1

Earned
10%

Possible
10%

Evaluation Criteria
Introduction/Review of the Nursing Issue/PICOT Question

55%

60%

Summary of Three Research Reports

5%

5%

Compare/Contrast the Three Research Reports

5%

5%

Conclusion/Recommendations for Future Nursing Practice

10%

10%

Clarity and Conciseness of Thought Throughout Paper (formal

writing style, grammar, sentence/paragraph structures & flow)
Minor issues, but over-all well written

5%

10%

APA Formatting Appropriate (title page, headers, page numbers, title

on 1st page of text, section headings, citations within the text and
reference page)

Grade: 90%
Cognitive Function in Alzheimers Disease:
Does Exercise Make a Difference?
Lisa Barker
Lynchburg College

Commented [SH1]: APA: Title page incorrect. See OWL

PowerPoint Slide #7 for proper formatting (posted on Moodle2)

Cognitive Function in Alzheimers Disease:

Does Exercise Make a Difference?
Alzheimers Disease is the sixth leading cause of death in the United States today,

Commented [SH2]: APA Formatting Error: Need shortened

version of title as header. See Moodle2 postings of OWL
PowerPoint Slide #9 and/or sample paper for proper formatting.

affecting 5 million individuals age 65 and older, and is projected to increase 40% to 7.1 million
by 2025 (Alzheimer's Association, 2014). As patient care moves more into the home and

Commented [SH3]: Proper APA Citation of paraphrased info.

community setting, nurses, especially those in home health and public health positions, will have
an increasingly important impact on the well-being and quality-of-life of Alzheimers Disease
(AD) patients. Because teaching is a core focus in providing nursing care, both to the patient and
to the family, nurses have the obligation of learning as much as possible about different ways
they can help their patients and how they can affect the quality and completeness of care. Being
the coordinator of care, nurses must also involve a variety of disciplines and therapies working
together to bring about the best possible outcome. In addition, because nurses can affect and
contribute to the interaction between the patient and other practitioners such as physical
therapists, occupational therapists and care providers, it is incumbent on nurses to be advocates
for patients to insure that those practitioners are also aware of current research and findings that
are applicable to and can benefit the AD patient. While there is currently no cure for AD,
numerous studies and trials have sought to examine various interventions to reduce symptoms or
delay progressionwith varying results. In this paper, we consider exercise which offers
multiple benefits for most every individual, with or without disease. Here we examine the effect
of exercise on cognitive function in AD patients and seek to answer the question, In elderly
patients diagnosed with Alzheimers Disease, how does a regular exercise/activity regimen
compared with a sedentary lifestyle affect cognitive function?

Commented [SH4]: Nice intro. Clear thesis statement. Clearly

laid out issue and explained importance to the profession of nursing.

Winchester et al. (2012) conducted a study that explored how exercise/physical activity

Commented [SH5]: Proper APA citation

effects mood, functional abilities, behavioral/neuropsychiatric symptoms and cognitive function

in Alzheimers Disease. For purposes of this paper, only the effect on cognitive function will be
analyzed in the following summary.
In the study conducted by Winchester et al., quantitative descriptive analysis was used to

Commented [SH6]: Good.

Could have included these two sentences with next paragraph

analyze data and address the question, In patients experiencing mild cognitive impairment of
Alzheimers Disease, does physical activity/exercise compared to a sedentary lifestyle decrease
the rate of cognitive, functional and behavioral decline? The researchers surveyed a sample of
AD patients at 9 outpatient clinics across California. These clinics were Alzheimers Research

Commented [SH7]: APA Citation Error of direct quote: See

OWL PowerPoint Slide #14 and following and/or sample paper
posted on Moodle2 for proper citation of a direct quote. If this error
repeated later in paper, faculty notations will be not added.

Centers of California (ARCC), each of which were affiliated with a University of California
institution, but each in a different city. The goal was two-fold: 1) to quantify the prevalence,
type and amount of physical activity in total hours per week (the dependent variable), in mild to
moderate AD patients; and 2) to determine if the patients who participated in exercise/physical
activity showed any change in global cognition, functional capacity or altered mood states
compared to patients who led a more sedentary lifestyle (Winchester et al., 2012).
Criteria for selection of participants was > 60 years of age, English or Spanish speaking,
a score of 18 or higher out of 30 on the Mini-Mental State Exam (MMSE) and < 8 out of 15 on
the Geriatric Depression Scale (GDS). Exclusion data in the selection process was significant
visual impairment, uncorrected hearing impairment, restricted mobility, and requirement of
wheelchair or walker for mobility, as these criteria would limit the ability of the participant to
engage in meaningful physical activity. The final demographic breakdown of the study
participants was 104 individuals, 46 women and 58 men, ages 63 to 98 years (mean 81 + 6.54),

Commented [SH8]: I am assuming you are paraphrasing here.

If not, need a direct quote citation

an education level of 16.67 years + 3.25, and 69.8% Caucasian, 20.1% Latino/Hispanic and
10.1% other.

Commented [SH9]: Very good

The tools used for this study were (1) the survey used for initial selection of participants,
(2) an informant who was assigned to each participant, and (3) the continuous data collection
tool the modified Yale Physical Activities Survey (YALE) for older adults used by the
informants to gather specific data for analysis as a baseline and at the one-year point. The
informant assigned to the patient was required to have face-to-face meetings with the participant
a minimum of 3 days per week throughout the study, providing key information about the
physical activity the patient was engaging in, how many hours and minutes per week. Care was
taken to insure that the informant who collected the baseline data also collected the data at the
12- month point, so they were very familiar with the patient and could identify changes in
activity patterns (in mental, physical, or social activities) over the 12 month period. The physical
activity categories were broken down into: (1) housework- dishwashing, shopping, laundry; (2)
yard work gardening, raking, sweeping; (3) exercise walking, swimming, aerobics; and (4)
recreational - dancing, bowling, needlework.
Baseline data for the two groups indicated that 84 of the 104 participants (the Active
group) regularly walked an average of 2.76 hours per week, while 20 of the participants (the
Sedentary group) did not. Using ANCOVA analysis, the researchers found that leisurely
walking was preferred over any other form of exercise, (F8.784=5.12, p<0.001, Ts103=3.23-6.14,
ps < 0.001, CI=0.39-1.21 and 0.59-2.37); and paired samples t-tests showed that individuals who
walked had higher MMSE scores at baseline than those who didnt exercise (25.55 + 3.24) vs.
(23.07 + 3.65; T103 = 2.97, p= 0.01, CI = 2.63-0.82). At the 12-month mark, the data revealed a
significant interaction between the change in global cognition and the time engaged in walking

Commented [SH10]: All data presented well

activities (F6.96 = 142.11, p< 0.001), with Active participants having higher MMSE (MMSE =
+2.22 + 0.82; N =84) than Sedentary participants (MMSE = -1.97 + 0.98; Paired T73 = 6.08,
p< 0.005, CI = 0.06-2.67; N = 20) (Winchester et al., 2012).
To determine if the effects indicated were dose-dependent, the Active group was divided
into groups those who walked for one hour/week (i.e., 1 h/week; N=50) and those who walked
over two hours/week (i.e., 2+h/week; N=34). The results showed that the effects of walking on
cognition were dose dependent, and that AD patients in the Sedentary group exhibited a
significant drop in MMSE scores over the one-year time period (T29 + 4.61, p= 0.001, CI = 2.695.09, N=20) whereas a significant improvement in MMSE scores was seen in the Active group
participants who walked 2+h/week (T23=4.19, p= 0.001, CI =3.14 0.28) (Winchester et al.,
2012).

The researchers suggest that using this knowledge as an intervention strategy to use

with AD populations, to potentially improve patient outcome. They also suggest that it would be
valuable to conduct future studies to further investigate the dose-dependent effect of exercise on
cognition in AD patients.
An Australian study, conducted by Vreugdenhil et al., (2012), evaluated the effectiveness
of a home exercise program designed to improve functional ability across multiple domains,

Commented [SH11]: Study Evaluation

Research Question: Clearly presented
Sampling: Clearly presented
Data Collection: Clearly presented
Results: Clearly presented
Researchers Recommendations: Clearly presented
Point Deductions: None Outstanding work!

however, for purposes of this paper, the focus will be only on outcomes related to cognitive
function. This randomized controlled trial followed 40 patients (16 men and 24 women) from
the Launceston General Hospital outpatient memory disorders clinic in Tasmania, Australia. To
be included in the study, all patients were required to:

live with their caregiver (family or friend) or have a caregiver who visited them daily
be free of any physical condition that would prevent them from full participation in the
prescribed exercises and activities
be free of any neurodegenerative disorders other than AD
if taking dementia medications, must have started taking them prior to the previous 3
months

Commented [SH12]: I would recommend in future, when using

research from abroad, explicitly state why you feel it applies in the
US.

not currently be engaged in aerobic exercise or resistance training more than once a week
The patients were randomly assigned to either a treatment group (exercise plus usual

treatment) or control group (usual treatment only). The treatment group was engaged in a 4month at-home exercise program, under the supervision of their caregiver. The exercise program
consisted of 10 simple exercises, each having three levels of progressing difficulty, which
focused on upper and lower body strength, balance training and at least 30 minutes of brisk
walking, with the participants being asked to perform the exercises/walking daily if possible.
The researchers followed up with the participants at the 2-week point and the 2-month point to
determine how well the participants were progressing with the exercises through the increasing
levels of difficulty.
Baseline data was collected (age, education level, date of onset of memory issues, use of
cholinesterase inhibitors, smoking and alcohol consumption, MMSE results, current activity
level - # hours walking/week, BMI, Geriatric Depression Scale, and Zarit Carer Burden), and the
data showed no significant differences between the two groups (Vreugdenhil, Cannell, Davies,
&Razay, 2012). Tools that were used to collect and evaluate [specifically cognitive] data were:
the Alzheimers Disease Assessment Scale Cognitive Sub-Scale (ADAS-Cog) and the MMSE.
At the 4-month mark, the participants were evaluated by an assessor who was blinded as

Commented [SH13]: Good methodology for the study!

to which participants were in which group. As previously indicated, the tools that were used for
cognitive assessment were the Alzheimers Disease Assessment Scale Cognitive Sub-Scale
(ADAS-Cog), which scores 0 to 70 with a higher score indicating greater impairment, and
consists of 11 tasks measuring memory impairment, language, praxis, attention issues and other
cognitive abilities, and the MMSE, which scores from 0 to 30, with a higher score meaning
better cognitive function. Also, it is of interest to note that unlike other studies reviewed, this

Commented [SH14]: It is interesting.

study included a Clinicians Interview-Based Impression of Change plus Caregiver Input (CIBIC-plus) which looks at the global change in the participant, using a seven-point scale to assess
the overall change with 1 signifying marked improvement from baseline, 4 signifying no change,
and 7 signifying change for the worse relative to baseline.
The outcome of the assessment of cognitive function at the 4-month mark indicated that
the exercise-treatment group, when compared with the control group had MMSE scores 2.6
points (p=0.001) higher, and the ADAS-Cog scores were decreased by 7.1 (p=0.001), both of
which indicate improved function/performance compared to the control group. The overall
global change (which is significantly influenced by cognitive performance) indicated that there
was a minimal improvement for the exercise-treatment group, whereas there was a minimal
worsening for the control group. The overall results of the study suggest that a communitybased exercise program specifically targeted to the needs of people with dementia is effective in
improving cognitive functional ability (Vreugdenhil et al., 2012). This is very important because
as cognitive function declines in dementia/Alzheimers patients, needs of the patient increase, as
does the burden for the caregiver, thus improvement in the patients outcome may potentially
also benefit, the caregiver. The researchers recommended that this connection be investigated
further in future studies, because practitioners may use this knowledge to better benefit patients
in both inpatient and outpatient settings.
In a broader evaluation of the effect of exercise on cognitive function, a study by Coelho

Commented [SH15]: Study Evaluation

Research Question: Clearly presented
Sampling: Clearly presented
Data Collection: Clearly presented
Results: Clearly presented
Researchers Recommendations: Clearly presented

et al., (2013) utilizing multimodal exercise interventions (motor activities and frontal cognitive
Point Deductions: None

tasks performed simultaneously) sought to evaluate the effect of this intervention on frontal
cognitive functions, and to then further evaluate patients gait as a function of that effect
(however, gait is not included in the focus of this paper). This quasi-experimental study, which

Commented [SH16]: Interesting but need to describe in more

detail. How was this done?

consisted of a sample of 27 patients with mild (CDR-1 Clinical Dementia Rating) and
moderate (CDR-2) Alzheimers disease, was divided into 2 groups, with the treatment group
being comprised of 8 CDR-1 patients and 6 CDR-2 patients, and control group had 7 CDR-1
patients, and 6 CDR-2 patients. While the assignment of patients was not random, it was done
for convenience in order to distribute the patients equally; however it should be noted that the
groups did not differ in any of the variables at baseline. The training/exercise group participated
in multimodal exercise in addition to their normal daily routine, while the control group
maintained their normal daily routine, with no participation in regular or structured exercise
programs.
The initial evaluation of the patients, who were community-dwelling citizens in Rio
Claro, Sao Paulo, Brazil, all had a clinical confirmation of AD, were classified using the Clinical
Dementia Rating (CDR) to indicate dementia severity, and were evaluated using the MiniMental State Exam (MMSE). Patients who were unable to ambulate independently or who had
visual or auditory impairment, or other limitation that may impair their gait, were excluded. The
patient baseline was obtained using the Frontal Assessment Battery (FAB) to assess executive
function. The battery consisted of six subtests: (i) similarities (abstract reasoning); (ii) lexical
fluency (mental flexibility); (iii) series motor (motor programming); (iv) conflicting instructions
(sensitivity to interference); (v) go-no go (inhibitory control); and (vi) prehension behavior
(primitive reflex). It varies on a scale of 0-18 points, and higher scores represent better
performance in frontal [cognitive] functions (Coelho et al., 2013). The Clock Drawing Test
(CDT) was also used to assess [cognitive] executive functions, which includes planning,
abstraction, logical sequencing and monitoring of the executive processing function. In addition,

Commented [SH17]: Good point

the Symbol Search-Subtest of the Weschler Adult Intelligence Scale-III (Symbol) was used for
assessing focused attention.
The intervention was implemented by having participants in the exercise group engage in
1-hour sessions, three times per week on alternating days over a 16-week period. The modalities
consisted of strength/resistance training, aerobic capacity, flexibility, balance, and agility
performed simultaneously with cognitive activities requiring abilities such as focused attention,
planned organization of responses, abstraction, motor sequencing, judgment, self-control and
mental flexibility (Coelho et al., 2013). Throughout the intervention, the degree of complexity
was increased in both the cognitive and motor activity requirements, effectively increasing
cognitive load and requiring more judgment, self-control and attention focus. As intensity
increased, the participants were carefully monitored for heart rate (up to a maximum of 65-75%
of the patients predicted maximum heart rate for their age) and blood pressure to insure patient
safety.
After the 16-week period, the primary finding in the treatment group was significant
improvements in abstraction, organization, motor sequencing, behavior self-control and
attention. In the control group, however, the participants worsened significantly in frontal
cognitive functions, especially in planning, organization, and motor sequencing (Coelho et al.,
2013). Comparing performance on the cognitive assessments (Baseline p vs. Intervention p),
the FAB total score was (p=0.76 vs. p<0.001); CDT score was (p=0.896 vs. p=0.001) and
Symbol was (p=0.109 vs. p<0.001), indicating a significant improvement in the treatment group.
Another finding in this study was related to the number of counting errors during the dual
task exercises. A significant difference was found between groups, and the control group
patients had an increased number of counting errors during the realization of the dual task. One

Commented [SH18]: See previous comment re: this

description. Should have given a brief overview earlier. Based on
this write-up, I am still somewhat unclear on how they did both
simultaneously.

10

possible explanation for this worse performance refers to the fact that patients in the control
group had shown significant deterioration in frontal cognitive functions, and were probably more
vulnerable to the impact of cognitive load as they walked. (Coelho et al., 2013).
The researchers point out in this study that this information may be valuable for
professionals who work with Alzheimers patients in that they may use a similar protocol to
stabilize and/or improve frontal cognitive function, at least potentially to some degree. They also
suggest that prospective studies with a more randomized design should be conducted to learn
more about maximizing and realizing these benefits.
These particular studies were chosen for review because of the diversity of perspective

Commented [SH19]: Study Evaluation

Research Question: Clearly presented
Sampling: Clearly presented
Data Collection: See above
Results: Clearly presented
Researchers Recommendations: Clearly presented

offered. They are similar in that they compare exercise/physical activity versus sedentary or less
Point Deductions: -5%

active lifestyles and evaluate the outcome over a given period of time. The studies differed
however, in their approach to or type of exercise. The first study, Winchester et al., (2012) was
not random, but was controlled. It looked at patients who already had a healthy exercise
regimen, versus patients who were sedentary. The patients were evaluated by an assigned
informant, over a period of one year. The second study, Vreugdenhil et al., (2012) a randomized
controlled trial, worked only with patients who did not have a significant regular exercise
program already in place, then introduced that intervention to the treatment group, being
supervised by their caregiver (with periodic follow-up) for a period of four months. The third
study, Coelho et al., (2013), which was not randomized but was controlled, looked at combining
exercise with cognitive activity simultaneously over a period of 16 weeks and compared this
treatment group to the control who did not receive multimodal treatment. The three studies were
unanimous in their finding that exercise does indeed improve cognitive functioning in patients

11

diagnosed with Alzheimers Disease, and each group of researchers did recommend that
additional studies be conducted to explore the effects of exercise on Alzheimers patients.

Commented [SH20]: Well done

In consideration of the results of these studies, one is lead to the conclusion that exercise
does indeed improve the cognitive functioning of Alzheimers patients. Specifically, the finding
that benefits are derived from exercise as simple as walking is very important because walking
would likely have the greatest appeal and encourage a high participation rate in Alzheimers
patients, because many patients may think of exercising as something more complicated, such as
going to the gym and this shows us that just simply walking can have a beneficial effect.

Commented [SH21]: Well done

After reviewing and evaluating these studies, I would recommend for future nursing
practice involving Alzheimers patients to embrace these findings and work with the patients and
their families/caregivers to educate them as to how they can help themselves by being active on a
daily basis and continuing to challenge themselves physically and mentally as much as possible,
whether they are in nursing homes, hospitals or in their own homes. The education should also
be repeated and supplemented with take-home information/handouts/pamphlets to insure that
they have a reminder once they leave the hospital/facility. This should be a major focus when
caring for Alzheimers patients because it is important that nurses begin engaging patients in as
much physical activity as early and as often as possible, and being creative in ways to increase
or engage patients and emphasizing it repeatedly to them, and especially their caregivers. I
would also recommend that nursing practice take on a more proactive approach when
coordinating patient care with practitioners in other specialties, such as physical therapy,
occupational therapy etc., emphasizing to them the necessity of teaching the patient (and
family/caregiver) ways to keep active and tailor it to the unique needs of that patient so that the
patient may be engaged at as high a level as possible in participating in their own care.

Commented [SH22]: Insightful recommendations

12

References
Alzheimer's Association. (2014, March). 2014 Alzheimer's disease facts and figures. (L. Bleiler,
Ed.) Alzheimer's & Dementia, 10(2), e47 - e92. Retrieved October 2014, from alz.org:
http://www.alz.org
Coelho, F., Andrade, L., Pedroso, R., Santos-Galduroz, R., Gobbi, S., Costa, J., Gobbi,L.,(2013).
Multimodal exercise intervention improves frontal cognitive functions and gait in
Alzheimer's disease: A controlled trial. Geriatrics & Gerontology International, 13, 198203. doi:10.1111/j.1447-0594.2012.00887.x
Vreugdenhil, A., Cannell, J., Davies, A., Razay, G., (2012). A community-based exercise
programme to improve functional ability in people with Alzheimer's disease: a
randomized controlled trial. Scandinavian Journal of Caring Sciences, 26(1), 12-19.
doi:10.1111/j.1471-6712.2011.00895.x
Winchester, J., Dick, M., Gillen, D., Reed, B., Miller, B., Tinklenberg, J.,Cotman, C., (2012,
June 16). Walking stabilizes cognitive functioning in Alzheimer's disease (AD) across
one year. (J. Starr, Ed.) Archives of Gerontology and Geriatrics, 56(1), 96-103. doi:
10.1016/j.archger.2012.06.016

MULTIPLE SIGNIFICANT APA ERRORS:

If Alz Dx source had an editor, the citation should have been referenced using that
individuals last name.
Missing & symbol before last author in list of multiple authors.
Punctuation between authors names and year should be period and not comma.
Any reference to date should include only year and not month
Last entry includes journal editors name. This in not used in APA formatting.
It would appear that you used something to automatically format your reference list. Either the
program is flawed OR you do not have it set for APA formatting. I suspect the former but you
may want to check the later if you decide to use it again. Personally, I would recommend using

Commented [SH23]: APA Error: Use black font

13

the resources posted on Moodle and formatting it manually. Then you can be in control of the
accuracy.