Many people worry about how their physical and mental abilities will reduce as they grow old. Dementia caregivers also worry about their risk of getting dementia.
Ramani Sundaram, a neuroscience research scientist working at Nightingales Medical Trust, has designed and managed the “Active Ageing” program at the Nightingales Trust Bagchi Centre for Active Ageing (Bangalore). It is a holistic program that uses a multi-modal activity-based approach. It is based on the ThinkingFit study conducted in the UK, and aims to bring lifestyle modification and ensure health and happiness of the elderly, thus making ageing a positive experience. The focus is on minimizing the risk of dementia, controlling hypertension, diabetes, and depression, and preventing falls.
In this two-part interview, Ramani explains the program’s concepts and components, shares the benefits seen in participants, and discusses how some elements of the program can be used by people who can’t leave home (like many caregivers). [note] Part 1 below introduces us to the program and its context and objectives, how participants are assessed before they join, and the three components of the program. The first component, i.e., physical activity, is also discussed.
Questions/ Comments by Dementia Care Notes: Please share your perspective on ageing in our society, which is the context within which your program is designed.
Ramani Sundaram, neuroscience research scientist: Longevity is here to stay and ageing is a natural phenomenon. However, ageing also brings anxiety of various age-related conditions like cardiovascular diseases and memory loss (dementia). Age-related conditions are mostly not treatable. They require lifelong management. Costs associated with managing such disabling conditions are high. Most people are therefore scared of problems they fear ageing will bring, such as decline of physical and mental health, reduced social connections, and possible financial problems.
Our experience of ageing depends on our surroundings. Unfortunately, our surroundings promote ageism. They make ageing seem a negative experience. For example, cosmetics are promoted to look younger and anti-ageing creams are heavily advertised. We do not notice that older people have their own beauty and don’t need special cosmetics to make them look younger. The media also portrays older people as frail and fragile, requiring help all the time.
All this makes growing older seem undesirable, and so, in our current surroundings, most people are anxious about getting older. Programs like our Active Ageing program use a systematic approach to improve the ageing experience.
DCN: Please give us a brief introduction to your Active Ageing program
RS: The fact is that improvement of health and well-being is possible at any age.
Our “Active Ageing” program is designed to enable older people to realize their potential for physical, social, and mental wellbeing. It is a systematic approach that includes physical activity and cognitive engagement in a social environment.
Our “Active Ageing” program is designed to enable older people to realize their potential for physical, social, and mental wellbeing. It is a systematic approach that includes physical activity and cognitive engagement in a social environment. The aim of the program is to help participants age well— this doesn’t equate to becoming a younger version of themselves but to enjoy the maximum of the current abilities and to dismantle ageism.
Our program has been functioning at the Nightingales Trust Bagchi Centre for Active Ageing, Bangalore since October 2014. Till end 2016, over 350 participants have benefitted through this program. They have been in the age-range of 50 -100 years and they attend it three days a week. All participants undergo periodic assessments every three months. A minimum of three months of active participation is required to measure the benefits of the program. Data is gathered to evaluate and confirm its effectiveness with respect to specified parameters of health, functionality and well-being. The program is now also functional at some other centres in Bangalore.
Our program is an ongoing program. Some participants stay with the program. Others take it for three months, or six months, or a year, depending on their schedule. Some participants tend to take a break and re-join later.
DCN: What is your program based on? Why is it called “Active Ageing”?
RS: “Active Ageing” is an approach that illustrates how people can become healthier and happier while they age, compared to how they were earlier. Our program design fits into the official definition of Active Ageing by WHO (see box).
We started this program because we wanted a lifestyle modification intervention to reduce the risk of dementia. Elders may not be interested in something called “dementia risk reduction” either because they are unaware of dementia, or because they consider it stigmatizing. By calling our program “Active Ageing” we reach and benefit many more elders. Also, “Active Ageing” is an acceptable and positive term and conveys the essence of what we are doing.
Our design is based on the ThinkingFit Study, a three-year research carried out by Dr. Thomas Dannhauser and his colleagues from The North Essex Foundation Trust and University College, London. This team developed a program which combines physical, social and mental activities in a fun way that keeps the elderly active. This study showed significant improvement in the participants’ physical fitness, cardiovascular health, memory, and quality of life. (see footnote for the reference paper)
DCN: “Active Ageing” is a phrase we see more and more in use by centres and programs. Are all these the same program? If not, how does one decide between them?
RS: Yes, there are now many active ageing centres promoting the concept of ageing well, which is encouraging. The programs offered are different and depend on who is offering them. I suggest that people look for something where there is equal importance to physical activity, mental stimulation, and social engagement.
Our Active Ageing program is a standard program which includes physical, cognitive, and social parameters that are essential components of the term “Active Ageing”. Our program is evidence-based, data driven, and piloted. People can therefore compare it to other active ageing programs to decide whether they want to try it.
DCN: What are the main components of your Active Ageing program?
RS: Our program looks at various age-related problems and how we can reduce the risk factors for these (or manage them better).
For example, most cardiovascular risk factors are modifiable. They can be prevented and managed through activities which include physical exercise, cognitive stimulation, and social interaction. We also know that after retirement, people may become less active physically and mentally, and may become more isolated socially. So, we aim to prepare people above the age of 60 years to participate in new activities and facilitate substantial lifestyle change.
Our hypothesis is that mental stimulation, social engagement, and physical activities have a preventive effect on age related conditions. This hypothesis is supported by scientific literature, and these activities have been associated with outcomes like enhanced cognition (improved mental and intellectual abilities), lower morbidity (reduced change of illnesses), and general well-being.
The main components of our program are:
- Physical activity: These include aerobics, chair based exercises, flexibility and strength training, dance routines; resistance exercises, and fall prevention exercises.
- Cognitive Engagement (mental stimulation): Activities in this component are designed for various cognitive processes such as memory, executive function, language, visuospatial abilities, speed of processing, etc.
- Socialization: The most important aspect of the program is socialization and thus all physical and cognitive activities are done in a group. There are exclusive social engagement programs which are mostly fun-driven, such as antakshari and musical chairs, etc. We also organize group outings.
DCN: Please describe the physical exercise component.
RS: The main aim of the physical activity component is to ensure that elders feel good after the session. They gradually enjoy health benefits through better management of cardiovascular parameters. The goals of the physical activities differ according to the regime followed on a particular day. We provide a variety of exercises that can be done by anyone irrespective of their medical/physical condition/history. The exercise intensity is adjusted based on the individual’s capacity and medical history.
Many older people initially found the concept of a gym an unsuitable for their age. However, as they started using various equipment, their perception about using a gym changed.
Our exercises include:
- Chair based exercises: This is the core physical activity that we find highly beneficial for the elders. This is a part of cardiovascular regime. It’s a very intensive workout and allows people to undergo good training while sitting on the chair. It is one of the safest types of exercises and at the same time the most enjoyable for the elders. We provide varieties of chair exercises by including resistance bands, free weights, etc.
- Elders Gym: Our Centre has an exclusive gym designed for the elders. Many older people initially found the concept of a gym an unsuitable for their age. However, as they started using various equipment, their perception about using a gym changed. The gym sessions allow us to make elders do exercises at their target heart rate for 30 mins. We are able to monitor their heart rates during these sessions, and that gives us and the elders a better understanding of their cardiac endurance.
- Yoga: As we all know, yoga has many benefits. Also, it is a very popular concept among elders. We have customized the asanas to suit the requirement of the age groups of our participants.
- Strength and Endurance: We have various workouts to enhance the core strength and endurance among the elders.
- Off Routine Cardio: These include dance aerobics, cardio kick boxing, and step based balance training.
DCN: What is the structure of a physical exercise session? How often is this done?
RS: The session is usually for 50 mins. It has 10 minutes of warm up, 30 minutes of intensive work out, and 10 minutes of cool down. Physical activity is done three days a week (every alternate day), and is under the guidance and supervision of the physical trainer (trained physiotherapist).
The sessions are done in a group of 15 persons. This includes people from different age groups which increases the sense of involvement and motivation for all participants. The sessions are enhanced by Bollywood beats (old songs and sometimes new ones, based on what they demand).
Doing any exercise for an hour can be boring and may seem undoable, but when done in a group, it becomes an enjoyable experience. In our groups, members actively participate by counting with instructor, motivating each other, and singing songs in absence of music and use many such ways to remain cheerful and active. They enjoy the workouts.
DCN: Sounds great! Can you share some preliminary results of how this physical exercise component has affected seniors?
We get feedback from them and their family about reduction in blood sugar, blood pressure, cholesterol, etc., which, in turn, results in their doctors reducing their medicine dosages.
RS: One thing is that we have received feedback from the participants about the benefits they have experienced. They tell us they feel more energetic and happy as they do these activities regularly. They are also able to manage their cardiovascular conditions better. We get feedback from them and their family about reduction in blood sugar, blood pressure, cholesterol, etc., which, in turn, results in their doctors reducing their medicine dosages. This reduction of dosage /monitoring is done by their own GP – we get the information from the family and update our records for the changed dosage.
As the program is evidence-based, we also gather data for our own analysis.
Our preliminary results have been encouraging. We have seen substantial improvement in physical well-being and cardiovascular fitness in the parameters we have been monitoring. These include the fitness index which serves as a measure for cardiac endurance, blood glucose levels, and BMI. Other parameters where we found significant changes are weight management, balance, and flexibility. Most of the times these improvements reflect in their medical reports (from their own doctors), which can confirm/ supplement our observations.
DCN: What type of examination and analysis is needed to decide on an individual’s program?
RS: All the older people who register for the program undergo a compulsory initial assessment. This includes physical, cognitive, and medical assessment.
The physical assessment is done by a physiotherapist while the medical assessment is done by a doctor. People need to bring their past medical reports and current list of medications. The physical and medical assessment covers detailed medical history, basic parameters (such as BMI, FAT%, RBS, BP, and target heart rate), modified step test results, and a general review by our centre’s physician. The physician assessment is done fine-tune the individual’s physical activities.
Most of the exercises in our program can be done by all older persons. However, our physiotherapist notifies each individual about the precautions to be taken as per the individual’s physical and medical limitations. Exercises are sometimes modified to be more suitable for the individual. Individuals are also reminded of these precautions and modifications when they are doing the exercises.
In our cognitive assessment, we look at the participant’s cognitive ability in various cognitive areas. This includes visual and auditory divided attention task, long term and short-term memory task, verbal fluency, visuospatial, and working memory task. The tools used are ACE-r, Digit Span, CVLT and TMT. In addition, the WHOQOL-Bref (WHO quality of life scale) is used to measure quality of life and everyday activities.
DCN: What check-ups do homebound persons (like many caregivers) need to start such exercise at home? What sort of training and supervision do they need, and how can they set up their home for the exercise?
RS: Anyone starting any exercise program needs to undergo a proper check-up and get suitable advice just like any participant in our program. If a homebound person wants to start such physical activities, they can approach the centre and get themselves screened. This will allow them to interact with the physiotherapist to understand the Do’s and Don’ts’.
It is ideal to do the prescribed physical activities under the supervision of physiotherapist. Homebound persons such as family caregivers can probably first attend some sessions at the centre before they start doing them at home. If they can make time, may be couple of hours a week, to undergo a few sessions after assessment, the physiotherapist can understand their potential and limitations, and explain the proper way of exercising and any risks and cautions involved. Thereafter, they can do some exercises at home. They should stay in touch with centre for periodic assessments/feedback.
Some simple exercises can be done at home, and these can be demonstrated and explained by the physiotherapist. These include walking at home, chair exercises, and free weights. Many heart rate monitoring devices are now available in the market. These can help people exercise at their target heart rate. Chair exercises only need a sturdy chair, and walk at home needs non-slippery flooring and some minimal space. American Heart Association has the walk at home regime that is available online (see box). And free weights may also be used–up to 1kg can be used (you can also use half/one litre water bottle). We advise wearing sport shoes during such workouts.
… warm up and cool down are very important and should not be skipped when doing the exercises at home.
Exercises using resistance bands and stability balls are better done under supervision as the chances of injury are high. So, they may not be suitable for doing at home. Again, I strongly recommend that the person visit the centre and see the exercise steps and understand the benefits and risks associated. They can spend a couple of hours a week for this at the centre before starting doing these at home. And I want to emphasize that warm up and cool down are very important and should not be skipped when doing the exercises at home.
In part 2 , we discuss the mental and social components of the program and talk about how homebound persons can adapt and use these. We also talk about the use of the program for persons with mild cognitive impairment or early dementia.
Reference: *(Dannhauser, Thomas M., et al. “A complex multimodal activity intervention to reduce the risk of dementia in mild cognitive impairment–ThinkingFit: pilot and feasibility study for a randomized controlled trial.” BMC psychiatry 14.1 (2014): 129.)
Ms Ramani Sundaram may be contacted by email at firstname.lastname@example.org. The centre running the program described here can be reached by contacting Nightingales Trust Bagchi Centre for Active Ageing, Bangalore (Email: email@example.com Phone: 080-69999775).
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Note: This is an interview of an expert/ volunteer. The views expressed and the suggestions given are those of the interviewed person, and not a recommendation being made by Dementia Care Notes. Suitability and applicability of the suggestions remain the responsibility of the reader. For professional advice suitable for your situation, please consult an appropriate professional.