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Mirror Neurons

Mirror neurons offer new rehabilitation methods for dementia

Epidemiological studies support a close relationship between physical activity and cognitive functioning (Rosano et al., 2005; Verghese et al., 2007). It has been suggested that participating in a physically active lifestyle may protect against dementia (Fratiglioni et al., 2004; Rovio et al., 2005). Similarly, a decrease in the level of physical activity, such as walking, coincides with a decline in cognitive functioning (Rosano et al., 2005). In addition, a decrease in the level of physical activity might even predict dementia (Waite et al., 2005).

However, epidemiological studies do not show a causal relationship between physical activity and cognition. Only when physical activity is applied as an intervention, a causal relationship can be demonstrated. Indeed, randomized controlled trials have observed a beneficial influence of physical activity such as walking on cognitive functions and mood in older persons without dementia and older persons at risk for dementia or in an early stage of dementia (Kramer et al., 1999; Lautenschlager et al., 2008; Scherder, Van Paasschen, Deijen, Van Der Knokke, Orlebke, Burgers, Devriese et al., 2005).

Despite the accumulating evidence that physical activity exerts a positive influence on cognition and behavior in patients with (early) dementia, there is also ample evidence that in daily practice by shortage of staff nursing home residents are left on their own. Without being animated to participate in activities and, more importantly, continuously being prompted to go on with activities, nursing home residents are very likely to remain inactive and spend most of their time without external stimulation. Activity measurements of aged care residents have confirmed this (Egerton and Brauer, 2009). Furthermore, a qualitative evaluation of health care facilities has revealed that nursing home residents spend more than 17 hours per day in bed (Bates-Jensen et al., 2004).
Such a passive environment is detrimental for the active functioning of any person, in particular the active functioning of a patient with dementia. As mentioned before, brain areas such as the prefrontal cortex that respond positively to physical activity, are affected in the three most prevalent subtypes of dementia: Alzheimer’s disease, vascular dementia, and frontotemporal dementia (Battaglia et al., 2007; Rabinovici et al., 2007; Varrone et al., 2002; Tatemichi et al., 1995. A dysfunction of this and related areas has serious consequences for cognition and behavior, for example a reduction in independent functioning and behavioural disturbances such as agitation and aggressiveness. In view of the expected increase in the shortage of nursing staff (Castle & Engberg, 2009) on one hand, and the impressive beneficial effects of physical activity, is it of great clinical importance to develop new strategies that do not require an additional effort of the nursing staff and is effective in stimulating patients with dementia to remain as active as possible. One such new stimulation strategy emerges from the presence of mirror neurons in the brain.

Mirror neurons for stimulation physical activity in patients with dementia

There is increasing evidence that observing the movements of someone else activates mirror neurons in brain regions, for example the prefrontal cortex, that are also active during the performance of the actual motor activity itself. Activation of mirror neurons can take place by observation of movements presented on a prerecorded video (Cheng, Tzeng, Decety, Imada, & Hsieh, 2006; Proverbio, Riva & Zani, 2009).
We argue that activation of mirror neurons is still possible in early stages of the three most prevalent subtypes of dementia, particularly in Alzheimer’s disease, the most prevalent subtype of dementia. Within this scope, it is important to note that plastic changes are still possible in dementia, a concept paraphrased as ‘use it or lose it’ (Swaab, 1991). We have recently demonstrated in a pilot study that activation of mirror neurons in dementia is both possible and beneficial by means of hand movement observation (Eggermont, Swaab, Hol and Scherder (2009). The results of that study showed that watching hand movements of someone else improved general attention and face recognition. Moreover, depression declined. 
In this project we argue that cognition and behavior will benefit from watching people doing two specific motor actions: people who walk and people who eat. Evidence for a beneficial effect of watching people who walk emerges from studies that show that mirror neurons involved in watching foot movements are located in among others, the frontal lobe (Rocca & Pilippi, 2010). In the present project we will invite in an implicit way older persons with dementia who are still ambulatory but hardly walk during the day, to watch older people who are walking. To obtain this goal, we will project on the wall of the room they are sitting during the day, daily situations in which older people are walking. We expect that this projection will stimulate the mirror neurons of these patients by which they will start walking again by themselves.
It is also known that neurons in the frontal lobe fire when observing motor actions of the mouth (Iacoboni & Mazziotta, 2007). Therefore, in the present project, we will project on the wall during mealtimes, people who are eating, clearly making masticatory movements. We expect that watching older persons making masticatory movements will invite older persons with dementia who hardly chew anymore, to start eating and chewing again. Particularly chewing is important as we recently reviewed the literature and observed a close relationship between chewing and cognition (Weijenberg et al., 2010).

Literature

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Prof. dr. Erik J.A. Scherder
Vrije Universiteit
Van der Boechorststraat 1
1081 BT Amsterdam
Telephone: +31205988761
Email: eja.scherder@psy.vu.nl