⁹. Walking is a complex neuro-motor activity ²⁰⁰, and the ability to walk underlies many functions necessary for independence. Consequently, walking is fundamental for human mobility. Mobility is known to deteriorate with increasing age, even in healthy old

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people ²⁰¹, and the reduction in walking speed is commonly seen as a result of advanced age or medical conditions ²⁰². The decline in mobility in older people increases the risk of institutionalization, morbidity, poorer QoL and mortality ²⁰³. It has been suggested that VaD may be associated with a faster decline in mobility than AD ²⁰⁴.

2.4.3 Muscle strength: sarcopenia and dynapenia

Muscle strength is defined as the amount of external force that a muscle can exert ²⁰⁵. Muscle strength reaches a peak between the ages of 20 and 30. It declines in middle age and continues to decline with increasing age. The loss of muscle mass occurs for several reasons: sarcopenia, inactivity, malnutrition, and altered cytokines signalling ¹³⁸. Rosenberg coined the term sarcopenia in 1988 ²⁰⁶. He stated that, “over the decades of life there is probably no decline in structure and function more dramatic than the decline in lean body mass or muscle mass.” The definition of sarcopenia has lately evolved from muscle mass towards muscle strength and function and physical performance. It is considered by some to be a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, with a risk of adverse outcomes, such as physical disability, poor QoL and death ^{207 208}. Sarcopenia is

considered a major determinant of physical frailty ²⁰⁹. The consequences of sarcopenia have a severe impact upon the elderly because it interferes with their ability to carry out ADL. Poor muscular support can lead to unstable joints and increase incidence of falls, and decreased muscle strength can also facilitate the onset or severity of osteoarthritis

138. The most significant atrophy is seen in the fast twitch type II muscle fibres (both size and number), as compared to the slow twitch type I ^{210 211}. The loss in fibre size is associated with an age-related decline in growth factors ²¹², as well as a lack of

mechanical stimuli for the fast twitch fibre ²¹³. A systematic review and meta-analysis ²¹⁴ demonstrated that lower limb muscle weakness is an important risk factor for falls, and that the effect is stronger in institutionalized older people than in community-dwellers.

The literature implies that muscle fibre loss is due to loss of motor neurons. Studies indicate that a 60-year-old has approximately 25-50% fewer motor neurons than a 20- year-old person ²¹⁵.

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Cesary, 2014

Figure 3. Relationship between sarcopenia and frailty ²¹⁶

In 2008, Clark and Manini ²¹⁷ argued that the age-related loss of muscle strength is only partially explained by the reduction in muscle mass, and that other physiological factors explain muscle weakness in older adults. Thus, they proposed that strength and mass loss should be defined independently: “sarcopenia” should be used in its original context to describe the age-related loss of muscle mass; and “dynapenia” was suggested as a term to describe the age-related loss of muscle strength and power. There are two types of factors that can contribute to dynapenia: neurological factors and properties of the skeletal muscles ²¹⁸. The complex and multifactorial interaction of the two systems is not fully understood, but plausible explanations are put forward by Clark et al. ²¹⁸.

Dynapenia also includes the age-related reduction in specific force. Specific force is defined as strength per unit of mass ²¹⁹ and describes the quality of the muscle ²²⁰. In old people, muscle tissue to some degree is replaced by fatty tissue ²²¹ that does not

contribute to force generation or to the production of movement ²²². The underlying mechanisms of the decreased muscle fibre quality are complex, and not yet fully understood, but according to Frontera ²²², at least three possibilities exist: (1) A lower concentration of myosin in muscle fibres due to a reduction in gene transcription and protein synthesis; (2) abnormal protein synthesis or regulation caused by genetic

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abnormality; or (3) post-translational modifications of normal proteins. One study demonstrated 30% lower power in the calf muscles in elderly people (70-80 years old) when compared to younger men (20-30 years old) ²²³. Cross-sectional and longitudinal studies indicate that the maximal muscle strength decreases by 15% every decade after the age of 50, and, after the age of 70, the reduction in strength will be about 30% every decade ^{220 224}. The capillary density, which affects the endurance of the muscle, is also reduced ²²⁰.

Declining strength in old age is associated with an increased risk of MCI and dementia

225-228. A relationship between muscle strength and rate of cognitive decline was demonstrated when participants with greater strength at baseline showed a

considerably slower rate of decline of cognition in a prospective observational study ²²⁶. This association has been demonstrated in both upper and lower limbs, but has only been investigated in community-dwelling older people. The biological mechanisms are poorly understood; however, multifactorial pathophysiological mechanisms, such as damaged mitochondria, microvascular disorder, inflammation, a lack of social

interaction, and derangement of homocystein metabolism, have been suggested ^{226 229}.

2.4.4 Falls and risk of falling in nursing homes

Fall risk is closely related to balance function, mobility and muscle strength, and fall incidence is about three times higher in institutionalized older people than those in the community ^{230 231}. Studies indicate that exercise has the potential to reduce several of the risk factors that contribute to falls in elderly people, and, for this reason, I find falls and risk of falling relevant in this thesis. The collaborators of the Prevention of Falls Network Europe (ProFaNE) have proposed the following definition of a fall: “an unexpected event in which the participants comes to rest on the ground, floor or lower level.” ²³². The consequences from falls can be devastating, as they are responsible for considerable morbidity, immobility and mortality ^{233 234}. Kallin ²³⁵, reported that 54% of the fallers in NHs suffered injuries, including fractures, as a result of their falls.

The complex multifactorial causes of falls among NH residents have been demonstrated in several studies ^236-238. A history of falling has been found to be a strong predictor for

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future falls in NHs ²³⁹ as well as dementia ^{240 241}. Declining cognition has been associated with performance of mobility activities in an unsafe manner ²⁴². Risk factors for falls among dementia patients living in group dwellings for people with dementia have been reported and include the following factors: being ADL dependence, displaying verbally disruptive/attention-seeking behaviour, being able to rise from a chair, walking with assistive devices, and participating in outdoor walks ²⁴¹. Others have found that the most important risk factors for falls and injuries in NHs include lower-extremity weakness, gait and balance instability, poor vision, cognitive and functional impairment, and sedating and psychotropic medications 238 243 244. These factors are similar to those found in community-dwelling populations (> 65 years old) ²⁴⁵. Decreased muscle strength at the knee and hip and reduced mobility also contribute to fear of falling ²⁴⁶ and fear of falling itself is a powerful predictor of falls ²⁴⁷.

Even though the literature is unequivocal, studies indicate that there is a non-linear association between standing balance and falls 241 248 249. Barker et al. ²⁴⁹ found that NH residents categorized as having mild mobility impairment had the highest risk of falling, meaning that the patients who needed supervision when performing mobility tasks were at a higher risk of falling than residents requiring hands-on assistance. Residents who required minimal assistance were likely to have cognitive impairment, and the inability to recognize, judge and avoid hazardous situations might contribute to increased risk. Residents who were chair-bound were unlikely to fall because they do not have the capacity to perform risky activities ²⁴⁹.

2.5 Functional decline and exercise in nursing homes

Physical functions such as muscle balance, mobility and muscle strength are fundamental for ADL-function. After NH admission, older adults with dementia demonstrate functional decline in personal hygiene, dressing and toileting that is greater than would be anticipated with a normal progression of the dementia disorder

250 251. Four reasons have been suggested for this fast functional decline: (1) the perception that residents with dementia will not be able to actively participate in functional and physical activities; (2) caregivers focus on task completion and add to the

Effects of a high intensity functional exercise program in nursing home residents with dementia