Objetivo: Analisar a eficácia de um programa psicomotor (cognitivo e motor) em pacientes idosos com demência. Método: O estudo incluiu 36 idosos com demência, de ambos os sexos, divididos em um grupo controle (n = 21) e um grupo experimental (n = 15). Os instrumentos utilizados foram a avaliação Geronto-psicomotora (GPA); o Mini Mental State Examination (MMSE) e o programa psicomotor e foi aplicado em 24 sessões de 60 minutos cada uma durante um período de 12 semanas. Resultados: os idosos no grupo experimental evidenciaram uma melhoria estatisticamente significante em termos de função cognitiva e motora geral em comparação com o grupo controle. Conclusões: a intervenção psicomotora produziu benefícios cognitivos e motores em pacientes idosos com demência, principalmente na mobilização articular, memória, práxis, habilidades motoras finas e orientação do tempo.
Objective: Analyse the effectiveness of a psychomotor (cognitive and motor) programme on elderly dementia sufferers. Method: The study included 36 elderly with dementia, of both sexes, divided into a control group (n=21) and an experimental group (n=15). The instruments used were the Geronto-psychomotor appraisal (GPA); the Mini Mental State Examination (MMSE) and the psychomotor programme and was applied in 24 sessions of 60 minutes each over a period of 12 weeks. Results: The elderly in the experimental group evidenced a statistically significant improvement in terms of overall cognitive and motor function compared to the control group. Conclusions: Psychomotor intervention produced cognitive and motor benefits in elderly dementia sufferers, principally in joint mobilisation, memory, praxes, fine motor skills and time orientation.
- reabilitação psicomotora
- reabilitação cognitiva e motora
- psychomotor rehabilitation
- cognitive and motor rehabilitation
Aging is a global phenomenon. Our societies have been aging rapidly, 1 with the increased proportion of the elderly, especially in industrialised countries, arising as a result of falling birth and mortality rates and increased life expectancy 2,3.
This increase in elderly populations in recent decades has led to a higher incidence of chronic and neurodegenerative conditions such as dementia 4.
In 2012, there were 35.6 million cases worldwide. Each year there are calculated to be around 7.7 million new cases of dementia sufferers, that is one new case every 4 seconds5.
The term “dementia” does not define a single disease, but rather a syndrome (a defined collection of clinical signs and symptoms), since a wide and heterogeneous group of pathological situations can cause this clinical condition 6,7,8,9. Dementia is characterised by an acquired pathological brain alteration, where deteriorisation is generally progressive and on three planes: cognitive, psychopathological and functional 6,10.
Rehabilitation refers to the utilisation of specific techniques aimed at improving performance in physical, psychological and development functions, inter alia. 11. To this end, psychomotor intervention is centred on a holistic, integrated vision geared to improving the well-being of the subject, promoting maximum functionality and quality of life 12.
Studies confirm that physical exercise is associated with a lower incidence of dementia 13,14 and show that the benefits of associating therapeutic exercise with cognitive stimulation are evident even when the exercise is for elderly individuals 15. Furthermore, other studies affirm that psychomotor stimulation improves cognition in patients with Alzheimer’s disease (AD) 16.
Special attention is being paid to intervention based on body stimulation using psychomotricity as a cognitive stimulation technique 17, 18. In the case of elderly dementia sufferers (regardless of the stage of dementia), application of this technique is highly effective, addressing as it does the cognitive area via physical motor activities, space-time coordination activities and raising awareness of the psycho-functional unit 17,18.
Studies on humans have shown that physical activity is associated with the increase in blood perfusion in the attention-related brain regions 19. Controlled random studies have demonstrated that physical exercise reduces depression and is beneficial to elderly dementia sufferers, since 17% to 86% also manifest depressive symptoms 20,21.
According to the literature, deficiency in certain cognitive domains was directly related to functional impairment in patients with AD 22. However, neuropsychiatric disorders were also directly related with functional performance in the activities 23, 24.
Psychomotor intervention programmes for the elderly focus on two fundamental aspects: provide constant redrafting of the body schema and adjustment of the perceptual-motor behaviours, together with coordination skills, so that the subject can adapt to the constant changes arising from the aging process and foster interpersonal communication, enabling the elderly to improve their motor effectiveness through positive awareness of their own bodies and motor skills, based on a reciprocal relationship established with their peers 25.
According to the same author, psychometric intervention benefits these patients, since balance is created between the individual and her body through movement and relaxation. In other words, the elderly are able to manage and express their emotions and anxieties with greater ease. Psychomotor intervention does not cure dementia, but contributes towards the well-being of the elderly subject 26.
Taking into account the negative impact of dementia on the lives of the elderly, this study is justified by the need for more research to develop the influence of psychomotricity in dementia so as to find more effective systems in maintaining life quality.
The purpose of this study was to assess the effectiveness of a psychomotor programme on the cognitive and motor variables in elderly subjects with dementia. More specifically, it aimed to analyse the effects of psychomotor intervention on variables such as static and dynamic balance, joint mobilisation, fine motor coordination (upper and lower limbs), motor skills, body awareness, alertness, memory, spatial and temporal structuring, perception and communication.
This was an experimental study with pre and post testing and 2 study groups (experimental and control). The Mini – Mental and Geronto-Psychomotor Appraisal tests were used for initial and final testing. The Graffar scale, Lawton scale and Barthel index were also used, as required by the Geronto-psychomotor appraisal.
The experimental group received the intervention over a period of 12 weeks, with two sixty-minute sessions per week. The intervention consisted of applying a psychomotor programme addressing cognitive and motor variables.
The control group underwent the same initial and final assessments but did not undergo the psychomotor programme.
The sample consisted of 36 elderly subjects (age ≥ 65 years), previously diagnosed with dementia, from day centres and residential homes in the Porto district (convenience sampling – figure 1). After initial assessment, the subjects were subdivided into the control and experimental groups by random sampling, with each group consisting of 5 to 8 members.
Figure 1: Sample selection
This study was intended exclusively for elderly subjects with (medically diagnosed) dementia, irrespective of its type or stage and of their sex and degree of autonomy. Subjects younger than sixty five, those not in day centres or residential care for the elderly, those with no cognitive impairment (according to medical diagnosis) and the bed-ridden or recent surgery patients were all excluded (table 1).
Table 1: Characterization of the elderly participants pre testing; age expressed in years.
Total sample (n=36)
Control group (n=21)
Data collection method
In order to be able to apply the GPA, the researcher had to undergo training in ”Application of the Geronto Psychomotor Assessment”. This training entails administering, allocating values and interpreting the test and scales, followed by practical experience in applying the GPA to various cases, in order to obtain approval and authorisation to use it. At the outset of the study the subjects’ carers and relatives were advised as to the to the aims, nature and benefits of applying the programme, informing them that the participants could withdraw from the study at any moment, in compliance with the Declaration of Helsinki, after which they completed the form giving their informed consent.
The technical directors of the different institutions acted as mediators between the researcher and the subjects’ families, delivering an explanatory document to them explaining the objectives and procedures of the study, followed by the informed consent form, a copy of the document for the guardian and the Graffar scale for completion (annexe 4). When there was no family member responsible for the subject, the institution itself assumed the responsibility for the subjects’ participation in the study.
After confirming the authorisations from the subjects’ guardians, the researcher began the data collection (psychomotor characterisation form) and began individual assessment of each participant using the MMSE and the GPA.
The psychomotor programme, drawn from the literature, was then applied (to the experimental group), followed by the final assessment with application of the GPA and the MMSE.
This study ensured participant confidentiality in accordance with the Declaration of Helsinki. A code was therefore assigned to each participant on the registration form to preserve their anonymity. All of these procedures only took place after the project had been approved by the ethical commission of the Universidade Fernando Pessoa and by the Hospital Conde Ferreira.
The instruments used measure the state of physical and mental well-being and affective components. These instruments were selected for two reasons: because they assess different aspects of physical and psychological well-being and also the cognitive and motor changes that occur in aging.
The instruments used were a Psychomotor Characterisation Form, Geronto-psychomotor Appraisal (GPA) 27, the Mini Mental State Examination (MMSE), the Graffar Scale 29 and the Psychomotor Programme.
2.3.1. Psychomotor characterisation form
This is the user identification form containing sociodemographic data (name, date of birth, age, marital status, nationality, profession, education, emotional state, personal and family antecedents).
2.3.2. Geronto-psychomotor appraisal (GPA)
The GPA was created in France and first published in 2011 by Editions Hogrefe France 30.
It lasts approximately one hour and has internal consistency – Cronbach alpha = 0.83 27.
The objective is to give a brief assessment of the cognitive and motor abilities so as to clarify the presentation of the participant and obtain a longitudinal view of the progress of the dementia and/or the effect of any therapy 31. It consists of 17 items assessing balance, joint mobilisation, memory, time – space structuring, praxes, perception and communication. Each item contains various sub-items valued between 0.5 and 1 point. The maximum value is the same for each item: 6 points. Analysing the scores for each item allows for identification of the individual’s strongest and weakest areas. For each item the subject must perform the different psychomotor activities proposed.
Application of the GPA involves use of the MMSE, Graffar scale, Lawton scale and Barthel index.
2.3.3. Mini Mental State Examination
This is used to assess people’s mental state. It takes 5 – 10 minutes and consists of various questions grouped into six categories: orientation to time and place (ten points), registration of three words (three points), attention and calculation (five points), recall of three words (three points), language (eight points), and constructive visual skills (one point) 32,28.
2.3.4. Graffar scale
This consists of five levels that characterise the subject’s socioeconomic status, namely: profession, level of education, main source of income, housing and neighbourhood characteristics. 29.
2.3.5. Lawton scale
This assesses the elderly person’s level of independence in terms of ability to perform the instrumental activities of daily living (IADL), categorised as eight tasks: ability to use the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications and ability to handle finances.
2.3.6. Barthel index
This instrument measures performance in activities of daily living (ADL): feeding, personal hygiene, toilet use, bathing, dressing and undressing, sphincter control, walking, transfers from chair to bed, negotiating stairs 35.
The Psychomotor programme presented was based on other programmes in the literature and focussed on two essential components — cognitive and motor. It consisted of twenty four 60-minute sessions that occurred twice a week over a period of 12 weeks 36, 37, 38, 39.
The sessions took place in randomly formed groups of 5 to 8 participants so as to work on interpersonal relations, recognition of others and involvement 38. The sessions were structured into six phases – initial dialogue, overall body mobilisation, central activities, activities to stimulate symbolic abilities and fine praxis, relaxation and closing dialogue. The sessions always began and ended with reality orientation.
The variables exercised were static/dynamic balance, joint mobilisation and fine motor skills for arms and legs, praxes, somatognosia, alertness, memory, spatial – temporal structuring, perception, communication and lateralization.
This project is a quasi experimental study. After data collection, a database was created using IBM – SPSS Statistics 19.0 for Windows. The same program was used for statistical processing of data.
Initially, the parametric inference assumptions were verified (n≥ 30): the homogeneity of variance (Levene Test), the normality of the distribution (Shapiro-Wilk Test, because n≤ 50) and dependent variable measured on a numeric scale. Non parametric methods were used where there was violation of normality assumption. A significance level of 5% (0.05) was chosen.
With regard to the quantitative analysis and data processing, in addition to descriptive statistics (mean, standard deviation, mode, minimum, maximum and correlation), comparative statistical inference was also used (Student’s t-test —normal distribution).
1. Intergroup results (control and experimental) pre and post intervention, for GPA and MMSE instruments27,32.
At the start of the intervention there were no statistically significant intergroup differences (Student’s t test) for the scores in the MMSE32 (t= 0.464, p= 0.646) and the GPA27 (t= -0. 995, p= 0.330).
Post intervention there were statistically significant differences in the scores between the experimental and control groups in the GPA27 (t=2.678, p=0.014). As for the mean MMSE 28,32, although there were differences between experimental and control groups at the post intervention test, these were not statistically significant (t=0.654, p= 0.520).
In both the pre (r = 0.748, p <0.001) and post (r = 0.801, p <0.00) intervention tests there was a strong correlation56 between the results of the Geronto-Psychomotor Appraisal 27 and the Mini Mental State Examination 28,32, in other words subjects with high scores in the Geronto-Psychomotor Appraisal 27 tended to have higher results in the Mini Mental State Examination 32 (figure 2 and 3).
Figure 2: Relationship between GPA and MMSE in the pre intervention screening 16,17,32,56.
Figure 3: Relationship between GPA and MMSE in thepost intervention screening16,17,32,56.
1. Results at the psychomotor level (GPA and MMSE)
Graphs 4a and 4b present the alterations to the psychomotor variables (cognitive and motor)16,17,40 between the pre intervention and post intervention tests for both groups (experimental and control).
Figure 4a and 4b: psychomotor variables at pre and post intervention for (a) control and (b) experimental group16,17,56.
The results show a significant improvement for the experimental group in the following psychomotor variables27,30,31: joint mobilisation (p=0.041), recall (p=0.020), temporal structuring (p=0.041), fine motor skills (p=0.006) and praxes (p=0.027). There was a significant improvement in the overall GPA30,31,40 score (p ≤ 0.001).
The control group scores revealed a significant decline in the following psychomotor variables27,30,31: joint mobilisation (p=0.001), body awareness (p=0.034), fine motor skills
(p=0.000), praxes (p=0.001), recall (p=0.004), orientation to place (p=0.005) and perception (p=0.002).
With regard to overall application of the GPA27,30,31 there was a significant decline (p ≤ 0.001).
The results indicate a statistically significant improvement for the experimental group in the cognitive variable, as assessed with the MMSE 32 (p=0.016) and a statistically significant deterioration in the control group56 (p ≤ 0.001).
1. Results at the cognitive and motor level
The motor variable is made up of static balance, dynamic balance, joint mobilisation, fine motor skills and the praxes40. The cognitive variable is made up of body awareness, alertness, recall, orientation to place and time, perception, communication and the MMSE32 (division of cognitive and motor results made by the author 16,17,40).
The Mann – Whitney revealed no intergroup (control and experimental), statistical differences for the motor variable (U= -1.351, p =0.177) or the cognitive variable (U= -0.016, p =0.987) at the pre-intervention screening56.
The Paired – Samples T Test and Wilcoxon Test were applied immediately pre and post intervention to assess the effect of the psychomotor intervention on the cognitive and motor variables56 (Figure 5a and 5b).
Figure 5a and 5b: cognitive and motor variables in the pre and post intervention tests for (a) control and (b) experimental groups16,17,40,56.
The post-intervention assessment results reveal a statistically significant improvement for the motor40,56 (p= 0.001) and cognitive17,56 (p= 0.012) variables in the experimental group. At the same time, a statistically significant decline was observed in the motor40 (p <0.001) and cognitive16,17 (p <0.001) variables in the control group.
Various studies measuring the impact of a guide to psychomotor intervention on the quality of life for elderly dementia sufferers have observed post-intervention improvement in functional capacity 41. A number of them have demonstrated improvements in motor skills but with a continued decline in cognitive capacity as the dementia progresses 42, 43. Their results indicated that psychomotricity is effective in improving motor function and quality of life in the elderly with mild to moderate dementia. Our study, however, revealed a statistically significant improvement at both motor and cognitive levels, reversing the progress of the dementia and thus enabling improved quality of life for the participants.
Our finding is borne out by other controlled and randomised clinical trials assessing the effects of therapeutic exercise in subjects aged 65 or older with cognitive impairment. These studies include quantitative studies for physical fitness, physical functioning and cognition, as in our study. Meta-analysis of the 30 studies reviewed, most with duration of 12 weeks of interventions, revealed that performing motor activities improved fitness, physical function, cognitive function and positive behaviour in dementia sufferers and those with related cognitive problems 44.
Furthermore, our results corroborate two recent studies assessing the effectiveness of a functional training programme on outpatients with dementia and whether such a programme could be implemented in a geriatric hospital to improve motor functioning in these patients47. Improvement was noted in motor capacity and maintenance of cognitive capacities for the subjects receiving the functional intervention 47, 48.
The authors also observed a statistically significant improvement in fine motor skills, joint mobilisation, recall, praxes and temporal orientation. The other variables maintained the same levels.
This result is echoed by a number of experimental studies assessing the relationship between the effect of a regular progamme of physical activity on falls and cognitive decline in elderly dementia sufferers, where agility and balance were observed to be associated with cognitive functions, 49,50,51 52,53,54 although other studies have failed to find that association 55.
Our results also tie in with those of studies demonstrating that motor intervention may be associated with an attenuation of neuropsychiatric symptoms in Alzheimer’s (such as, for example, inappropriate motor behaviour, indifference and depression) as well as reducing the load on the carer(s). At the same time these studies recorded a significant improvement in motor coordination, which may be associated with the positive effect of repeating tasks and maintaining attention 445,46.
Studies focussing specifically on AD patients also draw attention to the preventative role of physical exercise, which is shown to be important for maintaining balance, strength and cognition. At the same time, these studies also point to the association between practising motor activities and a a lower incidence of cognitive decline and dementia 51,52,53 .This association is supported by our study, where psychomotor activities were observed to act as a protection factor against the evolution of cognitive decline and dementia.
The data demonstrates the positive influence of a psychomotor programme in elderly dementia sufferers in general terms but also, more specifically, with regard to their motor and cognitive abilities. The subjects who did not participate in the programme (control group) showed a marked decline in psychomotor abilities overall, and in both motor and cognitive terms, assessed separately56.
The results showed that that the psychomotor programme had a positive influence on the cognitive and motor variables for elderly dementia sufferers. These improvements were statistically significant41,42,49,50.
Overall, it should be noted that performing psychomotor activities may allow people with dementia to delay the advance of the condition and contribute towards reducing functional losses, justifying the need to create and apply cognitive and motor rehabilitation programmes for elderly dementia sufferers39,43.
One limitation of the study was that participants’ emotional state was not considered during the programme and at the pre- and post- intervention assessments. Also, medications being taken and any changes of medication were not considered. Ideally, the sample size would be larger and the duration of the study longer39,50,52,53.
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