Exercise programs may be relevant for SwD living in institutional settings since they spend an extended period in those settings (24) with a high rate of functional decline (25) and they are frequently physically inactive (24, 26). Although exercise interventions are low cost, feasible and can be easily implemented, there is a lack of physical activity opportunities in institutions (27).
The caregivers as the person with more contact with SwD are the most appropriate ones to evaluate the outcomes of an exercise intervention. Therefore, the present study highlighted the caregiver's perception of exercise intervention as a possible strategy to mitigate symptoms and alleviate disease progression in institutionalized SwD.
The hypothesis that a 6-month exercise program can promote a positive caregivers’ perception concerning its effects on BPSD and functional capacity in institutionalized older adults with mild to moderate dementia was confirmed. This study also tested the hypothesis if a 6-month exercise program can promote a positive caregivers’ perception of the importance of an exercise intervention on QoL, but this hypothesis was not confirmed.
The present study attempted to adapt an exercise program for SwD, living in institutional settings to the physical exercise recommendations of ACSM and American Heart Association for older adults (13). The exercise intervention integrated several important physical abilities to perform the ADLs and involving playful and social group activities. Corroborating other studies that applied for similar training programs in terms of duration, frequency and type of population (9, 26) improvements were seen in all the physical fitness components evaluated in the group that participate in the 6 months’ exercise intervention (Fig. 2). It is possible that these positive results were linked with low scores seen before the intervention. These results also suggested that the exercise intervention was adjusted to the characteristics of our population and enough to induce physical adaptations. This underlines that the adaptation of the physical activity recommendations to this population, allows them to improve their levels of physical fitness.
Although some studies revealed positive outcomes of an exercise intervention on cognitive function, most of these studies were conducted in older adults without dementia (28, 29). In fact, in this special population physical exercise showed controversial results, with studies suggesting no alterations in general cognition in comparison with the control group (8). Our intervention did not significantly alter the general cognition in comparison with the control group. Probably, as suggested by Lautenschlager & Cox (30) to improve brain function and cognition, exercise intervention should be more extended in time.
BPSD are an intrinsic feature of dementia that is often treated with antipsychotics. Current person-centered philosophies of care in dementia, encourage non-pharmacological therapies as an alternative and/or complementary interventions for minimizing BPSD (31), including exercise programs. The literature points out controversial results, while Forbes et al. (8) found no clear evidence of the positive effects of an exercise intervention on BPSD, other authors affirm that exercise interventions can be beneficial to reduce some of the BPSD (32, 33). Besides the controversy, these studies agree that further work is needed to comprehend the potential of exercise as non-pharmacological therapy to manage BPSD (32). Evidence suggests that exercise may affect various BPSD in different ways (33). Indeed, the effects of exercise seem to be more beneficial on depressed mood, agitation and reduce "wandering" (33). The results from our study seem to be in line with this evidence, generally EG maintains their BPSD scores similarly to the scores reported on the baseline, while the CG worsen depression, apathy, aberrant motor behavior scores (Fig. 3). Importantly, in our study, the caregiver’s perceived a decreased of the total BPSD in the EG after the 6 months’ exercise intervention.
From our knowledge, no studies have addressed the caregiver’s perspective about the impact of exercise intervention in their BPSD distress. In our study, formal caregiver´s distress triggered by apathy, disinhibition and aberrant motor behavior increased in CG while after 6 months of an exercise intervention no alterations were seen regarding these distress causes in EG (Fig. 4). Evidence suggests that disruptive behaviors and low ADL levels among residents with dementia expose formal caregivers to demanding physical and emotional distress (7), leading to poorer QoL (34, 35). Thus, our results could suggest that exercise programs in institutionalized SwD may be useful as a strategy of BPSD- distress management. Strategies to alleviate the burden felt by formal caregivers leads to higher job satisfaction, increase their QoL and consequently improved staff attitudes and caring behaviors and, over time, resident well-being (36).
Functional status is related to institutionalization (37). Among other reasons, in most cases, older adults move to a nursing home when their functional capacity is diminish affecting their independency to perform ADL (38). In institutional settings, assistance in ADL for older adults living are often delivered in a standardized and depersonalized way that undermines independence (39). Particularly in SwD, fewer opportunities to perform ADL and the lack of physical activity opportunities exacerbates the functional decline in the institutional settings (40). Corroborating this evidence, the present study showed a progressive decline in the total functional capacity score and some of their domains including, transferring, feeding, and incontinence outcomes in the group without exercise intervention. Altering this tendency, the EG was capable of preserving their total functional capacity after the 6 months of exercise intervention (Fig. 5). Other studies have verified that exercise programs implemented in institutions can induce positive outcomes concerning the functional capacity of SwD (8, 41, 42)
It has been suggested that in institutional settings the participation in a wide range of activities improves the QoL of SwD (43). fact, activity engagement may contribute to the pleasure and enjoyment, the sense of connection and belonging and retain a sense of autonomy and personal identity (44). Importantly, caregivers also consider aspects such as social relationships, physical movement, attachment and affect, control over life, and contributing to the community as important for SwD QoL (45). A 3 months aerobic exercise randomize control trial (46) and 16 weeks multi center exercise program (4), both for older adults with Alzheimer´s Disease shown some evidence that exercise program can improve QoL. However, we did not found alterations on QoL following 6 months of EG or CG from the perspective of the caregivers (Fig. 5).
BPSD are commonly associated with a reduction in the QoL for the older adult with dementia (47) and increase of caregiver stress (43, 47). Therefore, we would expect an alteration of QoL in CG and possible preservation in EG. Although in the majority of the studies regarding, functional capacity and QoL evaluation of institutionalized SwD have been partially or fully reported by the formal caregivers, the fact that this is the perspective of the caregiver has not been highlighted. In fact, it seems relevant to empathize their perception since dementia care can contribute (due to disruptive behavior and the limited capacity of performing ADL) for the burden of formal caregivers (43). Additionally, from the author's knowledge, no previous studies had explored the effects of 6 months’ exercise intervention on BPSD score and caregivers’ distress in institutional settings. Higher levels of stress and poorer levels of well-being of formal caregiver’s impact negatively on the quality of care they provide and consequently have a negative effect on institutionalized SwD well-being (48). Therefore, interventions for residents with dementia perceived as positive by the formal caregiver may increase the well-being both of themselves and, by extension, those they care for. The results of our study showed that formal caregivers perceived some of the benefits of the engagement to exercise program in institutionalized SwD.
The main limitation of this study was the small sample size and the lack of randomization for group assignment. Recruiting voluntary people diagnosed with dementia willing to commit with a 6-month´ intervention was challenging and several institutions were therefore involved.