Tips for Progressive Resistance Training for Patients with Dementia

By Alex Germano, PT, DPT, GCS, Vestibular Rehabilitation Specialist (AIB‑VR)
Physical Therapist, Maryland

People with dementia and cognitive impairment are often overlooked when applying the principles of a progressive resistance training program. There are many true barriers to performing traditional strength training exercises and increasing maximum strength can be challenging within this population. These include difficulty instructing the patient on exercises, worry over safety when applying external load to the patient, and a high level of variability that makes consistent progression challenging. 

Progressive resistance training is a type of exercise program where a participant moves their body against a weight or external load, for some, this could look like moving their body weight. The progressive feature of this type of training is the most critical. During this type of training, weights, repetitions, sets, speed and rest can all be progressed to continue to challenge the participant and further increase muscle size and strength. Currently, the ACSM recommends older adults participate in strength training 2 or more days per week for all major muscle groups for 8-12 repetitions over 1-3 sets. This prescription can be helpful for mitigating the age-related loss of type II muscle fibers that older adults are susceptible to. 

Patients with dementia or other cognitive impairments benefit from progressive resistance training protocols because they can have positive impacts on cognition, improve ADL and IADL quality, and reduce caregiver burden. Treatment plans for patients with dementia should always include some type of progressive resistance training. 

This population comes with a variety of barriers to implementing this training, which will be discussed with appropriate solutions below.

1. Assess Cognitive Function Before PRT

Before applying a traditional PRT program, a clinician needs to have a good understanding of a patient’s cognitive baseline. By using thoughtful assessments, such as the Global Deterioration Scale, one can better understand a patient’s capacity for learning, following directions, and cueing techniques. 

Due to the added cognitive barriers that are present in this population, occupational therapists and speech-language pathologists will be a critical part of the treatment team to optimize cognitive function.

2. Set Up the PRT Session

When programming exercise for a person with dementia or cognitive impairment, consider utilizing blocked practice versus random practice. Early learners and patients who have cognitive impairment benefit from learning one exercise at a time. As someone becomes more proficient in a movement and demonstrates some carryover of the activity, it could be appropriate to transition to random practice where the person performs the initial exercise interspersed between other exercises. 

How to Make Sessions Meaningful for Patients with Dementia

It may also be helpful to select activities that are meaningful to the patient. For example, a patient may be confused or non-participatory when performing a traditional exercise like the deadlift but may be more agreeable and engaged with a functional lifting activity like picking up objects in the garden. By keeping the exercises fun and functional, clinicians can harness the power of procedural memory to achieve movement and participation in a PRT program. 

Gamification can also make exercises more interesting and fun for this population. However, gamification is often randomly applied without progressive overload. If using games to help improve patient participation, make sure to write down and progress the length of time the patient is performing the game, monitor rest intervals, and dose proper intensity (higher RPE).

Using Appropriate Applications

Also, consider the application of load for this population. Many patients with inattention and cognitive decline may find it unsafe to hold traditional dumbbells and kettlebells. To avoid this concern, clinicians can have the patient “wear” the weight by means of a weight vest or strapped weights to a gait/transfer belt. The patient may also more safely use resistance bands and suction toys (i.e. Squigz) to elicit movement against an external force. 

Consider using “weights” that are familiar to the patient, like grocery bags filled with items, laundry baskets loaded with books or packages like dog food. This may improve participation in an exercise program. When using non-traditional weights, it will be critical to write down as many details as possible to get an estimated weight of the item. This will be important when progressing the activity week to week. 

3. Factor in Variability

Unfortunately, patients with dementia often experience day-to-day variability. One day they may be able to clearly follow instructions, they are safe, and they can perform traditional exercises. The next day, they may be struggling with physical or cognitive abilities and the exercises that were once easily performed are now too complex and challenging for the patient. 

With this variability, many clinicians decide to abandon the original plan for progressive resistance training and instead look towards gamification or functional activities to get the patient moving. However, when clinicians continually abandon the plan for progressive overload, the patient will see very limited progress. 

A more helpful approach to variability comes in the form of scaling. Clinicians need to be prepared to scale each movement either upwards or downwards based on the patient’s ability each and every day. Clinicians should be able to provide a patient with a safe, but challenging, alternative for a movement while trying to maintain the intention of the original movement.

Here’s an example. Let’s say a clinician is performing deadlifts once a week and progressing weights each week with their patient, Dan. Dan had a bad night of sleep and was very unsafe in standing during their appointment. Instead of abandoning the deadlift, the clinician decides to modify the deadlift to a sitting position with the same amount of load. In doing so, the clinician in this scenario is able to maintain the original stimulus of the movement, while making it safe for Dan to perform based on his abilities on that particular day. 

4. Consider Appropriate Cueing Strategies

Cueing and explaining movement is often an area of growth for many clinicians. Talking quickly, using too many words, and talking during movement can be big barriers to movement in patients with dementia. Consider explaining movement as succinctly as possible. It can sound militant, but using fewer words is often much easier for patients with dementia to process. 

The timing of cues will also be important. Terminal feedback, or feedback after the patient has completed the exercise, should be utilized rather than concurrent feedback (feedback during movement). Patients with dementia may become confused with or ignore concurrent feedback. 

Finally, time for processing should be given after a cue is given. Up to ninety seconds may be needed for some patients! 

Keep These Tips in Mind When Introducing PRT to Patients with Dementia

Older adults with dementia and mild cognitive impairment benefit from the use of progressive resistance training, but it can be challenging to perform this type of program due to safety concerns, variability, and difficulty implementing cues. With the correct approach, these programs can become feasible for patients and meaningful outcomes can be achieved.