Neuropsychiatric symptoms also referred as to 'BPSD' (Behavioral and Psychological Symptoms of Dementia), are now considered as a major component

of the dementia syndrome and are as clinically significant as disorders of cognition BPSD are present from the early stages of the disease, constitute a mar!er of disease progression, are responsi"le for much of the suffering of "oth patients and caregivers, and strongly determine the care provided to the patient and his lifestyle, "oth in institutions for the elderly and in the home (#, $) %he general approach to BPSD includes the following& to assess causes and conse'uences( to correct visual and hearing impairment( and to loo! for physical causes of BPSD such as infection or pain %here is now a "road consensus insisting that patient care should not "e limited to pharmacological treatment "ut should also include non)pharmacological approaches %hese therapies are widely applied in day)care centers, day hospitals, physiotherapy departments, memory centers and speech therapy practices, amounting to a not)inconsidera"le economic cost %here are a wide variety of non) pharmacological therapies open to patients suffering from dementia Some of these therapies adopt a psychosocial approach while others "elong to the field of psychotherapy (*) Still more are "ased on physical or sensory stimulation (+) But of these techni'ues see! to optimi,e patient care "y targeting, according to the therapy applied, different aspects of the disease such as cognitive a"ilities, dependence, mood and "ehavioural disorders or patient well)"eing %hese techni'ues are e-tremely varied .ver the last twenty years, a large num"er of articles have "een pu"lished illustrating the "enefits of these therapies on /l,heimer's disease (/D) /ccording to the studies, reported improvements were o"served in different measurements %hese improvements were reflected in either a reduction of the depressive symptomatology, a slower decline of cognitive performances, a continued autonomy in activities of daily living (/D0), or an improvement in 'uality of life (1) %hese results are encouraging inasmuch as they suggest that a glo"al and multi)disciplinary approach (2, 3) of the disease, com"ining pharmacological and non)pharmacological treatments, is li!ely to attenuate some symptoms and to contri"ute to a certain well"eing for the patient Nevertheless, it is noteworthy that the vast majority of these results were derived from studies evaluating nonpharmacological treatments whose methodology leaves much to "e desired, their main wea!nesses "eing the a"sence of a control group, the a"sence of randomi,ation, the a"sence of a procedure for evaluating in "lind fashion and insufficient sample si,es (for review see 4ochrane 0i"rary (5)#+)) / total of #,2*$ studies were identified with regard to BPSD specifically, of which #2$ satisfied the inclusion criteria for the review of 0ivingston et al ($661) (#1) 7esults showed that specific types of psycho)education for caregivers a"out managing BPSD were effective treatments whose "enefits lasted for months, "ut other caregiver interventions were not 4ognitive stimulation appears to have lasting effectiveness for the management of BPSD %he authors concluded that lac! of evidence regarding other therapies is not evidence of lac! of efficacy /ccording to /P/ Practice guidelines for the treatment of /D and other dementia (#2), there is limited evidence from clinical trials that general psychosocial interventions, stimulation)oriented treatments, such as recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of ma-imi,ing pleasura"le activities for patients, improve "ehavior and mood, or support their use as part of the care of patients /s we have already said there are many non pharmacological techni'ues and starting from the results of several studies into preventative therapies (for review see 8edr,iews!i et al , $663 (#3)) there is also a growing interest in therapeutic programs which include physical activities Physical activity and normal aging Physical activity can "e considered either as a common element of /D0, such as household chores and wal!ing, or can "e considered as physical training (e g soliciting muscle power, "alance or physical force through activities such as jogging, aero"ics, and endurance training) %hese two categories can lead to different types of efficacy criteria

%a"le # summari,es the major pu"lished studies including information on neuropsychiatrie symptoms and other areas Physical activity is associated with decreased mor"idity in many chronic diseases including cardiovascular disease (#5, #9) or cancer ($6, $#) :or e-ample, 4hen et al ($665) ($$) have shown that practicing %ai)4hi for 16 minutes, * times a wee! for 2 months, improved the overall health of elderly men, especially their "lood pressure, strength and "ody fle-i"ility Studies that have focused on the relationship "etween physical fitness and cognitive aging have shown that people who maintain a good overall level of physical health have a less important cognitive decline relative to their age ($*,$+) /ccordingly, ;euve et al ($66+) ($1) and <an =elder et al ($66+) ($2) demonstrated that physical activities such as wal!ing offset cognitive decline in elderly patients and may improve cognitive performance
%a"le # >ffect of physical activity in normal aging and dementia

.ther studies focused on BPSD and demonstrated the positive impact of physical activity especially on depression ($3, $5) >ighteen studies have "een included in the metaanalysis of 4olcom"e et al ($66*) ($9) %hey tend to show a "eneficial effect of physical e-ercise on "oth cognition (especially e-ecutive functions) and "ehavioral distur"ances in normal elderly people (see also ?ramer et al (#999) (*6)) .ther studies found that e-ercise programs can improve functioning in frail nursing home residents and may "e an important and potent protective factor against /D0 decline (*#) Physical activity and dementia >ven if the lin! is not always demonstrated, it seems that physical e-ercise could "e a preventative factor of dementia ((*$)*1)) and that it should delay its onset :or e-ample, 0arson et al ($662) (*$) have shown that regular physical activity was associated with a reduced ris! of developing /D 7esults o"tained "y /""ott et al ($66+) (*2) also suggest that a simple activity such as wal!ing could have a preventative effect against the disease Several other studies (*3) confirm these findings /s every"ody !nows, dementia is one of the most common diseases associated with aging %his major pu"lic health pro"lem underscores the need for treatment and prevention strategies @owever, research into patients with dementia is limited and mainly concerns the effects of e-ercise on functional mo"ility (*5,*9) or sleep (+6) /""ott et al ($66+) (*2) demonstrated the "enefits of wal!ing, which had a positive impact on /D0 and physical performance, as well as on dia"etes Studies on patients suffering specifically from /D show that e-ercise programs may yield "enefits in coping with falls (+#), malnutrition (+$), cognitive functioning or in general health / review of the literature was recently conducted "y 8edr,iews!i et al (#3) on the associations "etween physical activity, cognition and physical functioning in /D patients 7unning, wal!ing, swimming, aero"ics and stretching, resulted in an improvement in cognitive functioning Some prospective studies such as 0aurin et al ($66#) (*+) found that physical e-ercise could decrease "oth cognitive impairment in elderly people and in demented patients :urthermore, Palleschi et al (#992) (+*) have, in turn, tested the effect of the practice of physical e-ercise (such as $6 minutes of e-ercise on a stationary "icycle, * times a wee! for * months) %he results evidenced a significant improvement in cognitive functions Some other studies focused on the management of BPSD :arina et al ($66$) (++) demonstrated the positive impact of physical e-ercise programs on eating disorders .la,aran et al ($66+) (+1) showed an improvement in depressive symptoms An addition to those physical e-ercise programs, other studies focused on softer interventions such as rela-ation, massage or yoga :or e-ample, Snyder et al (#991) (+2) and Sansone et al ($666) (+3) found that hand massage or therapeutic touch administered "efore formal care activities reduced the fre'uency and the intensity of agitated "ehavior in demented patients

:inally, 7olland et al ($663) (+5) demonstrated that a glo"al program of physical e-ercise (e g aero"ics, wal!ing, stretching) followed for twelve months led to an improvement of /D0 in patients with /D Bulti)domain interventions /long with these programs of physical e-ercise proposed in isolation, there are more glo"al non) pharmacologic therapies including multi)domains, com"ining physical e-ercise with other types of interventions (cognitive stimulation, occupational therapy, mentoring of caregivers) Bulti)domain interventions are capital "ecause most important studies on nonpharmacological treatment for BPSD include physical e-ercise and other strategies /lessi et al (#999) (+6) associated intensive physical activity during the day with a night)time program and suggested that such intervention improves sleep and decreases agitation in elderly people living in nursing homes :a"re et al ($66$) (+9) showed that the association "etween cognitive stimulation and practicing aero"ics ($ sessions each wee! for $ months) enhanced more cognitive functions, especially memory, than any of the interventions ta!en in isolation %eri et al ($66*) (16) have created a method which com"ines physical e-ercise for the patient (such as aero"ics or stretching) and a guide for the informal caregiver regarding the management of BPSD (e g information on dementia and "ehavioral disorders, identification and modification of "ehavioral distur"ances) %hey demonstrated a positive impact of their intervention with a significant improvement in physical condition and depression, a decrease in the num"er of institutionali,ations due to BPSD, and a "etter adherence "y informal caregivers 4onclusion Physical e-ercise programs proposed in isolation or in com"ination with other types of interventions have proved their effectiveness preserving a good overall level of physical and mental health An this way, it seems that physical e-ercise could "e a preventative factor of dementia and could help to prevent its onset %here is also evidence that physical activity is useful in the care of demented patients having an impact on their "ehaviors Andeed, physical activity improves overall physical health, decreases the ris!s of mor"idity of chronic diseases, and of falls At also reduces the impairment of /D0, and sustains and stimulates cognitive functions /vaila"le studies underline the positive effect of physical activity, most particularly when it is a component of multi)domain interventions, on depressive symptoms At is therefore important to promote research in this area in order to carry out the evaluation of the usefulness of nonpharmacological therapies, especially in the case of /D and related syndromes, and to "etter understand their mechanisms in order to develop and propose "etter adapted and glo"al care
[Sidebar] 7eceived Bay 9, $665 /ccepted for pu"lication Bay #9, $665

C7eferenceD

<iew reference page with lin!s 7eferences # Benoit B , /r"us 4 , Blanchard : , 4amus < , 4erase < , 4lEment 8)P et al 4oncertation professionnelle sur le traitement de l'agitation, de l'agressivitE, de l'opposition et des trou"les psychoti'ues dans les dEmences 0a 7evue de =Eriatrie ($662), %ome *#, NF9, #)3 $ 0y!etsos 4=, 0ofe, ., 8ones B et al Prevalence of neuropsychiatrie symptoms in dementia and mild cognitive impairment& 7esults from the cardiovascular health study 8/B/ ($66$), $55, #+31)#+5* * Stuss D% , <an 7ee!um 7 , Burphy ?8 Differentiation of states and causes of apathy An Borod 8 (>d)

%he neuropsychogy of emotion NewGor!, .-ford Hniversity Press ($666), *+6)*#+ + <er!ai! 7 , <an ;eert 84 , :ranc!e /0 %he effects of psychosocial methods n depressed, aggressive ans apathetic "ehaviours of people with dementia& a systematic review Ant 8 =eriats Psychiatry ($661), $6( *6#)*#+ 1 Boccardi, B , :risoni, = B ($661) 4ognitive reha"ilitation for severe dementia & 4ritical o"servations for "etter use of e-citing !nowledge Bechanisms of /ging and Development 2 <espa, / , =ori, = , Spa,,afumo, 0 ($66#) >valuation of non)pharmacologiecal intervention on antisocial "ehavior in patients suffering from /l,heimer's disease in a day care center /rchives of =erontology and =eriatrics *+, #)5 3 ;enish, > , Sto!er, / , Bourrellis, 4 , Pas'uet, 4 , =authier, > , 4orcos, > , Banchi, B % , De 7otrou, 8 , 7igaud, / S ($661) BEthode de prise en charge glo"ale non mEdicamenteuse des patients dEments institutionnalisEs 7evue Neurologi'ue, #2#, * $96)$95 5 4hung 84, 0ai 4?, 4hung PB, :rench @P Snoe,elen for dementia 4ochrane Data"ase Syst 7ev $66$, (+)&4D66*#1$ 9 Neal B, Briggs B <alidation therapy for dementia 4ochrane Data"ase Syst 7ev $66*((*)& 4D66#*9+ #6 Spector /, .rrell B, Davies S, ;oods B 7eality orientation for dementia 4ochrane Data"ase Syst 7ev $666((+)&4D66###9 ## %horgrimsen 0, Spector /, ;iles /, .rrell B /roma therapy for dementia 4ochrane Data"ase Syst 7ev $66*((*)&4D66*#16 #$ <in! /4, Bir!s 8S, Bruinsma BS, Scholten 78 Busic therapy for people with dementia 4ochrane Data"ase Syst 7ev $66+((*)&4D66*+33 #* 4lare 0, ;oods 7%, Boni, 4oo! >D, .rrell B, Spector / 4ognitive reha"ilitation and cognitive training for early)stage /l,heimer's disease and vascular dementia 4ochrane Data"ase Syst 7ev $66*( (+)&4D66*$26 #+ ;oods B, Spector /, 8ones 4, .rrell B, Davies S 7eminiscence therapy for dementia 4ochrane Data"ase Syst 7ev $661(($)&4D66##$6 #1 0ivingston = , 8ohnston ? , ?atona 4 , Paton 8 , 0y!etsos, 4 = Systematic review of psychological approaches to the management of neuropsychiatrie symptoms of dementia /m 8 Psychiatry ($661), #2$, #992 ) $6$# #2 /P/ & Practice guideline for the treatment of patients with /l,heimer's Disease and .ther Dementias /merican 8ournal of Psychiatry ($663), #2+ (#$) Suppl S& 1)12 #3 8edr,iews!i ? B , 0ee < B G , %rojanows!i 8 I Physical /ctivity and 4ognitive health /l,heimer's and Dementia ($663), *,95)#65 #5 4olcom"e S 8 , ?ramer / : , >ric!son ? A , Scalf P , Bc/uley > , 4ohen N 8 et al 4ardiovascular fitness, cortical plasticity, and aging PN/S ($66+), #6# **#2)**$# #9 :ried 0 P , ?ronmal 7 / , Newman / B , BiAd D > , Bittelmar! B B , Pola! 8 : , et al 7is! factors for 1) years mortality in older adultes & the cardiovascular @ealth Study 8/B/ (#995), #995, 151)19$ $6 Blair S N , 4heng G , @older 8 S As physical activity or physical fitness more important in defining health "enefits J Bed Sci Sports >-erc ($66#), ** *39)*99 $# Bean 8 : , <ora / , :rontera ; 7 , Benefits of e-ercise for community)dwelling older adults /rch Phys Bed 7eha"il ($66+), 51 *#)+$ $$ 4hen ?)B, 0in 8)N , 0in @)S , ;u @)4 , 4hen ;)% , 0i 4)@ , 0o S ? %he effects of a Simplified %ai)4hi >-ercise Program (S%>P) on the physical health of older adults living in long)term care facilities& / single group design with multiple time points Anternational 8ournal of Nursing Studies ($665), +1,16#)$63 $* ?ramer / : , >ric!son ? A 4apitali,ing on cortical plasticity& influence of physical activity on cognition and "rain function %rends 4ogn Sei ($663), ## (5), *+$)*+5 $+ ?rKmer / : , ;illis S 4ognitive plasticity and aging An B 7oss (>d) Psychology of 0earning and Botivation, vol +*, ($66*) N G & /cademic Press $1 ;euve 8 , ?ang 8 @ , Banson 8 > , Breteler B B B , ;are 8 @ , =rodstein : Physical activity, including wal!ing, and cognitive function in older women 8/B/ ($66+), $9$, #+1+)#+2# $2 <an =elder B B , %ijhuis B / 7 , ?almijn S , =iampaoli S , Nissien / , ?rom"out D Physical activity in relation to cognitive decline in elderly men& the fine study Neurology ($66+), 2* $*#2)$*$# $3 Bar"our, ? / , Blumental 8 / , >-ercise training and depression in older adults Neuro"iom /ging ($661), $2 ##9)#$* $5 %aylor /@, 4a"le N%, :aul!ner = et al Physical activity and older adults& / review of health "enefits and the effectiveness of interventions 8 Sports Sci ($66+), $$, 36*)3$1 $9 4olcom"e, S , ?ramer, / : :itness effects on the cognitive function of older adults& a meta)analytic study Psychological Sciences ($66*), #+,#$1)#*6 *6 ?ramer / : , @ahn S , 4ohen N 8 , Banich B % , Bc/uley > , @arisson 4 7 /ging, fitness and neurocognitive function Nature (#999), +66,+#5)+#9 *# 0a,ows!i D/, >cclestone N/, Byers /B et al / randomi,ed outcome evaluation of group e-ercise programs in long)term care institutions 8 =erontol / Biol Sci Bed Sci (#999), 1+, 2$#)2$5

*$ 0arson > B , ;ang 0 , Bowen 8 D , Bc4ormic! ; 4 , %eri 0 , 4rane P , et al >-ercise is associated with reduced ris! for incidence dementia among persons 21 years of age and older /nn Antern ($662), #++, 3*) 5# ** 7ovio S , ?arehold A , @el!ala > 0 , <iitanene B , ;in"lad B , %uomileto 8 , et al 0eisure)time physical activity at midlife and the ris! of dementia and /l,heimer's disease 0ancet Neurol ($661), +, 361)3## *+ 0aurin D , <erreault 7 , 0indsay 8 BacPherson ?(, 7oc!wood ? Physical activity and ris! of cognitive impairment and dementia in elderly persons /rch Neurol ($66#), 15, +95)16+ *1 0indsay 8 , 0aurin D , <erreault 7 , @e"ert 7 , @elliwell B , @ill 8 B >t al 7is! factors for /l,heimer's disease & a prospective analysis from the 4anadian Study of @ealth and /ging /m 8 >pidemiol ($66$), #12, ++1)+1* *2 /""ott 7 D , ;hite 0 7 , 7oss = ; ;al!ing and dementia in physically capa"le elderly men /44 4urrent 8ournal 7eview ($66+), <ol #*, Assue #$ #+ *3 %anne 8 @ ;al!ing protects elderly people from dementia, studies show BBA, $66+ *5 Bac7ae, P . , /splund 0 / , Schnelle, 8 : , .uslander, 8 = , /"rahamse, / , Borris, 4 / wal!ing program for nursing home residents& effects on wal! endurance, physical activity, mo"ility and 'uality of life 8ournal of /merican =eriatr Soc (#992) ++, #31)#56 *9 %eri, 0 , Bc4urry, S B , Buchner, D B , 0ogsdon, 7 = , 0a4roi-, / L , ?u!ull, ; / , Barlow, ; > , 0arson, > B >-ercise and activity level in /l,heimer's disease& a potential treatment focus 8ournal 7eha"ilitation 7es Dev (#995) *1, +##)+#9 +6 /lessi, 4 / , Goon, > 8 , Schnelle, 8 : , /l Samarrai, N 7 , M 4ruise P / / randomi,ed trial of a com"ined physical activity and environmental intervention in nursing home residents& do sleep and agitation improveJ 8ournal of /merican =eriatric Society (#999), +3,35+)39# +# Buchner DB, 0arson >B :alls and fractures in patients with /l,heimer)type dementia 8/B/ (#953), $1, #+9$)#+91 +$ ;hite @, Pieper 4, Schmader ? et al / longitudinal analysis of weight change in /l,heimer's disease 8 /m =eriatr Soc (#993), +1, 1*#)1*$ +* Palleschi 0 , <ena : , De=ennaro > , Adone = , Sottosanti = , =ianni ; , Barigliano < >ffect of aero"ic training on the cognitive performance of elderly patients with senile dementia of /l,heimer type /rchives of =erontology and =eriatrics (#992), 1, +3)16 ++ :arina, > , :ioravanti, 7 , 4hiavari, 0 , Am"ornone, > , /l"eroni, B , Pomati, S , Pinardi, = , Pignatti, 7 , M Bariani, 4 4omparing two programs of cognitive training in /l,heimer's disease& a pilot study /cta Neurologia Scandinavica, ($66$), #61, *21)*3# +1 .la,aran 8 , Buni, 7 , 7eis"erg B , Pena)4asanova 8 , Del Ser % , 4ru,)8entoft / 8 , Serrano, P , Navarro, > , =arcNa de la 7ocha, B 0 , :ran!, / , =aliano, B , :ernOnde,)Bullido, G , Serra, / , =on,Ole,) Salvador, B % M Seville, 4 Benefits of cognitive)motor intervention in B4A and mild to moderate /l,heimer disease Neurology ($66+), 2*, $*+5)$*1* +2 Snyder B , >gan > 4 , Burns ? 7 >fficacy of @and Bassage in Decreasing /gitation Behaviors /ssociated with 4are /ctivities in Persons with Dementia =eriatric Nursing (#991), 26)2* +3 Sansone P , Schmitt 0 Providing %ender %ouch Bassage to >lderly Nursing @ome 7esidents& a Demonstration Project =eriatric Nursing ($666), vol $#, NF2, *6*6)*65 +5 7olland G, Pillard :, ?lapous,c,a! /, 7eynish >, %homas D, /ndrieu S, 7iviPre D, <ellas B >-ercise program for nursing home residents with /l,heimer's disease& a #year randomi,ed, controlled trial 8 /m =eriatr Soc ($663), 11($) #15)#21 +9 :a"re 4 , 4hamari ? , Bucci P , Basse)Biron 8 , Prefaut 4 Amprovement of cognitive function "y mental and Q or individualised aero"ic training in healthy elderly su"jects Ant 8 Sports Bed ($66$), $*,+#1)+$# 16 %eri 0 , =i""ons 0 > , Bc4urry S B , 0ogston 7 = , Buchner D B , Barlow ; > , ?u!ull ; / , 0a4roi/ L , Bc4ormic! ; , 0arson B >-ercice Plus Behavioral Banagement in Patients with /l,heimer Disease & a 7andomi,ed 4ontrolled %rial /merican Bedical /ssociation ($66*), vol $96, NF#1, $6#1)$6$$