UBC Faculty Research and Publications

Formulation of evidence-based messages to promote the use of physical activity to prevent and manage… Ginis, Kathleen A M; Heisz, Jennifer; Spence, John C; Clark, Ilana B; Antflick, Jordan; Ardern, Chris I; Costas-Bradstreet, Christa; Duggan, Mary; Hicks, Audrey L; Latimer-Cheung, Amy E; Middleton, Laura; Nylen, Kirk; Paterson, Donald H; Pelletier, Chelsea; Rotondi, Michael A Feb 17, 2017

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-12889_2017_Article_4090.pdf [ 528.52kB ]
JSON: 52383-1.0343035.json
JSON-LD: 52383-1.0343035-ld.json
RDF/XML (Pretty): 52383-1.0343035-rdf.xml
RDF/JSON: 52383-1.0343035-rdf.json
Turtle: 52383-1.0343035-turtle.txt
N-Triples: 52383-1.0343035-rdf-ntriples.txt
Original Record: 52383-1.0343035-source.json
Full Text

Full Text

RESEARCH ARTICLE Open AccessFormulation of evidence-based messagesto promote the use of physical activity toprevent and manage Alzheimer’s diseaseare encouraged to use the evidence-based statement in their programs and resources. Researchers, clinicians, peoplewith Alzheimer’s disease and caregivers are encouraged to adopt the messaging statement and the recommendationsGinis et al. BMC Public Health  (2017) 17:209 DOI 10.1186/s12889-017-4090-5Kelowna, CanadaFull list of author information is available at the end of the article* Correspondence: kathleen_martin.ginis@ubc.ca1School of Health & Exercise Sciences, University of British Columbia,in the companion informational resource.Keywords: Exercise, Aging, Dementia, Fitness, Activities of daily living, Cognition, Health promotion, MessagingKathleen A. Martin Ginis , Jennifer Heisz , John C. Spence , Ilana B. Clark , Jordan Antflick , Chris I. Ardern ,Christa Costas-Bradstreet6, Mary Duggan7, Audrey L. Hicks2, Amy E. Latimer-Cheung8, Laura Middleton9,Kirk Nylen4, Donald H. Paterson10, Chelsea Pelletier11 and Michael A. Rotondi5AbstractBackground: The impending public health impact of Alzheimer’s disease is tremendous. Physical activity is apromising intervention for preventing and managing Alzheimer’s disease. However, there is a lack of evidence-based public health messaging to support this position. This paper describes the application of the Appraisal ofGuidelines Research and Evaluation II (AGREE-II) principles to formulate an evidence-based message to promotephysical activity for the purposes of preventing and managing Alzheimer’s disease.Methods: A messaging statement was developed using the AGREE-II instrument as guidance. Methods included(a) conducting a systematic review of reviews summarizing research on physical activity to prevent and manageAlzheimer’s disease, and (b) engaging stakeholders to deliberate the evidence and formulate the messaging statement.Results: The evidence base consisted of seven systematic reviews focused on Alzheimer’s disease prevention and 20reviews focused on symptom management. Virtually all of the reviews of symptom management conflated patientswith Alzheimer’s disease and patients with other dementias, and this limitation was reflected in the second part of themessaging statement. After deliberating the evidence base, an expert panel achieved consensus on the followingstatement: “Regular participation in physical activity is associated with a reduced risk of developing Alzheimer’s disease.Among older adults with Alzheimer’s disease and other dementias, regular physical activity can improve performance ofactivities of daily living and mobility, and may improve general cognition and balance.” The statement was ratedfavourably by a sample of older adults and physicians who treat Alzheimer’s disease patients in terms of itsappropriateness, utility, and clarity.Conclusion: Public health and other organizations that promote physical activity, health and well-being to older adults1* 2 3 2 4 5© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Ginis et al. BMC Public Health  (2017) 17:209 Page 2 of 17BackgroundThe current and impending public health impact ofAlzheimer’s disease is staggering. Alzheimer’s disease isthe most common form of dementia, characterized byprogressive neural decline resulting in severe cognitiveimpairment, compromised physical ability, and loss offunctional independence [1, 2]. The number of cases ofAlzheimer’s worldwide is expected to increase from 30.8million in 2010 to over 106 million in 2050. By 2050, it isprojected that 1 in 85 adults worldwide will be living withthe disease [3]. As no cure exists for Alzheimer’s disease,there is an urgent need for interventions to reduce the riskof developing it and to help manage the symptoms amongthose who have been diagnosed with it.Physical activity may be a practical, economical, and ac-cessible intervention for both prevention and managementof Alzheimer’s disease. Engaging in routine physical activitycould reduce the risk of developing the disease [4–11]. Forindividuals with Alzheimer’s disease, physical activity mayhelp to mitigate and even improve some of the men-tal [4, 12–25] and physical [12, 19, 20, 22, 24, 26–30]symptoms. Moreover, a recent population-based analysisof seven potentially modifiable Alzheimer’s disease riskfactors revealed that the largest proportion of diseasecases in the United Kingdom, United States and Europecould be attributed to physical inactivity. A 10% reductionper decade in inactivity and the other risk factors was pro-jected to reduce the prevalence of Alzheimer’s disease byup to 1.5 million cases in those countries [31]. Thesestatistics provide a powerful case for the importance ofpublic health campaigns and messaging to promotephysical activity for the prevention and management ofAlzheimer’s disease.Evidence-based practice guidelines are an importanttool to support the promotion of physical activity. Suchguidelines stipulate the types, amounts, and intensitiesof physical activity needed for a particular population toderive certain benefits. For instance, the World HealthOrganization recommends that adults aged 18-64 shoulddo at least 150 min of moderate-intensity aerobic activitythroughout the week in order to achieve cardiorespira-tory and muscular fitness, bone health, and to reducethe risk of non-communicable diseases and depression.Unfortunately, Alzheimer’s disease prevention and man-agement are not included in this list of outcomes be-cause the level of activity needed to achieve suchbenefits is not yet known [9]. Until appropriate dose–re-sponse data are available, it is impossible to formulatephysical activity guidelines specifically for the preven-tion and management of Alzheimer’s disease (cf., [32])or to endorse the current WHO guidelines as beneficialin this regard.The absence of guidelines might imply that physicalactivity is not beneficial for those seeking to reduce theirAlzheimer’s disease risk or to mitigate decline. Conse-quently, an important opportunity for public health pro-motion and disease prevention may be missed. Giventhe projected growth in Alzheimer’s disease cases overthe coming decades [3], and the potential for physicalactivity to affect that trajectory [31], it is vital to commu-nicate the Alzheimer’s disease-related benefits of activityto older adults.Latimer-Cheung and colleagues have articulated theimportance of using research evidence to formulatepublic health communications about physical activity[33]. Indeed, public health behaviour change programsare often criticized for lacking an evidence base [34], inpart because health promoters traditionally operate in anenvironment that lacks systematic processes to consoli-date research evidence into usable knowledge tools andresources. For instance, agencies responsible for promot-ing physical activity to Canadians with disabilities reportthat they want to use research evidence in their initia-tives, but they often lack the resources to do so [35]. Ifhealth promoters do not have access to evidence-basedmessages and resources, then it is difficult for them touse evidence in their programs.To address the evidence gap in public health physicalactivity messaging, Latimer-Cheung et al. published a casestudy in which the Appraisal of Guidelines, Research andEvaluation II (AGREE II) instrument was modified andapplied to develop recommendations for constructingmessages to support the Canadian Physical ActivityGuidelines [32]. In general, the development process in-volved a literature review and the engagement of an expertpanel to interpret the evidence and formulate recommen-dations based on the evidence. These steps were under-taken in a systematic manner that adhered to AGREE IIstandards for using evidence to develop and report clinicalpractice guidelines. Through this rigorous process, theauthors demonstrated how to translate physical activityresearch into evidence-based messaging recommendationsfor use by groups with a vested interest in physical activitypromotion.Given the need for evidence-based messaging thatcommunicates the public health benefits of physicalactivity for preventing or managing Alzheimer’s disease[36], coupled with the development of a systematicapproach to formulating evidence-based physical activitymessages [33], the purpose of the present project was todevelop an evidence-based statement about the bene-fits of physical activity for preventing and managingAlzheimer’s disease.Background and project overviewThe first author was contacted by a provincial, non-government organization that was interested in workingwith scientists to develop evidence-based messages andknowledge products to raise local (i.e., provincial) aware-ness regarding the benefits of physical activity for theprevention and management of Alzheimer’s disease. Thefirst-author–a researcher with expertise in developingphysical activity guidelines and evidence-based resourcesfor adults with chronic disease and disability (KAMG)–and a scientist from the sponsoring organization (JA)agreed to co-direct the project. The project directorsworked with an Appraisal of Guidelines Research andEvaluation II (AGREE-II) consultant and a researcherwith expertise on exercise and Alzheimer’s disease(JH). Local stakeholders and scientists were involvedin formulating the messaging statement and providingfeedback.The process for developing the messaging statementwas guided by AGREE-II [37], an internationally recog-nized protocol for assessing the rigor, comprehensivenessand transparency of steps taken to formulate clinicalpractice guidelines. AGREE-II has been used previously asa framework for developing physical activity guidelines[38–40] and messages to support physical activity guide-lines [33]. Paralleling the steps used by Latimer-Cheunget al., [31], the steps taken to develop the messaging state-ment were: a) determine the scope and purpose of thestatement; b) conduct a systematic review of relevant lit-erature; c) host a consensus meeting to formulate thestatement; d) disseminate the statement for stakeholderfeedback; (e) finalize the statement; and (e) review of thestatement and this document by an AGREE II consultant.Each of these steps are described in the Methods section.MethodsStatement scope and purposeThe following were determined by the project directorsand confirmed appropriate by the expert panel members(see Table 1). Overall statement objective: To provide an evidence-based messaging statement for the use of physicalactivity (a) to prevent Alzheimer’s disease, and(b) to help manage symptoms and complications ofAlzheimer’s disease. Clinical questions addressed by the statement: Canphysical activity help to prevent Alzheimer’s diseaseTable 1 Expert panelName Expertise and Institution Role(s)Jordan Antflick (PhD) Knowledge Synthesis, Knowledge Translation,Dissemination: Ontario Brain InstituteKnowledge BrokerChris Ardern (PhD) Guideline Development, Content (exercise,epidemiology): York UniversityContent Expert-Physical Activity Epidemiologyoperceopiveopee Doper’sslaerseimltonelsGinis et al. BMC Public Health  (2017) 17:209 Page 3 of 17Christa Costas-Bradstreet Dissemination: ParticipACTIONMary Duggan Knowledge Synthesis, Guideline DevelDissemination: Canadian Society for ExJennifer Heisz (PhD) Knowledge Synthesis, Content (Alzheimexercise, aging): McMaster UniversityAudrey Hicks (PhD) Knowledge Synthesis, Guideline Devel(exercise, aging, practice): McMaster UnAmy Latimer-Cheung (PhD) Knowledge Synthesis, Guideline Devel(disability, behavior change), KnowledgQueen’s UniversityHans Messersmith Knowledge Synthesis, AGREE, GuidelinMcMaster UniversityKathleen Martin Ginis (PhD) Knowledge Synthesis, Guideline Devel(disability, behavior change), KnowledgMcMaster UniversityLaura Middleton (PhD) Content (exercise, cognition, Alzheimedementia: University of WaterlooKirk Nylen (PhD) Knowledge Synthesis, Knowledge TranDissemination: Ontario Brain InstituteDon Paterson (PhD) Content (exercise, aging): Western UnivKatherine Rankin (BA) Dissemination: Dementia Alliance, AlzhBrant, Haldimand Norfolk, Hamilton HaMichael Rotondi (PhD) Evidence Synthesis, Meta-analysis modUniversityJohn Spence (PhD) Knowledge Synthesis, Guideline Develop(physical activity, behavior change): UniveStakeholder, Disseminationment andise PhysiologyStakeholder, Disseminationr’s disease, Content Expert- Alzheimer’s disease,Aging, Exercise, Cognitive Neurosciencement, ContentrsityContent Expert-Physiologyment, ContentTranslation:Content Expert-Exercise Behavior Changeevelopment: Panel Chair, Process Advisorment, ContentTranslation:Leadership, Project Directiondisease, Content Expert-Exercise, Cognitive Agingand Alzheimer’s diseasetion, Knowledge Brokerity Content Expert-Physiology, Aginger Societies of Content Expert – Alzheimer’s diseaseStakeholder, Dissemination: York Content Expert-Biostatisticsment, Contentrsity of AlbertaContent Expert-Exercise Behavior ChangeGinis et al. BMC Public Health  (2017) 17:209 Page 4 of 17in community-dwelling adults? Can physical activity bebeneficial for managing symptoms and complicationsassociated with Alzheimer’s disease (i.e., cognitive,affective, behavioural, sleep, physical, activities of dailyliving [ADL] and quality of life [QOL] outcomes)? Target population: Older adults who wish to preventAlzheimer’s disease AND older adults with adiagnosis of Alzheimer’s disease. Potential users of the statement: a) older adults andtheir families, (b) primary caregivers of older adultswith Alzheimer’s disease, c) health care providersincluding primary care physicians, physiotherapists,kinesiologists, attendant care providers, certifiedexercise physiologists, and occupational therapists,and d) local service organizations–such as theCanadian Society for Exercise Physiologists (CSEP)and the Alzheimer Society of Ontario –and publichealth and physical activity promotional agencies(e.g., ParticipACTION).Systematic review of systematic reviewsA systematic review of systematic reviews provided theevidence base for the messaging statement. Becauseseveral systematic reviews have already been publishedon Alzheimer’s disease, other dementias and physical ac-tivity [7, 8, 16, 19], a decision was made to review thesearticles rather than conduct yet another review. A reviewof reviews has the advantage of facilitating comparisonand synthesis of findings across multiple reviews thatmay vary in scope and quality. Smith et al.’s [41]methodology was employed to guide the review protocoland is described next.Scope of the review; literature search strategy and screeningThe following inclusion criteria were set: English-languagesystematic reviews or meta-analyses examining thebenefits of physical activity for either the management orprevention of Alzheimer’s disease in humans; reviewsmust have focused on physical activity interventions aimedat decreasing symptoms (e.g., declines in cognitivefunction, QOL, etc.) or managing Alzheimer’s disease; orlongitudinal/cross-sectional studies that evaluated the roleof physical activity in reducing the risk for Alzheimer’sdisease. A research assistant developed the search strategyin consultation with the project directors. The searchincluded PubMed and Cochrane Library databases (2003-August 2013) along with a hand search from referencelists of other papers.To identify reviews of physical activity for managingAlzheimer’s disease, databases were searched for key-words: physical activity AND dementia AND reviews. Thisyielded 424 citations. An initial scan of these citations re-vealed that most reviews consisted of studies that includedpeople with other dementias, not just Alzheimer’s disease.Though Alzheimer’s disease is the most common form ofdementia, different pathologies can underlie dementiasyndrome and most reviews did not distinguish partici-pants based on their pathologies. Given the state of theliterature, a decision was made to broaden our inclusioncriteria to include reviews that focused on exercise tomanage Alzheimer’s disease as well as other dementias.The title and abstract of each citation were scannedand papers that were clearly outside the scope of the re-view were excluded; 20 reviews remained. The researchassistant and one of the authors then reviewed the full textof these 20 articles and 14 met our inclusion criteria. Toidentify reviews of physical activity to prevent Alzheimer’sdisease, a secondary search of the 424 citations was con-ducted using keywords: physical activity AND Alzheimer’sdisease AND prevention AND reviews, yielding 60 cita-tions. After scanning titles and abstracts, 19 reviewsremained that focused specifically on prevention ofAlzheimer’s disease (not the prevention of other demen-tias). After full text reviews, 6 of these 19 articles met ourinclusion criteria. An updated literature search was com-pleted in November 2015, and seven new reviews wereadded (one on prevention, six on management), resultingin a total of 20 reviews on management and seven reviewson prevention.Data extraction and assessment of methodological qualityIndividually, the research assistant and a study authorextracted information from each review and assessedeach review’s methodological quality using the 11-itemA Measurement Tool to Assess Systematic Reviews(AMSTAR; http://www.amstar.ca/Amstar_Checklist.php)[42]. A score of 0–4 indicates low methodologicalquality, 5–8 indicates moderate methodological quality,and 9–11 indicates high methodological quality. Thereviewers were not blinded during these steps. The ex-tractions were completed in triplicate and AMSTARevaluations were completed in duplicate. Any discrepan-cies were resolved through conversation until 100%agreement was achieved. Higher quality reviews wereweighted more heavily than lower quality reviews whendeliberating the evidence.Stakeholder involvementStakeholders representing various local interest groups(service providers, qualified exercise professionals), phys-ical activity promoters, and knowledge brokers partici-pated in the expert panel (Table 1) by developing andrefining the messaging statement, and creating a sup-porting informational resource. Recognizing that somepotential statement users were not on the panel, thestatement was circulated to physicians who treat patientswith Alzheimer’s disease and they provided anonymousfeedback (N = 6). Healthy older adults drawn from anexercise and wellness program (N = 15) were given apaper copy of the statement and supporting resourceand were directed to an online questionnaire to provideanonymous feedback (see Table 2). In addition, caregivers(N = 5) of older adults who participated in an exerciseprogram for people with Alzheimer’s were given a papercopy of the statement and resource and completed a paperversion of the questionnaire items shown in Table 2.Consensus meetingIn September 2013, an expert consensus panel wasconvened for a 1-day meeting to review the evidence andformulate the statement. The meeting was chaired by oneof the project directors and an AGREE II expert. Panelmembers included ten university-based researchers withexpertise that spanned relevant content areas, knowledgesynthesis and physical activity guideline development,along with five stakeholders representing health care pro-fessional groups and service organizations. The researchassistant involved in the systematic review was alsopresent. Given the importance of evaluating the researchevidence with consideration of the context in which aresulting knowledge product will be disseminated [43], allbut one panel member was based in the same province asthe sponsoring organization and were thus familiar withthe local context in which the knowledge products wouldbe employed.Prior to the meeting, all panel members receivedtabular summaries of the systematic review evidence(versions of Tables 3 and 4). The Chair began the meet-ing with an overview of AGREE-II and the process to beused to formulate the statement. Next, the chair pre-sented the results from the systematic review of reviewson the use of physical activity to manage Alzheimer’sdisease, followed by the systematic review of reviews onphysical activity for prevention of Alzheimer’s disease.After each presentation, panel members discussed thestrength, quality and quantity of evidence. Through thesediscussions, the panel came to unanimous agreement thatinsufficient quality evidence was available to produce aspecific physical activity guideline (i.e., a prescription) forthe prevention or management of Alzheimer’s. The panelTable 2 Ratings of the statement and informational resource (i.e., “the toolkit”) obtained from health care providers and older adultsHealth care providersn M (SD) Range of responsesIn your opinion, is the toolkit appropriate for all community-dwellingindividuals with Alzheimer’s disease?5 4.40 (.55) 4–5In your opinion, does the toolkit provide useful information for peoplewith Alzheimer’s disease?5 4.80 (.45) 4–5Ginis et al. BMC Public Health  (2017) 17:209 Page 5 of 17In your opinion, does the toolkit provide useful information for healthcare practitioners?How confident are you that a client with Alzheimer’s disease couldengage in enough physical activity each week to meet the currentphysical activity guidelines?If given the opportunity, would you use this statement to recommendphysical activity in your practice?Does the statement provide useful information for older adults?Does the statement provide useful information for families andcaregivers of people with Alzheimer’s disease?Is the statement clear regarding the benefits of physical activity?In your opinion, is the toolkit appropriate for older adults with Alzheimer’sdisease or those who want to prevent Alzheimer’s disease?In your opinion, does the toolkit provide useful information for peoplewith Alzheimer’s disease or those who want to prevent Alzheimer’sdisease?In your opinion, does the toolkit provide appropriate information to helpolder adults become more physically active?In your opinion, does the toolkit provide clear information on the benefitsof physical activity for preventing Alzheimer’s disease?In your opinion, does the toolkit provide clear information on the benefitsof physical activity for managing Alzheimer’s disease?Note. All responses were made on a scale ranging from 1 to 5, with higher scores in5 4.40 (.55) 4–55 3.00 (.71) 2–45 4.00 (.71) 3–5Older adults Caregiversn M (SD) Range of responses n M (SD) Range of responses15 4.47 (.52) 4–5 5 4.20 (.45) 4–515 4.47 (.52) 4–5 5 4.20 (.45) 4–515 4.40 (.63) 3–5 5 4.20 (.45) 4–514 4.21 (.58) 3–5 5 4.20 (.45) 4–514 4.14 (.53) 3–5 5 3.80 (.87) 3–514 4.21 (.43) 4–5 5 4.00 (.00) 4–415 4.00 (.65) 3–5 5 4.00 (.00) 4–415 3.93 (.59) 3–5 5 4.20 (.45) 4–5dicating more favourable ratingsTable3SummaryofreviewsexaminingtheeffectsofexerciseinterventionsonsymptomsassociatedwithAlzheimer’sdiseaseandrelateddementiasReviewQualityscore#StudiesinreviewaTypeCharacteristicsOutcomesParticipantsDesignInterventionsPhysicalPsycho-logicalADLandqualityoflifeBlankevoortetal.,2010b[26]916NR/MAElderly(meanage>70years)withdementia10RCT,6caseseriesVariousstructuredexerciseprogramsPhysicalFunction:↑GaitSpeed,fast(k=2)ES=0.14;↑Gaitspeed,normal(k=6)ES=0.29;↑Endurance(k=5)ES=1.08;↑Lowerextremitystrength(k=7)ES=0.85↑Functionalmobility(k=6)ES=0.28BalanceandFalls:↑Balance(k=5)ES=1.76↑ADL(k=4)d=0.68Booteetal.,2006[27]81NRMod-severeADRCTGroupexercisePhysicalFunction:<>Functionalability(0/1),↑PhysicalTherapyAssessment(1/1)BalanceandFalls:↑Balance(1/1)Brettetal.,2015[12]912SRDementialivinginnursinghomeRCTAnyPAPhysicalFunction:↑Mobility(3/5)BalanceandFalls:↑Balance(1/2)Cognition:↑Cognition(5/7);Affect:↑Mood(3/4);↓Agitation(1/1)↑ADL(3/5)Burtonetal.,2015[28]114SR/MADementialivinginthecommunity3RCTand1quasi-experi-mentalStrength,balanceandmobilityexercisesBalanceandFalls:↓Falls(k=2)MD=-1.06*;<>Fallrisk(k=2)MD=-0.1;<>Balance(k=2)MD=0.51Cooperetal.,2012[13]101NRDementiaRCTComprehensiveexerciseprogram<>QOL(1/1)deSoutoBarretoetal.,2015[14]820SR/MADementiaRCTAnyexerciseAffect:↓Depression(k=7)SMD=-0.31*Behaviours:<>Behaviours(k=4)MD=-3.88Farinaetal.,2014[15]103MAADRCTAnyexercise(min.4weeks)Cognition:↑Globalcognition(k=3)SMD=0.75*Ginis et al. BMC Public Health  (2017) 17:209 Page 6 of 17Table3SummaryofreviewsexaminingtheeffectsofexerciseinterventionsonsymptomsassociatedwithAlzheimer’sdiseaseandrelateddementias(Continued)Forbesetal,2013[16]1116CROlderadults(>65yearsold)withdementiaRCTAnyexerciseCognition:↑Globalcognition(k=8)SMD=0.55*Behaviours:<>Challengingbehaviours(k=1)SMD=-0.60Affect:<>Depression(k=5)SMD=-0.14↑ADL(k=6)SMD=0.68*Forbesetal,2015[17]1117CROlderadults(>65yearsold)withdementiaRCTAnyexerciseCognition:<>Globalcognition(k=9)SMD=0.43;[excludingmoderate-severedementia(k=8)SMD=0.21]Affect:<>Depression(k=5)SMD=-0.14Behaviours:<>Challengingbehaviours(k=1)MD=-0.60↑ADL(k=6)SMD=0.68*Grootetal.,2016[52]918MAAlldementiaexceptthosethataffectmotorsystem(e.g.,Huntington’s,Parkinson’s)RCTAnyphysicalactivityCognition:↑Cognition(k=16)SMD=0.42*↑ADL(k=4)SMD=1.18*Hermansetal.,2007[18]90CRDementialivingindomesticsettingRCTWalkingandexercisetherapyBehaviours:NostudiesofwanderingmetinclusioncriteriaHeynetal.,2004[19]1030MAOlderadults(≥65years)withcognitiveimpairment(MMSE<26)RCTAnyexercisePhysicalFitness:↑Health-relatedphysicalfitness(k=40)ES=0.69*;↑Cardiovascular(k=18)ES=0.62*;↑Strength(k=17)ES=0.75*;↑Flexibility(k=4)ES=0.91*PhysicalFunction:↑Functionalperformance(k=20)ES=0.59*Cognition:↑Cognition(k=12)ES=0.57*Behaviour:↑Behaviour(k=13)ES=0.54*Ginis et al. BMC Public Health  (2017) 17:209 Page 7 of 17Table3SummaryofreviewsexaminingtheeffectsofexerciseinterventionsonsymptomsassociatedwithAlzheimer’sdiseaseandrelateddementias(Continued)JensenandPadilla,2011[29]66NRDementiaMixedExerciseandmotor-basedinter-ventionsforfallsprevention(2group-based;4individual)BalanceandFalls:↓Fallrisk(3/4)↑Balance(1/1)Littbrandetal.,2011[20]910;resultsfrom6lowqualitystudiesnotreportedNRDementiaRCTWalkingandcombinedexercisePhysicalFunction:↑Walkingperformance(2/2);<>Mobility(0/2)BalanceandFalls:<>Balance(0/1)↑ADL(1/1)O’Connoretal.,2009[21]81NRDementiaRCT,RMAnyPAorexerciseAffect:↑Positiveaffect,(1/2);↓Negativeaffect,(1/2)Pitkalaetal.,2013[30]820NRDementiaRCTAnyPAPhysicalFunction:↑Physicalfunction(16/20);↑Mobilityor↓functionallimitations(8/9moderate-to-highqualitystudies)Raoetal.,2014[22]56SRAmbulatoryolderadults(>65years)withADRCTwithsamplesize>15Aerobic,strength,andbalancedoranycombinationofthethreePhysicalFunction:Functionalability(k=6)ES=0.53*↑ADL(k=6)ES=0.80*Thuné-Boyleetal.,2012[23]616RCIADementiaExerciseinter-ventionstudies(6)andreviews(10)AnyexerciseAffect:↓Agitation(4/4);↓Depression(4/8);Behavior:↓Wandering(1/2);↑Nighttimesleep(3/5)Yu,2011[24]612NRADExperi-mentalorquasi-experi-mentalAerobicexercise(aloneorcombination;>2weeks)PhysicalFitness:↑6minwalk(1/1);↑Strength(1/1);PhysicalPerformance↑Physicalperformance(4/5)Cognition:↑Globalcognition,MMSE(4/4)Affect:↑Mood(4/6)↓ADLlimitations(2/2)Yuetal.,2006[25]818NRADAnyAerobicexerciseCognition:↑Globalcognition(2/2)Note:ADAlzheimer’sdisease,ADLactivitiesofdailyliving,CRCochranereview,MAmetaanalysis,NRnarrativereview,PAphysicalactivity,QOLqualityoflife,RCTrandomizedcontrolledtrial,RCIArapidcriticalinterpretiveapproach,SMDstandardmeandifference,MDmeandifference,ESeffectsize;knumberofstudiesValuesinparenthesesindicatethenumberofstudiesoreffectsizesinareviewthataddressedthatoutcome(denominator)andthenumberthatindicatedsignificantimprovements(numerator)*Significanteffectsize,p<.05a Formeta-analyses,‘#ofstudies’referstothenumberofuniquestudiesincludedinthereportedmeta-analysesbBlankevoortetal.didnotreportthestatisticalsignificanceofeffectsizesnordidtheyreportconfidenceintervalsGinis et al. BMC Public Health  (2017) 17:209 Page 8 of 17halt65lthlatiunGinis et al. BMC Public Health  (2017) 17:209 Page 9 of 17Table 4 Summary of reviews examining whether physical activity inAlzheimer’s disease and related dementiasReference QualityscoreType Characteristics of included reviews# ofstudiesaDesign ParticipantsBeckett et al.2015 [4]7 MA 9 Prospectivecohort studiesCognitively heolder adults, ≥Barnes et al.,2011 [5]4 NR 2 Prospectivecohort studiesNo dementiadiagnosis atbaselineBeydoun et al.,2014 [6]7 MA 8 Cohort studieswith samplesize > 300Generally heaolder adultsDaviglus et al.,2011 [7]9 NR&12 Cohort studieswith sampleGeneral popudeveloped coagreed, however, that sufficient quality evidence existed toproduce a consensus statement regarding the use ofphysical activity for these purposes.To assist in formulating the statement, as a startingpoint, panel members were presented with the followingpreliminary statements: “Among people with Alzheimer’sDisease, physical activity can improve important aspects ofwell-being including physical fitness, physical performance,cognitive functioning and mood;” and “Habitual physicalactivity can reduce the risk of developing Alzheimer’sDisease.” These statements were constructed by the leadauthor. The first statement was a summary of conclusionsdrawn in the reviews shown in Table 3, particularly thosecited by Yu [24]. Yu’s conclusions were considered anappropriate starting point because they captured a broadrange of outcomes. Note however, that Yu’s review did notconsider the quality of the reviewed evidence so thoseconclusions could not be considered definitive. TheMA size ≥ 300 ≥50 yearHamer et al.,2009 [8]11 MA 5 Prospectivecohort studiesDiagnosis ofdementia/ADPatterson et al.,2007 [10]6 NR 3 Longitudinalcohort studiesRepresentative oCanadian demogexclusion of demat baselineRolland et al.,2008 [11]5 NR 24 LongitudinalepidemiologicalstudiesNo dementia diaat baseline, ≥60Note. aFor meta-analyses, ‘# of studies’ refers to the number of unique studies incluAD Alzheimer’s disease, HR hazard ration, MA meta-analysis, NR narrative review, ORRR relative riskealthy older adults is associated with a reduced risk of developingConclusionsPAhyyearsAny PA PA is associated with a ↓ risk of developing ADin adults 65 years and older. RR of .61, 95% CI0.52-0.73 for physically active older adultscompared to non-active counterparts.Any PA Of seven potentially modifiable risk factorsexamined, physical inactivity contributed to thelargest proportion of AD cases in the US and asubstantial proportion of cases globally.y Any PA RR of AD = 0.58 (0.49,0.70) for the groupreporting the highest PA versus the lowest PA.PAR% = 31.9%, 95% CI 22.7–41.2%.on intries,Self-reportedPA.NR: 8/12 studies reported a protective effect ofmoderate to high levels of PA on risk of AD;second preliminary statement paralleled Hamer et al.’s [8]conclusion that “physical activity is inversely associatedwith risk of dementia”. In that meta-analysis, the qualityof the evidence had been taken into considerationalthough the data were drawn from studies published in2007 and earlier. The evidence was then discussed untilthe panel achieved a unanimous consensus statement.Next, the panel discussed the potential health benefitsand risks associated with the statement. The panelacknowledged the extensive body of evidence showingthe wide range of health and fitness benefits that olderadults can accrue from regular physical activity [9]. Thepanel also noted evidence that populations with demen-tia do not report considerable or consequential adverseevents associated with physical activity [44].The panel recommended that the evidence base bereviewed at least every three years to ascertain whetherthe messaging statement requires updating. During thesehowever, the associations were not alwayssignificant after adjusting for confoundingfactors or when looking across high andmoderate activity levels.MA: Across 9 cohort studies, higher PAassociated with ↓risk of incident AD (HR = 0.72);however, substantial heterogeneity amongstudies.Any PA PA ↓risk of AD by 45%. RR of AD = 0.55 for thegroup reporting the highest PA versus thelowest PAfraphic,entiaAny PAor energyexpenditure3/3 studies provided evidence that regularphysical activity is associated with a reducedrisk for AD.gnosisyearAny PAor energyexpenditure20/24 studies suggested a significant andindependent preventive effect of physical activityon cognitive decline, or dementia, or AD risk.Physical activity could reduce the incidenceof AD.ded in the reported meta-analysesodds ratio, PA physical activity, PAR% population attributable risk percent,has convened once by teleconference and twice by email toGinis et al. BMC Public Health  (2017) 17:209 Page 10 of 17modify the statement based on the new evidence. AnAGREE-II expert formally audited our procedures for de-veloping the statement, using the AGREE-II Online Guide-line Appraisal Tool (http://www.agreetrust.org/appraisal/15654) [37].ResultsSystematic reviewWith regard to preventing Alzheimer’s disease, physical ac-tivity was associated with a reduction in risk of Alzheimer’sdisease in all seven review articles. There were 33 uniquestudies included in the reviews. These studies capturedvirtually any type of physical activity or energy expenditure(see Table 4). Two review articles were of high meth-odological quality [7, 8], four were of moderate qual-ity [4, 6, 10, 11], and one was low quality [5]. Six ofthe seven reviews concluded that physical activity wasassociated with a significant reduction in risk ofAlzheimer’s [4–8, 10], although one of the high qual-ity reviews graded the quality of evidence as low [7].The seventh review [11] noted that 20 out of 24reviewed studies reported a significant associationbetween physical activity and reduction of risk ofAlzheimer’s disease, but the authors stopped short ofmaking conclusions about the effects of physical ac-tivity because of an absence of RCT-derived evidence.The authors did, however, conclude that an active lifestyleseems to have a protective effect on brain functioning andreviews, consideration should be given to whether thequality and quantity of evidence have developed suffi-ciently to allow for formulation of physical activityguidelines. At this time, because only the initial messa-ging statement development process has been funded,the feasibility of ongoing updates is uncertain.The consensus panel also discussed facilitators andbarriers to implementing the messaging statement, in-cluding resource implications and informational needs.Panel members worked in sub-groups to identify contentfor an informational resource to support the uptake ofthe messaging statements. Discussions were guided byexisting research on physical activity messaging andinformational needs of older adults [45], along with con-sideration of dementia symptoms [46, 47]. The resultantrecommended content could be generally categorized asclarification messages, motivational messages, and infor-mation for caregivers, and was subsequently given to atechnical writer who drafted and wrote the content forthe informational resource (http://www.braininstitute.ca/physical-activity-and-alzheimers-disease-toolkit).Since the original consensus panel meeting, the panelmay also slow the course of Alzheimer’s disease. Overall,the studies reported in the reviews provided consistentevidence that physical activity is associated with a reducedrisk for developing Alzheimer’s disease.With regard to managing Alzheimer’s disease andother dementias, there were 121 unique studies capturedby the 20 systematic reviews. These studies includedphysical activity interventions involving structuredexercise, group exercises, strength, balance and mobilityexercises, walking and exercise therapy, and “any exercise”in general (see Table 3). Many studies had more than oneoutcome of interest — the effects of physical activity oncognitive, affective, behavioural, physical (physical fitness,performance, balance), ADL and QOL were the outcomesexamined in this review.CognitionEight reviews reported on cognition and included fromtwo [25] to 12 [19] studies. Six of the reviews were of highmethodological quality, with five out of six providing evi-dence of positive effects of physical activity on cognition.Specifically, four reviews that included meta-analysesyielded significant average effect sizes, expressed asstandardized mean group differences, ranging from 0.42 to0.75. The fifth review found that exercise improved cogni-tion in five of seven studies [12]. Whereas a 2013 Cochranereview found significant effects on cognition [16], the mostrecent (2015) Cochrane review [17], included just one add-itional trial [16] but found no significant effect (p = .08)and rated the available evidence as very low quality. Theother two reviews were narrative reviews of moderate qual-ity; both concluded exercise is a promising intervention forimproving cognition [24, 25]. It is important to note thatmost of the studies included in the reviews employed aglobal measure of cognitive impairment, such as the MiniMental State Examination [48] or the Montreal CognitiveAssessment [49], rather than measures of specific aspectsof cognitive function. Taking this factor into consideration,overall, there is promising evidence that physical activitymay have positive effects on global cognition. However,given the conflicting conclusions from the two recentCochrane review [16, 17], no firm conclusion can be made.AffectSeven reviews examined affect-related outcomes and con-sisted of one to eight studies. Two Cochrane reviews ofhigh methodological quality found no significant effect ofphysical activity on depression [16, 17]. One meta-analysisof moderate quality found that physical activity reduceddepression [14]. Four other reviews, one of high quality[12] and three of moderate quality [21, 23, 24], allreported that some studies showed exercise can alleviatedepression or enhance mood whereas other studies didnot. Taken together, the extant research provides no con-sistent evidence that physical activity improves depressionor other aspects of mood in this population.Ginis et al. BMC Public Health  (2017) 17:209 Page 11 of 17BehavioursSix reviews examined the effects of physical activity onchallenging behaviours associated with dementia. Two ofthese reviews specifically addressed wandering; one wasa high quality Cochrane review but the authors did notfind any suitable studies to include in their review [16].The other was of moderate quality and reported short-term decreases in wandering in one of two includedstudies [23]. The latter review also addressed nighttimesleep [23] and reported that three of the five includedstudies showed improvements. The other two reviewsexamined a range of challenging behaviours such as ag-gression, restlessness, wandering, and rummaging. Twowere high quality Cochrane reviews [16, 17] that con-sisted of a single study and found no significant effectsof exercise. The other two were moderate quality meta-analyses; one of which included 13 studies and foundsignificant effects of physical training across a range ofbehavioural outcomes [19] and the other included sevenstudies which found no effect [14]. Based on thesereviews, there is no consistent evidence that exerciseimproves challenging behaviours.Physical outcomesWhen reviewing the literature on physical outcomes, itbecame apparent little consistency existed across the re-views, and across the studies captured by those reviews,in operational definitions and measures of physicaloutcomes such as “physical fitness,” “mobility,” “physicalfunction,” and “physical performance”. For instance,measures of walking performance were classified as anindex of physical fitness in one review [24], physicalfunction in another review [20], and reflected in ADLmeasures [50]. We have retained the original nomencla-ture of each review article to categorize the physicaloutcome measures; however, it is important to note thatthe categories are not clearly defined nor are they mutu-ally exclusive.Physical fitnessTwo reviews examined outcomes that their authorscategorized as “physical fitness” [19, 24]. One review wasof high methodological quality [19] and included severalmeta-analyses of four to 40 studies that revealed signifi-cant effects of exercise training on cardiovascular,strength, flexibility, and overall fitness outcomes. A nar-rative review of moderate quality [24] reported on a sin-gle trial that improved 6-min walk distance and anotherthat improved muscular strength.Physical performance/functionEight reviews reported on outcomes that their authorscategorized as physical function or performance. Fourwere high quality. One high quality review reportedaverage effect sizes (but did not report statistical signifi-cance or confidence intervals) ranging from 0.14 to 1.08for the effects of physical activity on gait speed (fast andnormal), endurance, lower extremity strength and func-tional mobility and concluded that multicomponentexercise training interventions can improve physicalfunctioning [26]. Similarly, a high quality meta-analysisof twenty studies found significant medium-sized effectsof exercise on measures of functional performance [19].Of the two high quality reviews that consisted primarilyof adults with Alzheimer’s disease living in residentialcare facilities, one reported significant improvements intwo out of two reviewed studies of walking performance,but no improvements in mobility [20] whereas the otherreview reported improvements in mobility in three outof five reviewed studies [12].There were four moderate quality reviews. One was asystematic review that reported that exercise increasedfunctional ability [22]. The other three were narrativereviews [24, 27, 30]. Boote et al.’s [27] review includedjust one study, and focused on adults with moderate-severe Alzheimer’s disease. They concluded that regularexercise can significantly increase muscle strength andbalance, but does not improve functional abilities asmeasured on the Changes in Advanced Dementia Scale[51]. In contrast, Pitkala et al.’s [30] review of 20 RCTsconcluded there is consistent evidence that intensiveexercise interventions enhance mobility and may alsoimprove physical functioning if administered over thelong-term. Likewise, Yu et al. [24] summarized the out-comes of five studies as showing improvement in phys-ical performance among older adults with Alzheimer’sdisease who participated in comprehensive exercise pro-grams that had an aerobic exercise component.Looking across the various physical outcomes, consistentevidence exists that physical activity can improve mobi-lity–that is, people’s ability to walk, and to move around.Because so few studies employed true assessments ofphysical fitness (e.g., validated measures of cardiovascularendurance or muscle strength), no conclusions can bemade regarding fitness outcomes.Balance and falls preventionSix reviews examined balance. One high quality meta-analysis [26] of five studies found a very large effect ofphysical activity on balance whereas another high qualitymeta-analysis of two studies found no effect [28]. Thetwo other high quality reviews assessed adults in resi-dential care. Littbrand et al.’s narrative review of a singlestudy reported no effects on balance and Brett et al.’ssystematic review of two studies reported effects onbalance in only one. Two moderate quality narrativereviews, each including just one study, concluded thatphysical activity interventions improved balance [27, 29].Two reviews directly examined falls; one of high qualityand one of moderate quality, and both reported thatexercise programs designed to prevent falls were foundto be beneficial [29]. Taken together, there is promisingGinis et al. BMC Public Health  (2017) 17:209 Page 12 of 17evidence that physical activity may improve balance andreduce the risk of falls.Activities of Daily Living (ADL)Seven reviews addressed ADLs. Four high quality[16, 17, 26, 52] meta-analyses, two of which wereCochrane reviews, included four to six studies. All fourreported medium to large-sized effects of physical activityon ADL. One of the Cochrane reviews concluded thatthere is promising evidence that exercise programs cansignificantly improve the ability to perform ADL [16].Two high quality reviews that examined adults in residen-tial care concluded that exercise improved or reduced thedecline in ADL [12, 20]. Of the two moderate quality re-views, one reviewed six studies and reported a significantimprovement in ADL [22] and the other reviewed [24]two studies and concluded that comprehensive exercisethat includes aerobic exercise could help older adults withAlzheimer’s disease reduce ADL decline, and maintainbasic and instrumental ADL. Taken together, the reviewsprovide consistent evidence that physical activity haspositive effects on ADL.Quality of Life (QOL)One review examined QOL. This high quality narrativereview, consisting of a single study, reported no effectsof exercise on QOL [13]. At this time, there is insuffi-cient evidence to draw any conclusions regarding theeffects of physical activity on QOL in this population.The messaging statementDrawing on discussions of the evidence presented inTables 3 and 4, the panel achieved consensus on thefollowing statement (see Table 5): “Regular participationin physical activity is associated with a reduced risk ofdeveloping Alzheimer’s disease. Among older adults withAlzheimer’s disease and other dementias, regular phys-ical activity can improve performance of activities ofdaily living and mobility, and may improve generalcognition and balance”. Panel members agreed there isinsufficient or inadequate evidence to address whetherphysical activity can improve other outcomes such asaffect, the risk of falling, quality of life, and challengingTable 5 The messaging statement“Regular participation in physical activity is associated with a reduced riskof developing Alzheimer’s disease. Among older adults with Alzheimer’sdisease and other dementias, regular physical activity can improveperformance of activities of daily living and mobility, and may improvegeneral cognition and balance.”behaviours associated with dementia and Alzheimer’sdisease.Although one review [20] indicated no major adverseeffects of physical activity, few studies reported adverseeffects [19, 20]. In generally healthy older adults, seriousadverse events associated with physical activity are rare[53]. Regarding people with Alzheimer’s disease, the panelcould not make an evidence-based decision regarding therisks associated with physical activity. Nevertheless, thepanel acknowledged the low incidence of adverse physicalactivity-related events among people with dementia [44].The panel agreed no evidence existed that physical activityis associated with increased risk of disease, or furtherprogression or onset of Alzheimer’s disease.Stakeholder feedbackStakeholder feedback was positive. For all three samples,mean ratings of appropriateness and utility of the physicalactivity messaging statement and informational resourceranged from 3.8 to 4.8 out of 5 (see Table 2). Older adultsrated the clarity of information on the benefits of physicalactivity for preventing and managing Alzheimer’s diseaseat, or slightly below 4.0. This feedback resulted in minorwording changes to the informational resource.Editorial independenceThe Ontario Brain Institute funded the messaging state-ment development project. Members of the Instituteobserved the consensus meeting but had no influence onthe final statement whatsoever. No panel members de-clared a conflict of interest.AGREE-II evaluationThe messaging statement received an overall qualityscore of 6 out of 7 and was recommended for use.Table 6 shows ratings for each AGREE-II domain, areasidentified for improvement, and subsequent modifica-tions to this document that were made in response tothe appraisal.DiscussionA lack of evidence-based guidelines regarding the use ofphysical activity to prevent and manage Alzheimer’sdisease may create a lost opportunity for promotingphysical activity to older adults who may be motivatedto be active for these reasons. To address this gap, ourconsensus panel formulated an evidence-based messa-ging statement by following the AGREE-II protocol. Thefirst part of the messaging statement is wholly consistentwith conclusions drawn in several reviews [4, 5, 8, 9]and speaks to the role of physical activity for preventingAlzheimer’s disease: “Regular participation in physicalactivity is associated with a reduced risk of developingAlzheimer’s Disease.” Though this statement is basedpoenttcocalbohavagityailspst,r sinkpinectnst mntsinglyinoGinis et al. BMC Public Health  (2017) 17:209 Page 13 of 17Table 6 AGREE-II domains, scores, areas for improvement, and resDomain Score Areas for improvem1. Scope and Purpose 18/21 • Include specific ousetting to the clini• Additional details apopulation wouldrating (e.g., specificstage and/or sever2. Stakeholder Involvement 19/21 None3. Rigour of Development 47/56 • Provide further detevidence (e.g., timeoutcomes of intere• Eligibility criteria fostated/listed• Provide an explicit lkey evidence understatement4. Clarity of Presentation 18/21 • The inclusion of a swith the final consemake the statemenin the report5. Applicability 21/28 • No explicit commethe report concernimplications of apprecommendations,exclusively on observational data, it satisfies several ofBradford Hill’s criteria for causation [54] including astrong and consistent association with temporal sequen-cing. It is also biologically plausible and consistent withemerging evidence that physical activity can change thestructure and function of the brain. In particular, physicalactivity may mitigate age-related atrophy of the hippocam-pus, a key brain structure affected by Alzheimer’s diseasethat is critical for memory function [55]. The evidencereviewed did not differentiate between physical activitiesand sedentary tasks, however this distinction should beconsidered in future research given the emerging evidencethat physical activity and sedentary behaviour may be in-dependent predictors of health in aging [56, 57].The second part of the statement reflects the bestavailable evidence regarding the effects of physicalactivity on symptoms and complications associated withAlzheimer’s disease. The majority of reviews used thebroader classification of dementia (rather than Alzheimer’sdisease per se) as the study inclusion criterion and thisqualifier is reflected in the statement: “Among older adultswith Alzheimer’s disease and other dementias, regular phys-ical activity can improve performance of activities of dailyliving and mobility, and may improve general cognitionand balance.” This statement is generally consistent withassessment undertake6. Editorial Independence 8/14 • An explicit statementwas not included, nostatement to indicateof the funding bodyfinal consensus statemnses/actions takenin the report Response/Actionmes of interest andquestionut the targete increased thee ranges, specifyingof the disease)• These details were added• These details cannot be provided giventhe limited research baseon the search foreriods searched,etc.)tudies not explicitlying/identification of thening the consensus• Additional details have been added• An explicit statement has been added• Space restrictions preclude statement-by-statement links to the evidence; howeverit’s now noted that the evidence in Tables 3and 4 has been used to guide the consensusstatemention or an appendixus statement wouldore easily identifiable• A table/box was added to highlight thefinal statementwere included inpotential resourceng ther was a formal• Notes from the panel’s discussion ofresource implications have been addedthe conclusions cited by several research groups [4,20, 23, 29, 30]. However, some conclusions cited inthose reviews were not carried over to our statement, in-cluding those pertaining to effects on affect, sleep, agitation,and wandering. These discrepancies are largely attributableto our consideration of review quality–higher quality reviewscarried more weight in our deliberations–as well as thequantity and consistency of evidence across reviews. Paren-thetically, given the inconsistencies across studies in theamount of exercise prescribed, and the disease severity ofparticipants, it is perhaps not surprising that some areas ofresearch have yielded inconsistent findings and that smallchanges to the evidence base can lead to new conclusions.It is important to consider the implications of includingother dementias in our analysis of the effects of PA onAlzheimer’s disease symptom management. AlthoughAlzheimer’s neuropathology is present in up to 80% ofdementia cases, each form of dementia is associated witha different symptom profile and rate of symptom progres-sion [1]. Such heterogeneity means that the benefits of PAmay differ by dementia subtype. That said, all forms ofdementia impact the health and functioning of the brainand interfere with the individual’s ability to perform activ-ities of daily living [1]. Moreover, commonly used pharma-cological therapies are prescribed for symptoms that cann/reportedregarding the funderr was an explicitthe views or interestsdid not influence theent• An explicit statement has been addedGinis et al. BMC Public Health  (2017) 17:209 Page 14 of 17be shared across Alzheimer’s disease and other dementias,even though these therapies may not be very effective andare commonly associated with adverse effects [58]. There-fore, the evidence-based messages regarding the benefitsof regular PA for mitigating certain dementia symptomswith minimal adverse effects has important clinical rele-vance for individuals with Alzheimer’s disease and otherforms of dementia. Future research is needed to evaluatewhether the benefits of PA for dementia symptomsdepend on symptom origin, profile or severity.It is also important to consider the implications of themessaging statement and toolkit for Alzheimer’s diseasepatients living in residential facilities. Only one reviewfocused exclusively on studies set in nursing homes withpatients with mild to severe forms of dementia [12].Although a limitation is that the 12 studies in thatreview had small samples, the authors of that reviewcame to similar conclusions as the reviews involvingcommunity dwelling adults with Alzheimer’s. Thus, themessaging statement should be applicable to all individ-uals with Alzheimer’s disease regardless of their livingarrangement. Of note, the review also concluded thatinterventions set in nursing homes had the greatestbenefit when the PA program included a combination ofaerobic, strength and stretching activities that weredifferent from patients’ daily routine and were led by atrained physiotherapist. Programmers may find thisinformation useful when implementing the messagingrecommendations in nursing homes.Though necessary for health education and promotion,guidelines and messaging statements are insufficient formotivating behaviour change in the absence of informa-tion on how to achieve the recommended behaviour [45].Accordingly, the Ontario Brain Institute has producedBoost Your Brain and Body Power - Physical Activity andAlzheimer’s Disease [59]. This toolkit includes an informa-tional resource that incorporates content generated by theexpert panel, and promotes the Physical Activity Guide-lines for Older Adults [32], while taking into accountsome of the unique concerns of a person with dementia(e.g., limited flexibility and balance, lapses in memory).The resource also describes the types of physical activitiesa person at risk for, or living with Alzheimer’s, should doand provides tips for staying safe and motivated.ApplicabilityWe believe that the messaging statement and accom-panying toolkit will have important implications forpractice and research by providing inspiration for pro-moting physical activity for people with Alzheimer’sdisease. One implication may be increased availabilityand development of fitness programs for people withAlzheimer’s disease. Furthermore, given a clear statementof the benefits of physical activity, service providers (e.g.,exercise programmers, fitness centers, continuing carefacilities) should be more inclined to offer programs tai-lored for older adults. The statement and accompanyinginformational resource should also reduce existing infor-mational barriers that have discouraged health care practi-tioners from recommending physical activity. We alsoacknowledge potential resource implications of applyingthe statement. Individuals looking to increase theirphysical activity may incur financial costs associated withtransportation, equipment or program fees. More staffand training may be necessary to facilitate increaseddemand and health care providers may require more timeto discuss physical activity with patients during routineappointments.Regarding research, the statement should stimulatemore investigation of physical activity for preventing andmanaging Alzheimer’s disease, particularly research onthe types and amounts of activity that yield benefit. Suchresearch is needed in order to develop Alzheimer-specific physical activity guidelines, an important nextstep, given that clinicians were not particularly confidentin Alzheimer’s patients’ ability to meet the general,national physical activity guidelines for older adults (seeTable 2). As has been demonstrated through physicalactivity guideline development processes for other popu-lations with chronic disease, mobility impairments andsevere physical deconditioning [39, 40], lower volumesof exercise may be an appropriate recommendation forpeople with chronic conditions while still conferringsignificant benefits.Dissemination and implementationThe Ontario Brain Institute has released the messagingstatement and informational resource on its website andin partnership with several local organizations includingParticipACTION, the Alzheimer Society of Ontario, andthe Active Living Coalition of Older Adults. ParticipAC-TION has produced a webinar that supplements thestatement. To reach the scientific community, these re-sources will be disseminated through academic journalsand conferences. The OBI has also actively promoted(e.g., newsletters, webinars) the tool kit to clinicians andpractitioners with the intent that it be shared with anynewly diagnosed patients and their families.SurveillanceWe are unaware of any efforts to monitor physicalactivity patterns of adults with Alzheimer’s disease.However, the Alzheimer’s Society of Canada has re-cently initiated exercise programs for older adultswith Alzheimer’s disease and other dementias (cf.Minds in Motion). By tracking program participants–through accelerometry, or brief, validated question-naires that can be completed by caregivers–it couldGinis et al. BMC Public Health  (2017) 17:209 Page 15 of 17be determined whether those who achieve Canada’sphysical activity guidelines are deriving greater phys-ical and health outcomes than those who do not. Inaddition, the Canadian Longitudinal Study of Aging[60] is tracking the activity patterns of healthy olderadults and symptoms of Alzheimer’s disease/dementiaover 20 years. These data will allow for ongoing sur-veillance of the association between physical activityand risk for Alzheimer’s disease.LimitationsWe were unable to formulate a more specific exer-cise prescription for preventing or managing Alzhei-mer’s disease because the evidence is insufficient fordetermining dose–response relationships betweenphysical activity and disease risk and outcome. Theevidence is also sparse regarding the effects of phys-ical activity on certain Alzheimer’s disease-relatedoutcomes such as risk of falling, and QOL, which ne-cessitated exclusion of these outcomes from ourstatement. We were unable to generate a statementfor managing Alzheimer’s disease specifically becausethe majority of reviews used the broader classifica-tion of ‘dementia’ as the study inclusion criterion;this is an unfortunate characteristic of the extant lit-erature. We also acknowledge that the expert paneland stakeholder surveys were comprised primarily oflocal (provincial) participants; this compilation en-sured that international peer-reviewed research wasused to formulate a locally relevant messaging state-ment and informational resource. And finally, we ac-knowledge that the literature search did not includegrey literature (e.g., unpublished studies, organizationalreports, materials not controlled by commercial pub-lishers). However, given that the messaging recommenda-tions are largely consistent with the conclusions generatedin some of the most recent highest quality systematic re-views, we are confident that our search captured the mostrelevant research on physical activity and Alzheimer’sdisease.ConclusionsPublic health practitioners are often criticized for notincorporating research evidence in their behaviourchange practices and initiatives [34]. Organizationsthat promote physical activity want to use researchevidence in their practices, but are often limited in theircapacity to do so [35]. In response to the needs of anorganization that promotes brain health, this project hasdemonstrated how research evidence can be used to for-mulate evidence-based messages and knowledge productsthat can be disseminated by public health and otherorganizations to promote the use of physical activity toprevent and manage Alzheimer’s disease. Organizationsthat promote physical activity, health and well-being toolder adults are encouraged to use the evidence-basedmessaging statement in their programs and resources.Researchers, clinicians, people with Alzheimer’s diseaseand caregivers are encouraged to adopt the messagingstatement and the recommendations in the companioninformational resource.AbbreviationsADL: Activities of daily living; AGREE: Appraisal of Guidelines Research andEvaluation; AMSTAR: A Measurement Tool to Assess Systematic Reviews;QOL: Quality of life; RCT: Randomized Controlled Trial; WHO: World HealthOrganizationAcknowledgementsWe gratefully acknowledge Adrienne Sinden for assistance with preparationof this manuscript.FundingThis project was supported by the Ontario Brain Institute and the AlzheimerSociety Brant, Haldimand Norfolk, Hamilton Halton. Members of the OntarioBrain Institute observed the consensus meeting but had no influence on thefinal statement whatsoever. A representative from the Alzheimer Societyattended the panel meeting but did not participate in subsequentteleconferences or the preparation of this manuscript.Availability of data and materialsThe database of articles generated and analysed during this project is includedin this article. The stakeholder feedback dataset generated and analysed duringthe current study is available from the corresponding author on reasonablerequest.Authors’ contributionsKMG led the project, interpreted the data, drafted sections of the manuscriptand was responsible for the final draft of the manuscript; JH, IBC, and CPconducted the systematic review; JH and JCS drafted sections of themanuscript; JA established the scope of the project and co-led the project;KMG, JH, JCS, IBC, CIA, CC-B, MD, ALH, AEL-C, LM, KN, DHP, CP, and MRparticipated in the expert panel meeting, provided feedback on manuscriptdrafts, and read and approved the final version of the manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationAll authors have consented to publish this manuscript. Two expert panelmembers (HM, KR) did not make authorship contributions to the manuscript.They have provided written, signed consent for their names to be publishedin Table 1.Ethics approval and consent to participateNot applicable.Author details1School of Health & Exercise Sciences, University of British Columbia,Kelowna, Canada. 2Department Kinesiology, McMaster University, Hamilton,Canada. 3Faculty of Physical Education and Recreation, University of Alberta,Edmonton, Canada. 4Ontario Brain Institute, Toronto, Canada. 5School ofKinesiology and Health Science, York University, Toronto, Canada.6ParticipACTION, Toronto, Canada. 7Canadian Society for Exercise Physiology,Ottawa, Canada. 8School of Kinesiology and Health Studies, Queen’sUniversity, Kingston, Canada. 9Department of Kinesiology, University ofWaterloo, Waterloo, Canada. 10Canadian Centre for Activity and Aging,Western University, London, Canada. 11School of Health Sciences, Universityof Northern British Columbia, Prince George, Canada.Received: 22 September 2016 Accepted: 30 January 2017Ginis et al. BMC Public Health  (2017) 17:209 Page 16 of 17References1. Association As. 2016 Alzheimer’s disease facts and figures. AlzheimersDement. 2016;12(4):459–509.2. Alzheimer’s Association. 2013 Alzheimer’s disease facts and figures.Alzheimers Dement. 2013;9(2):208.3. Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting theglobal burden of Alzheimer’s disease. Alzheimers Dement. 2007;3(3):186–91.4. Beckett MW, Ardern CI, Rotondi M. A meta-analysis of prospective studieson the role of physical activity and the prevention of Alzheimer’s disease inolder adults. BMC Geriatr. 2015;15(1):1.5. Barnes DE, Yaffe K. The projected effect of risk factor reduction onAlzheimer’s disease prevalence. Lancet Neurol. 2011;10(9):819–28.6. Beydoun MA, Beydoun HA, Gamaldo AA, Teel A, Zonderman AB, Wang Y.Epidemiologic studies of modifiable factors associated with cognition anddementia: systematic review and meta-analysis. BMC Public Health.2014;14(643):1–33.7. Daviglus ML, Plassman BL, Pirzada A, Bell CC, Bowen PE, Burke JR, ConnollyES, Dunbar-Jacob JM, Granieri EC, McGarry K. Risk factors and preventiveinterventions for Alzheimer disease: state of the science. Arch Neurol.2011;68(9):1185–90.8. Hamer M, Chida Y. Physical activity and risk of neurodegenerative disease: asystematic review of prospective evidence. Psychol Med. 2009;39(1):3.9. Paterson DH, Warburton DE. Review Physical activity and functionallimitations in older adults: a systematic review related to Canada’s PhysicalActivity Guidelines. Int J Behav Nutr Phys Act. 2010;7(38):1–22.10. Patterson C, Feightner J, Garcia A, MacKnight C. General risk factorsfor dementia: a systematic evidence review. Alzheimers Dement.2007;3(4):341–7.11. Rolland Y, Abellan van Kan G, Vellas B. Physical activity and Alzheimer’sdisease: from prevention to therapeutic perspectives. J Am Med Dir Assoc.2008;9(6):390–405.12. Brett L, Traynor V, Stapley P. Effects of physical exercise on health andwell-being of individuals living with a dementia in nursing homes: asystematic review. J Am Med Dir Assoc. 2015;17(1):104–16.13. Cooper C, Mukadam N, Katona C, Lyketsos CG, Ames D, Rabins P, Engedal K,de Mendonca Lima C, Blazer D, Teri L, et al. Systematic review of theeffectiveness of non-pharmacological interventions to improve quality oflife of people with dementia. Int Psychogeriatr. 2012;24(6):856–70.14. de Souto Barreto P, Demougeot L, Pillard F, Lapeyre-Mestre M, Rolland Y.Exercise training for managing behavioral and psychological symptoms inpeople with dementia: a systematic review and meta-analysis. Ageing ResRev. 2015;24:274–85.15. Farina N, Rusted J, Tabet N. The effect of exercise interventions on cognitiveoutcome in Alzheimer’s disease: a systematic review. Int Psychogeriatr.2014;26(1):9–18.16. Forbes D, Thiessen EJ, Blake CM, Forbes SC, Forbes S. Exercise programs forpeople with dementia. Cochrane Database Syst Rev. 2013;12:Cd006489.17. Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs forpeople with dementia. Cochrane Database Syst Rev. 2015;4:Cd006489.18. Hermans DG, Htay UH, McShane R. Non-pharmacological interventions forwandering of people with dementia in the domestic setting. CochraneDatabase Syst Rev. 2007;1:Cd005994.19. Heyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training onelderly persons with cognitive impairment and dementia: a meta-analysis.Arch Phys Med Rehabil. 2004;85(10):1694–704.20. Littbrand H, Stenvall M, Rosendahl E. Applicability and effects of physicalexercise on physical and cognitive functions and activities of daily livingamong people with dementia: a systematic review. Am J Phys Med Rehabil.2011;90(6):495–518.21. O’Connor DW, Ames D, Gardner B, King M. Psychosocial treatments ofpsychological symptoms in dementia: a systematic review of reportsmeeting quality standards. Int Psychogeriatr. 2009;21(2):241–51.22. Rao AK, Chou A, Bursley B, Smulofsky J, Jezequel J. Systematic review of theeffects of exercise on activities of daily living in people with Alzheimer’sdisease. Am J Occup Ther. 2014;68(1):50–6.23. Thuné-Boyle I, Iliffe S, Cerga-Pashoja A, Lowery D, Warner J. The effect ofexercise on behavioral and psychological symptoms of dementia: towards aresearch agenda. Int Psychogeriatr. 2012;24(07):1046–57.24. Yu F. Guiding research and practice: a conceptual model for aerobicexercise training in Alzheimer’s disease. Am J Alzheimers Dis Other Demen.2011;26(3):184–94.25. Yu F, Kolanowski AM, Strumpf NE, Eslinger PJ. Improving cognition andfunction through exercise intervention in Alzheimer’s disease. J NursScholarsh. 2006;38(4):358–65.26. Blankevoort CG, van Heuvelen MJ, Boersma F, Luning H, de Jong J, ScherderEJ. Review of effects of physical activity on strength, balance, mobility andADL performance in elderly subjects with dementia. Dement Geriatr CognDisord. 2010;30(5):392–402.27. Boote J, Lewin V, Beverley C, Bates J. Psychosocial interventions for peoplewith moderate to severe dementia: a systematic review. Clin Eff Nurs.2006;9(S1):e1–15.28. Burton E, Cavalheri V, Adams R, Browne CO, Bovery-Spencer P, Fenton AM,Campbell BW, Hill KD. Effectiveness of exercise programs to reduce falls inolder people with dementia living in the community: a systematic reviewand meta-analysis. Clin Interv Aging. 2015;10:421–34.29. Jensen LE, Padilla R. Effectiveness of interventions to prevent falls in peoplewith Alzheimer’s disease and related dementias. Am J Occup Ther.2011;65(5):532–40.30. Pitkala K, Savikko N, Poysti M, Strandberg T, Laakkonen ML. Efficacy ofphysical exercise intervention on mobility and physical functioning in olderpeople with dementia: a systematic review. Exp Gerontol. 2013;48(1):85–93.31. Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primaryprevention of Alzheimer’s disease: an analysis of population-based data.Lancet Neurol. 2014;13(8):788–94.32. Tremblay MS, Warburton DE, Janssen I, Paterson DH, Latimer AE, Rhodes RE,Kho ME, Hicks A, LeBlanc AG, Zehr L. New Canadian physical activityguidelines. Appl Physiol Nutr Metab. 2011;36(1):36–46.33. Latimer-Cheung AE, Rhodes RE, Kho ME, Tomasone JR, Gainforth HL,Kowalski K, Nasuti G, Perrier M-J, Duggan M. Evidence-informedrecommendations for constructing and disseminating messagessupplementing the new Canadian Physical Activity Guidelines. BMC PublicHealth. 2013;13(1):1.34. Green LW, Ottoson J, Garcia C, Robert H. Diffusion theory and knowledgedissemination, utilization, and integration in public health. Annu Rev PublicHealth. 2009;30:151.35. Sweet SN, Perrier M-J, Podzyhun C, Latimer-Cheung AE. Identifying physicalactivity information needs and preferred methods of delivery of peoplewith multiple sclerosis. Disabil Rehabil. 2013;35(24):2056–63.36. Price AE, Corwin SJ, Friedman DB, Laditka SB, Colabianchi N, Montgomery KM.Older adults’ perceptions of physical activity and cognitive health: Implicationsfor health communication. Health Educ Behav. 2011;38(1):15–24.37. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, FerversB, Graham ID, Hanna SE, Makarski J. Development of the AGREE II, part1: performance, usefulness and areas for improvement. Can Med Assoc J.2010;182(10):1045–52.38. Tremblay MS, Kho ME, Tricco AC, Duggan M. Process description andevaluation of Canadian Physical Activity Guidelines development. Int JBehav Nutr Phys Act. 2010;7(1):42.39. Martin Ginis KA, Hicks A, Latimer A, Warburton D, Bourne C, Ditor D,Goodwin D, Hayes K, McCartney N, McIlraith A. The development ofevidence-informed physical activity guidelines for adults with spinal cordinjury. Spinal Cord. 2011;49(11):1088–96.40. Latimer-Cheung AE, Martin Ginis KA, Hicks AL, Motl RW, Pilutti LA, DugganM, Wheeler G, Persad R, Smith KM. Development of evidence-informedphysical activity guidelines for adults with multiple sclerosis. Arch Phys MedRehabil. 2013;94(9):1829-1836. e1827.41. Smith V, Devane D, Begley CM, Clarke M. Methodology in conducting asystematic review of systematic reviews of healthcare interventions.BMC Med Res Methodol. 2011;11(1):15.42. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, HenryDA, Boers M. AMSTAR is a reliable and valid measurement tool toassess the methodological quality of systematic reviews. J Clin Epidemiol.2009;62(10):1013–20.43. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, RobinsonN. Lost in knowledge translation: time for a map? J Contin Educ Health Prof.2006;26(1):13–24.44. Rhodes RE, Temple VA, Tuokko HA. Evidence-based risk assessment andrecommendations for physical activity clearance: cognitive andpsychological conditions. Appl Physiol Nutr Metab. 2011;36(S1):S113–53.45. Latimer AE, Brawley LR, Bassett RL. A systematic review of three approachesfor constructing physical activity messages: What messages work and whatimprovements are needed? Int J Behav Nutr Phys Act. 2010;7(1):36.46. Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S.Prevalence of neuropsychiatric symptoms in dementia and mild cognitiveimpairment: results from the cardiovascular health study. JAMA.2002;288(12):1475–83.47. Lyketsos CG, Steinberg M, Tschanz JT, Norton MC, Steffens DC, Breitner JC.Mental and behavioral disturbances in dementia: findings from the CacheCounty Study on Memory in Aging. Am J Psychiatry. 2000;157(5):708–14.48. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical methodfor grading the cognitive state of patients for the clinician. J Psychiatr Res.1975;12(3):189–98.49. Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I,Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: abrief screening tool for mild cognitive impairment. J Am Geriatr Soc.2005;53(4):695–9.50. Collin C, Wade D, Davies S, Horne V. The Barthel ADL Index: a reliabilitystudy. Disabil Rehabil. 1988;10(2):61–3.51. McCracken A, Gilster S, Connerton E, Canfield H, Painter-Romanello M.Developing a tool to measure functional changes in advanced dementia.Nursingconnections. 1992;6(2):55–66.52. Groot C, Hooghiemstra AM, Raijmakers PGHM, van Berckel BNM, ScheltensP, Scherder EJA, van der Flier WM, Ossenkoppele R. The effect of physicalactivity on cognitive function in patients with dementia: a meta-analysis ofrandomized control trials. Ageing Res Rev. 2016;25:13–23.53. Chodzko-Zajko W. American College of Sports Medicine. ACSM’s Exercise for•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services Submit your next manuscript to BioMed Central and we will help you at every step:Ginis et al. BMC Public Health  (2017) 17:209 Page 17 of 17Older Adults. Baltimore: Lippincott Williams & Wilkins; 2013.54. van Reekum R, Streiner DL, Conn DK. Applying Bradford Hill’s criteria forcausation to neuropsychiatry. J Neuropsychiatry Clin Neurosci.2014;13(3):318–25.55. Erickson KI, Voss MW, Prakash RS, Basak C, Szabo A, Chaddock L, Kim JS, HeoS, Alves H, White SM. Exercise training increases size of hippocampus andimproves memory. Proc Natl Acad Sci. 2011;108(7):3017–22.56. Dogra S, Stathokostas L. Sedentary behavior and physical activity areindependent predictors of successful aging in middle-aged and olderadults. J Aging Res. 2012;2012:1–8.57. Santos DA, Silva AM, Baptista F, Santos R, Vale S, Mota J, Sardinha LB.Sedentary behavior and physical activity are independently related tofunctional fitness in older adults. Exp Gerontol. 2012;47(12):908–12.58. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatricsymptoms of dementia: a review of the evidence. JAMA. 2005;293(5):596–608.59. Ontario Brain Institute. Physical activity and Alzheimer’s disease toolkit. 2014.60. Raina PS, Wolfson C, Kirkland SA, Griffith LE, Oremus M, Patterson C, TuokkoH, Penning M, Balion CM, Hogan D. The Canadian longitudinal study onaging (CLSA). Can J Aging. 2009;28(03):221–9.•  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submit


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items