Tai-Chi, Yoga and Exercise
Yao et al (2008) developed a Tai-Chi exercise programme for people with dementia living in the community within Michigan (USA), and undertook a piece of research to investigate peoples’ experiences of taking part in the programme. The authors emphasize that people with dementia can be at an increased risk of falls for a number of factors associated with the disease (NHS Inform 2017). Yao et al’s (2008) research aimed to ascertain if participation in Tai-Chi has the potential to reduce the risk of falls in people with dementia, and whether or not participants experienced any changes in their emotional or psychological well-being as a result of taking part in tai-chi.
In a literature search completed prior to the development of the program, Yao et al (2008) identified the Sticky Hands Tai Chi teaching method as an effective approach to delivering a Tai Chi class to group consisting of people with dementia and their carers. Nyman (2015) explains that the Sticky Hands technique works well as it does not place high demands on a person to memorise specific tai-chi movements; the person with dementia maintains palm-to-palm contact with their partner allowing them to follow all their movements with ease. Yao et al’s (2008) research involved participants taking part in a sixteen week program of tai-chi; this consisted of classes led by trainers twice per week for four weeks and participants completing exercises at home three times per week for the remaining twelve weeks. The sample consisted of 20 participants; 10 people with dementia and 10 carers, 9 of whom were family members and one was a paid carer (Yao et al 2008). The authors also note that the caregivers included had no physical or cognitive impairments (Yao et al 2008).
Data was collected using both standardized and non-standardized methods (Yao et al 2008). A standardized measure was used to determine any affect that participation had on reducing participants’ falls risk, this was achieved by completing Timed Up and Go (TUG) tests with participants prior to commencement of the program, again following the completion of the four weeks of trainer-led group classes, and finally at the end of the 16 week program of exercises at home (Yao et al 2008). Jones (2009) explains that the TUG test involves participants being asked to stand from a chair, walk to a point 3m away, turn and return to the chair. This activity is timed, and a result determining the person’s risk of falling is calculated based on the person’s age, frailty and length of time taken to fully complete the task (Jones 2009). Yao et al (2008) found that participants’ TUG test times improved by an average of 16% after participation in the four weeks of group classes. Interestingly however, the authors observed a reduction in average TUG test times when the test was re-administered following the 16 week at-home tai-chi program, indicating that the physical benefits were higher when participants took part in tai-chi in a group setting.
Information gathered during exit interviews with carer participants indicates that the group setting helped to motivate members to participate and were overall perceived to be more enjoyable (Yao et al 2008), this may be linked to the positive TUG results observed at the end of the group sessions. Information gathered during exit interviews also highlighted that participants found that taking part in the tai chi program enabled them to feel close to one another and provided an opportunity to take part in a meaningful activity together, rather than as a carer facilitating activity for the person with dementia (Yao et al 2008). The exit interview data suggests that the use of the Sticky Hands tai-chi teaching method positively contributed to enabling all the participants to take part, and allowed for a supportive and meaningful experience for all involved (Yao et al 2008).
Sherrington et al (2008) completed a large scale piece of research around people with dementia taking part in different types of exercise, and the effect that this had on falls. Sherrington et al’s (2008) work involved 9,603 participants taking part in 44 trials and the findings are similar Yao et al’s (2008) conclusions in that participants’ rate of falls fell by 17% when they took part in balance based exercise such as tai chi and yoga. Furthermore, Sherrington et al (2008) found that fall rates reduced by 42% when participants took part in regular balance based exercise programs that did not focus on walking.
Bonura and Tenenbaum (2014) undertook a randomized control trial with a group of older adults aged between 65-92 years that aimed to establish if there was any link between participation in yoga and improvement in psychological health. The study was completed over a six week period, during which time 98 participants were split into three groups: one group who took part in chair-based yoga, one group taking part in chair-based exercise and a final group who took part in no new exercise. Bonura and Tenenbaum (2014) completed a number of standardized assessments (State Anger Expression Inventory, State Anxiety Inventory, Geriatric Depression Scale, Lawton’s PGC Morale Scale, General Self-Efficacy Scale, Chronic Disease Self-Efficacy Scales, and Self- Control Schedule) with research participants prior to, during and one month following the completion of the intervention. It was concluded that the individuals who took part in the chair based yoga program had improved psychological health in comparison to the group taking part in chair exercise, and the group who took part in no new exercise. (Bonura and Tenenbaum 2014).
The authors write that it is important to note that the use of yoga as a therapeutic intervention for people with dementia will not reverse any cognitive decline that has already occurred (Bonura and Tenenbaum 2014). Furthermore, Bonura and Tenenbaum (2014) write that there is a fairly limited amount of robust research that has been completed around the use of yoga as a therapeutic intervention. However, they go onto discuss that the small amount of research that has been published positively attributes participation in yoga to improved mood and self-efficacy and reduced anxiety in people with dementia (Bonura and Tenenbaum 2014). Nevertheless, Bonura and Tenenbaum (2014) also highlight the argument that an alternative-therapies based intervention cannot replace traditional medical treatments for symptoms of low mood and depression associated with dementia. The authors refer to a study completed by Janakirmaiah (2000) who found that participation in yoga was a less effective treatment for depression than electroconvulsive therapy (ECT). Conversely, Janakirmaiah’s (2000) research also found participation in yoga as an early intervention to treat symptoms of depression in dementia to be equally as effective as pharmaceutical interventions.
Following a detailed literature review, Wu et al (2014) concluded that the development of a program that combined bite-sized elements of tai-chi, yoga, Feldenkrais and dance movement therapy would allow people with dementia to access the positive outcomes associated with each activity, without the physical or cognitive demands required to participate in a session dedicated entirely to one of the four. This was a study based at a day centre for people with dementia living in the local community of an area in San Francisco, USA and there were 11 participants (Wu et al 2014). It should be noted that the small sample size could have a negative impact on the results of the study, as Aveyard (2014) explains, it can be argued that limiting the geographical area and background of participants included in a study may result in research findings that are not applicable or relevant to a wider range of people. The participants of Wu et al’s (2014) research were predominantly white females (8/11 fell into this category), and all attendees of the same day centre, which should be kept in mind when considering the conclusions made by the authors. However, the results are still useful for the purpose of this literature review given that the study focuses on participation in exercise by people with dementia (Wu et al 2014).
Wu et al (2014) identified three themes which were used to guide the development and identify the goals of the project: “’Functional changes: body awareness and movement memory’, ‘Emotional changes: personal meaning and stories’ and ‘Social changes: interpersonal relationships’” (Wu et al 2014, p 357).
To address the first theme of, “body awareness and movement memory” (Wu et al 2014, p357), the researchers included routine and repeated exercises during each session. Participants were also encouraged to spend time during each class reflecting on how each movement made different parts of their body feel, through the use of touch and mindfulness (Wu et al 2014). The theme “personal meanings and stories” (Wu et al 2014, p 357) was included by the researchers working to ensure that the sessions were personalized for the members of the group. This was achieved through the completion of initial telephone interviews with participants’ family or carers to establish their interests, likes and dislikes (Wu et al 2014). Wu et al (2014) also identified favourite pieces of music for each participant and included these during sessions. These actions allowed the researchers to deliver sessions that were designed to be personal and meaningful for each member of the group. The researchers also aimed to create a positive, relaxed and peaceful environment during the classes to allow for all members to feel comfortable taking part (Wu et al 2014). Sessions were planned in such a way that encouraged this calm and open environment; the facilitators would not put any pressure on group members or try to correct any mistakes (Wu et al 2014). In addition, participants were allowed the time to share any feelings or personal stories openly during the sessions (Wu et al 2014). The final theme, “interpersonal relationships” (Wu et al 2014, p357) was incorporated into the classes through including simple group games that encouraged members to interact and work together. This allowed for the participants to build relationships and was conducive to creating a supportive environment during the sessions (Wu et al 2014).
The researchers collected and analysed data using the constant comparative method (Wu et al 2014) which Kolb (2012) explains is a qualitative approach involving obtaining information via observation, interviews and written feedback which is then coded and translated into theory. On completion of the coding process, Wu et al (2014) concluded that participation in the exercise program resulted in improved mood and overall well-being experienced by the people with dementia who took part.
It is important to note that the authors state more research is required to further assess the effectiveness of the exercise program, given the small sample size and qualitative research approach (Wu et al 2014).
To conclude, research indicates that participation in yoga, tai-chi and exercise can be of benefit to people with dementia (Yao et al 2008, Bonura and Tenenbaum 2014 and Wu et al 2014). Any exercise-based intervention must be adapted appropriately to allow for all to participate regardless of their cognitive or physical ability (Wu et al 2014). Taking part in exercise by people with dementia can improve well-being, encourage social participation (Bonura and Tenenbaum 2014) and has the potential to reduce the risk of falls (Yao et al 2008).