Exercise to keep dementia at bay

SINGAPORE - Several strides have been made in recent years to knock down the notion that there is no life for people after they are struck with dementia.

While there is no cure in sight, some advances have improved the quality of life for people with dementia and put a brake - at least temporarily - on the decline in memory and other mental functions.

Two classes of medication have emerged over the last 10 years to slow down the rate of decline and, in some patients, even roll back their conditions to what they were six to 12 months ago.

But medication can be costly (about $140 to $200 a month) and come with side effects.

The better news: More evidence has emerged that non-drug options such as physical exercise, mental stimulation and social interaction can also impede the progress of dementia.

In recent years, hospitals here, such as National University Hospital (NUH), Tan Tock Seng Hospital (TTSH) and Khoo Teck Puat Hospital (KTPH), have embarked on programmes which use one or all three of these elements for its dementia patients.

Dr Reshma Merchant, a geriatrician and the head of general medicine at NUH, said non-drug options are especially important for older adults, where the interaction between many types of medication can be harmful. Non-drug treatment also sometimes gives people a greater sense of control over their mental and physical health, she said.

Researchers in Singapore and elsewhere are also thinking of new ways to enhance cognitive training, the so-called brain exercises, so that improvements extend beyond the particular area trained, to other areas and more general functioning.

For instance, the National Neuroscience Institute (NNI) in Singapore is developing a computer programme which uses real-life situations to train patients' weakened cognitive functions.

The Israelis have also come up with a new device which delivers high-frequency electromagnetic waves to the patient as he completes a cognitive test. The waves are said to make the stimulated areas of the brain more receptive to cognitive training. A public hospital here is doing research on this technology while a private clinic here is offering it to patients.

Cutting brain cells and connections

The problem is urgent. As the population ages, the number of people with dementia here is expected to soar from 28,000 now to 80,000 by 2030.

In a healthy brain, brain cells (or neurons) make chemicals called neurotransmitters that send tiny bursts of information from one cell to another across small gaps called synapses.

These synaptic connections enable important mental functions involving memory, use of language and numbers, judgment and ability to reason, among others to occur. But in people with dementia, damage to the brain caused by illness whittles down neurons and synaptic connections, and mental functions are gradually lost. Some people also experience changes in mood (such as extreme mood swings) and behaviour (including apathy or agitation).

Historically, it was thought that people were born with a fixed number of brain cells, and the synaptic connections between neurons, once established during development, could not be regenerated.

But now, more evidence shows that the brain remains plastic throughout life and it can form new connections, maybe even in those with dementia.

And engaging in exercise, social interaction and mentally stimulating activities seems to encourage such connections to form.

Furthermore, the benefits extend beyond the brain to the whole person, said Dr Philip Yap, a senior consultant at the department of geriatric medicine at KTPH. He said: "Such activities meet the human need for engagement and having a sense of purpose, meaning and pleasure in life. They reduce the feelings of loss and helplessness that often accompany dementia."

Cognitive retraining

Programmes incorporating one or more of these elements have been gaining popularity here.

NUH embarked on a programme for dementia patients and frail elderly people in its geriatric and medicine wards last December.

TTSH and KTPH have programmes targeted at patients with dementia at their outpatient clinics.

TTSH started a cognitive retraining programme called Mindfit for those with mild cognitive impairment and early Alzheimer's disease - the most common type of dementia - who are still able to perform daily tasks but may experience memory problems, such as being unable to remember appointments in their daily lives.

During the 1 1/2 hour weekly programme, which runs over six weeks, occupational therapists and psychologists help patients overcome their memory problems using strategies such as dividing up information into chunks. More than 25 patients have taken part so far.

As early as 2006, Alexandra Hospital started a weekly three-hour programme called A New You, for patients with early dementia.

It combines physical exercise (such as stretches and warm-up exercises) with cognitive training and stimulation (playing mahjong and solving puzzles) and social interaction (story telling and singing).

It is now run by nurses, psychologists and social workers at KTPH, which opened in 2010 with most of its staff from Alexandra Hospital then.

The programme started with a handful of patients. Now, it has two groups, each with 15 to 20 patients.

Encouraged by the positive effects it has on patients' sense of well-being, KTPH started a similar weekly programme called Music and Activities Programme (MAP) for patients with moderate-stage dementia who have lost the ability to plan and form an agenda in daily life.

The weekly three-hour programme, run by occupational therapists, a music therapist and a nurse, provides a structured routine incorporating physical exercise (such as a leisurely walk), with cognitive stimulation (such as simple puzzles) and social interaction. Music activities include singing, music and movement, and memory sequences accompanied by music as well as drumming. There are about 10 to 15 participants a week.

Results have been promising. A study on 43 patients published in Dementia And Geriatric Cognitive Disorders in 2011 found that those who underwent MAP for three hours every week over eight weeks had less depressive and disruptive behaviour as a result than non-participants.

Music therapy has also been found to facilitate active participation from patients, even those with late-stage dementia, said Dr Yap.

This could be because the amygdala - which processes emotions and is one of the last parts of the brain to be affected by dementia - still receives, reacts to and expresses mood and emotion.

Dr Yap said: "Music provides a mind over body experience that can transcend physical ills and enhances one's sense of well-being."

Brain exercises with a twist

Researchers are also developing new ways to enhance cognitive tests or brain exercises.

People can get better at solving Sudoku puzzles or memory games but these improvements are often not "translatable" to real-life tasks.

Researchers at NNI and Integrated Health Information Systems (IHiS) hope to change this. They are enhancing computer software they have recently developed so that it can train and improve the brain functions of people with early dementia and stroke.

The software is as effective as a pen and paper test in picking up people with these conditions.

It tests patients on four cognitive domains: memory, language, executive function and visual spatial function.

Instead of using pen and paper, they use a mouse or touchscreen to perform tasks on a computer screen. Data from their actions and decisions is captured and transformed into scores that reflect their performance.

What makes both the diagnostic and therapeutic software unique and possibly more sensitive is that it uses a three-dimensional environment drawn from real-life situations surrounding an HDB flat, a transport system and a supermarket.

The researchers hope to enhance the software so that it can single out patients' weaker brain functions and train them using real-life situations such as going to a supermarket to find and buy food items, sorting them out in the kitchen and choosing which to use in preparing breakfast for the family.

Dr Nagaendran Kandian, a consultant neurologist at NNI, said: "Participants will be motivated to work harder so that they can improve in performing daily tasks which are important to them."

The study plans to recruit 100 people with early dementia and stroke by this year.

Two years ago, researchers in Israel developed a new device to enhance the effect of cognitive training by combining it with a treatment called transcranial magnetic stimulation. The stimulation is currently used as an alternative form of treatment overseas for conditions such as depression and chronic pain.

As the patient answers questions by touching buttons on a computer touchscreen, an electromagnetic coil placed near his head delivers magnetic pulses about 2cm deep inside his skull (left).

These stimulate areas of the brain responsible for memory and learning affected by Alzheimer's disease and make them more receptive to cognitive training.

The early evidence is promising. Small clinical trials in Israel and the United States showed that patients with Alzheimer's disease who underwent the treatment showed a more marked improvement in their cognitive scores than those who did not have it.

The trials also showed the improvement was maintained for at least a year after treatment, said Dr Charles Siow, a neurologist in private practice who has treated two patients with the device this year.

One of them was a 75-year-old retiree and a grandfather of four who was diagnosed with Alzheimer's about two years ago.

His wife, who did not want to be named, said her husband became more alert after the treatment.

She said: "He used to just lie there but now, he shows interest in watching television and looking through the newspaper. He also said he wants to think of a Chinese name for our unborn grandchild, just as he did for our four other grandchildren."

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