Dragorosso.eu

Original article
Effects of Tai Chi Chuan on cognition of elderly women with Efeitos da prática de Tai Chi Chuan na cognição de idosas com comprometimento cognitivo leve Juliana Yumi Tizon Kasai1, Alexandre Leopold Busse2, Regina Miksian Magaldi3, Maria Angela Soci4, Priscilla de Moraes Rosa5, José Antônio Esper Curiati6, Wilson Jacob Filho7 aBStract
Objective: To detect the effects of Tai Chi Chuan practice on the
Objetivo: Detectar os efeitos da prática de Tai Chi Chuan na cognição de
cognition of elderly subjects with Mild Cognitive Impairment. idosas com comprometimento cognitivo leve. Métodos: Estudo piloto
Methods: This is a pilot study with 26 elderly patients (mean
com 26 idosas (média de idade de 74 anos) com comprometimento age of 74 years) with Mild Cognitive Impairment. The evaluation cognitivo leve. Os instrumentos de avaliação foram: Escala Subjetiva instruments were Subjective Memory Complaint Scale (SMC), de Queixas de Memória (EQM), Teste Comportamental de Memória de Rivermead Behavioral Memory Test (RBMT) and Digit Span Forward Rivermead (RBMT) e Amplitude de Dígitos Verbal Direta e Indireta (DD and Backward (DSF and DSB) from the Wechsler Adult Intel igence e DI, respectivamente) derivadas do Weschler Adult Intelligence Scale Scale (WAIS). One group of 13 patients received two weekly 60- (WAIS). Um grupo de 13 pacientes recebeu duas aulas semanais de minute classes of Tai Chi Chuan (Yang style) for 6 consecutive 60 minutos de Tai Chi Chuan (estilo Yang) por 6 meses consecutivos, months, and the rest formed the Control Group. The Tai Chi Chuan e o restante formou o Grupo Controle. O grupo Tai Chi Chuan também Group was also evaluated as to learning of the Tai Chi Chuan foi avaliado quanto ao aprendizado da prática dos exercícios de Tai practical exercises by means of a Specific Learning Test applied Chi Chuan através de um Teste de Aprendizado Específico aplicado after three months of intervention. results: After six months of
após três meses de intervenção. resultados: Após seis meses de
intervention, the TCC Group showed significant improvement on the intervenção, o grupo Tai Chi Chuan apresentou melhora significativa RBMT and the SMC (p = 0.007 and p = 0.023, respectively). The no RBMT e na EQM (p = 0,007 e p = 0,023, respectivamente). O Control Group showed no significant differences in the cognitive Grupo Controle não apresentou diferenças significativas nos testes tests during the study. There was a significant correlation between cognitivos no decorrer do estudo. Houve correlação significativa the Tai Chi Chuan Learning Test and RBMT (p = 0.008), showing that entre o Teste de Aprendizado de Tai Chi Chuan e o RBMT (p = 0,008), patients with a better performance in exercising TCC also showed apontando que os pacientes com melhor performance na prática a better performance in memory. conclusions: In this study, a six-
de Tai Chi Chuan apresentaram melhor desempenho da memória. month program of Tai Chi Chuan afforded a significant improvement conclusões: Neste estudo, um programa de seis meses de Tai Chi
of the performance of memory complaints in the elderly with Mild Chuan propiciou uma melhora significativa do desempenho e das Cognitive Impairment. Additional randomized studies with larger queixas de memória de idosas com comprometimento cognitivo leve. samples and more prolonged fol ow-up are needed to confirm these Estudos adicionais randomizados com casuística maior e seguimento mais prolongado são necessários para confirmar estes benefícios. Keywords: Tai ji; Health services for the aged/psychology; Pilot
Descritores: Tai ji; Serviços de saúde para idosos/psicologia; Projetos
projects; Neuropsychological tests; Memory disorders/therapy; piloto; Testes neuropsicológicos; Transtornos da memória/terapia; Alzheimer disease; Alzheimer disease/rehabilitation; Alzheimer Doença de Alzheimer; Doença de Alzheimer/reabilitação; Doença de disease/prevention & control; Exercise movement techniques Alzheimer/prevenção e controle; Técnicas de exercício e de movimento Study carried out at Serviço de Geriatria do Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
1 Assistant physician of the Department of Geriatrics of the Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
2 PhD; Assistant physician of the Department of Geriatrics of Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
3 Assistant physician of the Department of Geriatrics of the Hospital das Clínicas of Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
4 Physical educator; Director of the Sociedade Brasileira de Tai Chi Chuan – São Paulo (SP), Brazil.
5 Physical therapist; Teacher of Tai Chi Chuan of the Sociedade Brasileira de Tai Chi Chuan – São Paulo (SP), Brazil.
6 PhD; Assistant physician of the Department of Geriatrics of Faculdade de Medicina da Universidade de São Paulo – USP, São Paulo (SP), Brazil.
7 Full professor of Geriatrics of the Faculdade de Medicina of Universidade de São Paulo – USP, São Paulo (SP), Brazil.
Corresponding author: Juliana Yumi Tizon Kasai – Rua Oscar Freire, 1967, apto. 81-A – Pinheiros – CEP 05409-011 – São Paulo (SP), Brazil – Tel.: 11 3582-0462 – e-mail: [email protected] on Aug 14, 2009 – Accepted on Jan 18, 2010 Effects of Tai Chi Chuan on cognition of elderly women with mild cognitive impairment intrODUctiOn
maximal heart rate and 55% of the maximal uptake of In Western societies, dementia is among the main causes of loss of functional capacity and autonomy in elderly A variety of benefits related to Tai Chi Chuan was individuals. With the aging of population, the number described. Numerous studies demonstrated a positive or persons in the world with Alzheimer’s disease (AD) impact of Tai Chi Chuan on balance, muscular strength, has been increasing considerably. Therefore, efforts flexibility, posture control, and consequently on the have been made to identify the individual at a high prevention of falls in the elderly(13-15,17-18).
risk of developing Alzheimer’s disease and to test One recently published study showed that the group interventions that prevent or retard the manifestation that practiced Tai Chi Chuan displayed improvement in learning and in memory when compared to the Control The need for an effective therapy, especially Group after one year. These results suggest that, besides during the initial stages of the disease of the so-called improving memory performance, Tai Chi Chuan may Mild Cognitive Impairment (MCI) has been the focus retard its alterations during the aging process(19).
of various studies. Patients without a diagnosis of dementia, but with some form of objective evidence OBjective
of cognitive decline, are considered as having mild cognitive impairment(2). Considering the known benefits of Tai Chi Chuan, this There is no consensus, however, as to the paper was developed in order to assess the effects of instruments for neuropsychological evaluation and this practice on the cognition of the elderly with mild diagnostic criteria(3). Observational studies suggest cognitive impairment, a theme that is still practically that the elderly with no dementia, but with a decline in memory objectively reported or demonstrated, show a greater risk of developing Alzheimer’s disease over time(4-5). Some medications have already been tested and afford benefits in the treatment of dementia, but inclusion criteria
this has not been demonstrated yet in individuals with Elderly women aged 60 years or more; absence of MCI(6-7). Thus, cognitive rehabilitation through non- programmed physical exercise over the previous 12 pharmacological means is increasingly being sought(8).
months; memory complaint offered by the patient or Currently, interest has grown as to the role of risk by family members over the previous year; screening factors related to the individual’s lifestyle (such as score of the Rivermead Behavioral Memory Test lower smoking, diet, and sedentary life) in the prevention than 10; Mini Mental State Examination (MMSE) of memory deficit and dementia(9-11). A systematic within normality, corrected by educational level(20); review of 18 longitudinal studies (1966 to 2001) Geriatric Depression Scale (GDS) within normality(21); concluded that aerobic exercises provide consistent functionality preserved in basic and instrumental benefits to cognitive performance in sedentary elderly Physical exercises have well-defined effects on the health of the elderly, but the appropriate forms of exclusion and non-inclusion criteria
practicing them are scarce, since aging is accompanied Presence of clinical criteria for dementia, depression, by an organic decline, such as a wearing of the joints, and anxiety by the criteria of the Diagnostic and visual deficits, balance modifications, and lowered Statistical Manual of Mental Disorders of the muscular resistance. Various literature reports suggest American Association of Psychiatry (DSM IV)(24); that Tai Chi Chuan has the characteristics necessary for chronic alcoholism; serious psychiatric disorders; appropriate physical exercise in the elderly(13).
cranioencephalic trauma or cerebrovascular accident Tai Chi Chuan was originally developed as a martial occurred in the previous year; use of medications that art, but it has been practiced for centuries in China as interfere in cognition (antidepressants, anxiolytics, a physical activity, primarily by the elderly population, antipsychotics, opiates, anti-vertigo drugs, anti- due to its low impact and low speed(14). This millennial Parkinson agents, anticonvulsants); clinical conditions practice consists in the execution of gentle circular that contraindicate light physical exercise, as per the movements associated with breathing, concentration, American Heart Association; serious auditory and/or and relaxation exercises(15). Various prior studies have visual deficit; significant changes in ancillary tests such classified Tai Chi Chuan as a moderate intensity exercise, as blood glucose, sodium, potassium, urea, calcium, since its practice makes the individual reach 60% of the magnesium, complete blood count, erythrocyte Kasai JYT, Busse AL, Magaldi RM, Soci MA, Rosa PM, Curiati JAE, Jacob Filho W sedimentation rate, liver enzymes, thyroid hormones, The Digit Span Forward (DSF) and Backward (DSB) serology for syphilis, folic acid, and vitamin B12.
tests derived from the Wechsler Adult Intelligence Scale After signing the informed consent form, the elderly (WAIS) consist in the repetition of verbally given digit women included in the study were non-randomly sequences in the forward and backward orders. They distributed into an intervention group with Tai Chi measure the capacity for concentration and working Chuan classes (n = 13) and a Control Group (n = 13). memory, respectively. The number of digits increases The control group was instructed not to practice Tai over the time of testing, until the subject fails in two Chi Chuan until the end of the study. Both groups were consecutive sequences of a certain number of digits(27).
assessed at the beginning of the study and after three After three months of intervention, the Tai Chi and six months. The female gender was chosen because Chuan group was evaluated as to learning of the Tai of the dominance of this sex in the elderly population, Chi Chuan activities by means of a specific quantitative which would facilitate the recruitment of research test. This test was drawn up and applied by the Brazilian Society of Tai Chi Chuan, varying from zero to 10 for each Tai Chi Chuan posture performed.
assessment instruments
intervention
The Subjective Memory Complaints Scale (SMC) is derived from the Cambridge Examination for Mental After approval by the Research Ethics Committee, the Disorders of the Elderly (CAMDEX) and was developed study was carried out at the Elderly Memory Outpatient so that the greater the number of complaints, and the Clinic (AMI, acronym in Portuguese) of the Geriatrics greater interference these had in the individual’s life, Department of Hospital das Clínicas of Faculdade the greater was the punctuation from zero to 21. This de Medicina da USP. The 60-minute Tai Chi Chuan test evaluates the perception of memory by the patient classes (Yang style) were given by a physical therapist twice a week. After warm-up, the exercises focused The Rivermead Behavioral Memory Test (RBMT) on muscular strength, improvement of flexibility, is composed of a series of practical tasks seeking to motor coordination, and control of concentration and breathing. The intensity and complexity of the exercises simulate daily life situations, thus diminishing the interference of cultural or educational level factors. The patients were also instructed to practice the This test is divided into two scores: Screening (SCR) exercises at home, using a didactic brochure. If they and Standard Profile (SDP). The screening score varied missed a class, the teacher recommended increasing the from zero to 12 points (normal: greater than or equal to 10) and was used as an inclusion criterion. The more detailed standard profile varied from zero to 24 points (normal: greater than or equal to 22), and is more Statistical analysis
appropriate for memory follow-up. Values below the In order to compare the means between the groups cutoff scores indicate cognitive impairment(26).
as to the continuous variables, the Student’s t test was The test is composed of the following items: name used. Kolmogorov-Smirnov tests were used to verify if and last name (recognition of name and last name the scales in each group showed normal distribution, from a photograph); hidden belonging (remembering and the test did not reject the normality of distributions to ask for a belonging to be returned); appointment for any of the scales at the three time points observed. (asking a question when an alarm goes off); pictures Variance analyses (ANOVA) were performed with (recognizing familiar pictures); immediate and delayed repeated measurements and two factors, in which the story (memorizing a story immediately and after a few group (control or intervention) was the fixed factor and minutes), immediate and delayed route (memorizing the time point (initial, three months, and six months) a route sequence through the evaluation room immediately and after a few minutes); message (leaving a message in the middle of the path in a specific place), orientation (temporospatial orientation and general knowledge questions, such as the name of the current The samples were similar in the age, schooling and president) and date (correctly evoking the day, month, initial cognitive assessments (RBMT, SMC, DSF, and and year). Classifications vary according to the score: DSB) variables, as shown on table 1. There were two normal, weak memory, moderate impairment, and losses in the TCC group after three months of the study due to drop-out and uncontrolled hypothyroidism.
Effects of Tai Chi Chuan on cognition of elderly women with mild cognitive impairment table 1. Baseline characteristics of the sample
significant improvement in memory performance of control group
the elderly patients who practiced Tai Chi Chuan. It is characteristics
tai chi group
important to point out that RBMT is a test with four different versions, which facilitates the longitudinal follow-up for measuring loss of memory and to monitor the effects of cognitive rehabilitation, without suffering the influence of schooling, age, or gender, and with a reduced effect of learning. There was also a significant RBMT: Rivermead Behavioral Memory Test; SMC: Subjective Memory Complaint Scale; DSF: Digit Span Forward; difference in the SMC of the intervention group, i.e., DSB: Digit Span Backward. *Matched t test the elderly women who practiced Tai Chi Chuan had a decrease in complaints related to memory.
The TCC group showed a significant increase in the Studies involving the cognitive function and Tai Chi mean Rivermead Test (RBMT) scores after six months Chuan are still scarce in the medical literature. Most (p = 0.007), indicating a major improvement in memory studies associate aerobic physical exercise and cognition performance for the elderly women who practiced Tai Chi in the elderly population. Various studies have classified Chuan in comparison to the Control Group (Table 2). Tai Chi Chuan as a moderate intensity physical activity, since 60% of the maximal heart rate is reached, along table 2. Description of the cognitive scale among groups and time points
with 55% of the maximal oxygen uptake(14,16). Therefore, Baseline
the positive results found in the present study are related to the fact that Tai Chi Chuan, besides being considered as a physical exercise, works on concentration in performing a long sequence of movements (the sequence of movements requires memorization), maintaining the focus on body consciousness, relaxation, and breathing. This hypothesis is reinforced by the direct correlation found in this study between the Tai Chi Chuan Learning Test and the mean scores of RBMT in the TCC group, RBMT: Rivermead Behavioral Memory Test; SMC: Subjective Memory Complaint Scale; DSF: Digit Span Forward; DSB: Digit Span Backward; SD: standard deviation. *Variance analyses (ANOVA).
which reinforces the direct relation between memory performance and the practice of Tai Chi Chuan.
In a systematic review by Cochrane Collaboration, The TCC group showed a significant drop in memory the efficacy of aerobic physical exercise in the cognitive complaints (p = 0.023), i.e., there was marked improvement function of the elderly without prior cognitive impairment in complaints regarding memory (perception of memory) was assessed. Eleven controlled randomized trials with in the elderly patients who practiced Tai Chi Chuan participants aged 55 years or older were selected. The relative to the controls. The DSF scale showed a significant conclusion was that there is evidence that aerobic difference in the ANOVA analysis, suggesting a difference physical exercise is beneficial for the cognitive function in working memory between the two groups that was in the elderly, with effects observed on motor function, evident in the third month of the study (p = 0.031). On cognitive speed, and attention. Nevertheless, data the other hand, there was no significant difference on the are insufficient to demonstrate that the improvement DSB scale (p = 0.164), and, therefore, no improvement was noted in the attention and concentration of the elderly in cognitive function is due to an improvement in women who practiced Tai Chi Chuan in comparison to the cardiovascular aptitude. Additional studies are needed to confirm if the aerobic training is necessary, or if There was a direct correlation between the Learning the benefit may be attained with any type of physical Tai Chi Chuan Test and the score means of the RBMT (Pearson’s correlation coefficient) in the TCC Group (p In a randomized clinical trial involving 32 elderly = 0.008), which reinforces the direct relation between subjects with cognitive impairment, a significant memory performance and the practice of Tai Chi Chuan cognitive improvement (RBMT) was also observed in the group that participated in a resistance exercise program (muscle building) for nine months, but no improvement was observed as to memory complaints, as DiScUSSiOn
in the present study involving Tai Chi Chuan. Working The results showed a significant difference in RBMT memory, attention, and concentration presented no after intervention in the TCC Group, which reveals a significant differences related to muscle building Kasai JYT, Busse AL, Magaldi RM, Soci MA, Rosa PM, Curiati JAE, Jacob Filho W activities, results that are similar to those of the study reFerenceS
1. Lautenschlager NT, Cox KL, Flicker L, Foster JK, van Bockxmeer FM, Xiao J, Positive results relating Tai Chi Chuan and cognitive et al. Effect of physical activity on cognitive function in older adults at risk for improvements were found in a study by Chan et al. that alzheimer disease: a randomized trial. JAMA. 2008;300(9):1027-37.
compared the cognitive function of 4 distinct groups 2. Thal LJ. Therapeutics and mild cognitive impairment: current status and future after 12 months (n = 140, age over 56 years, with no directions. Alzheimer Dis Assoc Disord. 2003;17(Suppl 2):S69-71.
prior cognitive modifications): Tai Chi Chuan group, 3. Busse A, Bischkopf J, Riedel-Heller SG, Angermever MC. Mild cognitive physical activity group (dancing and tennis), Tai Chi impairment: prevalence and incidence according to different diagnostic Chuan plus physical activity group, and control group criteria. Results of the Leipzig Longitudinal Study of the Aged (LEILA75+). Br J Psychiatry. 2003;182:449-54.
(no programmed activity). The assessment instruments 4. van Oijen M, de Long FJ, Hofman A, Koudstaal PJ, Breteler MM. Subjective for this study were the Hong Kong List Learning Test (a memory complaints, education, and risk of Alzheimer’s disease. Alzheimers memory scale validated in China) and a modified scale version of the Boston Naming Test. The findings revealed 5. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med. a significant association between the practice of Tai Chi Chuan and/or physical activity with better performance in 6. Loy C, Schneider L. Galantamine for Alzheimer’s disease and mild cognitive cognitive tests compared to the control group, including impairment (Cochrane Review). In: The Cochrane Library, Issue 3, 2007. learning, memory retention, and repetition. These data suggest that both Tai Chi Chuan and the other types of 7. Birks J, Grimley EJ, Iakovidou V, Tsolaki M. Rivastigmine for Alzheimer’s disease (Cochrane Review). In: The Cochrane Library, Issue 3, 2007. Oxford: physical activity help to preserve cognitive function in elderly adults. The elderly that practiced Tai Chi Chuan 8. Busse AL, Jacob Filho W, Magaldi RM, Coelho VA, Melo AC, Betoni RA, et al. plus physical activity showed better performances on the Effects of resistance training exercise on cognitive performance in the elderly tests compared to the group that only practiced Tai Chi individuals with memory impairment: results of a controlled trial. einstein. Chuan, which indicates that different types of exercises may have different effects on the functions of memory. 9. Jorm AF. Prospects for the prevention of dementia. Aust J Ageing. The group that practiced Tai Chi Chuan showed greatest memory preservation after one year, with a 10. Lautenschlager NT, Almeida OP, Flicker L, Janca A. Can physical activity improve the mental health of older adults? Ann Gen Hosp Psychiatry. 2004;3(1):12.
significant difference relative to the other groups. These 11. Fratigliono L, Paillard-Borg S, Winblad B. An active and socially integrate lifestyle findings, as those in the present study, suggest that Tai in late life might protect against dementia. Lancet Neurol. 2004;3(6):343-53. Chi Chuan plays an important role in the cognition of 12. Colcombe S, Kramer AF. Fitness effects on the cognitive function of older elderly individuals and might have a protective effect adults: a meta-analytic study. Psychol Sci. 2003;14(2):125-30.
against dementia, although more studies are necessary 13. Li JX, Hong Y, Chan KM. Tai Chi: physiological characteristics and beneficial effects on health. Br J Sports Med. 2001;35(3):148-56.
Despite the encouraging results of this research, 14. Zhang JG, Ishikawa-Takata K, Yamazaki H, Morita T, Ohta T. The effects of some limitations must be considered. An adequate Tai-Chi-Chuan on physiological function and fear of falling in the less robust randomization of the sample and the cognitive elderly: an intervention study for preventing falls. Arch Gerontol Geriatr. 2006;42(2):107-16.
assessment made by a blind examiner would produce 15. Wang C, Collet JP, Lau J. The effects of Tai Chi on health outcomes in more consistent results. On the other hand, the small patients with chronic conditions: a systematic review. Arch Intern Med. sample size and the short follow-up time, considering that the technique utilized demands a long learning 16. Verhagen AP, Immink M, van der Meulen A, Bierma-Zeinstra SM. The efficacy of period for optimal results, may have negatively Tai Chi Chuan in older adults: a systematic review. Fam Pract. 2004;21(1):107- 17. Li F, Harmer P, Fisher KJ, McAuley E. Tai Chi: improving functional balance and predicting subsequent falls in older persons. Med Sci Sports Exerc. cOnclUSiOn S
18. Thornton EW, Sykes KS, Tang WK. Health benefits of Tai Chi exercise: The findings of the present study suggest that the six- improved balance and blood pressure in middle-aged women. Health Promot month practice of Tai Chi Chuan is related to a significant improvement of the memory and self-perception 19. Chan AS, Ho YC, Cheung MC, Albert MS, Chiu HF, Lam LC. Association (reported complaints) of the memory in elderly women between mind-body and cardiovascular exercises and memory in older adults. J Am Geriatric Soc. 2005;53(10):1754-60.
Further randomized studies with larger samples 20. Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”. A practical method and longer follow-up are needed to test the effects for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-98.
identified in this study and to explore the potential of 21. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adev M, et al. Development Tai Chi Chuan practice in the prevention and treatment and validation of a geriatric depression screening scale: a preliminary report. J of cognitive decline in the elderly population. Psychiatr Res. 1982-1983;17(1):37-49.
Effects of Tai Chi Chuan on cognition of elderly women with mild cognitive impairment 22. Lawton MP. The function assessment of the elderly people. J Am Geriatr Soc. 26. Wilson BA, Cockburn J, Baddeley A. The rivermead behavioral memory test. Cambridge: Thames Valley Test Company; 1991.
23. Katz S, Akpom CA. Index of ADL. Med Care. 1976;14(5 Suppl):116-8.
27. Wechsler D, Wais R. Manual. New York: The Psychological Corporation; 24. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: APA; 1994.
28. Angevaren M, Aufdemkampe G, Verhaar HJ, Aleman A, Vanhees L. Physical activity and enhanced fitness to improve cognitive function in older people 25. Schmand B, Jonker C, Hooijer C, Lindeboom J. Subjective memory complaints without known cognitive impairment. Cochrane Database Syst Rev. may announce dementia. Neurology. 1996;46(1):121-5.

Source: http://www.dragorosso.eu/pdf/22.pdf