Exercício físico como estratégia não farmacológica para a redução de sintomas psicológicos e comportamentais em idosos com comprometimento cognitivo leve e demência: revisão sistemática de ensaios clínicos randomizados

RODRIGUES, Susana Lígia da Silva; SILVA, Jamily Matias da; OLIVEIRA, Maria Clara Cordeiro de; SANTANA, Charleny Mary Ferreira de; CARVALHO, Kaliandra Meneses; BARBOSA, Breno José Alencar Pires

doi:10.1590/0004-282X-ANP-2020-0539

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View And Review • Arq. Neuro-Psiquiatr. 79 (12) • Dez 2021 • https://doi.org/10.1590/0004-282X-ANP-2020-0539 copiar

Exercício físico como estratégia não farmacológica para a redução de sintomas psicológicos e comportamentais em idosos com comprometimento cognitivo leve e demência: revisão sistemática de ensaios clínicos randomizados

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

Antecedentes: Idosos com demência podem manifestar sintomas comportamentais e psicológicos durante o percurso da doença. Terapias não farmacológicas, como por exemplo a atividade física regular, são consideradas como uma das estratégias para manejar esses sintomas. Objetivo: O objetivo deste estudo é investigar se a participação em programas de exercício físico é efetiva na redução de sintomas comportamentais e neuropsiquiátricos de idosos com comprometimento cognitivo leve (CCL) e demência. Métodos: Foi realizada uma revisão da literatura nas bases de dados Medical Literature Analysis and Retrieval System Online — MEDLINE (PubMed), Scientific Electronic Library Online (SciELO), Web of Science, Scopus e SPORTDiscus de 2010 a 2020. Os estudos elegíveis foram: ensaios clínicos randomizados envolvendo idosos com CCL ou demência, que medissem como desfecho primário ou secundário a mudança nos sintomas neuropsiquiátricos e psicológicos. Os estudos tiveram grupo com apenas o exercício físico como intervenção em comparação a um grupo controle. Resultados: De 175 publicações identificadas na pesquisa inicial, apenas sete estudos atenderam aos critérios de elegibilidade. Quatro em sete estudos demonstraram efeitos positivos na redução dos sintomas comportamentais, enquanto os demais não fizeram diferenciação entre os ganhos conforme o tipo de protocolo. Conclusões: Exercícios aeróbicos e de fortalecimento muscular de intensidade moderada a vigorosa podem ter um benefício potencial no manejo dos sintomas psicológicos e comportamentais da demência. Esta revisão mostrou a necessidade de mais estudos de intervenção, buscando investigar como desfecho primário o efeito absoluto do exercício físico e seu impacto nos sintomas comportamentais e psicológicos de idosos com CCL e demência, principalmente nas fases iniciais da doença.

Palavras-chave:
Comportamento; Demência; Exercício Físico; Adesão à Medicação

Author (year)	Country	Sample, mean age	Characterization	Instruments
Ballard et al. (2016)²⁰20. Ballard C, Orrell M, YongZhong S, Moniz-Cook E, Stafford J, Whittaker R, et al. Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) Program. Am J Psychiatry. 2016 Mar;173(3):252-62. https://doi.org/10.1176/appi.ajp.2015.15010130 https://doi.org/https://doi.org/10.1176/...	United Kingdom	n=277 (G1: antipsychotic review=146; G2: no antipsychotic review=131), institutionalized 43 males/120 females 85.2 years old (IG: 86,9; CG: 86,4)	Mild to advanced stages of dementia Sedentary	NPI, CSDD, CMAI
Hoffmann et al. (2016)²³23. Hoffmann K, Sobol NA, Frederiksen KS, Beyer N, Vogel A, Vestergaard K, et al. Moderate-to-high intensity physical exercise in patients with alzheimer’s disease: a randomized controlled trial. J Alzheimers Dis. 2016;50(2):443-53. https://doi.org/10.3233/JAD-150817 https://doi.org/https://doi.org/10.3233/...	Denmark	n=200 (IG=107, CG=93), outpatient memory clinic 113 males/87 females 70.5 years old (IG: 69.8; CG: 71.3)	Mild AD Physically active	NPI, HAM-D
Cancela et al. (2016)²²22. Cancela JM, Ayán C, Varela S, Seijo M. Effects of a long-term aerobic exercise intervention on institutionalized patients with dementia. J Sci Med Sport. 2016 Apr;19(4):293-8. https://doi.org/10.1016/j.jsams.2015.05.007 https://doi.org/https://doi.org/10.1016/...	Spain	n=189 (IG=73, CG=116), institutionalized 63 males/126 females 81.7 years old (IG: 80.6; CG: 82.9)	Unespecified stage of dementia Sedentary	NPI, CSDD
Telenius et al. (2015)²⁴24. Telenius EW, Engedal K, Bergland A. Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized controlled trial. PLoS One. 2015 May;10(5):e0126102. https://doi.org/10.1371/journal.pone.0126102 https://doi.org/https://doi.org/10.1371/...	Norway	n=163 (IG=82, CG=81), institutionalized 43 males/120 females 86,7 years old (IG: 86.9; GC: 86.4)	Mild to moderate AD Sedentary	NPI, CSDD
Öhman et al. (2017)²¹21. Öhman H, Savikko NRN, Strandberg TE, Kautiainen H, Raivio MM, Laakkonen ML, et al. Effects of frequent and long-term exercise on neuropsychiatric symptoms in patients with Alzheimer’s disease – Secondary analyses of a randomized, controlled trial (FINALEX). Eur Geriatr Med. 2017 Apr;8(2):153-7. https://doi.org/10.1016/j.eurger.2017.01.004 https://doi.org/https://doi.org/10.1016/...	Finland	n=179 (home-based exercises=63, group exercises=57, CG=59), voluntary 110 males/69 females 77.8 years old (G1: 77.4; G2: 77.9; CG: 78.1)	Mild to advanced AD NA	NPI, CSDD
Lamb et al. (2018)²⁵25. Lamb SE, Sheehan B, Atherton N, Nichols V, Collins H, Mistry D, et al. Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. BMJ. 2018 May;361. https://doi.org/10.1136/bmj.k1675 https://doi.org/https://doi.org/10.1136/...	England	n=494 (IG=329, GC=165), memory clinics, general hospitals, community dementia services, primary care 301 males/69 females 77 years old (IG: 76.9; GC: 78.4)	Mild to moderate dementia NA	NPI
Henskens et al. (2018)¹⁹19. Henskens M, Nauta IM, van Eekeren MCA, Scherder EJA. Effects of physical activity in nursing home residents with dementia: a randomized controlled trial. Dement Geriatr Cogn Disord. 2018;46(1-2):60-80. https://doi.org/10.1159/000491818 https://doi.org/https://doi.org/10.1159/...	Netherlands	n=87 (G1: ADL+EX=22; G2: ADL=21 G3.EX=22 and CG =22), institutionalized 20 males/67 females 85.7 years old (ADL+EX: 86.9; ADL: 86.05; EX: 85.14: CG: 84.73)	MCI to advanced dementia NA	CMAI, CSDD, AES

Author (year)	Intervention	Medication	Results
Ballard et al. (2016)²⁰20. Ballard C, Orrell M, YongZhong S, Moniz-Cook E, Stafford J, Whittaker R, et al. Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) Program. Am J Psychiatry. 2016 Mar;173(3):252-62. https://doi.org/10.1176/appi.ajp.2015.15010130 https://doi.org/https://doi.org/10.1176/...	IG (GEX): Type: aerobic training (outdoor or exercise bike), resistance training and balance* Duration: 60 min/36 weeks Frequency: once a week Intensity: not specified	Antipsychotic	Reduced neuropsychiatric symptoms, except for agitation and depression NPI: T0: IG: 12.02/CG: 15.05; T1: IG: 11.73/CG: 14.89 Effect size: -3.59, p<0.05 CSDD: T0: IG: 4.16/CG: 4.86; T1: IG: 5.15/CG: 5.43 Effect size: -1.21, p=0.43 CMAI: T0: IG: 46.36/CG: 47.91; T1: IG: 46.94/CG: 50.75 Effect size: -1.76, p=0.47
	CG: social interaction	Antipsychotic
Hoffmann et al. (2016)²³23. Hoffmann K, Sobol NA, Frederiksen KS, Beyer N, Vogel A, Vestergaard K, et al. Moderate-to-high intensity physical exercise in patients with alzheimer’s disease: a randomized controlled trial. J Alzheimers Dis. 2016;50(2):443-53. https://doi.org/10.3233/JAD-150817 https://doi.org/https://doi.org/10.3233/...	IG: Type: aerobic exercise: 3×10 min. on ergometer bicycle, cross trainer and treadmill (2–5 min rest between) Duration: 60 min/16 weeks Frequency: three weekly sessions Intensity: moderate to vigorous	Anti-dementia (acetylcholinesterase inhibitors and/or memantine) Antidepressant	Reduced neuropsychiatric symptoms, except for depression NPI: T0: IG: 10.0/CG: 9.4; T1: IG: 8.8/CG: 11.4 Effect size: -3.,5, p=0.002 HAM-D: T0: IG: 1.9/CG: 2.0; T1:/IG: 1.7/CG: 1.8 Effect size: -0.1, p=0.791
	CG: usual care	Anti-dementia (acetylcholinesterase inhibitors and/or memantine) Antidepressant
Cancela et al. (2016)²²22. Cancela JM, Ayán C, Varela S, Seijo M. Effects of a long-term aerobic exercise intervention on institutionalized patients with dementia. J Sci Med Sport. 2016 Apr;19(4):293-8. https://doi.org/10.1016/j.jsams.2015.05.007 https://doi.org/https://doi.org/10.1016/...	IG: Type: aerobic training (recumbent bicycle) Duration: 15 min/60 weeks Frequency: daily ** Intensity: self-selected	Anti-dementia (acetylcholinesterase inhibitors and/or memantine)	Reduced neuropsychiatric symptoms, except for depression NPI: T0: IG: 9.70/CG: 11.32; T1: NA Effect size: NA, p=0.020 CSDD: T0: IG: 6.31/CG: 6.71; T1: NA Effect size: NA
	CG: recreational activities (card games, reading and manual work)	Anti-dementia (acetylcholinesterase inhibitors and/or memantine)
Telenius et al. (2015)²⁴24. Telenius EW, Engedal K, Bergland A. Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized controlled trial. PLoS One. 2015 May;10(5):e0126102. https://doi.org/10.1371/journal.pone.0126102 https://doi.org/https://doi.org/10.1371/...	IG: Type: resistance training for lower limb muscles (12 MR) and 2 balance exercises Duration: 50 to 60 min/12 weeks Frequency: twice weekly sessions Intensity: vigorous	NA	Reduced apathy and agitation, except for depression NPI: T0: IG: 5.8/CG: 4.8; T1: IG: 5.1/CG: 5.4 Effect size: Apathy: 0.3, p=0.048 Agitation: 0.2, p=0.07 CSDD: T0: IG: 4.7/CG: 4.9; T1: IG: 3.8/CG: 3.8 Effect size: 0.2, p=0.39
	CG: mild physical activity, reading, games, talking, listening to music	NA
Öhman et al. (2017)²¹21. Öhman H, Savikko NRN, Strandberg TE, Kautiainen H, Raivio MM, Laakkonen ML, et al. Effects of frequent and long-term exercise on neuropsychiatric symptoms in patients with Alzheimer’s disease – Secondary analyses of a randomized, controlled trial (FINALEX). Eur Geriatr Med. 2017 Apr;8(2):153-7. https://doi.org/10.1016/j.eurger.2017.01.004 https://doi.org/https://doi.org/10.1016/...	IG (GE and HE): Type: aerobic training (Nordic walking and bike); resistance training; balance and dual-task exercises (15 min for each modality) Duration: 60 min/52 weeks Frequency: twice weekly sessions Intensity: gradually increased	1 in 4: Antidepressant 1 in 10: Antipsychotic	No improvements in neuropsychiatric symptoms NPI: T0: IG: (GE:12.05, HE: 13.45)/CG: 16.56; T1: NA Effect size: not significant/NA, p=0.41 CSDD: T0: IG: (GE:3.9, HE: 4.8)/CG: 5.9; T1: NA Effect size: not significant/NA, p=0.81
	CG: usual care (physical therapy, if necessary)	NA
Lamb et al. (2018)²⁵25. Lamb SE, Sheehan B, Atherton N, Nichols V, Collins H, Mistry D, et al. Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. BMJ. 2018 May;361. https://doi.org/10.1136/bmj.k1675 https://doi.org/https://doi.org/10.1136/...	IG: Type: aerobic training (static cycling) and resistance training (5 exercises for arms and legs) Duration: 60–90-min/16 weeks Frequency: twice weekly sessions Intensity: moderate to vigorous***	Anti-dementia (acetylcholinesterase inhibitors and/or memantine)	No improvements in neuropsychiatric symptoms NPI: T0: IG: 7.5/CG: 10; T1: IG: 12/CG: 9 Effect size: -2.1, p=0.14
	CG: usual care (physical therapy when necessary)	Anti-dementia (acetylcholinesterase inhibitors and/or memantine)
Henskens et al. (2018)¹⁹19. Henskens M, Nauta IM, van Eekeren MCA, Scherder EJA. Effects of physical activity in nursing home residents with dementia: a randomized controlled trial. Dement Geriatr Cogn Disord. 2018;46(1-2):60-80. https://doi.org/10.1159/000491818 https://doi.org/https://doi.org/10.1159/...	IG (GEX): Type: aerobic training (walk outdoors - 500mts or 1km), resistance training: 13 exercises for upper and lower extremities and the torso: 3 sets of 8 reps Duration: 30-45-min/24 weeks Frequency: three weekly sessions Intensity: gradually increased	NA	No improvements in depressive symptoms, apathy and agitation CSDD: T0: IG: 8.3/CG: 8.1; T1: IG: 8.6/CG: 6.7 Effect size: 0.1, p=0.89 CMAI: T0: IG: 51.8/CG: 52.3; T1: IG: 53.4/CG: 52 Effect size: -4.3, p=0.11 AES: T0: IG:23.8/CG: 28.4; T1: IG: 25/CG: 24.8 Effect size: -0.1, p=0.91
	CG: social interaction (drinking tea)/usual care	NA

Criteria/study	Ballard et al.²⁰20. Ballard C, Orrell M, YongZhong S, Moniz-Cook E, Stafford J, Whittaker R, et al. Impact of antipsychotic review and nonpharmacological intervention on antipsychotic use, neuropsychiatric symptoms, and mortality in people with dementia living in nursing homes: a factorial cluster-randomized controlled trial by the Well-Being and Health for People With Dementia (WHELD) Program. Am J Psychiatry. 2016 Mar;173(3):252-62. https://doi.org/10.1176/appi.ajp.2015.15010130 https://doi.org/https://doi.org/10.1176/...	Hoffmann et al.²³23. Hoffmann K, Sobol NA, Frederiksen KS, Beyer N, Vogel A, Vestergaard K, et al. Moderate-to-high intensity physical exercise in patients with alzheimer’s disease: a randomized controlled trial. J Alzheimers Dis. 2016;50(2):443-53. https://doi.org/10.3233/JAD-150817 https://doi.org/https://doi.org/10.3233/...	Cancela et al.²²22. Cancela JM, Ayán C, Varela S, Seijo M. Effects of a long-term aerobic exercise intervention on institutionalized patients with dementia. J Sci Med Sport. 2016 Apr;19(4):293-8. https://doi.org/10.1016/j.jsams.2015.05.007 https://doi.org/https://doi.org/10.1016/...	Telenius et al.²⁴24. Telenius EW, Engedal K, Bergland A. Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized controlled trial. PLoS One. 2015 May;10(5):e0126102. https://doi.org/10.1371/journal.pone.0126102 https://doi.org/https://doi.org/10.1371/...	Öhman et al.²¹21. Öhman H, Savikko NRN, Strandberg TE, Kautiainen H, Raivio MM, Laakkonen ML, et al. Effects of frequent and long-term exercise on neuropsychiatric symptoms in patients with Alzheimer’s disease – Secondary analyses of a randomized, controlled trial (FINALEX). Eur Geriatr Med. 2017 Apr;8(2):153-7. https://doi.org/10.1016/j.eurger.2017.01.004 https://doi.org/https://doi.org/10.1016/...	Lamb et al.²⁵25. Lamb SE, Sheehan B, Atherton N, Nichols V, Collins H, Mistry D, et al. Dementia And Physical Activity (DAPA) trial of moderate to high intensity exercise training for people with dementia: randomised controlled trial. BMJ. 2018 May;361. https://doi.org/10.1136/bmj.k1675 https://doi.org/https://doi.org/10.1136/...	Henskens et al.¹⁹19. Henskens M, Nauta IM, van Eekeren MCA, Scherder EJA. Effects of physical activity in nursing home residents with dementia: a randomized controlled trial. Dement Geriatr Cogn Disord. 2018;46(1-2):60-80. https://doi.org/10.1159/000491818 https://doi.org/https://doi.org/10.1159/...
Random allocation	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Blinding of allocation	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Similar groups	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Blinding of participants	No	No	No	No	No	No	No
Blinding of therapists	No	No	No	No	No	No	No
Blinding of evaluators	Yes	Yes	No	Yes	No	Yes	Yes
<15% loss sample	No	Yes	No	Yes	Yes	Yes	No
Analysis by intention to treat	Yes	Yes	Yes	Yes	No	Yes	No
Difference between groups	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Trend measurements central and variability	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Total (0–10)	7	8	6	8	6	8	6

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[1] Correspondence: Breno José Alencar Pires Barbosa; Email brenojb@gmail.com.