Cendoroglo Maysa Seabra
Sao Paulo Med J. 2014;132(3):195-6. doi: 10.1590/1516-3180.20141323t2.
This is an update of our previous 2008 review. Several recent trials and systematic reviews of the impact of exercise on people with dementia are reporting promising findings.
Primary: Do exercise programs for older people with dementia improve cognition, activities of daily living (ADLs), challenging behaviour, depression, and mortality in older people with dementia? Secondary: Do exercise programs for older people with dementia have an indirect impact on family caregivers' burden, quality of life, and mortality? Do exercise programs for older people with dementia reduce the use of healthcare services (e.g. visits to the emergency department) by participants and their family caregivers?
We identified trials for inclusion in the review by searching ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group's Specialised Register, on 4 September 2011, and again on 13 August 2012. The search terms used were: 'physical activity' OR exercise OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR 'tai chi'.
In this review, we included randomized controlled trials in which older people, diagnosed with dementia, were allocated either to exercise programs or to control groups (usual care or social contact/activities) with the aim of improving cognition, ADLs, behaviour, depression, and mortality. Secondary outcomes related to the family caregiver(s) and included caregiver burden, quality of life, mortality, and use of healthcare services.
Independently, at least two authors assessed the retrieved articles for inclusion, assessed methodological quality, and extracted data. Data were analysed for summary effects using RevMan 5.1 software. We calculated mean differences or standardized mean difference (SMD) for continuous data, and synthesized data for each outcome using a fixed-effect model, unless there was substantial heterogeneity between studies, when we used a random-effects model. We planned to explore heterogeneity in relation to severity and type of dementia, and type, frequency, and duration of exercise program. We also evaluated adverse events.
Sixteen trials with 937 participants met the inclusion criteria. However, the required data from three trials and some of the data from a fourth trial were not published and not made available. The included trials were highly heterogeneous in terms of subtype and severity of participants' dementia, and type, duration and frequency of exercise. Only two trials included participants living at home. Our meta-analysis suggested that exercise programs might have a significant impact on improving cognitive functioning (eight trials, 329 participants; SMD 0.55, 95% confidence interval (CI) 0.02 to 1.09). However, there was substantial heterogeneity between trials (I 2 value 80%), most of which we were unable to explain. We repeated the analysis omitting one trial, an outlier, that included only participants with moderate or severe dementia. This reduced the heterogeneity somewhat (I2 value 68%), and produced a result that was no longer significant (seven trials, 308 participants; SMD 0.31, 95% CI -0.11 to 0.74). We found a significant effect of exercise programs on the ability of people with dementia to perform ADLs (six studies, 289 participants; SMD 0.68, 95% CI 0.08 to 1.27). However, again we observed considerable unexplained statistical heterogeneity (I2 value 77%) in this meta-analysis. This means that there is a need for caution in interpreting these findings. In further analyses, we found that the burden experienced by informal caregivers providing care in the home may be reduced when they supervise the participation of the family member with dementia in an exercise program (one study, 40 participants; MD -15.30, 95% CI -24.73 to -5.87), but we found no significant effect of exercise on challenging behaviours (one study, 110 participants; MD -0.60, 95% CI -4.22 to 3.02), or depression (six studies, 341 participants; MD -0.14, 95% CI -0.36 to 0.07). We could not examine the remaining outcomes, quality of life, mortality, and healthcare costs, as either the appropriate data were not reported, or we did not retrieve trials that examined these outcomes.
AUTHORS' CONCLUSIONS: There is promising evidence that exercise programs can have a significant impact in improving ability to perform ADLs and possibly in improving cognition in people with dementia, although some caution is advised in interpreting these findings. The programs revealed no significant effect on challenging behaviours or depression. There was little or no evidence regarding the remaining outcomes of interest.
这是我们之前2008年综述的更新。最近几项关于运动对痴呆症患者影响的试验和系统评价报告了有前景的研究结果。
主要目的：针对老年痴呆症患者的运动项目是否能改善其认知、日常生活活动能力（ADL）、挑战性行为、抑郁症状及死亡率？次要目的：针对老年痴呆症患者的运动项目对家庭照顾者的负担、生活质量及死亡率是否有间接影响？针对老年痴呆症患者的运动项目是否能减少参与者及其家庭照顾者对医疗服务的使用（如急诊就诊次数）？
在本综述中，我们纳入了随机对照试验，其中被诊断为痴呆症的老年人被分配到运动项目组或对照组（常规护理或社交接触/活动），目的是改善认知、ADL、行为、抑郁症状及死亡率。与家庭照顾者相关的次要结局包括照顾者负担、生活质量、死亡率及医疗服务使用情况。
至少两名作者独立评估检索到的文章是否纳入、评估方法学质量并提取数据。使用RevMan 5.1软件对数据进行汇总效应分析。对于连续数据，我们计算平均差或标准化平均差（SMD），并使用固定效应模型对每个结局的数据进行综合分析，除非研究间存在实质性异质性，此时我们使用随机效应模型。我们计划探讨与痴呆症严重程度和类型以及运动项目类型、频率和持续时间相关的异质性。我们还评估了不良事件。
16项试验共937名参与者符合纳入标准。然而，三项试验所需数据及第四项试验的部分数据未发表且无法获取。纳入的试验在参与者痴呆症的亚型和严重程度以及运动类型（如强度、频率和持续时间）方面高度异质性。只有两项试验纳入了居家生活的参与者。我们的荟萃分析表明，运动项目可能对改善认知功能有显著影响（八项试验，329名参与者；SMD 0.55，95%置信区间（CI）0.02至1.09）。然而，试验间存在实质性异质性（I²值80%），其中大部分我们无法解释。我们重复分析，排除了一项仅纳入中度或重度痴呆症参与者的异常试验。这在一定程度上降低了异质性（I²值68%），但结果不再显著（七项试验，308名参与者；SMD 0.31，95% CI -0.11至0.74）。我们发现运动项目对痴呆症患者进行ADL的能力有显著影响（六项研究，289名参与者；SMD 0.68，95% CI 0.08至1.27）。然而，在这项荟萃分析中，我们再次观察到相当大的无法解释的统计异质性（I²值77%）。这意味着在解释这些结果时需要谨慎。在进一步分析中，我们发现当非正式照顾者监督痴呆症家庭成员参与运动项目时，他们在家中提供照顾所经历的负担可能会减轻（一项研究，40名参与者；MD -15.30，95% CI -24.73至-5.87），但我们发现运动对挑战性行为（一项研究，110名参与者；MD -0.60，95% CI -4.22至3.02）或抑郁症状（六项研究，341名参与者；MD -0.14，95% CI -0.36至0.07）没有显著影响。由于未报告适当数据或我们未检索到研究这些结局的试验，我们无法检查其余结局结局，即生活质量、死亡率和医疗费用等结局。
有证据表明运动项目对改善痴呆症患者的ADL能力可能有显著影响，对认知功能改善也可能有影响，尽管在解释这些结果时建议谨慎。这些项目对挑战性行为或抑郁症状没有显著影响。关于其余感兴趣的结局几乎没有证据。
