Medical and social background

The demographic development leads to a constantly increasing percentage of elderly people worldwide. This has become an issue for all people concerned, their families, the health care system and the society as a whole because a great amout of elderlies depend on care. The increase in life expectancy includes many „disabled life years“.

The health care systems and the medical research face the challenge of researching the disablement-process in order to develop and implement effective prevention and rehabilitation measures. This process of research is characterised by the key words disablement, frailty and sarkopenia.

It is analysed in numerous studies, which etiologies form the basis of the development of care dependency, how the identified factors interact, and in which way they can be influenced.

The neuro-muscular-skeletal unit is in the centre of the development and according to that also in the centre of prevention of care dependency. The risk and the status of care dependency can be deduced from the neuromuscular performance. Mainly „lower body performances“ (Guralnik ete al 1995) are equally cause, consequence and indicator of immobility and reduced daily living skills.

The locomotion can be seen as the common pathologic final path of multiple interacting aging and disease processes.

In regard to therapeutic options the neuromuscular systems are of particular interest because they can be influenced effectively by specific movement programs.

The muscle is an organ system that can be especially damaged through immobility and can be improved effectively through specific movement programs.

The muscular wasting (sarkopenia) associated with age can be analysed morphologically, effectively and with acceptable effort, and is highly associated with the risk of care dependency.

Falling and fractures caused by falling are clinical indicators of the neuro-muscular-skeletal development associated with age and disease and are as such also predictors and reasons of the process.

There is more and more proof of the fact that muscular functions and locomotion can be improved through movement programs, falling can be avoided and the occurrence of care dependency can be delayed.

The goal of reducing the lifetime with „disability“ and at the same time lengthening the active years of the life is characterised by the key word „compression of disability“.

The therapeutic influence on the mentioned processes can be phrased according to the temporal positioning of the deficit either as prevention or as rehabilitation. Has care dependency or limitation of mobility and functional independence already occured, we talk about rehabilitation.

In geriatric rehabilitation clinics it is proven worldwide every day that with a combined use of curative medicine and rehabilitative methods existing care dependency, functional disabilities and particularly losses of mobility can be reduced.

Constant care dependency as dependency on assistance in ADLs is in any case a massive restriction of quality of life, and also burdened with high a high risk of further functional deterioration, increased morbidity and mortality.

The burden affects equally the patients, their families and friends, the facilities of geriatric care and the health care system as well as the society as a whole.

An important consequence of the increasing familiar and institutional geriatric care is the decreasing number of caring family members. As a result of this a high degree of productivity gets lost in the society.

The great number of care patients, who have to be looked after, requires measures to reduce the extend of care dependency and the number of care patients, and that with an preferably economical input of personnel capacity.

Right here is the starting-point to develop intelligent exercising concepts that apply effective, age-specific and personally economical movement programs by the use of exercising or therapy equipment.

Practical Consequences of the social scenario

Specific physical activity is a frequently tested method to prevent, delay or reduce age-associated care dependency. These preventive and rehabilitative measures can be implemented in different settings: at home in the private residence, in hospitals, in rehabilitation clinics, but also in nursing homes and outpatient facilities.

There is a need for well trained physicians, nursing staff and therapists, adequate concepts, room and equipment.

The availability of trained therapists is a shortage in the implementation of extensive measures. A 1:1–therapy is not possible in the long run because of the great number of care-dependent people.  

It it obviously worthwhile to develop and use exercising equipment more intensely in order to minimize the need for personnel-intensive 1:1-therapies.

These movement programs have to be directed specifically to the key functions of age-associated locomotion and care dependency, they have to be practical, safe and effective.

Congnitive competent elders are able to learn movement programs and implement them into their everyday life. This method is limited for people with dementia.

People with dementia are limited in their ability to learn and realise movement programs.

It is certainly not the case that patients with dementia can not improve their (loco)motor functions, but they need more personnel resources for the motoric learning process as well as for the subsequent realisation of exercising on a regular basis.

With that said, exercising is an adequate approach in order to treat the motor function of people with dementia effectively and economically.

Exercisers which support the motoric learning process of patients with dementia have to meet the following requirements beyond the usual demands:

• simple or self-explanatory in explanation instruction
• easy in implementation,
• especially safe in use,
• robust against faulty operation,
• the adjustment of the different exercising programs must be easy and robust,
• the wanted effect must be achievable in a feasible period of time,
• a documentation of the exercises must be easy to realise.

A cognitive intact person can be trained effectively in handling therapy and exercising equipment, can be pointed to risks,  can possibly make diverse and complex adjustments independently, can ask in case of problems, can make a report about the progress of exercising, and can identify risks by himself.

These characteristics are limited for users with dementia. Patients with dementia have cognitive but also emotional and conative disorders that reduce compliance and adherence.

A therapy exerciser must be oriented towards these requirements.

With the aid of a feasibility-study we have tested if the upper body exercisers THERA-vital (Medica) are suitable for patients with dementia to exercise or be treated  

• with acceptable personnel effort,
• adequate safety and
• good possibilities of documentation

Study report

Elderly patients of geriatric clinics and residents of nursing homes with and without dementia were supposed to exercise on three consecutive days with therapeutic instruction and presence each time for 10 minutes on the tested upper body exerciser.

Goal: finding out,

• if patients with dementia have the ability to complete the exercises correctly and constantly,
• which and how much personnel and therapeutic interventions they need 
• if patients with dementia differ from patients without dementia in the performance of this standard exercise

Participants:

15 men and 9 women, age 60 and older, 14 of them with dementia; 11 of them residents of two nursing homes that are specialised in people with dementia and 13 patients of the geriatric clinic in Esslingen.

Average age 79,7 SD 8,4, Range 60 – 93,

Involvement criteria:

• age 60 years or older,
• residents of nursing homes or patients of a geriatric clinic,
• normal cognitive abilities or in different stages of dementia
• controllable by nursing staff / physicians / therapists, i.e. cooperative and being able to realise simple instructions.
• insofar mobile that a safe transfer to the exerciser and a safe positioning in the ergometer with the assistance of one person is possible

Exclusion criteria:

• inability or reluctance to comprehend the explanation about the intended action
• unable to be transferred to the exerciser and to be positioned safely in the exerciser with the assistance of one person
• every single active or passive (mimic, gestures) resistance to the invitation to the therapy 
• acute diseases or disorders which could collide with the realisation of the therapy
• every condition that would involve a risk beyond the normal daily routine.

Setting:

Geriatric centre in Southern Germany (Geriatric Centre Esslingen).

The geriatric centre consists of a geriatric clinic (acute and rehabilitation), a nursing home and assisted living homes.

Description of the intervention:

On three consecutive days for 10 minutes each time arm ergometry with the exerciser "THERA-vital", self-selected level of activity,  in sitting position, with visual feedback of the constancy of movement, in the presence of a therapist.

The therapist was placed next to the user, explaining the implementation and encouraging verbally when interruptions of the exercise occurred.

The intervention was implemented by two specifically instructed assistants who adapted to each other in an interrater-training.

The syle of encouragement was standardised. In a casual tone in case of interruptions was said: "Well done. Please continue. It has not been 10 minutes yet.“

If the user did not continue exercising the verbal request was repeated only once.

It was not asked why the patient did not want to continue until he or she interrupted persistently. It was spoken neutrally, not in a pressing or even threatening way.

It was pointed out to the patients (expressis verbis) during the agreement talk that took place before the first day of participation that they are able to cancel their participation anytime without giving reasons.

Result parameter / Target figures

• occurrence and number of side effects
• compliance of patients, measured by the time period of the participation in the therapy.
• number of the therapist's required verbal interventions to reach the entire 10 minutes of exercising.
• spontaneous verbal and non-verbal defense and displeasure reactions of the participants.

The total time of the participance was measured per stopwatch manually.

The exerciser's electronics noted the total time and the time of active exercising.

This data was transmitted online to the exerciser's printer which prepared a report about time, active period of time and power.

Background / safety measures

During the entire study care for the participants was ensured by specialists (physicians, psychologists, nursing staff, physiotherapists).

In case of emergencies the clinic's heart alert system was available. The clinic staff or alternatively the nursing staff of the nursing homes were informed in detail about the study. It was clarified if physical contraindications exist.

Character and extend of the intervention stayed within the usual exercising or therapy limits of the chosen patients. The clinic patients as well as the nursing home residents knew generally about the procedure.

By interviewing the participants we made sure that  none of them had exercised with this or another arm ergometer before.

The report of the study was approved by the facility's ethics committee, the patients or their juridical person in charge agreed after detailed information in written form.

Results

70 out of 72 planned sessions (24 x 3) were realised, 2 participants (2 women, 1x with, 1x without dementia) refused the third session.

 Major physical side effects did not appear.

One female participant (with dementia) complained about pain in her hand each time after the exercise.

One participant (with dementia) was exercising with only one arm temporarily.

All of the patients without dementia exercised for 10 minutes each time actively without any further encouragement.

All of the patients with dementia appeared cooperative as far as they came to the exerciser, allowed to be positioned and began to exercise. 

Four out of the 14 participants with dementia did not adhere to the given time of 10 minutes (all of them female):

• one participant interrupted all three sessions (after 4 min, after 1:30 min, after 1 min)
• one participant interrupted two sessions (the 2. and 3. session each time after 4:30 min),
• two participants interrupted once (one the first time after 6:30 min and one the 3. session after 1:30 min)

Two more male participants with dementia only came up to 9 minutes of activity during the first session.

All of the other participants with dementia made use of the 10 minutes.

A noticeable difference between people with and without dementia was the number of verbal interventions which patients with dementia needed to continue the exercise.

Patients without dementia did not need verbal interventions to continue, all patients suffering from dementia needed verbal interventions.

Patients with dementia needed at most 5 requests to continue, on average each participant with dementia was requested verbally to continue 3 times each session because of spontaneous interruptions.

The participants without dementia were exercising the given time of 10 minutes in every session. Merely during the time of active exercising two male participants did not exclusively move their arms actively for the entire 10 minutes. One participant had an activity time of 06:48 during the second session and 04:41 during the third session. The other participant had an activity time of 07:04 during the third session. All of the other sessions had the required time of 10 minutes.

Discussion

Arm ergometry is a matter of a clinical proved and scientifically analysed movement-therapeutic intervention.

It is qualified for cardiovascular exercising, i.e. endurance training (1-3). Further indications are improvement of muscular strength and coordination.

Arm ergometry is performed in a sitting position, is therefore also possible for users who can not stand.

The neuronal system is highly specialised in reciprocal, site-alternating movements. This is evident for lower extremities in walking and running movements, but also for upper extremeties.

Altogether pedaling with arms or legs meets several specific requirements of the motoric learning:

• it exercises the constancy of movements
• it makes a high number of repetitions possible,
• the movement is easy to learn
• the safe guidance of the movement with the aid of the exerciser minimises risks
• the technical structure makes a precisely adaptable and measurable power and speed possible. 

The well-defined physical strain makes the exercise manageable, reproducible and well measurable, especially in case of cardiovascular troubles.

A dosage is objective and easy achievable.

Pedaling is an approved intervention in case of post-apoplectic conditions.

The systematic recording of reactions beyond cognitive restricted patients confirms the clinical experience that the studied exercisers, arm ergometer THERA-vital, Medica, Hochdorf, are appropriate for the therapy of patients with dementia.

Dr. Martin Runge
20.09.2009

Aerpah-Klinik Esslingen-Kennenburg
Kennenburger Str. 63, 73732 Esslingen