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The main purposes of this thesis were to evaluate a high-intensity functional weight-bearing exercise pro­gramme, regarding its applicability (attendance, achieved intensity, adverse events) as well as its effect on physical functions and activities of daily living (ADL) among older people living in residential care facilities, with a special focus on people with dementia. Furthermore, a main purpose was to systematically review the applicability and effects of physical exercise on physical functions, cognitive functions, and ADL among people with dementia.

A high-intensity functional weight-bearing exercise programme that includes lower-limb strength and balance exercises in standing and walking, was evaluated in a randomised controlled trial among 191 older people, dependent in ADL, living in residential care facilities, and with a Mini-Mental State Examination (MMSE) score of ten or more. One hundred (52.4%) of the participants had dementia. Participants were randomised to an exercise programme or a control activity, consisting of 29 supervised sessions over 3 months, as well as to an intake of a protein-enriched energy supplement or a placebo drink immediately after each session. The effect on physical functions was evaluated using the Berg Balance Scale, usual and maximum gait speed, and one-repetition maximum in a leg press machine measuring lower-limb strength. The effect on ADL was evaluated using the Barthel Index. These outcome measures were followed up at 3 and 6 months by blinded assessors and analysed using the intention-to-treat principle.

The evaluation of the applicability of the high-intensity functional weight-bearing exercise programme showed that there was a high rate of attendance, a relatively high achieved intensity in the exercises, and all except two adverse events were assessed as minor or temporary and none led to manifest injury or disease. No statistically significant differences were observed in applicability when comparing participants with dementia and participants without dementia. In addition, the applicability of the programme was not associated with the participants’ cognitive function. Significant long-term effects of the exercise programme were seen regarding functional balance, gait ability and lower-limb strength in comparison with the control activity. The intake of the protein-enriched energy supplement did not increase the effect of the training. Age, sex, depression, dementia disorder, nutritional status, and level of functional balance capacity did not influence the effect on functional balance of the high-intensity functional weight-bearing exercise programme. There were no significant differences between the groups regarding overall ADL performance. Analyses for each item revealed that a significantly smaller proportion of participants in the exercise group had deteriorated regarding indoor mobility at 3 and 6 months. For people with dementia, there was a significant difference in overall ADL performance in favour of the exercise group at 3 months, but not at 6 months.

In a systematic review, randomised controlled trials, evaluating the effects of physical exercise among people with dementia, were identified according to pre-defined inclusion criteria. Two reviewers independently extracted predetermined data and assessed methodological quality. Ten studies were included in the review and the majority of the participants were older people with Alzheimer’s disease living in residential care facilities. Four studies reached “moderate” methodological quality and six “low”. The results showed that among older people with Alzheimer’s disease in residential care facilities, combined functional weight-bearing exercise over 12 months at an intended moderate intensity seems applicable for use regarding attendance and adverse events and there is some evidence that the exercise improves walking performance and reduces ADL decline. Furthermore, there is some evidence that walking exercise over 16 weeks performed individually, where the participant walks as far as possible during the session, reduces decline in walking performance, but adverse events need to be evaluated.

In conclusion, among older people who are dependent in ADL, living in residential care facilities, and have an MMSE score of 10 or more, a high-intensity functional weight-bearing exercise programme is applicable for use and has positive long-term effects on functional balance, gait ability, and lower-limb strength and seems to reduce ADL decline related to indoor mobility. An intake of a protein-enriched energy supplement immediately after the exercise does not appear to increase the effect of the training. In people with dementia, the exercise programme may prevent decline in overall ADL performance, but continuous training may be needed to maintain that effect. The positive results regarding applicability and effects of combined functional weight-bearing exercise among people with dementia is confirmed when the scientific literature is systematically reviewed. It seems to be important that exercise interventions among people with dementia last for at least a few months and that the exercises are task-specific and intended to challenge the individual’s physical capacity. Whether physical exercise can improve cognitive functions among people with dementia remains unclear. There is a need for more exercise studies of high methodological quality among people with dementia disorders.

The main purpose of this thesis was to study, whether drinkable yoghurt enriched with probiotic bacteria could have any effect on constipation and body weight (BW) among older people with dementia. Further, it concerns poor nutritional status among older people with physical and cognitive impairments and its relationship with factors commonly occur in older people living in residential care facilities. It also discusses how body composition changes with ageing and the associations between changes in muscle mass and functional balance after a high-intensity weight-bearing exercise program (the HIFE program) and the ingestion of an additional milk-based protein-enriched energy supplement.

A six-month feasibility study that included a probiotic drink was performed among 15 old people who were living in special units for people with dementia and who all had constipation. The effects of the probiotic drink on stool habits, and BW were studied. The outcome measures were followed daily for bowel movements and at three and six months for BW. The staff found the study easy to carry out and that the drink was well accepted by the participants. No convincing beneficial effects on stool habits were observed. In addition, a mean BW loss of 0.65 kg/month was registered. A poor nutritional intake, low physical activity level, and an over-night fast of almost 15 hours, 4 hours longer than recommended were also observed.

As a part of the FOPANU Study (Frail Older People-Activity and Nutrition Study), a randomized controlled trial was carried out in Umeå - the associations between nutritional status and factors common among old people with physical and cognitive impairments living in residential care facilities was studied. Assessments were made of nutritional status using the Mini Nutritional Assessment (MNA) scale, fat-free mass (FFM) and fat mass (FM) using both bioelectrical impedance spectroscopy (BIS) and skinfold thickness measurements. The effects of a high- intensity functional exercise program with an additional protein-enriched milk drink on ability to build muscle mass were evaluated. Analyses were made to investigate whether nutritional status, assessed using the MNA scale, was associated with medical conditions, drugs, activities of daily living (Barthel ADL index), cognitive impairment (Mini Mental State Examination (MMSE)), and depressive symptoms (Geriatric Depression Scale (GDS)) at baseline. The associations were assessed with multiple linear regression analyses with additional interaction analyses.

An independent association was found between poor nutritional status and having had a urinary tract infection (UTI) during the preceding year and being dependent in feeding for both women and men, and having lower MMSE scores for women. A large proportion of the participants, were at risk of malnutrition or were already malnourished. Women, but not men, had significantly lower Fat-Free Mass Index (FFMI) and Fat Mass Index (FMI) with age.

Bioelectrical impedance spectroscopy results correlated with skinfold thickness measurements, but on different levels on value for FM%.

Despite the high-intensity exercise had long-term effects (at six months, three months after the exercise) on functional balance, walking ability and leg strength. No effects on muscle mass and no additional effects from the protein-enriched drink could be observed after the three months of high intensity exercise. A negative, long-term effect on the amount of muscle mass and BW was revealed at six months (three months after the intervention had ended). The effects from the exercise did not differ for participants who were malnourished. No statistical interactions were observed between sex, depression, dementia disorder, and nutritional status, and the level of functional balance capacity on the outcome at three or six months.

In summary, the majority of the included older people with dementia had a low dietary intake, low physical activity level, and lost BW despite receiving a probiotic drink supplement every day for six months. The supplementation had no detectable effect on constipation. Among the participants in the FOPANU Study, UTI during the preceding year was independently associated with poor nutritional status. Being dependent in feeding was associated with poor nutritional status as were lower MMSE scores for women but not for men. Despite the high-intensity exercise program had long-term effects on the fysical function was no effect on the amount of muscle mass at three months observed. The FFM and FM expressed as indexes of body height were inversely related to age for women, but not for men. A high-intensity exercise program did not have any effect on the amount of muscle mass. The ingestion of a protein-enriched drink immediately after exercise produced no additional effect on the outcome and the results did not differ for participants who were malnourished. The negative long-term effect on amount of muscle mass, and BW, indicate that it is necessary to compensate for increased energy demands during a high-intensity exercise program. High age, female sex, depression, mild to moderate dementia syndrome, malnutrition, and severe physical impairment do not seem to have a negative impact on the effect of a high-intensity functional weight-bearing exercise program. Consequently, people with these characteristics in residential care facilities should not be excluded from training and rehabilitation including nutrition. More research is needed in large randomized controlled trials to further explore the association between energy balance and malnutrition among frail old people, with a special focus on UTI and constipation, but also to study how physical exercise affects older people’s nutritional status.