Postural stability in older adults with mild to moderate cognitive impairment and Alzheimer’s disease

Older adults with Alzheimer’s disease are at high risk of experiencing falls; their risk is double that of their healthy peers. The guidelines for achieving a fall risk reduction via an exercise-based intervention, for this population group, are unclear. Therefore, this thesis primarily aimed to develop, and to proof a concept of, an exercise-based intervention to improve postural stability as one means of reducing falls risk in older adults with mild to moderate cognitive impairment due to Alzheimer’s disease. A mixed methods study design was employed to achieve the study aim, via the following objectives: 1) to explore postural stability and the factors contributing to, or impacting on, postural instability in older adults with mild to moderate Alzheimer’s disease; 2) to identify and evaluate the psychometric properties of two commonly used clinical measures of postural stability (the Physiological Profile Approach and the Timed Up and Go test) for use in a proof of concept study of an exercise-based intervention; 3) to explore what older adults, with mild to moderate cognitive impairment due to Alzheimer’s disease, and their significant others, considered important to include in a sustainable and engaging exercise-based intervention; and 4) to proof a concept of the exercise-based intervention. The systematic review (n = 18 studies) suggested that older adults with mild to moderate Alzheimer’s disease have reduced static and dynamic postural stability compared to their peers without cognitive impairment. The instability was mostly associated with activities that require attentional demand; for instance, dual task activities and when visual input is reduced (for example, activities with eyes closed). A preliminary psychometric properties study (n = 13) suggested that falls risk screening, by the Physiological Profile Approach (moderate to good correlations rs = 0.604-0.745, p < 0.05; 33% sensitivity and 89% specificity) and the Timed Up and Go test (moderate to good correlations rs = 0.548-0.719, p < 0.05; 75% sensitivity and 67% specificity), might be appropriate to measure postural instability and predict falls risk in older adults with cognitive impairment for both research and clinical purposes. Both tests are feasible to be used in a community setting. Qualitative semi-structured interviews, conducted with 10 older adults with cognitive impairment and 7 support people, suggested that factors that might optimise delivery and engagement in exercise were: 1) having the choice of an individual- or a group-based exercise programme; 2) that exercise should be enjoyed and be pleasurable; 3) that exercises should stimulate brain activity; 4) that a support system is necessary; 5) that the programme should be of short duration; and 6) that the programme should include complex activities (e.g. dual task) that challenge their postural stability. These factors are however contingent of the understanding that while people living with cognitive impairment perceive that exercise is beneficial, as their cognition declines, a cyclic process of 1) awareness; 2) denial; 3) acceptance; and 4) coping strategies, influences decisions and degree of exercise engagement. Based on these three preliminary studies, “Balance Wise”, an exercise-based intervention, was designed and tested among older adults with memory loss (group-based n = 9, individual-based n = 1) in a feasibility case series. It was conducted for 30 minutes once a week. To measure falls risk and postural stability, the Physiological Profile Approach, the Timed Up and Go test [basic], the Timed Up and Go test [cognitive] and the Step Test were used. The Timed Up and Go test [cognitive] and the Step Test were added to test attentional demand in dual task activity and postural stability in standing respectively. “Balance Wise” was found to be feasible, accepted, practical and safe to be conducted among older adults with memory loss. Most participants chose to join the group-based option. Improvements in functional postural stability performance and dynamic stability, measured by the Timed Up and Go test [basic] (turning to non-dominant side p < 0.05, r = -0.79; turning to dominant side p < 0.05, r = -0.82 and the Step Test (p < 0.05, r = -0.81), respectively, were demonstrated. Dropout was 5 out of 15 participants. Adherence was from 10% to 100% of 10 sessions of interventions. Findings from systematic reviews (Chapter 4, study 1) found strong evidence for justifications of the need of an intervention study to improve postural stability and risks of falling. The findings derived from study 2 to 4 (Chapter 6 to 7) should be interpreted with caution because of their limitations such as small sample size and heterogeneous of the population being studied. Therefore it limits the applicability of the findings to be transferred for practise. The recruitment was challenging. This difficulty may be related to the cyclical process of denial and level of acceptance identified in the qualitative study. Even though, the thesis began by targeting older adults with mild to moderate cognitive impairment due to Alzheimer’s disease, participation by adults categorised in this way was found to be almost impossible to achieve. So, during the thesis, the target group evolved to become older adults with self-declared memory loss (with or without diagnostic evidence). The data synthesising and integration of the findings highlighted a few considerations for an intervention targeting older adults with memory loss: 1) support systems are required, not only for older adults with memory loss, but also for their support person; 2) the higher the complexity of the activity, the more difficulty older adults, with cognitive impairment, have to execute it; those who have more severe cognitive impairment need supported one-to-one based exercise; and 3) supported and uninfluenced decision making is required to protect the autonomy of older adult with cognitive impairment. Therefore, this thesis suggests the need for further exploration in the recruitment strategies of this vulnerable group of the population. For those who need one-to-one based exercise, the cost effectiveness of such an intervention will need to be evaluated in future studies. It is also recommended that physicians should use standardised tools to diagnose Alzheimer’s disease especially in the early phase of declining of cognitive function. Until these strategies are in place, researching postural stability to reduce risks of falling among older adults with Alzheimer’s disease in New Zealand is impossible due to the lack of specificity with such a broad terminology and spectrum of diseases presentation

Kesan realiti visual berasaskan terapi ke atas ketahanan berjalan dan kualiti hidup penghidap osteoarthritis lutut

Realiti Virtual Berasaskan Terapi (RVBT) semakin popular dan giat digunakan dalam perkhidmatan rehabilitasi. Namun, bukti keberkesanan RVBT dalam kalangan penghidap Osteoarthritis (OA) lutut pada masa ini masih terhad. Kajian ini bertujuan menentukan kesan RVBT berbanding terapi senaman konvensional ke atas ketahanan berjalan dan kualiti hidup warga emas yang menghidap OA lutut. Kajian rawak terkawal ini melibatkan 44 peserta (min umur dan sisihan piawai = 66.32 ± 5.73 tahun) yang menerima RVBT (kumpulan kajian, n = 22) atau terapi senaman konvensional (kumpulan kawalan, n = 22) selama 45 minit pada kekerapan dua kali seminggu selama 12 minggu. Kesan terapi ke atas ketahanan berjalan diukur menggunakan ujian Berjalan Enam Minit (BEM), manakala perubahan kualiti hidup dinilai menggunakan soal selidik Short Form-36 (SF-36) versi Bahasa Malaysia. Analisis hasil kajian adalah secara pendekatan ‘intention to treat’, menggunakan ujian Mixed Model ANOVA. Hasil kajian menunjukkan kesan masa yang signifikan (p < 0.05) dan saiz kesan yang besar antara 0.43 dan 0.54 bagi semua pembolehubah susulan kedua-dua terapi. Peningkatan sebanyak 17% (kumpulan kajian) dan 18.9% (kumpulan kawalan) ditunjukkan dalam ketahanan berjalan. Manakala, skor komponen fizikal dan komponen mental SF-36 masing-masing meningkat sebanyak 37.8% dan 19.4% dalam kumpulan kajian, dan 45.7% dan 20.6% dalam kumpulan kawalan. Namun, kesan kumpulan dan kesan interaksi didapati tidak signifikan (p > 0.05) dalam kajian ini. Kesimpulannya, RVBT adalah sebanding terapi senaman konvensional di dalam meningkatkan ketahanan berjalan dan kualiti hidup penghidap OA lutut. RVBT boleh dijadikan sebagai satu pilihan terapi bagi populasi ini

Kesan pendedahan konsep kepelbagaian budaya terhadap tahap kompetensi dalam kalangan pelajar prasiswazah sains rehabilitasi

Kompetensi budaya adalah penting bagi anggota kesihatan profesional dalam menyediakan perawatan dan khidmat yang bersesuaian kepada individu daripada pelbagai latar belakang budaya. Pendidikan yang berstruktur dapat meningkatkan tahap kompetensi budaya dalam kalangan anggota kesihatan profesional. Objektif kajian ini adalah untuk menilai tahap kompetensi budaya dan perubahannya dalam kalangan pelajar prasiswazah setelah mengikuti kursus elektif Kepelbagai Budaya. Seramai 152 orang pelajar prasiswazah Tahun 3 dari Program Fisioterapi, Audiologi, dan Sains Pertuturan di Universiti Kebangsaan Malaysia telah melengkapkan satu soal selidik yang menilai kompetensi budaya sebelum dan selepas tamat kursus tersebut. Lebih daripada 80% pelajar mempunyai pengalaman bekerjasama dengan individu yang berbeza latar belakang budaya. Tahap kompetensi budaya para pelajar meningkat secara signifikan setelah mengikuti kursus. Kajian ini membuktikan keperluan bimbingan kepada pelajar di peringkat prasiswazah dalam membentuk anggota kesihatan profesional yang kompeten secara menyeluruh dalam menyediakan khidmat kepada pelbagai golongan masyarakat

Mental health problems during COVID-19 pandemic among undergraduates in clinical compared to non-clinical programs

This study aimed to determine undergraduates’ mental health status, quality of life and burn-out status in clinical and non-clinical programs as well as its association during COVID-19 pandemic period. A cross sectional survey was carried out by distributing the questionnaire through online social media platforms such as WhatsApp, Facebook, and Twitter. Mental health, burn-out statuses and quality of life of the undergraduates were assessed using 21-item Depression Anxiety Stress Scale (DASS-21), Copenhagen Burnout Inventory and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF) respectively. A total of 308 respondents (111 from clinical, 197 from non-clinical programs), mean (SD) age=21.88(1.29) years participated in this cross-sectional online survey. The results revealed that undergraduates in the non-clinical programs are more likely to experience higher levels of depression, anxiety and stress, whichdemonstrated by higher median (IQR) scores in each component of DASS-21 (Non-clinical VS Clinical) [depression, 18 (10-28) VS 8 (2-20); anxiety, 16 (8-26) VS 10 (2-16), and stress, 20 (12-28) VS 12 (4-22)]. Similarly, higher burnout median score, 58.83 (48.83 - 75.00) was noted among undergraduates in non-clinical programs with a lower mean (SD) Q-LES- Q-SF score=58.75 (18.03). Undergraduates with good internet accessibility had higher quality of life scores [2.06(1.03-4.13)]. The association between lower mental health status, QoL and burn-out among non-clinical students remained significant even after adjustment for gender, household income, type of university (IPTA vs IPTS), race, and internet accessibility at university. Our findings suggest that undergraduates from clinical programs had better mental health status and quality of life when compared to their peers from non-clinical programs during COVID-19 pandemic period

Preferences, perception of readiness and satisfaction towards online distance learning among undergraduates in Malaysia during COVID-19 pandemic

While there is abundance of studies regarding online distance learning (ODL) among university students, information regarding ODL among undergraduates in Malaysia is limited, more so during the Covid-19 pandemic. This was a cross-sectional online survey involving a total of 308 undergraduates from various universities in Malaysia aimed to evaluate undergraduates’ perception of readiness and satisfaction towards online distance learning, platform preferences, attitudes and motivations, barriers towards ODL and also factors contributing to these variables. Questionnaires that include Online Learning Readiness Scale (OLRS) and additional information regarding challenges faced by undergraduates and their satisfaction levels towards ODL were used in this survey. The results showed that the undergraduates preferred a combination of face-to-face and online learning (68.8%) rather than online learning alone (5.5%). Majority of the respondents preferred having synchronous classes as compared to asynchronous classes (37.7%) and they rated Google Meet as their most preferred platform for their classes. In addition, the undergraduates shown fairly goodperception and neutral satisfaction towards ODL. Factors such as ethnicity and the state where the undergraduates lived were found to more likely cause them to have poor satisfaction towards ODL. While, undergraduates who have handphones have a higher satisfaction level towards ODL. Several challenges were encountered throughout ODL with the most challenging was the unsupportive environment, which in turn causing the undergraduates to be distracted and losing focus during ODL. Our findings highlighted that majority undergraduates preferred a combination of face-to-face and online learning rather than online learning alone. These findings will be beneficial for educators in the planning for future teaching and learning methods. Future studies with a larger sample size are needed to evaluate the independent risk factors related to low motivations, perceptions and satisfaction among undergraduates using ODL

Depression, anxiety, and stress related to online distance learning (ODL) does not influence academic performance : findings from an online survey among undergraduates in Malaysia

While there has been widespread reporting of a negative impact on students' mental health and academic performance because of ineffective online learning systems during COVID, Malaysian data remained scarce. In this online survey, the correlation between online distance learning (ODL), mental health status and academic performance of Malaysian undergraduates during COVID-19 pandemic were examined. Academic performance was measured using self-reported questionnaires in which respondents were also asked to state their cumulative grade points average (CGPA). Reduction in CGPA was considered as a decline in academic performance. Data on ODL readiness and satisfaction as well as mental health status were obtained. Among 256 respondents of this study with mean age (SD) 22.10 (1.05), a total of 27.3% reported to have decline in CGPA during Covid-19 pandemic. Female undergraduates were more likely to perform better as more had maintained or improved their academic performance. Self-directed learning, learning control, learning motivation, and satisfactionwere significantly associated with academic performance (p<0.05) but not computer-internet self-efficacy and online communication self-efficacy. There were also significant negative correlations between ODL and Mental Health Status. However, mental health status does not appear to be significantly associated with decline in academic performance. Our study findings suggest that ODL preference and satisfaction have an impact on the academic performance. While, mental health status related to ODL was not associated with academic performance. Students getting used to the shift into remote learning over time may explain why mental health status had no effect on their academic performance. Future studies should focus on the know how to deliver effective ODL techniques to improve undergraduates’ satisfaction with the hope to further improve their academic performance

Postural stability in older adults with mild to moderate cognitive impairment and Alzheimer’s disease

Older adults with Alzheimer’s disease are at high risk of experiencing falls; their risk is double that of their healthy peers. The guidelines for achieving a fall risk reduction via an exercise-based intervention, for this population group, are unclear. Therefore, this thesis primarily aimed to develop, and to proof a concept of, an exercise-based intervention to improve postural stability as one means of reducing falls risk in older adults with mild to moderate cognitive impairment due to Alzheimer’s disease. A mixed methods study design was employed to achieve the study aim, via the following objectives: 1) to explore postural stability and the factors contributing to, or impacting on, postural instability in older adults with mild to moderate Alzheimer’s disease; 2) to identify and evaluate the psychometric properties of two commonly used clinical measures of postural stability (the Physiological Profile Approach and the Timed Up and Go test) for use in a proof of concept study of an exercise-based intervention; 3) to explore what older adults, with mild to moderate cognitive impairment due to Alzheimer’s disease, and their significant others, considered important to include in a sustainable and engaging exercise-based intervention; and 4) to proof a concept of the exercise-based intervention. The systematic review (n = 18 studies) suggested that older adults with mild to moderate Alzheimer’s disease have reduced static and dynamic postural stability compared to their peers without cognitive impairment. The instability was mostly associated with activities that require attentional demand; for instance, dual task activities and when visual input is reduced (for example, activities with eyes closed). A preliminary psychometric properties study (n = 13) suggested that falls risk screening, by the Physiological Profile Approach (moderate to good correlations rs = 0.604-0.745, p < 0.05; 33% sensitivity and 89% specificity) and the Timed Up and Go test (moderate to good correlations rs = 0.548-0.719, p < 0.05; 75% sensitivity and 67% specificity), might be appropriate to measure postural instability and predict falls risk in older adults with cognitive impairment for both research and clinical purposes. Both tests are feasible to be used in a community setting. Qualitative semi-structured interviews, conducted with 10 older adults with cognitive impairment and 7 support people, suggested that factors that might optimise delivery and engagement in exercise were: 1) having the choice of an individual- or a group-based exercise programme; 2) that exercise should be enjoyed and be pleasurable; 3) that exercises should stimulate brain activity; 4) that a support system is necessary; 5) that the programme should be of short duration; and 6) that the programme should include complex activities (e.g. dual task) that challenge their postural stability. These factors are however contingent of the understanding that while people living with cognitive impairment perceive that exercise is beneficial, as their cognition declines, a cyclic process of 1) awareness; 2) denial; 3) acceptance; and 4) coping strategies, influences decisions and degree of exercise engagement. Based on these three preliminary studies, “Balance Wise”, an exercise-based intervention, was designed and tested among older adults with memory loss (group-based n = 9, individual-based n = 1) in a feasibility case series. It was conducted for 30 minutes once a week. To measure falls risk and postural stability, the Physiological Profile Approach, the Timed Up and Go test [basic], the Timed Up and Go test [cognitive] and the Step Test were used. The Timed Up and Go test [cognitive] and the Step Test were added to test attentional demand in dual task activity and postural stability in standing respectively. “Balance Wise” was found to be feasible, accepted, practical and safe to be conducted among older adults with memory loss. Most participants chose to join the group-based option. Improvements in functional postural stability performance and dynamic stability, measured by the Timed Up and Go test [basic] (turning to non-dominant side p < 0.05, r = -0.79; turning to dominant side p < 0.05, r = -0.82 and the Step Test (p < 0.05, r = -0.81), respectively, were demonstrated. Dropout was 5 out of 15 participants. Adherence was from 10% to 100% of 10 sessions of interventions. Findings from systematic reviews (Chapter 4, study 1) found strong evidence for justifications of the need of an intervention study to improve postural stability and risks of falling. The findings derived from study 2 to 4 (Chapter 6 to 7) should be interpreted with caution because of their limitations such as small sample size and heterogeneous of the population being studied. Therefore it limits the applicability of the findings to be transferred for practise. The recruitment was challenging. This difficulty may be related to the cyclical process of denial and level of acceptance identified in the qualitative study. Even though, the thesis began by targeting older adults with mild to moderate cognitive impairment due to Alzheimer’s disease, participation by adults categorised in this way was found to be almost impossible to achieve. So, during the thesis, the target group evolved to become older adults with self-declared memory loss (with or without diagnostic evidence). The data synthesising and integration of the findings highlighted a few considerations for an intervention targeting older adults with memory loss: 1) support systems are required, not only for older adults with memory loss, but also for their support person; 2) the higher the complexity of the activity, the more difficulty older adults, with cognitive impairment, have to execute it; those who have more severe cognitive impairment need supported one-to-one based exercise; and 3) supported and uninfluenced decision making is required to protect the autonomy of older adult with cognitive impairment. Therefore, this thesis suggests the need for further exploration in the recruitment strategies of this vulnerable group of the population. For those who need one-to-one based exercise, the cost effectiveness of such an intervention will need to be evaluated in future studies. It is also recommended that physicians should use standardised tools to diagnose Alzheimer’s disease especially in the early phase of declining of cognitive function. Until these strategies are in place, researching postural stability to reduce risks of falling among older adults with Alzheimer’s disease in New Zealand is impossible due to the lack of specificity with such a broad terminology and spectrum of diseases presentation

Perspectives of People with Mild to Moderate Cognitive Impairment and Their Caregivers about Physical Activity and Exercise for Fall Prevention: A Qualitative Study

Older adults with cognitive impairment are at high risk of experiencing falls. Although no specific fall prevention guidelines presently exist for this population, exercise programmes to prevent falls are recommended. Limited literature exploring what older adults with mild to moderate cognitive impairment think about or how they make sense of the need for such programmes exists. This study explored the perspectives of older adults with mild to moderate cognitive impairment and their caregivers about exercise and physical activity in the context of fall prevention. Underpinned by Interpretive Phenomenological Analysis, qualitative semi-structured interviews were undertaken with nine community-dwelling adults (>65 years) with mild to moderate cognitive impairment and their caregivers (N = 6). Three themes of acceptance, denial, and accommodation were identified. The fluctuating concept of ‘self’ appeared to influence individual decisions to exercise or be physically active and what sort of physical activity to undertake more than any practical barriers. We suggest that healthcare professionals emphasise the concept of personhood, listening to and reinforcing biographic narratives of older adults living with cognitive impairment to foster a sense of autonomy, and shared decision-making while emphasising fall prevention activities that older adults with cognitive impairment might like to engage with

Exercise to Improve Postural Stability in Older Adults with Alzheimer&rsquo;s Disease: A Systematic Review of Randomized Control Trials

In this systematic review, we aim to synthesize published evidence on the effects of exercise in improving postural stability among older adults with Alzheimer&rsquo;s Disease (AD). A systematic electronic literature search was undertaken in Pedro, Cochrane, MEDLINE, ProQuest, Science direct and Clinical trial databases involving human participants published from year 2000&ndash;2022. This search was updated in June 2022. The studies chosen were based on predetermined criteria. Data relating to the contents and parameters of exercise in persons with AD were gathered and analyzed. A total of 8 experimental studies met the inclusion criteria. Overall, the selected studies were of a medium quality. In these studies, information and physical exercises were used to improve postural stability in older adults with AD. The findings of the review suggest that performing combined strength, balance and executive function training can improve postural stability. However, we are unable to conclude the specific dose for specific type of exercise. More high-quality studies are required pertaining to exercise prescription for older adults with AD. Mostly, information and physical exercise were delivered via face-to-face sessions conducted by health professionals. The structure of exercises summarized in this review may be beneficial for older adults with AD to improve postural stability and as a result reduce falls

Fear of falls, physical performance and physical activity levels among older adults with falls and recurrent falls

Older adults who fall recurrently have sub-optimal physical performance especially muscle strength, mobility and balance. Recurrent falls lead to a heightened fear of falls. However, there is limited information regarding other domains of physical performance, namely flexibility and endurance. In addition, there is still limited knowledge pertaining fear of falls and physical activity levels among Malaysian community-dwelling older adults who are recurrent fallers. The aim of our study was to compare fear of falls, physical performance and physical activity levels among older adults with falls and recurrent falls. This cross- sectional study was carried out in two Malaysian urban districts. Physical performance was examined using Functional Fitness MOT (FFMOT). Modified Baecke Questionnaire and Activities-Specific Balance Confidence (ABC-6) Scale were administered to evaluate the level of daily physical activity and fear of falls respectively. A total of 35 older adults participated in this study, 20 fallers (mean age: 71.95±8.22) and 15 recurrent fallers (mean age: 76.73±8.82) respectively. Our study results showed that older adults with recurrent falls had significantly reduced lower extremity strength, dynamic balance, endurance, balance confidence in activities of daily living and physical activity levels compared to faller group (p < 0.05). Although flexibility and upper limb strength were not significantly different among fallers and recurrent fallers, overall improvement in physical performance should be targetted in falls prevention and management. This is vital to prevent further deterioration in physical performance among older adults with recurrent falls