In-depth Review: DAPA Trial for Dementia and Physical Activity

This report provides a critical appraisal of the DAPA (Dementia And Physical Activity) trial, a randomized controlled trial investigating the effects of moderate to high-intensity exercise training on individuals with dementia. The review assesses the trial's validity, results, and applicability to local contexts, utilizing a CASP checklist framework. Key aspects examined include the clarity of the research question, randomization procedures, patient accountability, blinding, group similarity at baseline, and equal treatment of groups aside from the experimental intervention. The report analyzes the treatment effect size and precision, considering the impact of the DAPA trial on cognitive function, as measured by ADAS-cog scores, and physical fitness. Ultimately, the review concludes that the DAPA trial's results, indicating a detrimental effect of exercise on cognitive ability, cannot be readily applied locally and that the benefits do not outweigh the harms and costs. The report concludes that the trial suggests physical exercises do not slowdown the cognitive and metacognitive decay in a patient having dementia rather it worsens the situation in the patients.

Running head: A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH
DEMENTIA
A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
Name of the Student:
Name of the University:
Author Note:

1A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
Executive Summary
This report critically appraise the research paper named “Dementia And Physical Activity
(DAPA) trial of moderate to high intensity exercise training for people with dementia:
randomised controlled trial” by Lamb et al., (2018). 494 patients participants with dementia
were part of the trial meeting the inclusion criteria. They were divided into 2:1 randomly with
the larger group was the exercise unit and the smaller group was the usual care unit. They
were followed up in sixth and twelfth month and evaluated based on ADAS-cog score. Their
physical fitness improved marginally. The overall result was not positive for the DAPA test
as it worsened the cognitive ability of the patients with dementia.

2A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
Table of Contents
1. Introduction............................................................................................................................3
2. Discussion..............................................................................................................................3
2.1. Section A : Are the results of the trial valid?..................................................................3
2.1.1. Did the trial address a clearly focused issue?...........................................................3
2.1.2. Was the assignment of patients to treatments randomised.......................................4
2.1.3. Were all of the patients who entered the trial properly accounted for at its
conclusion?.........................................................................................................................4
2.1.4. Were patients, health workers and study personnel ‘blind’ to treatment?...............5
2.1.5. Were the groups similar at the start of the trial........................................................5
2.1.6. Aside from the experimental intervention, were the groups treated equally?..........5
2.2. Section B: What are the results?.....................................................................................6
2.2.1. How large was the treatment effect?........................................................................6
2.2.2. How precise was the estimate of the treatment effect?............................................6
2.3. Section C: Will the results help locally?.........................................................................7
2.3.1. Can the results be applied to the local population, or in your context?...................7
2.3.2. Were all clinically important outcomes considered?...............................................7
2.3.3. Are the benefits worth the harms and costs?............................................................7
3. Conclusion..............................................................................................................................8
References..................................................................................................................................9

3A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
1. Introduction
Dementia and physical activity trial is an experiment conducted on people suffering
from dementia like Alzheimer's disease. Dementia is a general term to describe a cluster of
symptoms related to memory loss, critical thinking ability (Woods et al., 2018). Up to 80% of
the total cases are associated with Alzheimer's disease (Jack et al., 2018). In this report an
article named “Dementia And Physical Activity (DAPA) trial of moderate to high intensity
exercise training for people with dementia: randomised controlled trial” by Lamb et al.,
(2018) is being critically appraised. Effect of DAPA on people suffering from dementia will
be evaluated in this report.
2. Discussion
2.1. Section A : Are the results of the trial valid?
2.1.1. Did the trial address a clearly focused issue?
Yes the trial has focussed and addressed an issue clearly.
Participants in the trial were 77 years old on average. The people with dementia were
selected after being confirmed on their cognitive and metacognitive ability score. The
inclusion criteria was applied where The participants had to walk 3.05 metre without any
external help, sit on a chair (Lamb et al., 2018). The patients were divided into 2 parts. 329
participants were part of the physical activity unit. They were under usual care along with
supervised physical activity of 4 months. Other 165 participants were under usual care only.
494 individuals took part in the trial and all of them had dementia and met the inclusion
criteria. The outcomes of the 2 groups were compared quantitatively. The major outcome that
was considered was the ADAS-cog score of the participants in one year. The people under
physical activity were tested on their physical fitness (Atherton et al., 2016). The level of

4A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
stress was also considered by carer burden in a scale of 0 to 88 where high score indicated
greater level of stress in life (Forbes et al., 2015).
2.1.2. Was the assignment of patients to treatments randomised?
Yes the assignments of patients to treatment was done in random manner.
The allocation of the 494 patients to the treatments were done in the 1:2 ratio. 165
patients were allocated in the usual care section while rest of the 329 patients were in the
physical activity section. As all the participants met the inclusion criteria the allocation was
random. No criteria or specifications were followed to segregate the patients in two groups in
1:2 ratio. However scores from provided questionnaires based on outcome was acquired prior
to the randomisation. The suppression of facts made the trial investigator masked and the
allocation was randomly controlled (Groot et al., 2016).
2.1.3. Were all of the patients who entered the trial properly accounted for at its
conclusion?
Yes all the participants if the trial were properly accounted for at its conclusion.
“Alzheimer’s disease assessment scale – cognitive subscale (ADAS-cog)” was used to
measure the outcome of the trial. All 494 of the participants were evaluated for 12 months.
The trial was not interrupted for any patients. The patients were randomly allocated in the
exercise unit and usual care unit. The patients that participated in the trial were all evaluated
after the completion of the trial and definite result of each and every patient was reflected
with clarity.
2.1.4. Were patients, health workers and study personnel ‘blind’ to treatment?
No the patients, health workers and study personnel were not ‘blind’ to treatment.

5A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
The interviewers including health professionals selected participants based on
inclusion criteria where they were checked for their cognitive and physical ability. Their
gender and ethnicity were also recorded along with their responses in the provided
questionnaire. They were followed up and interviewed in sixth and twelfth month. Patients
and their representatives were aware of the trial procedures and interventions. Their feedback
was collected through questionnaires. Feedback days were held where the patients discussed,
questioned and expressed their opinions on the protocols and methods in the trial.
2.1.5. Were the groups similar at the start of the trial
Yes groups were similar at the start of the trial.
As inclusion criteria was fixed to selected candidates were similar and they were
grouped randomly. Though size of the groups were in the ratio of 1:2 , the composition was
homogeneous. The people with dementia were selected after being confirmed on their
cognitive and metacognitive ability score (sMMSE score of more than 10). Participants in the
trial were 77 years old on average. Their physical ability was also tested before the inclusion
in the trial. Patients with severe mental and physical illness were excluded. So the
participants at the start of the trial were in a similar physical and mental situation.
2.1.6. Aside from the experimental intervention, were the groups treated equally?
Yes except the intervention process the two groups were treated equally.
The usual care unit did not have any strengthening training or aerobic exercises. The
exercise unit involved supervised physical and aerobic exercises in the presence of
professionals like physiotherapist in addition to their usual care (Cheng, 2016). Except this
individuals of the two groups were treated equally. After the randomisation they were
followed up at six and twelve months of interval. Interviews were taken of the patients to

6A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
ensure quality assurance. So the DAPA trial had these two groups with intervention
difference to measure the difference of effect (Brasure et al., 2018).
2.2. Section B: What are the results?
2.2.1. How large was the treatment effect?
The treatment effect was detrimental to the patients in terms of cognitive and
metacognitive ability.
The patients were measured based on their allocated group at the end of 12 months.
The average ADAS-cog score was 25.2 in the exercise unit with standard deviation of 12.3
while it was 23.8 with standard deviation of 10.4 in the usual care unit. The cognitive and
metacognitive awareness level decreased more in the exercise unit who underwent aerobic
exercises and supervised physical training (Brown et al., 2015). Their metacognitive
impairment got worse after the trial. Though the physical ability and fitness improved in the
exercising unit.
2.2.2. How precise was the estimate of the treatment effect?
The estimate of the treatment effect was precise as the 95% confidence intervals in
every subgroup were consistent with the overall finding.
Effect of DAPA trial on people with mild to moderate dementia was the objective of
the study and it was found that the exercise affects the metacognitive ability of the
individuals suffering from Dementia. The effect of impairment does not slow down with the
physical training but it gets worse. Although the physical fitness went up in the individuals
under the intervention of strength training and exercise.

7A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
2.3. Section C: Will the results help locally?
2.3.1. Can the results be applied to the local population, or in your context?
No the results can not be applied to the local population.
The effects of DAPA trial on the dementia patients were mostly negative and the
condition they had further deteriorated afterwards. The cognitive and metacognitive ability of
the participants was decreased after they had exercise and strength training sessions. So
physical exercise is not at all recommended to the patients with dementia.
2.3.2. Were all clinically important outcomes considered?
No all clinically important outcomes were not considered.
The adverse effects of moderate to high intensity training on patients with dementia
was not considered before the DAPA trial was applied on the patients. The trial and the
evaluation of results also reflected that there were no positive effect on the patients after the
supervised physical activity and exercise. Although physical fitness of those participants
improved marginally their cognitive ability decreased considerably. Alternative forms of
exercise like psychomotor exercises based on neurology which can improve physical ability
can be implemented in future (Lamb et al., 2018).
2.3.3. Are the benefits worth the harms and costs?
No the benefit does not worth the harm and cost.
The DAPA trial had no positive effect on the patients with dementia. The results
reflected that physical exercise is not at all recommended to improve cognitive impairment in
individuals suffering from dementia. Application of this method degrades their condition
further. Some improvement was seen in the physical ability of the patients under the physical
activity unit who went through exercise regimes. The detrimental effects caused by it were
greater in enormity and magnitude.

8A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
3. Conclusion
The purpose of this report is to critically appraise the research article named by Lamb
et al., (2018). The result reflected that the cognitive awareness went down more in the
exercise unit compared to the usual care unit. Though the effect of physical and aerobic
exercises was positive on physical ability and fitness of the participants the effect on
cognitive ability was detrimental (Telenius, Engedal & Bergland, 2015). The DAPA trial
deteriorated the cognitive awareness level of the patients having moderate level of dementia.
The outcome of the test was not positive and indicated physical exercises do not slowdown
the cognitive and metacognitive decay in a patient having dementia rather it worsens the
situation in the patients.

9A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
References
Atherton, N., Bridle, C., Brown, D., Collins, H., Dosanjh, S., Griffiths, F., ... & McShane, R.
(2016). Dementia and Physical Activity (DAPA)-an exercise intervention to improve
cognition in people with mild to moderate dementia: study protocol for a randomized
controlled trial. Trials, 17(1), 165.
Brasure, M., Desai, P., Davila, H., Nelson, V. A., Calvert, C., Jutkowitz, E., ... & McCarten,
J. R. (2018). Physical activity interventions in preventing cognitive decline and
Alzheimer-type dementia: a systematic review. Annals of internal medicine, 168(1),
30-38.
Brown, D., Spanjers, K., Atherton, N., Lowe, J., Stonehewer, L., Bridle, C., ... & Lamb, S. E.
(2015). Development of an exercise intervention to improve cognition in people with
mild to moderate dementia: Dementia And Physical Activity (DAPA) Trial,
registration ISRCTN32612072. Physiotherapy, 101(2), 126-134.
Cheng, S. T. (2016). Cognitive reserve and the prevention of dementia: the role of physical
and cognitive activities. Current psychiatry reports, 18(9), 85.
Forbes, D., Forbes, S. C., Blake, C. M., Thiessen, E. J., & Forbes, S. (2015). Exercise
programs for people with dementia. Cochrane Database of Systematic Reviews, (4).
Groot, C., Hooghiemstra, A. M., Raijmakers, P. G. H. M., Van Berckel, B. N. M., Scheltens,
P., Scherder, E. J. A., ... & Ossenkoppele, R. (2016). The effect of physical activity on
cognitive function in patients with dementia: a meta-analysis of randomized control
trials. Ageing research reviews, 25, 13-23.

10A CRITICAL REVIEW OF DAPA TRIAL FOR PEOPLE WITH DEMENTIA
Jack, C. R., Bennett, D. A., Blennow, K., Carrillo, M. C., Dunn, B., Haeberlein, S. B., ... &
Liu, E. (2018). NIA-AA Research Framework: Toward a biological definition of
Alzheimer's disease. Alzheimer's & Dementia, 14(4), 535-562.
Lamb, S. E., Sheehan, B., Atherton, N., Nichols, V., Collins, H., Mistry, D., ... & Lall, R.
(2018). Dementia And Physical Activity (DAPA) trial of moderate to high intensity
exercise training for people with dementia: randomised controlled trial. bmj, 361,
k1675.
Telenius, E. W., Engedal, K., & Bergland, A. (2015). Effect of a high-intensity exercise
program on physical function and mental health in nursing home residents with
dementia: an assessor blinded randomized controlled trial. PloS one, 10(5), e0126102.
Woods, B., O'Philbin, L., Farrell, E. M., Spector, A. E., & Orrell, M. (2018). Reminiscence
therapy for dementia. Cochrane database of systematic reviews, (3).