Alzheimer’s Disease

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Exercise interventions can help improve measures of cognitive dysfunction, depression, mood and affect, risk of falls, sleep disturbances, physical function, walking ability, strength, mobility, and the ability to perform activities daily living in patients with Alzheimer’s disease. The most well-studied exercise interventions are multi-modal and include stretching, walking, strengthening and balance programs.

CONTENTS

What is Alzheimer’s?

Alzheimer’s, or more correctly Alzheimer’s disease, is the most common form of dementia afflicting elderly people. However, it is difficult to diagnose clinically. The National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer’s Disease and Related Disorders Association (ADRDA) have provided diagnostic guidance, which were updated most recently in 2011. The NINCDS and ADRDA specify that the criteria for diagnosing an individual with Alzheimer’s disease first requires a diagnosis of general dementia, which is defined as: having a condition which interferes with the ability to function at work or during usual activities, which represents a decline from previous levels of function, which is not explained by delirium or major psychiatric disorder, and which can be defined as a cognitive impairment (involving either impaired memory, reasoning, language or visual-spatial abilities or changes in personality) (McKhann et al.).

How is Alzheimer’s diagnosed?

The criteria for refining the diagnosis from dementia to Alzheimer’s disease requires that the individual displays: a clear development of cognitive dysfunction over a sustained period of time, with obvious impairments in memory in addition to impairments in non-memory related functions, including reasoning, language and visual-spatial abilities (mainly object agnosia and prosopagnosia). The NINCDS and ADRDA also specify that the criteria for refining the diagnosis from dementia to Alzheimer’s disease also requires the exclusion of: any evidence for cerebrovascular disease, (including history of a stroke), the presence of significant infarcts or severe white matter hyper-intensity burden, distinctive features of Dementia with Lewy bodies, distinctive features of behavioral variant fronto-temporal dementia, distinctive features of semantic variant primary progressive aphasia or non-fluent-agrammatic variant primary progressive aphasia, presence of other neurological disease, or presence of other non-neurological medical comorbidity or medication use that might affect cognition (McKhann et al.). The diagnosis of Alzheimer’s disease may be strengthened or confirmed by the presence of biomarkers, including those of brain amyloid-beta (Aβ) protein deposition and of downstream neuronal degeneration or injury.

What is the incidence of Alzheimer’s?

The incidence of Alzheimer’s disease varies with age and population. Studies exploring the incidence of Alzheimer’s disease in very old (aged >85 years), Western populations tend to show very high values, with numbers ranging between 64 – 118 per 1,000 person-years (Bachmann et al. Aevarsson et al. Letenneur et al. Launer et al.). In contrast, studies exploring younger age groups in the same populations tend to report a much smaller incidence of around 7 – 9 per 1,000 person-years (Letenneur et al. Bachmann et al. Bickel and Cooper). Similarly, certain populations outside of the West display lower incidence of Alzheimer’s disease, including Japan (Yoshitake et al.) and India (Chandra et al.).

The risk of developing Alzheimer’s disease increases with increasing age. Additionally, there are geographical differences in the incidence of Alzheimer’s disease, with some populations appearing to be more at risk than others.

What is the prevalence of Alzheimer’s?

The prevalence of Alzheimer’s disease varies with age and population. Several research teams have assessed the current prevalence of Alzheimer’s disease both worldwide and in specific countries. Brookmeyer et al. (1998) performed a systematic review of of the prevalence of Alzheimer’s disease in the United States and calculated that in 1997 the prevalence of Alzheimer’s disease in the United States was 2.32 million. Hebert et al. performed a study to assess the prevalence of Alzheimer’s disease in 3 adjacent neighborhoods in Chicago, Illinois, in the United States. They then applied these prevalence estimates to United States Census Bureau estimates of the overall population and calculated that in 2000 the prevalence of Alzheimer’s disease in the United States was 4.5 million. Later, Brookmeyer et al. (2007) later performed a systematic review of the prevalence of Alzheimer’s disease in the whole world. From this review, they calculated that in 2006 there were 26.6 million cases of Alzheimer’s disease worldwide.

The most recent estimate of the worldwide prevalence of Alzheimer’s disease is around 26.6 million cases, while the most recent estimate of cases in the United States is around 4.5 million cases.

What is the forecast for Alzheimer’s?

Several research teams have created estimates for the future prevalence of Alzheimer’s disease, both worldwide and in specific countries (Tobias et al. Hebert et al. Brookmeyer et al. 1998; Brookmeyer et al. 2007). The most recent estimate for the prevalence of Alzheimer’s disease is that it will nearly quadruple to 8.64 million in US and to 106.2 million worldwide to 2050 and at this point around 1 in 45 Americans and 1 in 85 persons worldwide will have the disease.

The forecast worldwide prevalence of Alzheimer’s disease in 2050 is around 106.2 million cases (1 in 85 people) worldwide, of which 13.2 million will be in the United States (1 in 45 people).

What are activity-related risk factors for Alzheimer’s?

Activity-related risk factors for developing Alzheimer’s disease include a low level of muscular strength (Boyle et al. Buchman et al.), a higher level of frailty (Buchman et al. Buchman et al.), low body mass index (Buchman et al.), a reduced level of physical activity (Broe et al. Crowe et al. Kondo et al. Friedland et al.), and a low level of mental activity (Crowe et al. Kondo et al. Friedland et al.) or low educational status (Gatz et al. Friedland et al.) may all be key areas of concern.

Low levels of physical activity, low levels of mental or social activity, low body mass index (BMI), low muscular strength and greater physical frailty all put individuals at a greater risk of developing Alzheimer’s disease.

What are other risk factors for Alzheimer’s?

There are a wide range of other risk factors for developing Alzheimer’s disease, many of which are related to other non-communicable diseases. Having a first-degree or second-degree relative with a history of dementia is a key risk factor (Graves et al. Amaducci et al.). Also, the presence of type II diabetes is a very important risk factor (Peila et al. Luchsinger et al. Luchsinger et al. MacKnight et al. Xu et al. Xu et al. Arvanitakis et al. Leibson et al. Kopf & Frölich et al. Daviglus et al.), as are a history of stroke (Honig et al.) coronary artery disease, heart failure or peripheral artery disease (Newman et al. Qiu et al. Purnell et al.), obesity (Kivipelto et al.), hypercholesterolemia (Kivipelto et al. Kivipelto et al. Daviglus et al.) and high blood pressure (Kivipelto et al. Kivipelto et al.). Smoking and alcohol consumption do not appear to be risk factors (Graves et al. Amaducci et al. Heyman et al. French et al. Graves et al.), although there have been suggestions that when removing studies with commercial interests, a connection can be identified between increased Alzheimer’s disease and smoking incidence (Cataldo et al. Daviglus et al.). Whether previous head trauma, previous thyroid disease and family history of Down’s syndrome are risk factors is less clear, as studies are conflicting (French et al. Graves et al. Amaducci et al. Heyman et al. Mortimer et al.).

Type II diabetes, a history of coronary artery disease or peripheral artery disease, hypercholesterolaemia and high blood pressure may all be associated with a slightly greater risk of developing Alzheimer’s disease. A family history of neurological disorders may also be a risk factor but whether prior head injury, smoking or alcohol consumption or prior head injury are risk factors is less clear.

Is exercise useful for Alzheimer’s?

A number of studies have investigated the use of exercise for the treatment of various aspects of Alzheimer’s, including cognitive dysfunction, communication, behavioral disturbance, depression, mood and affect, nutritional status, risk of falls, sleep disturbances, physical function, walking ability, mobility, aerobic fitness, upper and lower body strength, and the ability to perform activities daily living as follows:

Study Approach Finding
Rolland et al. The researchers performed a randomized, controlled trial to examine the effect of an exercise program on the ability to perform activities of daily living (ADLs), physical performance, nutritional status, behavioral disturbance and depression in 134 patients with Alzheimer's disease. The researchers randomly allocated the subjects to either an exercise group, which performed an exercise program for 1 hour, 2 times per week involving walking, strength, balance, and flexibility training, or to a control group, which received routine medical care. The trial was performed for 1 year. The researchers reported that the average reduction in ADL ability and for 6m-walking speed was smaller in the exercise group than in the control group. However, the researchers did not observe any differences in respect of behavioral disturbance, depression, or nutritional status between the 2 groups.
Venturelli et al. The researchers performed a study to assess the effects of a walking program on functional and cognitive decline in 21 elderly nursing home residents with late-stage Alzheimer's disease. The researchers randomly allocated the subjects to either a walking group or to a control group for a 24-week trial. The researchers reported that the walking group significantly improved 6-minute walking test (20%) and Barthel index of activities of daily living (23%) while the control group did not improve. Also, the walking group displayed a significantly slower state of decline than the control group in respect of cognitive dysfunction, as assessed by the Mini-Mental State Examination (-13% vs. -47%).
Lautenschlager et al. The researchers performed a randomized controlled trial to assess the effects of physical activity on the rate of cognitive decline among older adults at risk of Alzheimer’s disease. The researchers randomly allocated 170 subjects to either an education and usual care group (the control group) or home-based program of physical activity group (exercise group) for a 24-week trial. Only 138 participants completed the trial. The researchers reported that at the end of the 24-week trial, the change in the Alzheimer Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) score (on a possible range from 0 – 70) was an increase of 0.26 points in the exercise group and a decrease of 1.04 points in the control group. At 18-month follow-up, the researchers reported that the change in the ADAS-Cog scores was an increase of 0.73 points in the exercise group and an increase of 0.04 points in the control group.
Hernandez et al. The researchers performed a study to assess the effects of supervised physical activity on cognitive functions, balance and risk of falls in 16 elderly patients with Alzheimer's disease. For a 6-month period, the exercise group performed supervised exercise while the control group performed no exercise. After the intervention, the researchers found that scores in the Mini-Mental State Examination (MMSE), Berg Balance Scale (BBS) and Timed Up-and-Go (TUG) decreased significantly in the control group but not in the exercise group. However, there was no difference between groups in respect of the agility/dynamic balance (AGIBAL) item of the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) test battery.
Nascimento et al. The researchers performed a study to assess the effects of multimodal exercise program on sleep disturbances and on the ability to perform activities daily living (ADLs) in 42 patients with Alzheimer's disease and in 35 patients with Parkinson's disease.  The researchers allocated the subjects to either control groups or exercise group. The exercise groups performed 3 sessions per week of a multimodal exercise program lasting 1-hour per session for 6 months. The researchers found that in both exercise groups there were significant improvements in scores on both ADLs (as measured by the Pfeffer Questionnaire for Instrumental Activities) and in sleep disturbances (as measured by the Mini-Sleep Questionnaire) while the control group displayed either maintenance or slight degradation in scores.
Pitkälä et al. The researchers performed a randomized controlled trial to assess the effects of intense and long-term exercise on physical function and mobility in 210 home-dwelling patients with Alzheimer’s disease. Pitkälä et al., The researchers randomly allocated the subjects into either a group-based exercise group, a home-based exercise group, and a control group. The researchers found that the decrease in physical function was significantly faster in the control group than in either of the exercise groups, as assessed by the Functional Independence Measure (FIM) and the Short Physical Performance Battery. In the home-based exercise group, the group-exercise group and the control group, the changes in the FIM were -7.1, -10.3 and -14.4. The researchers did not report the occurrence of any adverse effects.
Suttanon et al. The researchers performed a randomized controlled trial to assess the feasibility and safety of a home-based exercise program in 40 patients with Alzheimer's disease and to assess the effects of the program on balance, mobility and falls risk. The researchers randomly allocated the subjects to either a home-based balance, strengthening and walking group or to a home-based education group (the control group) for a 6-month trial. The researchers reported that the exercise group improved significantly more than the control group in respect of scores of mobility (as assessed by the Functional Reach score) and in respect of fall risk (as measured by the Falls Risk for Older People score).
Coelho et al. The researchers performed a trial to assess the effects of a multimodal exercise intervention on cognitive function in 27 patients with Alzheimer's disease. The researchers allocated the subjects to either an exercise group or to a control group for a 16-week intervention. The exercise group performed a 1-hour training session 3 times a week while the control group did not. The researchers reported that the exercise group significantly improved cognitive functions, as measured by their scores in the Frontal Assessment Battery and the Symbol Search Subtest but did not improve their score in the Clock Drawing Test. The researchers reported that the control group significantly decreased their scores in the Clock Drawing Test.
Williams and Tappen The researchers assessed the effects of 3 different interventions on mood and affect in 90 nursing home residents with Alzheimer’s diseases. The researchers randomly allocated the subjects into 3 groups: supervised walking, multi-modal exercise (walking, resistance training, balance training and stretching), and social conversation. The researchers provided the interventions 5 days a week for up to 30 minutes per session over a 16-week period. The researchers found that mood (as assessed by the Alzheimer Mood Scale and Dementia Mood Assessment measures) were significantly greater in the multi-modal exercise group than in the other 2 groups. They also reported that affect (as assessed by the Lawton Observed Affect Scale) was also significantly greater in the multi-modal exercise group than in the other 2 groups.
Teri et al. The researchers performed a randomized controlled trial to assess the effects of exercise and caregiver training in behavioral management techniques on physical function and depression in 153 community-dwelling patients with Alzheimer’s disease. The researchers randomly allocated the subjects to either a combined exercise and caregiver training program, called the Reducing Disability in Alzheimer Disease (RDAD) program, or to routine medical care. The RDAD program was conducted in the patients' home over 3 months. The exercise component of the RDAD program comprised walking, resistance training, balance training and stretching and was performed for up to 30 minutes per session per day. The intervention was carried out for a 3-month period and follow-ups were carried out for up to 2 years. The researchers reported that after 3 months, the RDAD group had improved their scores for physical function while the routine medical care group had decreased their scores (as assessed by the 36-item Short-Form Health Survey's (SF-36) physical functioning and physical role functioning subscales). The researchers also reported that after 3 months, the RDAD group improved their Cornell Depression Scale for Depression in Dementia scores while the routine medical care group had decreased their scores. The researchers reported that, at the 2 year follow-up, the RDAD group retained superior physical function scores to the routine medical care group.
Arkin The researcher assessed the effects of physical exercise plus cognitive and social stimulation on aerobic fitness and upper and lower body strength in 24 persons with Alzheimer's disease. The subjects took part in 16 – 20 exercise sessions and 10 community activity sessions per semester for 2 – 8 semesters. The exercise sessions included flexibility, balance, aerobic and resistance training. The researcher reported that the subjects significantly improved 6-minute walk performance, upper and lower body strength and duration of aerobic exercise.
Cott et al. The researchers performed a randomized control trial to assess the effects of a combined walking and talking program on communication, walking ability and physical function in residents with Alzheimer disease in 3 geriatric long-term care facilities in Metropolitan Toronto in. The researchers randomly allocated the subjects to 1 of 3 groups: a walk-and-talk group, a talk-only group, or a control group. The intervention groups performed 30 minutes of training, 5 times per week for a 16-week period. The researchers found that there were no significant differences between groups in respect of communication (as assessed by the Functional Assessment of Communication Skills for Adults), walking ability (as assessed by the 2-minute walk test) and function (as assessed by the London Psychogeriatric Rating Scale).
Tappen et al. The researchers assessed the effects of exercise and conversation both independently and together on physical function in 65 frail nursing home residents with Alzheimer’s disease. The researchers allocated the subjects to 1 of 3 groups: an exercise group, a conversation group and a combined exercise and conversation group. The exercise group performed 30 minutes of self-paced assisted walking interspersed with rest as needed, 3 times per week for 16 weeks. The conversation group performed 30 minutes of conversation 3 times per week for 16 weeks. The combined group performed 30 minutes of self-paced assisted walking with concomitant talking interspersed with rest as needed, 3 times per week for 16 weeks. The researchers reported that functional mobility decreased by 20.9%, 18.8% and 2.5% in the exercise, conversation and combined groups, respectively. However, compliance was significantly different between groups, being 57%, 90% and 75% in the exercise, conversation and combined groups, respectively. The researchers observed that the conversation appeared to improve compliance with the walking intervention.
Teri et al. The researchers explored adherence to a community-based exercise program intended to increase balance, flexibility, strength and endurance in 30 individuals with Alzheimer’s disease. The researchers assessed the subjects in respect of walking speed, functional reach, standing balance, health status (using the Medical Outcomes 36-item Study Short Form (SF-36), the Sickness Impact Profile, and number of restricted activity days, bed disability days, falls, and exercise participation) before and after a 12-week exercise intervention period. The exercise intervention including walking, strength training, and balance and flexibility exercises. The researchers reported that the individuals with Alzheimer’s disease performed more poorly on the measures of physical performance than benchmarks for similarly-aged healthy adults. However, they also reported that there was 100% adherence with the exercise intervention and 33% of the subjects completed all of the exercises in each session. The researchers therefore concluded that exercise training in individuals with Alzheimer’s disease is both necessary and feasible.
Friedman and Tappen The researchers performed a randomized, non-blinded two-group experimental study to compare the effects of planned walking with talking on communication performance in 30 nursing home patients with Alzheimer's disease. The researchers randomly allocated the subjects to 1 of 2 groups. The walking group walked individually for 30 minutes, 3 times per week for 10 weeks. The talking group conversed with caregivers for 30 minutes, 3 times per week for 10 weeks. The researchers reported that communication improved significantly in the planned walking group compared with the talking group.
Francese et al. The researchers performed a randomized controlled trial to assess the effect of regular exercise on muscular strength and the cognitive aspect of activities of daily living (ADLs) in nursing home residents with Alzheimer’s disease. The regular exercise training comprised a multi-modal program using of various unconventional tools, including beanbags, beach balls, a squoosh ball, Velcro ball and mitt, parachute leg weights, canes, and music, performed for 20 minutes, 3 mornings a week, over a 7-week intervention period. The researchers found that a regular exercise program did lead to significantly increased muscular strength but they did not find any increases in the cognitive ability to perform ADLs, as measured by the score on the Changes in Advanced Dementia Scale (CADS).
Steinberg et al. The researchers assessed the effects of a home-based exercise program in 27 home-dwelling patients with Alzheimer’s disease on functional performance, cognition, neuropsychiatric symptoms, quality of life and caregiver burden. The researchers randomly allocated the subjects to either an exercise group or a control group. The researchers observed that the exercise group displayed a trend for improved hand function, greater lower extremity strength but increased depression and lower quality of life. However, the researchers did not observe any significant differences between groups.
Santana-Sosa et al. The researchers assessed the effects of a multi-modal exercise program on the ability to perform activities of daily living (ADLs) and physical function in 16 patients with Alzheimer’s disease. The researchers randomly allocated the subjects to either an exercise group or to a control group for a 12-week intervention. The exercise group performed a program involving resistance training, stretching, joint mobility, balance and coordination exercises, 3 times per week for 75 minutes per session. The researchers reported that the exercise group significantly improved  both upper and lower body muscular strength and flexibility, agility, dynamic balance (using the Tinetti scale), endurance and the ability to perform ADLs (as measured by the Barthel index). However, there were no significant changes in the control group.
Smith et al. The researchers assessed the effects of exercise training on semantic memory activation in 17 participants with mild cognitive impairment and in 18 cognitively intact controls, matched for gender, age, education, genetic risk, and medication use. The subjects performed a 12-week exercise intervention involving supervised treadmill walking at a moderate intensity. The researchers found that both groups experienced a significant increase in cardiovascular fitness of around 10%. Additionally, the researchers found that the cognitively impaired group significantly improved performance on a list-learning task and MRI scans revealed that 11 brain regions displayed a significant decrease in activation intensity as a result of the exercise intervention. The researchers concluded that exercise may improve neural efficiency, memory and may improve cognitive function.

Based on these interventions, it appears that exercise may be able to help improve measures of cognitive dysfunction, depression, mood and affect, risk of falls, sleep disturbances, physical function, walking ability, strength, mobility, and the ability to perform activities daily living in patients with Alzheimer’s disease.

What is the economic burden of Alzheimer’s?

A small number of studies have reviewed the economic burden of Alzheimer’s disease. Most studies indicate that the cost of care for this disorder is astonishingly high. The following table presents data from various studies, showing the average annual cost per person and whether the cost includes direct costs only (i.e. nursing home fees etc.) or also includes an estimate of the indirect costs (i.e. the opportunity costs associated with unpaid caregiver time as a labour contribution lost to the economy):

Study Year Geography Annual cost per person Direct/indirect/total
Ernst and Hay 1983 United States $17,643 Total
Hux et al. 1998 Canada $25,724 Total
Leon et al. 1996 United States $30,096 Direct only
Souêtre et al. 1999 United Kingdom £30,750 Total
Max et al. 1990 Northern California $34,517 Total
Welch et al. 1992 United States $43,500 Direct only
Cavallo and Fattore 1997 Lombardy region of Italy $44,736 Indirect only
Rice et al. 1993 Northern California $47,000 Total
Ernst and Hay 1991 United States $173,932 Total

Based on these studies, the total direct and indirect annual costs per person associated with Alzheimer’s disease appear to range between $17,643 – $173,932, although the majority of costs seem to range between $25,000 – $45,000 per person per year. At a broadly median cost of $35,000 and an approximate current prevalence of around 26.6 million case worldwide, the current cost can be very roughly estimated as around $931 billion per year.

Evidence-based recommendations for exercise

Some researchers have provided details of the exercise interventions that have been successfully used to create successful outcomes in the treatment of various aspects of Alzheimer’s disease, as follows:

Study Intervention
Santana-Sosa et al. The researchers assessed the effects of a multi-modal exercise program on the ability to perform activities of daily living (ADLs) and physical function. The exercise program was performed 3 times per week and lasted 75 minutes per session. The session started and finished with a very light 15-minute warm-up and 15-minute cool-down period comprising very gentle walking and light stretching. In the main exercise session, the training included joint mobility, resistance training, and coordination exercises. Joint mobility exercises were performed for the shoulder, wrist, hip, knee and ankle joints. The resistance training involved 9 exercises with elastic resistance bands performed for 3 sets of 15 repetitions each) targeting the chest, biceps, triceps, shoulder, knee extensors, hip abductors, hip adductors, and calves. Stretches were performed for each muscle group after the resistance exercise. Finally, coordination exercises were performed with foam balls of gradually decreasing size.
Williams and Tappen The researchers assessed the effects of 3 different interventions on mood and affect in 90 nursing home residents with Alzheimer’s diseases, including a multi-modal exercise protocol. The exercise protocol included 10 minutes of strength, balance, and flexibility exercises followed by walking. The strength training exercises included partial sit-to-stands, calf raises and sitting push-pulls. The balance exercises included side-stepping first to the right, then left, then backward, and finally in circular movements. The exercises were progressed by increasing the number of repetitions from 3 – 9 repetitions by adding 2 repetitions per week. The walking was progressed by adding minutes to the time up to a total of 20 minutes.
Teri et al. The researchers explored adherence to a community-based multi-modal exercise program in 30 individuals with Alzheimer’s disease. The multi-modal exercise program comprised of endurance exercise, resistance training, balance and flexibility training. The resistance training portion involved performing strengthening exercises on 3 nonconsecutive days per week, alternating with the endurance exercise days. The strengthening exercises targeted the lower body and included calf raises, ankle dorsiflexion, knee extension and flexion, hip flexion, hip extension, and hip abduction. The exercises were initial performed without weight for 1 set of up to 12 repetitions. Ankle weights were used once the exercises could be completed with bodyweight. The balance training was performed as either a warm-up or as a cool-down in conjunction with either the resistance training or endurance exercise. The balance training comprised transfer exercises (chair sit-to-stand), base-of-support exercises (forward lean), and advanced walking skills (backwards walk). The flexibility training involved stretches for the back, shoulders, hips, hamstrings, ankle plantar-flexors, neck and hand. The endurance exercise was targeted at increasing duration of walking time and was performed for at least 30 minutes on at least 3 nonconsecutive days per week, alternating with resistance training days. Walking speed was increased if and when this was possible.

Based on these study interventions, it appears that experts and researchers working to provide individuals with Alzheimer’s with suitable exercise programs make use  of multi-modal programs to improve aerobic fitness, muscular strength, joint flexibility and balance.

Conclusions

On the basis of these studies and reviews relating to the successful studies involving exercise treatments for individuals with Alzheimer’s , the following conclusions might be drawn:

Area Conclusion
Exercise is effective in Alzheimer’s disease Exercise interventions can help improve measures of cognitive dysfunction, depression, mood and affect, risk of falls, sleep disturbances, physical function, walking ability, strength, mobility, and the ability to perform activities daily living in patients with Alzheimer’s disease.
Multi-modal programs have been most studied The most well-studied exercise interventions that have been found to help improve various outcomes for patients with Alzheimer’s disease are multi-modal in nature and include stretching, walking, strengthening and balance interventions.

Based on these study interventions, it appears that experts and researchers working to provide individuals with Alzheimer’s with suitable exercise programs make use  of multi-modal programs to improve aerobic fitness, muscular strength, joint flexibility and balance.

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