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RESEARCH

The Acute Effects of a Specialized Movement Program on the Verbal

Abilities of Patients With Late-Stage Dementia

BY SHOSHANA DAYANIM, PHD

Little research exists concerning the cognitive effects of exercise on elders with Alzheimer’s dementia (AD), and none concerning late-stage AD. This study provides an initial investigation of the possible cognitive effects of a specialized exercise program for patients with late-stage AD. In a pretest/posttest design, patients participated in 20-minute movement groups. Results indicated a statistically significant decrease in patients’ aphasia and/or agnosia following the program. This study is the first to indicate that movement has the ability to immediately affect the memory recall of patients with late-stage AD. These techniques may be used by caregivers seeking increased lucidity during interactions.

Key words: Alzheimer’s disease, dance therapy, dementia, exercise, memory

able to make only nonsense word sounds (if he or she is

Ample research exists on the health benefits for able to make any sounds) but may still be able to walk,

exercise among the elderly, including overall dance rhythmically to music, or catch a ball. Perhaps be-

good physical health, emotional health, and cog- cause of this slower deterioration of motor skills (versus

nitive health. Conversely, little research exists on the po- the more prominent loss of speech), few researchers have

tential benefits of exercise or physical activity on elders focused on dementia and movement.4

experiencing cognitive impairment due to dementia de- Furthermore, although existing research purports that

spite the known benefits to unimpaired elders.1 exercise or movement programs result in cognitive bene-

As early to moderate dementia does not prevent partici- fits for patients with early to moderate dementia, there is

pation in exercise programs,2 one cannot attribute the an absence of research concerning whether or not these

lack of research in this area to patients’ inability to partici- benefits extend to late-stage dementia. Existing studies fo-

pate in the research. In fact, deterioration of motor skills is cus on longer-term effects of physical activity in patients

not usually seen until the later stages of dementia3 and may with dementia and ignore the possibility of immediate

not appear for years after memory decline is noticeable.

For example,an individual with late-stage dementia may be Alzheimer’s Care Today 2009; 10(2):93–98

Specialized Movement Verbal Ability Alzheimer Dementia 93

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Ample research exists on the health

benefits for exercise among the elderly,

including overall good physical health,

emotional health, and cognitive health.

Conversely, little research exists on the

potential benefits of exercise or physical

activity on elders experiencing cognitive

impairment due to dementia despite the

known benefits to unimpaired elders.

cognitive benefits, which may be of great use to care tak-

ers seeking to communicate with patients.This study pro-

vides an initial investigation of the possible acute

cognitive effects of a specialized exercise program on in-

dividuals with late-stage dementia.

A Exercise’s effects on the cognitive abilities of Alzheimer’s dementia

Research investigating the impact of exercise on the cog-

nitive abilities of patients with Alzheimer’s dementia (AD)

falls into 2 groups.The first type of study uses a pre- and

posttest method of the same group participating in a phys-

ical activity.The second type of study is an experimental or

quasi-experimental design in which an experimental

group participates in an exercise program and is compared

with a control group, which receives either a nonmove-

ment-oriented program or no program.

Studies tracking the impact of exercise interventions

for patients with AD found increases in cognitive abili-

ties. For example, in an exercise-training program for pa-

tients with early AD (n 15) meeting 3 times weekly for

3 months, Palleschi and colleagues5 found a significant

increase in cognitive performance. Rolland and col-

leagues6 also found that a group (n 23) of patients

with moderate to severe AD significantly improved on

cognitive tests after participating in an endurance exer-

cise program of walking and bicycling. However, the ab-

sence of a control group in these studies weakens their

positive findings.

Other studies compared participation in exercise

groups with social groups. Friedman and Tappen7 found

that a 30-minute walking group meeting 3 times a week

significantly improved the verbal and nonverbal communi-

cation skills of patients with moderate to severe dementia

over the course of 10 weeks, whereas a social group meet-

ing with the same frequency showed no improvement. In

another experimental study, Scherder and colleagues8

compared 3 randomly assigned groups of adults (n 43)

with pre-Alzheimer’s cognitive impairment. Both the treat-

ment groups—a walking group and a group including only

hand and face exercises—had significantly improved

scores on tasks measuring executive functioning and ver-

bal fluency, whereas the control group, which included

only social visits, did not improve.

By contrast, Sobel9 compared social recreation stimula-

tion using bingo with daily physical activity among pa-

tients with early-stage Alzheimer’s attending adult day care

centers (n 50). Physical activity included 20 minutes of

walking or arm and leg extensions. He examined short-

term memory, word retrieval, and word recognition and

found that the cognitive stimulation from bingo signifi-

cantly increased retrieval and word recognition, but the

physical activity did not.

Several studies have compared the use of a specialized

movement therapy program with a recreational or social

program. Powel10 compared the effects of a 1-hour,

12-week movement therapy program versus a recreational

therapy program on institutionalized dementia patients

(n 30).He found a significant improvement in the move-

ment group, when compared with the recreational group,

on memory and IQ scales but not on scales measuring

social or behavioral changes.

Diesfeldt and Diesfeldt-Groenendijk11 evaluated the ef-

fects of participation in movement therapy on psychogeri-

atric nursing home residents with organic brain syndrome

(n 40), a diagnosis used to describe AD and other de-

mentias when this study was conducted. The authors

stated that these patients were able to give consent, had

difficulty performing daily tasks,were disoriented,and had

memory disorders. Using a repeated test design with a 1-

month interval, they tested the experimental group and

control group before and after the movement therapy ses-

sions.The movement therapy participants showed signifi-

cant increases in a free recall test when compared with the

control group and qualitatively exhibited greater retrieval

activity than the control group.

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The current study was designed similarly to the Dies-

feldt and Diesfeldt-Groenendijk11 study with a control

group and a repeated test design. Two important differ-

ences,however,were the current study’s inclusion of a test

prior to and following each movement therapy group and

the participation of a population that included patients

who were more demented than those Diesfeldt and

Diesfeld-Groenendijk describe.

B Theories on exercise’s positive effects on cognition

Although a clear reason has not been established for why

exercise appears to affect cognition and behavior, theo-

ries have been suggested. Craik et al12 relate increase in

age with a decline in mental and physical energy as well

as decreased capacity for attention.These may be a func-

tion of a decline in the processing abilities of the central

nervous system. One existing theory is that physical exer-

cise, which increases the amount of endorphin and sero-

tonin levels in the brain, may in turn increase the

functioning of the central nervous system and enhance

cognitive performance.13

C

Another theory is postulated by Eggermont et al14 in

their conclusion of their review on the biological links to

dementia.They theorize that exercise could restore cere-

bral hypoperfusion, the decrease of the perfusion of the

blood into the brain, resulting in renewed circulation

through the cortical capillaries, which, in turn, could revi-

talize brain functioning.

This study hypothesizes that a specified 20-minute

movement program would positively affect aphasia and/or

agnosia of a patient with late-stage dementia, as seen

through increased abilities to name common objects and

colors.

D E Participants (N 22, females 16, males 6) were re-

cruited on the basis of the recommendation of the medical

staff on the locked dementia unit in a hospital home where

patients resided for between 8 months and 4 years.Partici-

pants were between 61 and 93 years (average age of 79)

with a diagnosis of stage 6 or 7 senile dementia/

Alzheimer’s type. Participants included approximately

equal numbers of African American, white, Hispanic, and

Asian American adults. All participants were mobile and

able to walk with or without using assisted devices to pre-

vent falls. Some patients rarely spoke or made sounds,

The specialized movement therapy program

has the ability to provide immediate acute

effects on memory recall of patients with

late-stage AD. After 20 minutes of move-

ment therapy, participants appeared more

organized in their speech abilities.

whereas others spoke in a nonsensical order. Patients

were either incontinent or in need of assistance with toi-

leting. Patients were prone to wandering or sitting in one

place all day. Patients were not consistently able to say

their names and no longer recognized familiar faces.

Participants were taking a variety of medications to treat

dementia, depression, and other ailments typical among

elderly patients with AD.

F Patients with signed consent forms from caregivers, who

were mobile with a diagnosis of dementia and were resid-

ing on a locked unit, were selected to participate in this

study. Participants were administered a pretest while sit-

ting in the common room in the unit where they ate their

meals and participated in most recreation activities. This

test was administered between 1 and 3 times based on

availability of the patient. The test was readministered

20 minutes later to evaluate whether the passing of time

alone changed the patients’ answers. The initial adminis-

tration included asking the patient the color of an object

and the identity of an object.The second administration re-

peated the same questions but included different colors or

objects. For example, in the first round a patient may have

been asked to identify the color blue and then a banana,

and in the second administration the color brown and

then an apple.The inclusion of only 2 questions was nec-

essary to avoid any passage of time factors, as the patients’

ability to focus was extremely limited, especially prior to

group participation.

Participants also participated in seated movement ther-

apy groups.The number of groups varied between 1 and

10, depending on the patients’ availability on the day and

time of the group. Patient availability was not reliable as

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TABLE 1.

Moving With Dementia Movement Therapy Group

Preparation: Sit in a circle in groups of no more than 6 patients plus leadera

Purpose: To explore kinosphere (personal space), orient, and organize Stretching—reaching up and out with arms Work through body—warm up/move each part

of the body head to toe using self-touch as much as possible. When possible, ask each member of the group to select a movement for a specified body part

Purpose: To ground and organize using weight and space Toss/hit 1 or 2 balloons

This uses weight and space to expand patients’ kinosphere

Play catch with a ball or balloon filled with beads This uses weight and space for organizing; it

works on eye contact, decision making (each patient chooses to throw to someone), and control

Use large ball on floor for rolling and kicking This uses weight and space for grounding and

organizing Use co-oper band, a stretchy band onto which

each participant in the circle holds This is for grounding by use of weight and

interaction Purpose to refocus to self

Repeat balloon toss Repeat self touch

aThese methods need not be in a group setting but may also be used in one-on-one interactions.

TABLE 2.

their proneness to wandering or to “bad days” was unpre-

dictable and it was against hospital policy for groups to be

mandatory. Prior to the start of the group and at the end of

the group a recreation therapist,certified nursing assistant,

or nurse who was not in the room for the group asked

each participant the same questions as mentioned previ-

ously. The group included activities designed to provide

the patient with body orientation and spatial awareness

with the intention of increased mental organization. An

outline of the 20- to 30-minute session is broken down in

Table 1.The group was designed on the basis of standard

movement therapy work with patients with dementia.The

session included the same format for every administration.

G Analysis was carried out using the Statistical Package for

the Social Sciences version 11.0. Correlational analyses

were conducted to rule out the possibility that the vari-

ance in the number of times each member received the

test or attended a group could affect his or her ability to

identify objects or colors.A repeated measures t test was

calculated to measure the impact of the movement inter-

vention versus no intervention.

H Table 2 compares raw scores from the pre- and posttests by

number of trials. Correlational analysis indicated that the

number of sessions did not significantly relate to the partici-

pants’ ability to identify objects or colors. T tests indicated

that there was a statistically significant increase in partici-

pants’ ability to identify objects correctly when comparing

scores from the time lapse testing (M 0.09, SD 0.19) to

scores from the movement intervention testing, M 0.25,

Comparison of Trials With and Without Group Participation (Task: Ability to Name Colors and Objects)

No group Group

Mean number of trials

1.89 tests 3.47 groups

% named object correctly

Pretest Posttest

56 46 33 60

% named color correctly

Pretest Posttest

44 34 28 65

Alzheimer ’s Care Today | Apri l–June 2009 96

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SD 0.38, t(14) 3.47, P .005, 2 0.46.There was

also a statistically significant increase in participants’abilities

to identify colors correctly when comparing scores from the

time lapse testing (M 0.08,SD 0.30) to scores from the

movement intervention testing, M 0.35, SD 0.36,

t(14) 3.78, P .005, 2 0.51.The 2 statistic for both

items indicated a large effect size, suggesting a considerable

difference in the scores.15 The control pretests were gener-

ally higher than those participating in movement groups.

This may be a result of the inclusion of several patients who

were slightly more verbal and refused to attend groups.

I The results for this study indicate that the specialized move-

ment therapy program has the ability to provide immediate

acute effects on memory recall of patients with late-stage

AD. After 20 minutes of movement therapy,participants ap-

peared more organized in their speech abilities. This is con-

sistent with Diesfeldt and Diesfeldt-Groenendijk’s11

research focused on midlevel functioning AD patients.

Perhaps the difference in results between the current

study and Diesfeldt’s11 versus Sobel’s,9 which did not regis-

ter an increase in word recognition and retrieval after par-

ticipation in physical activities, is in the severity of patients

with AD.The participants in the current study were in the

last stages of AD, whereas Sobel’s participants were in the

early stages of AD; this study’s participants could not have

completed the cognitive tests administered to Sobel’s par-

ticipants.The type of program may also be a factor in the

differences. Sobel’s exercise program included walking or

leg and arm exercises, whereas movement therapy utilizes

purposeful movement intended to help organize a patient

mentally through the use of movement rather than exercise

physically.

This is an important finding as it suggests that some forms

of physical activity—in this case movement therapy—can

help mentally organize patients with AD as severe as those

in the late stage of dementia in which they often have

limited to no speech.

This program is simple and may be utilized for patients

with AD by a caregiver or family member seeking a

method of increased communication with their loved one.

Although the duration of the cognitive effects was not ex-

amined, a moment of clarity between a patient with AD

and a family member would certainly be an improvement

and much welcomed change for the family member.

One limitation of this study, as with the exercise studies

referenced earlier, is the small number of participants due

to the limited number of residents on this particular de-

mentia unit. Future research should include a larger num-

ber of participants from various residents in hope to gain

additional subgroup comparisons. For example, the small

sample size prevented the examination of possible medic-

inal effects. Future research should also investigate the du-

ration of the increased object and color recall following

the movement session. Furthermore, future research

should include a more comprehensive cognitive assess-

ment before and after movement sessions.

Shoshana Dayanim, PhD, Assistant Professor, Department of Psychology, Argosy University, Chicago, Illinois, and Research Associate, Emory University, Atlanta, Georgia.

This research was funded by a grant from the Thomas and Jeanne Elmezzi Foundation at Hebrew Hospital Home, Bronx, New York. Parts of this research were presented at the Annual International American Dance Therapy Conference in October 2000.

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