Title

The effect of an exercise intervention on physical and cognitive function, psychological health and quality of life among older adults with dementia in Bangkok, Thailand

Date of Award

2012

Degree Type

Thesis

Degree Name

Doctor of Philosophy

School

School of Nursing and Midwifery

Faculty

Computing, Health and Science

First Advisor

Dr Joyce Hendricks

Second Advisor

Professor Robert U Newton

Third Advisor

A/Prof Daniel Galvao, A/Prof Christine Toye, Dr Orapitchaya Krairit

Abstract

Dementia is a crucial health problem for older adults throughout many parts of the world and has now become a major issue in Thailand. In Thailand a formal long term care system has not been well established and accessibility to these treatments is limited because of their cost. Caregivers inevitably play a vital role in caring for people with dementia in their own homes. Exercise, a low cost and effect treatment, has been used in high income countries to delay the progression of dementia, however, the effectiveness of this intervention within the Thai context has not yet been examined. This study used a mixed method approach to examine the effect of a home-based exercise program for Thai elderly with dementia. The study had three phases. Phase I, the development of an exercise intervention program; Phase II, a preliminary study; and Phase III, a randomised controlled trial. Phase I was exploratory descriptive qualitative research which examined the cultural issues related to exercise for elderly with dementia. Nine health professionals and ten dyads were interviewed. It was found that in the Thai culture exercise was equated to undertaking activities of daily living and the cultural more that being old meant that older people should rest and not take part in physical activity. This cultural challenge was addressed by the inclusion of an educational session to emphasise the importance and benefits of exercise. Also identified was the need for exercise to be home based and individualised. These findings were incorporated in developing the exercise intervention program used in Phase II and Phase III of the study. In Phase II, the safety, feasibility and appropriateness of a home-based exercise intervention program was established. First, the home-based exercises and physical function tests, including muscle strength and physical function performance battery tests were trialled in Australia and found to be appropriate. At this time inter-raterreliability in the use of measurement tools for conducting tests between the exercise physiologists and the researcher was established until satisfaction was met. Later, in Thailand, a preliminary study using a quasi-experimental pre-and post-test design, was carried out. Ten participants were recruited from the neurological and elderly clinics situated in a tertiary hospital in Bangkok. All participants were tested at baseline and then randomly assigned into a control and intervention group (five participants in each group). The intervention group received a four week home-based exercise program, home visits and an educational package. The results of this phase revealed that satisfactory inter-rater reliability between the researcher and the research assistant was established in Thailand. The developed home-based exercise intervention program and psychological measures were feasible, safe and appropriate to use in the next phase. Only some small adaptations were made. The muscle strength tests with machines were inappropriate in the Thai context and some aspects of physical function performance battery test comprising the 6 metre-backward walk and stair climbs were both unsafe and inappropriate in the Thai context. Therefore, these measures were removed from the next phase of the study. Furthermore, adherence to exercise was low because of caregiver availability and a lack of knowledge regarding exercise; therefore, this issue emphasised the role of educational sessions. A three month period between pre-and post-test was used for the Phase III randomised control trial. The significant results from the preliminary study were used to refine the processes used in the randomised controlled trial. In Phase III, the randomised controlled trial was conducted in Thailand to examine the benefits of the developed home-based exercise intervention program in terms of physical function, psychological health, cognition and quality of life. The results from this phase were reported in two different sections: physical function and other aspects, respectively. Sixty-six out of 84 participants were eligible to take part in this study and were randomly assigned into a control or intervention group (n=32 and n= 34 respectively). The control group received routine care provided by staff and the intervention group received a 12 week, home-based exercise intervention program including an educational session, home visits and telephone calls. Five participants withdrew from the study for health reasons, caregiver availability or concerns, and one participant (who differed because he was not able to afford the medication that all other participants were taking) was excluded before data analysis. Thus, data from 30 participants in each group were analysed using Mulivariate Analysis of Variances and Mann-Whitney U tests to compare between pre-and post-test scores. There were no significant differences between the control and intervention groups at the start of the trial. The muscle strength, physical function performance tests and Activities of Daily Living showed significant differences (p<0.001) for all variables between the intervention and control group over time. In particular, chest press, squats, elbow flexion, leg extensions, and speed of chair rise were significantly improved (p<0.005) over time for the intervention group. Further, positive trends of Katz’s Activities of Daily Living, Thai Activities of Daily Living, the 400 metre-walk, peak oxygen consumption and speed of the 6 metre-usual and fast walk were seen in the intervention group, whereas negative trends were seen in the control group. For the psychological health, cognition and quality of life sections, only the Mini Mental Status Examinations showed significant improvement in the intervention group, whereas a decline (p<0.05) was found in the control group. Further, a positive trend in Quality of Life-Alzheimer’s Disease rated by carers and the potential change in scores between pre-and post-tests for the Neuropsychiatric Inventory and the Thai Geriatric Depression Scale were found in the intervention group. For this group of assessments, a negative trend was found in the control group. However, the QOL-AD, rated by people with dementia themselves, showed a decline in the intervention group. This developed home-based exercise intervention program was safe, feasible, appropriate and provided benefits in terms of physical and cognitive functions for people with dementia living in Bangkok, Thailand. The significant aspects of this home-based exercise were that it is simple, convenient and culturally appropriate to the Thai context. Therefore, this home-based exercise intervention program should be implemented as part of dementia care to slow the deterioration seen among people with dementia and to help maintain independence, thus delaying caregiver burden. There were some limitations to this study (small sample size, short duration of the exercise program and lack of generalisation to other groups living in remote areas) but, despite these limitations, the positive results and trends found in the study highlighted the relevance and potential benefits of carefully designed exercise interventions for people with dementia. Further studies with a larger sample size, a longer period of exercise intervention and longer follow-up period as long term compliance and outcome measurement would be required in a larger study.

http://library.ecu.edu.au/record=b2255205~S7


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