FEATURE ARTICLE
Benefits of Physical Exercise for Older
Adults With Alzheimer’s Disease
The physical and mental benefits of exercise
are widely known but seldom available to per-
sons suffering from Alzheimer’s disease (AD).
This article presents information on the po-
tential benefits of physical exercise for people
with AD, discussing some of the metabolic
and neuropathological changes regarded as
underlying causes of AD, as well as some of
the psychological and organic abnormalities
that can be modified through exercise. The
extent to which physical exercise programs
can play a role in the treatment of AD is ad-
dressed in the second part of the article, de-
scribing the most relevant clinical studies in
this field. Finally, the article provides informa-
tion about how to prescribe physical exercise
for AD patients, mainly by giving examples of
structured physical programs designed for
older adults with dementia. (Geriatr Nurs
2008;29:384-391)
lzheimer’s disease (AD), the most com-
A mon cause of dementia, is a progressive
and irreversible neurodegenerative dis-
ease characterized by cognitive deficits such as
amnesia, apraxia, agnosia, aphasia, and execu-
tive dysfunction. It is among the leading causes
of death among the elderly.1 Although it may
not be possible to prevent or alter the course of
the underlying disease, benefits of nonpharmaco-
logical approaches in the management of people
with AD have been highlighted, especially strate-
gies aimed at slowing cognitive and physical de-
cline, as well as maintaining or ameliorating
patients’ quality of life.2 Physical exercise is
regarded as a useful tool in this regard; cross-
sectional and longitudinal studies have demon-
strated that exercise has beneficial effects, such
as decreasing depression, increasing overall
health, and improving cognitive performance, in
older adults.3 Moreover, it has been postulated
that exercise may play a role in reducing the
risk of cognitive decline.4 Despite the growing
384
Carlos Ayán Pérez, PhD
J. M. Cancela Carral, PhD
evidence on the benefits of exercise on the health
and functioning of older adults with cognitive dis-
orders, the available literature lacks clinical evi-
dence that supports recommendations for
exercise guidelines in people with AD.5 This arti-
cle describes the main symptoms of AD and the
possible benefits of exercise for this disease. It
also reviews the major studies that have exam-
ined the influence of exercise in patients with
AD and provides basic exercise guidelines for
older adults with dementia.
Potential Benefits of Physical
Exercise in Alzheimer’s Disease
Benefits of exercise in AD patients can be ex-
plained through 3 pathways. First, some meta-
bolic and neuropathological changes, regarded
as underlying causes of AD, can be modified in
some way through exercising. Second, some psy-
chological and organic abnormalities that accom-
pany the course of the disease can be
ameliorated. Third, AD patients may take advan-
tage of the same potential benefits of physical ex-
ercise that healthy older people experience.
Metabolic and Neuropathological Effects of
Exercise in AD
ß-amyloid (Aß) is an abnormal protein that is
strongly related to the formation of neuritic
plagues and neurofibrillary tangles that interfere
with the transmission of information to higher
levels of the brain.6 In this regard, Adlard and col-
leagues7 found that 5 months of voluntary exer-
cise resulted in a decrease in extracellular Aß
plaques in the frontal cortex, the cortex at the
hippocampus level, and the hippocampus in
transgenic mice genetically engineered to exhibit
AD neuropathological changes. Although the po-
tential mechanism underlying the exercise effect
remains unclear, it is likely due to anatomical,
Geriatric Nursing, Volume 29, Number 6
neurochemical, and electrophysiological changes Potential Benefits of Exercise on
related to neuronal plasticity. Complications Related to the Course of AD
Reduced regional cerebral blood flow (CBF)
Loss of body weight, which is common among
has been regarded as a required cofactor in the
AD patients,21 is associated with reduced muscle.
cause of AD. It has been confirmed that aerobic
This contributes to decreased muscular strength
exercises increases CBF in frontal, parietal, and
and increased frequency of falls,22 as well as to
temporal cortices of older adults.8 In addition,
loss of functional independence.21 In this regard,
growth of capillaries and enhanced cerebral per-
multiple studies have demonstrated improve-
fusion has been observed in the primary cortex
ments in falls and balance related to exercise pro-
motor of rats as a result of prolonged exercise.9
grams.23,24 Moreover, there is evidence that
Similarly, low levels of cerebral perfusion have
strength training can offset loss of skeletal mus-
been observed in the frontal and occipital cortex
cle mass, as well as improve cognitive decline.25
in AD, which provides evidence for cerebromi-
The latter effect can also be obtained through
crovascular pathology underlying this disease.10
cardiovascular training.26Therefore, physical
Hypoperfusion below a critical level leads to dys-
exercise may represent a simple and effective
functional upregulation of nitric oxide (NO)
intervention.
levels, which could result in a decrease in tis-
Another benefit associated with exercise for
sue-type plasminogen activator (t-PA) activity.
individuals with AD is the improved mood. De-
This reduction is associated with an increase in
pression is common in AD, affecting between
Aß.11 However, activity of t-PA enhances the pro-
5%–23%, of the patients.27 Previous reports indi-
duction of plasmin, which may degrade Aß. Thus,
cate that people with AD who exercised were
an upregulation of NO could attenuate this dys-
much less likely to be depressed.28 Indeed, aer-
function in AD, an effect that could be achieved
obic activities have been found to reduce physi-
through exercise because physical activity leads
ological response to stress and improve one’s
to enhanced NO release and increases cerebral
sense of well-being through the release of
perfusion12 as well as t-PA activity.13
endorphins.29
Evidence suggests decreased cerebral meta-
Finally, several studies of exercise interven-
bolic rate for glucose14 and a decrease of acetyl-
tions with nursing home residents with dementia
choline in AD patients.15 Because carbohydrate
resulted in reductions of unwanted behaviors
metabolism is important in synthesizing acetyl-
typically related to AD, such as wandering,
choline,16 improving carbohydrate oxidation
pulling at clothes, making of repetitive noises,
could be an appropriate method for increasing
swearing, and aggressive behavior, as well as
acetylcholine brain stores. In this regard, aerobic
improvements in communication and social
exercise (which has been seen to increase signif-
participation.30
icantly the release of acetylcholine in conscious
rats17) improves circulating blood glucose levels
and contributes to the regulation of glucose
Additional Effects of Physical Exercise on
homeostasis.18 Furthermore, exercise stimulates
Dementia
gene expressions of nerve growth factors that
are important for neurogenesis, production, Several potential benefits of exercise shown
and function of neurotransmitters and for for healthy people could play a role in AD treat-
synaptogenesis.2 ment. These include enhanced appetite,31 im-
Dopamine (DA) induces behavioral and physi- proved sleep,32 increased bone density,33 and
ologic changes. Abnormally reduced DAergic improved balance.23 In this regard, it must be
function has been reported in AD, and DA levels noted that secondary risk factors associated
are significantly reduced in the caudate nucleus with AD onset, such as vascular disease,34 inac-
and putamen of AD patients.19 Several studies in- tivity, or hypertension,17 can be ameliorated
dicate that calcium ions (Ca) affect brain func- through aerobic activities.
tion. Exercise increases serum calcium levels, Finally, several studies conducted with trans-
and serum calcium is transported to the brain genic mice have shown that aerobic exercise in-
that simulates DA synthesis. Subsequently, the in- creases the thickness of the motor cortex and
creased DA levels induce behavioral and physio- the expression of growth factor in the brain,35 in-
logic changes.20 ducing angiogenesis in both the cerebellar and

Geriatric Nursing, Volume 29, Number 6 385

386

Table 1.
Physical interventions programs with early to early-moderate AD patients.
Study N Intervention Frequency Volumen/Intensity Interventionist Outcomes

Namazi 11 Mobility (joint Daily sessions for 20 min/8 rpt per Specialized fitness Reduced agitated
et al.38 movements and 7 weeks exercise. instructor behaviors
stretching); Light 20 min/8 rpt per
exercise movement exercise
tasks (walk, sit and
stand, etc.)
Palleschi 15 Aerobic: Cycling Thrice-weekly- 20 min at 70% of Not described Improved attention,
et al.39 on arms only sessions, during maximal heart rate verbal and cognitive
stationary bike 3 months. capabilitites
Arkin30 11 Flexibility (stretching); Twice-weekly- 2 rpt of 15 for 10 min; University Significant
Aerobic (walking on sessions, plus 5 min with weekly students improvements in
treadmill, cycling on a weekly increases of 1 min until aerobic capacity,
stationary bike); volunteer-work reach 20 min (treadmill muscular strength, and
Strength out, during a year set at one mile/hour). 2 mood
(strengthening large sets of
muscle groups using 10-12 rpt, resting
MedX weight 30 min (weights
machines) increased by 2-5
pounds)
Rolland 23 Aerobic: Walking A mean of 7 Main daily duration of Caregivers Improved nutritional
et al.40 and cycling (5-12) weeks exercise was 35 min staturs and cognitive
(10-80 min). Intensity function; Less frequent
Geriatric Nursing, Volume 29, Number 6

individually adapted behavioural problems;

Unchanged patient
autonomy
Teri et al.46 30 Balance (transfer, Three non 10-15 min as warm Caregiver Better mood and
base-of-support and consecutive up or cool down instructed by behavior while
walking exercises); sessions a week, period.Free weight, a professional exercising
Flexibility (stretching); for 3 months 1 set of 12 rpt; Load trainer
Strength (lead shot incremented by 0.5- 5
weights); Endurance pounds; 30 min at
(walking) normal pace, speed
gradually increased
Geriatric Nursing, Volume 29, Number 6

Teri et al.47 76 Same as above Same as above Same as above Same as above Increased levels of
physical activity,
physical function and
health; Decreased
levels of depression
Rolland 56 Aerobic (walking); Twice-weekly- Moderate walking Occupational Slower progressive
et al.48 Strength (callisthenic sessions held in up to 30 min. therapist deterioration in ADLs
movements); groups of 2-7 Individualized
Flexibility(stretching); people for intensity; Total
Balance (small step 12 weeks volume of each
trials) session: 60 min
Arkin49 24 Balance; Flexibility; Two-weekly-sessions, 20-30 min of moderate University Significant fitness and
Aerobic (treadmill plus one voluntary walking/cycling, students/ mood gains; no effect
and stationary bike); session of brisk combined with Family in behavioural
Strength (weight walking, for 2-8 cognitive stimulation; member disturbances,
resistance machines) semesters 20-30 min of upper- depression or
lower body strength on nutritional scores
5 machines
Williams 90* Aerobic group 5 individual sessions Walking at normal Graduate Improvements in affect
and (walking), vs. a week for 16 weeks pace up to 30 min; 30 nursing/ and mood (especially
Tappen50 Comprehensive min; (walking up to Physical in the comprehensive
exercise group: 20 min); therapy exercise group)
Strength (callisthenic 3-9 rpt per exercise students
movements); Balance
(side stepping);
Flexibility; Aerobic
(walking)
* 44% of the sample rated as severely impaired patients.
rpt5repetitions;
ADls5activities of daily living.
387
motor cortices36 and activating endogenous ho-
meostatic mechanisms that counteract the ongo-
ing neurodegenerative process.37 However,
although these results are remarkable, the appli-
cability of studies using animal models human
conditions is unknown, and further research is
needed.
Clinically Relevant Studies
Despite the growing evidence showing that
physical exercise can be an appropriate nonphar-
macological strategy in the treatment of AD pa-
tients, few studies have focused on the benefits
of exercise in AD, and some of those available
have serious methodological flaws. For instance,
several studies have confirmed the efficacy of
aerobic and weight-training sessions in reducing
agitated behavior,38 improving cognitive func-
tion, and reducing the risk of falls,39,40 as well
as improving mood and fitness level.30 However,
the samples sizes were small, interventions in
some cases were short, and some studies did
not include a control group (Table 1).
In well-controlled studies (Table 2), walking,
whether alone or combined with cognitive
stimulation, was shown to be an appropriate
intervention for improving communication
performance.41,42 However, similar interventions
did not confirm this beneficial effect,43,44 and the
issue remains controversial.
Because AD patients are sometimes cared for
by family members, teaching caregivers to facili-
tate and supervise exercise activity has been re-
garded as a useful solution.45 In this regard,
a community-based program designed to in-
crease balance, flexibility, strength, and endur-
ance in AD patients guided by their caregivers
has shown important and beneficial effects.46
Moreover, follow-up research that included a con-
trol group and tested a larger sample showed that
AD patients who trained with their caregivers
were more active, improved their physical func-
tion and affective status, and had fewer depres-
sive symptoms.47
It is important to note, however, that care-
givers are sometimes elderly and unlikely to
seek out structured exercise programs. There-
fore, it is necessary to include specialized person-
nel to guide the training sessions or to take part in
long-term exercise programs carried out in nurs-
ing homes. Clinically relevant studies have
shown that following this trend, more complex
exercise training programs, resulting in fitness
and mood improvements, can be carried out
with AD patients.48-50

Table 2.
Effects of walking alone or combined with conversation, versus only
conversation in AD patients
Study N (n) Intervention Outcomes Conclusion
41
Friedman et al. 30 Walking for 30 Improvement in A conversation only
minutes, three times communication group, did not get
a week, for 10 weeks skills a higher
improvement
Tappen et al.42 71 (261/212) Walking (assisted1 or Improved adherence Walking while talking,
combined with to exercise sessions is a better
conversation2) for 30 and less functional intervention than
minutes, three times decline in combined assisted walking
a week, for 16 weeks group alone
Sobel43 50 One 20-minute session No effect on language Playing Bingo (20’)
of walking or arm ability and verbal induced a significant
and leg extension recognition improvement than
did physical activiy.
Cott et all.44 74 (30) Talking while walking No significant Walking did no better
in pairs for 30 differences in than talking 5 days
minutes three times communication a week, for 16 weeks
a week for 16 weeks skills

388 Geriatric Nursing, Volume 29, Number 6

Designing Exercise Programs for
People with AD
From the findings of the clinical studies re-
viewed, 2 basic guidelines for carrying out exercise
interventions with AD patients in the early to mod-
erate stages of the disease can be addressed. First,
aerobic exercise, such as walking (particularly
when combined with conversation) at least 30 min-
utes during most days of the week or cycling 20
minutes at moderate intensity 3 days per week
seem to be efficient ways to improve attentional,
verbal, and cognitive capabilitites.39,41,42 Second,
muscular strength by means of lifting low free or

Table 3.
Structure of a typical exercise session designed for demented older adults
Activity Objective Example

General movements Warm-up and kinaesthetic Sitting: hand

of the body work touching nose, knee,
alongside with the rhythm shoulder, etc.
of music (3 min)
Mobility of the upper Range of Motion Sitting: flexion,
joints of the body (3 min) extension and rotation
of joints. Squeeze
or rolling a ball
Resistance exercises (5 min) Muscular strengthening Standing or sitting:
pushing, pulling
and lifting, with
or without implements
(balls, wooden sticks, etc.)
or against
the partner
Fine motricity (5 min) Coordination Standing or sitting:
mobility of the fingers,
right extremity touching
left one and vice
versa; making
balls of paper
Mobility of the lower Range of Motion Standing: rotation
extremities (5 min) of ankles, bending
knees, etc.
Lower extremities Balance and Strength Sitting: pushing
performance (15 min) or lifting lower
extremities; 5 rpt, holding
a ball between the legs;
standing: lifting a leg,
shifting centre of gravity
between legs; walking in
different directions, with
or without obstacles
(steps, benches, etc.)
Playing games (5 min) Socialization Passing rubber
balls, clipping
hands alongside
a rhythm, etc.
Relaxation Cooling down Breathing and exhaling
alongside with stretch
movements
Data from Netz et al.51

Geriatric Nursing, Volume 29, Number 6 389

lead-shot weights or strengthening large muscle
groups using weight machines on 3 nonconsecu-
tive days per week can be effective in improving fit-
ness and mood.30 However, comprehensive
exercise sessions, rather than walking or strength-
ening alone, must be emphasized.50
It is clear that physical exercise guidelines for
those in the first stages of AD are similar to those
applied to healthy older people, but the question
of how to design exercise programs for patients
with more serious dementia has not been re-
solved. Fear of falling, deconditioning, and the ef-
fects of medications, as well as illness and fatigue,
often result in limited treatment time, making it
difficult to engage cognitively impaired frail el-
ders in exercise programs. In this regard, some ba-
sic interventions have shown to be effective51:
 2 to 3 weekly 45-minute sessions should be held
during the morning in groups of up to 15
participants.
 Music can be used in some relevant parts of the ses-
sions.52 However, some precautions must be taken
because it may be distracting or produce sensory
overload in some of the patients.
 Low-intensity exercises, usually performed while
sitting, must be used in the first sessions of the pro-
gram. After a basic fitness level has been achieved,
exercises can be done in a standing position.
 Resting time should be progressive. During the ini-
tial stages of the program, exercises require teacher-
participant interaction, while other participants wait
their turn. After patients are used to the day-to-day
routine, waiting time can be shortened if interac-
tions are performed in pairs, and thus performance
time is self-regulated.
 Sessions can be divided into warm-up (3 minutes),
fitness work (35 minutes), and socialization/cool
down (8 minutes), as shown in Table 3.
 It may be useful to identify participants’ past exer-
cise patterns and physical activities. For instance, if
a patient used to play basketball, strength can be de-
veloped by means of lifting light medicine balls,
and coordination can be developed by means of
throwing rubber balls into a hoop.
Conclusion
Given the neuropathological and metabolic
characteristics of AD, the physical fitness level
of the patients, and the potential benefits of phys-
ical exercise, AD patients, especially those in the
390
early stages of the disease, can likely take advan-
tage of physical training. Clinical guideline rec-
ommendations are scarce, however, because
few studies have been carried out. Thus, more
research is needed.
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CARLOS AYA´N PE´REZ, PhD, is from the School of Education
and Sports’ Science, University of Vigo, Pontevedra, Spain.
J.M. CANCELA CARRAL, PhD, is from the School of Educa-
tion and Sports’ Science, University of Vigo, Pontevedra,
Spain.
ACKNOWLEDGEMENTS
We thank Professor Ana Iriso, Dr. Cheryl Cott, Dr. Sylvie
Lauque, Dr. Rebecca Logdson, Dr. Yael Netz, and Dr. Vicente
Martı´n, for providing the required information.
0197-4572/08/$ - see front matter
Ó 2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.gerinurse.2007.12.002
391