Effective multicomponent interventions in comparison to active control and no interventions on physical capacity, cognitive function and instrumental activities of daily living in elderly people with and without mild impaired cognition - A systematic review and network meta-analysis

Compared to exercise, the effects of exercise combined with cognitive training in people with mild cognitive impairment: a network meta-analysis

OBJECTIVES

The study aimed to evaluate the relative effectiveness of exercise combined with cognitive training (E&CT) in improving cognitive function compared to exercise alone.

METHOD

PubMed, Embase, Cochrane Central Register of Controlled Trials, SPORTDiscus, and OpenGrey were systematically searched. Additional screenings were performed by reviewing citations of relevant articles. Studies were included if they met inclusion criteria. Both pairwise and network meta-analyses were performed using a random effects model in Stata 15.0.

RESULTS

Totally, 46 trials from 54 literature (n = 2846) were eligible for inclusion in the meta-analysis. The network meta-analysis indicated that exercise alone was more efficacious than E&CT in improving global cognition and multicomponent exercise exhibited the highest likelihood (SUCRA value= 89.0%) of being the most effective type. Regarding memory function, E&CT presented greater potential than exercise alone, with the interactive modality ranking first (SUCRA value = 88.4%). Multicomponent exercise was identified as the top intervention for enhancing executive function. The overall quality of the included studies was rated as moderate, and the certainty of evidence ranged from low to high.

CONCLUSION

Multicomponent exercise emerged as the optimal intervention for improving global cognition and executive function. Nevertheless, for memory function, the interactive modality of E&CT demonstrated the highest probability of being the most effective choice.

VR Cognitive-based Intervention for Enhancing Cognitive Functions and Well-being in Older Adults with Mild Cognitive Impairment: Behavioral and EEG Evidence

Objective: Mild cognitive impairment (MCI) has been recognized as a window of opportunity for therapeutic and preventive measures to slow cognitive decline. The current study investigated the efficacy of the virtual reality (VR) cognitive-based intervention on verbal and visuospatial short-term memory (STM), executive functions (EFs), and wellbeing among older adults with and without MCI. Method: The immersive VR cognitive-based intervention comprised eight 60-minute sessions, held twice a week over a span of 30 days. The participants consisted of 31 non-MCI older adults in the experimental group (mean age ± SD = 66.31 ± 3.12 years), 29 older adults with MCI in the experimental group (mean age ± SD = 68.19 ± 5.03 years), and 30 non-MCI older adults in the control group (mean age ± SD = 64.97 ± 3.35 years). The dependent variables were assessed by using a battery of computerized test, the well-being of older people questionnaire and resting-state EEG. A repeated-measures ANCOVA was employed to examine the effects of the developed VR intervention. Results: Significant improvements were observed in both STMs and EFs following the intervention, as indicated by behavioral and EEG findings, ranging from small to large effect sizes (i.e., = .05-.17). However, enhanced wellbeing was specifically observed among older adults with MCI in the experimental group, F(2, 87) = 6.78, p .01, = .11. Conclusions: The present findings lend support to the efficacy of VR cognitive-based interventions across clinical and non-clinical populations. These results underscore the immediate impact of the intervention across multimodal assessments, including neurophysiological changes, cognitive, and behavioral outcomes.

Cognitive interventions for healthy older adults: A systematic meta-review

Objectives

With increasing global life expectancy, cognitive interventions hold promise in mitigating cognitive decline and fostering healthy aging. Despite the demand for evidence-based interventions, there have been few attempts to summarize existing evidence. This study aims to assess the effectiveness and feasibility of unimodal and multimodal cognitive interventions for cognitively healthy older adults.

Method

Systematic meta-review, selecting articles from four databases: PubMed, Web of Science, Embase, and Cochrane Library. Quality assessment carried out with AMSTAR2. Findings were summarized and discussed narratively.

Results

Thirty-nine articles were included, with 21 meta-analyses and 18 qualitative systematic reviews. The total number of reviews was 38 for cognitive training, 4 for cognitive stimulation, and 1 for multicomponent interventions. Most reviews had low or critically low quality.

Conclusions

The prevailing evidence supports cognitive training. Continued research into cognitive stimulation and multicomponent protocols is encouraged. Longer follow-ups are important for identifying combined and clinically significant results. Rigorous risk of bias and quality assessment is necessary to enhance the evidence base.

Effects of a 12-week digital training equipment program on cognitive function and mental health in older women: a randomized controlled trial

Objective

Combined interventions of physical activity and cognitive training have been shown to effectively enhance physical and mental factors in older adults. Digital-based tools offer various social advantages and may be more effective in improving the physical and mental well-being of older adults. As digital health content can simultaneously provide physical activity and cognitive training, this study aims to investigate the effects of a digital-based physical and cognitive training program on the physical and mental health of older women and to explore the potential of digital tools for older adults.

Methods

The participants, older women, engaged in the program three times a week for 12 weeks, with each session lasting 30 minutes (10 minutes for each of the three components). The content included digital health tools such as VR, motion tracking, and touchscreens designed for cognitive and physical fitness. Measurements were taken one week before and after the intervention for both groups, assessing body composition, cognitive function, depression, and quality of life.

Results

Data from 36 participants were analyzed. Interaction effects were observed in body fat mass (P = .011) and body fat percentage (P = .01), with improvements noted in the digital intervention group. Cognitive function (P = .017) and depression (P = .017) also showed significant improvements in the digital intervention group. Quality of life subdomains, including Physical Function (P = .009), Limitation of Physical Function (P = .004), and Pain (P = .002), demonstrated significant interaction effects, though no interaction effects were found in other subdomains.

Conclusion

This study found that digital-based combined interventions did not significantly impact body comb position but did improve cognitive function and depression in older women. These findings suggest that digital tools can be effectively utilized for the comprehensive management of cognitive function and mental health well-being. Such insights contribute to promoting healthy aging and provide an efficient method for managing the mental and physical health of older adults.

The use of dance to improve the health and wellbeing of older adults: A global scoping review of research trials

BACKGROUND

Dance is a promising health resource for older adults, but empirical evidence remains inconsistent. The lack of synthesised evidence regarding program design, dose, and delivery limits understanding of factors influencing participation and health outcomes. This scoping review aimed to map the scope, range, and effectiveness of dance programs for older people, and identify gaps and opportunities for future research and practice.

METHODS

Searches across five databases (September 2023) identified 148 studies evaluating 116 dance programs (≥4 weeks) for older adults (≥55 years, N = 8060), Dance interventions delivered to clinical groups were excluded. Intervention design and delivery were charted against the TIDieR reporting checklist. Program outcomes including adherence, safety, and positive tests were charted into established taxonomies.

RESULTS

Demographic information, program details, and implementation were often insufficiently reported. Participant groups differed by age range, with underserved communities underrepresented. Programs varied extensively in key factors including dose, prospective 'active ingredients', delivery approach, facilitator expertise, and class size. While dance was physically safe, adherence rates in older adults are comparable to other community exercise programs. Less than 40% of health assessments showed positive change, with more consistent benefits to physical endurance, strength, and function, moderate impacts on psychosocial health, and limited benefits to cognitive and brain health, and falls and falls risk.

CONCLUSION

Dance is a meaningful, safe, adaptable, and low-cost health resource for older adults. Key opportunities for advancing research include improved access for underserved groups, program suitability assessments, strategies to support adherence and engagement including theory-informed approaches, and incorporation of participant and practitioner insights. Identification of key 'active ingredients' and dance program factors may improve understanding of causal pathways and mechanisms to optimise engagement and health impacts. Stronger reporting practices will facilitate comparisons across studies and more robust evidence synthesis. This review provides a critical knowledge foundation to guide future approaches in dance for health and offers reporting recommendations.

Effect of serious games over conventional therapy in the rehabilitation of people with multiple sclerosis - a systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to quantify the effect of serious games over conventional therapy on upper-limb activity, balance, gait, fatigue, and cognitive functions in people with multiple sclerosis.

MATERIALS AND METHODS

Search strategies were developed for PubMed, Embase, Cochrane Library, and Scopus. Studies were selected if participants were adults with multiple sclerosis; the intervention consisted of a virtual reality serious game-based program; the control group received conventional therapy; outcomes included upper limb activity, balance, gait, fatigue, or cognitive functions; and used a randomized controlled trial design. Data were synthesized using a standardized mean difference with a random-effects model.

RESULTS

From 2532 studies, seventeen trials were selected (n = 740). Overall, serious games programs effect on upper limb activity, gait, verbal memory, verbal fluency and attention seemed neutral. Balance functions appeared to be improved by semi-immersive virtual reality serious games (SMD = 0.48;95%CI = 0.12-0.84;p = 0.01;I2=0%), fatigue by treadmill serious games (SMD = 0.80;95%CI = 0.40-1.20;p < 0.001) and visuo-spatial memory by semi-immersive virtual reality general cognitive serious games (SMD = 0.35;95%CI = 0.04-0.65;p = 0.03;I2=0%).

CONCLUSION

This review suggests, with a very-low-to-low certainty of evidence, that while some specific serious games may improve balance, fatigue and visuo-spatial memory, their overall effect on upper limb activity, gait, and other cognitive functions appears neutral.

Effects of combined training in individual with Intellectual and Developmental Disabilities: a systematic review and meta-analysis of randomized controlled trials

PURPOSE OF THE ARTICLE

This study aims to evaluate the literature, peer-reviewed clinical trials investigating the effects of combined exercise interventions on individuals with Intellectual and Developmental Disabilities.

MATERIALS AND METHODS

Various databases, using various descriptors and Boolean operators were utilized.

RESULTS

Eight studies meet the eligibility criteria. Regarding the anthropometric measures/body composition variable, the meta-analysis revealed that combined physical exercise did not have a significant effect (standard mean difference (SMD) = -0.16; 95% CI, -0.34 to 0.03; Z = 1.68; p = 0.09). For the lipid profile variable, the combined exercise interventions did not show a significant effect (SMD = -0.07; 95% CI, -0.43 to 0.29; Z = 0.38; p = 0.71). Combined exercise training had a significant effect on increasing functional capacity (SMD = 0.28; 95% CI, 0.01 to 0.54; Z = 2.03; p = 0.04), cardiorespiratory function (SMD = 0.80; 95% CI, 0.34 to 1.26; Z = 3.41; p ≤ 0.001), and strength (SMD = 0.77; 95% CI, 0.45 to 1.08; Z = 4.78; p ≤ 0.001).

CONCLUSIONS

Participants from the intervention group that took part in combined exercise training showed a higher probability of improving their functional, cardiorespiratory, and strength capacity compared to the control group.

Multicomponent Intervention on Improving the Cognitive Ability of Older Adults with Mild Cognitive Impairment: A Pilot Randomized Controlled Trial

This pilot randomized controlled trial aimed to evaluate the feasibility and potential outcomes of an innovative 16-session multicomponent intervention model to improve cognitive abilities in older adults with mild cognitive impairment (MCI) by promoting healthy lifestyle, cognitive skills, tai chi and mindfulness practices. This study was a multicentre, randomized controlled, two-arm, parallel-group, unblinded trial in Hong Kong. 57 Chinese older adults with MCI recruited from three local elderly centers were randomly assigned to either the control or intervention group. The study results support the feasibility and efficacy of the multicomponent intervention, and recommend future larger-scale randomized control trials.

Multimodal Exercise and Cognitive Training Program Improves Cognitive Function in Amnestic Mild Cognitive Impairment

OBJECTIVE

To investigate the preliminary efficacy of a combined physical exercise + cognitive training intervention for older adults with amnestic mild cognitive impairment (aMCI).

DESIGN

Randomized clinical trial.

SETTING

Veteran Affairs Hospital, Palo Alto, CA.

PARTICIPANTS

Sample included 72 community-dwelling volunteers (mean age 72.4 ± 9.5) diagnosed with aMCI.

INTERVENTION

Participants were randomized to either a combined aerobic and resistance exercise + cognitive training (CARE+CT) or stretching exercise + CT (SE+CT).

MEASUREMENTS

Primary outcomes included intervention specific assessments of word list and name-face recall. Secondary cognitive outcomes included standardized composite scores that reflect cognitive domains (e.g., learning and memory, executive function, processing speed, visuospatial ability, language). Secondary physiological outcomes included VO2 max and functional capacity (e.g., distance walked 6-minute walk test). APOE and BDNF were determined from whole blood samples.

RESULTS

Controlling for age and employment status, linear mixed effects models revealed that all participants experienced significant improvement in the delayed recall of word list, learning and memory and executive function. Only the CARE+CT condition had significant improvement in processing speed and functional capacity. APOE4 status impacted cognitive benefits of those in the SE+CT condition.

CONCLUSIONS

Results provide preliminary support for combined exercise and cognitive training interventions for older adults with aMCI. Further research is needed to understand the mechanisms involved as well as the impact of these interventions in diverse samples.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01962038.

Effectiveness of a multicomponent activity and horticultural intervention for the hospitalized older adults: A randomized controlled trial: Effectiveness of Intervention for the Hospitalized Older Adults

This study evaluated the effectiveness of different intervention programs in improving function among hospitalized older individuals using the Comprehensive Geriatric Assessment (CGA). A randomized controlled trial consisted of three groups: routine care, horticulture, and multicomponent activities (n = 32 each). Horticultural and multicomponent activity interventions showed beneficial effects on the CGA in hospitalized older individuals, particularly regarding cognitive function and quality-of-life. Additionally, horticultural activities significantly contributed to the perception of older adults' health status. We recommend to select older patients in geriatric wards with long-term hospitalization and adjust the frequency of activities or choose a single intervention program to provide long-term and effective intervention effects.

Combined exercise and cognitive interventions for adults with mild cognitive impairment and dementia: A systematic review and network meta-analysis

BACKGROUND

Exercise and cognitive interventions are beneficial for adults with preclinical and clinical dementia, but it is unclear whether the combination of these two components could generate synergistic benefits and what intervention designs would optimize this effect.

OBJECTIVES

This review aims to compare the effects of combined exercise and cognitive interventions on cognitive, psychological, functional outcomes, and health-related quality of life with the corresponding single approach and control groups in adults with mild cognitive impairment and dementia. It also aims to identify the optimal intervention design and factors affecting treatment effects.

METHODS

A comprehensive search was conducted in ten databases from inception to 23rd November 2022. The methodological quality of studies was evaluated by the Cochrane risk of bias tool. Pairwise meta-analyses were performed to assess the effects of combined interventions relative to the single type of intervention and control groups, with further subgroup analysis to explore the factors affecting treatment effects. Network meta-analyses were used to identify the optimal intervention components.

RESULTS

Twenty-nine randomized controlled trials involving 2910 participants were included. The results of pairwise meta-analyses indicated that combined interventions were superior to exercise in improving response inhibition, working memory, and delayed recall, but were not superior to cognitive interventions in all outcomes. Combined interventions were superior to active/passive controls in improving global cognition, response inhibition, immediate recall, delayed recall, category fluency, processing speed, and visuospatial ability. Influences of the clinical severity of dementia (mild cognitive impairment vs dementia), combination format (sequential vs simultaneous combination), mode of delivery (group-based vs individual-based vs mixed), training duration (short: ≤12 weeks vs medium: 13-24 weeks vs long: >24 weeks), and types of control (active vs passive control) were not detected. The network meta-analysis results indicated that the optimal intervention components varied across different outcomes, with multimodal exercise combining cognitive training demonstrated the greatest effects among all other combined or single component interventions in improving global cognition.

CONCLUSIONS

This review suggests the advantage of combined interventions over exercise with comparable effects when compared with cognitive interventions in the population with mild cognitive impairment and dementia. Full scale multi-arm randomized controlled trials to compare the effects of combined interventions with cognitive interventions are warranted.

Physical activity and exercise for the prevention and management of mild cognitive impairment and dementia: a collaborative international guideline

BACKGROUND

Physical activity and exercise have been suggested as effective interventions for the prevention and management of mild cognitive impairment (MCI) and dementia, but there are no international guidelines.

OBJECTIVES

To create a set of evidence- and expert consensus-based prevention and management recommendations regarding physical activity (any bodily movement produced by skeletal muscles that results in energy expenditure) and exercise (a subset of physical activity that is planned, structured, repetitive), applicable to a range of individuals from healthy older adults to those with MCI/dementia.

METHODS

Guideline content was developed with input from several scientific and lay representatives' societies. A systematic search across multidisciplinary databases was carried out until October 2021. Recommendations for prevention and management were developed according to the GRADE and complemented by consensus statements from the expert panels.

RECOMMENDATIONS

Physical activity may be considered for the primary prevention of dementia. In people with MCI there is continued uncertainty about the role of physical activity in slowing the conversion to dementia. Mind-body interventions have the greatest supporting evidence. In people with moderate dementia, exercise may be used for maintaining disability and cognition. All these recommendations were based on a very low/low certainty of evidence.

CONCLUSIONS

Although the scientific evidence on the beneficial role of physical activity and exercise in preserving cognitive functions in subjects with normal cognition, MCI or dementia is inconclusive, this panel, composed of scientific societies and other stakeholders, recommends their implementation based on their beneficial effects on almost all facets of health.

Feasibility, usability, and acceptance of "Brain-IT"-A newly developed exergame-based training concept for the secondary prevention of mild neurocognitive disorder: a pilot randomized controlled trial

Background

Exergames provide a promising new approach to implement simultaneous motor-cognitive training, which may support preventing the decline in cognitive functioning in older adults who have a mild neurocognitive disorder (mNCD).

Objectives

To evaluate feasibility, system usability, and acceptance of "Brain-IT", a newly developed training concept combining exergame-based motor-cognitive training and heart rate variability (HRV) guided resonance breathing for the secondary prevention of mNCD.

Methods

A pilot randomized controlled trial (RCT) with an allocation ratio of 2:1 (i.e., intervention:control) was conducted. The control group proceeded with usual care. The intervention group performed a 12-week training according to the "Brain-IT" training concept implemented with the "Senso Flex" (Dividat AG) exergaming system in addition to usual care. Feasibility and usability outcomes were analyzed using descriptive statistics. User acceptance was analyzed qualitatively and using Friedman analysis of variance (ANOVA), as well as Wilcoxon signed-rank tests.

Results

Eighteen participants (77.3 ± 9.8 years; 44.4% females) were included. On average, we recruited 2.2 participants per month, and 35.3% of the individuals contacted were included. The intervention group had an attrition rate of 20% and mean adherence and compliance rates of 85.0 and 84.1%, respectively. The mean system usability score, measured with the system usability scale, was 71.7. High levels of exergame enjoyment, an increase in exergame enjoyment, and internalization of training motivation with large effect sizes (p = 0.03, r = 0.75 and p = 0.03, r = 0.74, respectively), as well as acceptable perceived usefulness, were observed. Preliminary data on the effects of the "Brain-IT" training are promising.

Conclusion

The feasibility and usability of the "Brain-IT" training are acceptable. However, frequent occurrences of technical problems and difficulties in using the exergame training system were identified as barriers to performing the "Brain-IT" training. To optimize feasibility, either improvements or alternative solutions are required in the hardware and software of the exergame used to implement the "Brain-IT" training. The "Brain-IT" training itself was well-accepted by older adults who have mNCD. Therefore, the effectiveness of the "Brain-IT" training concept should be investigated in future studies.

Trial registration

clinicaltrials.gov/ct2/show/NCT04996654.

Physical activity interventions in older adults with a cognitive impairment: A critical review of reviews

This critical review explores the review material on physical activity combined with cognitive stimulation interventions in older adults with cognitive impairment and/or dementia. A critical, systematic, review of the review method was used, considering four electronic databases: WEB OF SCIENCE, SCOPUS, MEDLINE, and the COCHRANE ELECTRONIC LIBRARY. The search terms "exercise," "physical activity," "cognitive impairment," "dementia," and "systematic review" were used. All available reviews were marked against predetermined inclusion and exclusion criteria. There were 32 reviews that met the inclusion criteria. A combination of various types of training and aerobic exercises were the most frequently reported interventions; meanwhile, dual task training programs (combining physical exercise with cognitive stimulation), functional training programs along with exercises combination, aerobic exercise as well as strength, stretching, or balance workouts were also reported. The evidence is compelling; exercise can improve physical health by ensuring cognitive, psychological, and behavioral benefits. Overall, exercise can improve the physical and mental health of people living with dementia: there is sufficient evidence to recommend multimodal exercise.

Feasibility of a pilot dyadic randomized controlled trial testing the effects of three behavioral interventions on older adults' cognitive, physical and everyday function

Introduction: Maintaining functional abilities is critical for optimizing older adults' well-being and independence. This randomized controlled trial (RCT) pilot examined the feasibility of testing the effects of three commercially available interventions on function-related outcomes in older adults. Methods: Pairs of community-dwelling older adults (N=55, Mage=71.4) were randomized to a 10-week intervention (cognitive-COG, physical-EX, combined exergame-EXCOG, or control-CON). Cognitive, physical, and everyday function were assessed at baseline, immediately post-intervention, and 6-months post-intervention. Feasibility was evaluated using recruitment, enrollment, training adherence, and retention metrics. Variability and patterns of change in functional outcomes were examined descriptively. Results: A total of 208 individuals were screened, with 26% subsequently randomized. Across training arms, 95% of training sessions were completed and 89% of participants were retained at immediate post-test. Variability in functional outcomes and patterns of change differed across study arms. Discussion: Results support a fully powered RCT, with several modifications to the pilot study design, to investigate short- and long-term training impacts.

Brain Health Indicators Following Acute Neuro-Exergaming: Biomarker and Cognition in Mild Cognitive Impairment (MCI) after Pedal-n-Play (iPACES)

Facing an unrelenting rise in dementia cases worldwide, researchers are exploring non-pharmacological ways to ameliorate cognitive decline in later life. Twenty older adults completed assessments before and after a single bout of interactive physical and cognitive exercise, by playing a neuro-exergame that required pedaling and steering to control progress in a tablet-based video game tailored to impact executive function (the interactive Physical and Cognitive Exercise System; iPACES v2). This study explored the cognitive and biomarker outcomes for participants with mild cognitive impairment (MCI) and normative older adults after 20 min of pedal-to-play exercise. Neuropsychological and salivary assessments were performed pre- and post-exercise to assess the impact. Repeated-measures ANOVAs revealed significant interaction effects, with MCI participants experiencing greater changes in executive function and alpha-amylase levels than normative older adults; within-group changes were also significant. This study provides further data regarding cognitive effects and potential mechanisms of action for exercise as an intervention for MCI.

Factors for optimizing intervention programs for cognition in older adults: the value of exergames

This review presents factors that could optimize the effectiveness of an intervention program on cognitive health in older adults. Combined, multi-dimensional and interactive programs appear to be relevant. On one hand, for the characteristics to be implemented in the physical dimension of a program, multimodal interventions stimulating the aerobic pathway and muscle strengthening during the solicitation of gross motor activities, seem to be interesting. On the other hand, regarding the cognitive dimension of a program, complex and variable cognitive stimuli appear to hold the greatest promise for generating cognitive benefits and the broadest transfers to untrained tasks. The field of video games also brings interesting enrichment through the gamification of situations and the feeling of immersion. However, some gray areas remain to be clarified, notably the ideal response dose, the balance between physical and cognitive solicitation and the programs’ customization.

Effectiveness of an Individualized Exergame-Based Motor-Cognitive Training Concept Targeted to Improve Cognitive Functioning in Older Adults With Mild Neurocognitive Disorder: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Simultaneous motor-cognitive training is considered promising for preventing the decline in cognitive functioning in older adults with mild neurocognitive disorder (mNCD) and can be highly motivating when applied in the form of exergaming. The literature points to opportunities for improvement in the application of exergames in individuals with mNCD by developing novel exergames and exergame-based training concepts that are specifically tailored to patients with mNCD and ensuring the implementation of effective training components.

OBJECTIVE

This study systematically explores the effectiveness of a newly developed exergame-based motor-cognitive training concept (called "Brain-IT") targeted to improve cognitive functioning in older adults with mNCD.

METHODS

A 2-arm, parallel-group, single-blinded randomized controlled trial with a 1:1 allocation ratio (ie, intervention: control), including 34 to 40 older adults with mNCD will be conducted between May 2022 and December 2023. The control group will proceed with the usual care provided by the (memory) clinics where the patients are recruited. The intervention group will perform a 12-week training intervention according to the "Brain-IT" training concept, in addition to usual care. Global cognitive functioning will be assessed as the primary outcome. As secondary outcomes, domain-specific cognitive functioning, brain structure and function, spatiotemporal parameters of gait, instrumental activities of daily living, psychosocial factors, and resting cardiac vagal modulation will be assessed. Pre- and postintervention measurements will take place within 2 weeks before starting and after completing the intervention. A 2-way analysis of covariance or the Quade nonparametric analysis of covariance will be computed for all primary and secondary outcomes, with the premeasurement value as a covariate for the predicting group factor and the postmeasurement value as the outcome variable. To determine whether the effects are substantive, partial eta-squared (η²_p) effect sizes will be calculated for all primary and secondary outcomes.

RESULTS

Upon the initial submission of this study protocol, 13 patients were contacted by the study team. Four patients were included in the study, 2 were excluded because they were not eligible, and 7 were being informed about the study in detail. Of the 4 included patients, 2 already completed all premeasurements and were in week 2 of the intervention period. Data collection is expected to be completed by December 2023. A manuscript of the results will be submitted for publication in a peer-reviewed open-access journal in 2024.

CONCLUSIONS

This study contributes to the evidence base in the highly relevant area of preventing disability because of cognitive impairment, which has been declared a public health priority by the World Health Organization.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05387057; https://clinicaltrials.gov/ct2/show/NCT05387057.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/41173.

Multicomponent Training in Progressive Phases Improves Functional Capacity, Physical Capacity, Quality of Life, and Exercise Motivation in Community-Dwelling Older Adults: A Randomized Clinical Trial

OBJECTIVE

To evaluate the effect of a multicomponent progressive training program (MPTP) on functionality, quality of life (QoL) and motivation to exercise (EM) in a group of older adults (OA) of a community.

METHODS

A total of 55 participants of 69.42 ± 6.01 years of age were randomized into two groups; experimental (EG:35) and control (CG:20), and subjected to 27 weeks of MPTP. Functionality (pre/post-intervention) was assessed using the Short Physical Performance Battery (SPPB), Time Up and Go (TUG), Walking While Talking Test (WWT), Manual Dynamometry (MD), Forced Expiratory Volume in the first second (FEV₁), Sit and Reach (SR), Back Scratch (BS), and walk for 2 min (2 mST). QoL was assessed using the SF-36 questionnaire and EM using the BREQ-3. The Kolmogorov-Smirnov and Levene tests were applied. A two-way repeated measures ANOVA was applied. A significance level of p < 0.05 was accepted for all comparisons.

RESULTS

The EG compared to the CG improved in SPPB (ΔEG/CG: 29.67%/p < 0.001), TUG (ΔEG/CG: 35.70%/p < 0.05), WWT (ΔEG/CG: 42.93%/p < 0.001), MD (ΔEG/CG: 20.40%/p < 0.05), FEV₁ (ΔEG/CG: 21.37%/p < 0.05), BS (ΔEG/CG: 80.34%/p < 0.05), 2 mST (ΔEG/CG: 33.02%/p < 0.05), SF-36 (ΔEG/CG: 13.85%/p < 0.001), and Intrinsic Regulation (ΔEG/CG: 27.97%/p < 0.001); Identified by regulation (ΔEG/CG: 9.29%/p < 0.05).

CONCLUSION

An MPTP improves functionality, QoL and EM, and is a safe and effective method for community OAs.

Comprehensive geriatric assessment and multidisciplinary team interventions for hospitalized older adults: A scoping review

BACKGROUND/OBJECTIVES

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment process to evaluate medical, psychosocial, and functional capability. It is useful to develop a coordinated and integrated plan for frail older patients. This study aimed to examine the current scope of CGA based multidisciplinary team interventions in acute care setting to improve the health outcomes for older adults.

METHODS

We searched electronic databases: PubMed, Ovid, PsychINFO, Scopus, RISS and KoreaMed from 2011 to 2021. The selected articles were extracted by three reviewers and cross checked by the fourth reviewer to resolve any conflicts. Data were synthesized and analyzed descriptively and thematically. Articles are nested three themes: inpatient (IN), emergency room (ER) and oncology patient (ONCO).

RESULTS

Of the 1830 articles that were screened, 710 were potentially eligible. Finally, 26 articles were selected and categorized as IN (n=8), ER (n=7) and ONCO (n=11). Geriatricians and nurses participated in most of the multidisciplinary teams followed by other health professionals. The most effective primary outcomes were focused and retrieved across five domains, screening, prevention, treatment, quality of care, and rehabilitation. The subdomains are problem lists which is common and problematic among hospitalized older patients and retrieved from the most commonly used multidisciplinary interventions according to each domain.

CONCLUSION

CGA based multidimensional intervention (MDI) are likely to be an effective in care of older adults. There is remarkable paradigm shift required to improve better health outcomes for hospitalized older adults. It also suggests that there is a need to design the CGA based MDI to build a standardized protocol for older adults to maintain functional capacity and increase likelihood of living in their own home.

The relative effectiveness of different combination modes for exercise and cognitive training on cognitive function in people with mild cognitive impairment or Alzheimer's disease: a network meta-analysis

OBJECTIVES

To compare and rank the relative effectiveness of different modes for exercise combined cognitive training (ECT) in people with Alzheimer's disease (AD) or Mild Cognitive Impairment (MCI).

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, SPORTDiscus, PsycInfo, and OpenGrey systematically from inception to May 2020. Studies were included that met the inclusion criteria: randomized controlled trials, involving people with MCI or dementia, performing ECT without other interventions, and assessing global cognitive function, memory function, and executive function. Pairwise and network meta-analyses were performed using a random effects model.

RESULTS

We included 20 articles from 16 studies with 1180 participants. For global cognition, separate modality had the highest probability of being the optimal approach (the surface under the cumulative ranking curve (SUCRA) value = 77.5%). For memory function, the interactive mode had the greatest probability of being the best choice (SUCRA = 84.7%). Concerning executive function, the dual-task modality and separate modality had similar SUCRA values. Subgroup analysis revealed no differences for the relative effectiveness of ECT among people with MCI or among all participants.

CONCLUSIONS

Separate and interactive combination modality had the highest probability of being the most effective mode for overall cognition and memory performance. However, the evidence is insufficient to reveal the best combination mode for executive function.

Supplemental data for this article is available online at https://doi.org/10.1080/13607863.2022.2026879 .

Does physical exercise improve the capacity for independent living in people with dementia or mild cognitive impairment: an overview of systematic reviews and meta-analyses

OBJECTIVE

To summarise existing systematic reviews which assessed the effects of physical exercise on activities of daily living, walking, balance and visual processing in people with dementia or mild cognitive impairment.

METHODS

In this overview of systematic reviews and meta-analyses, seven electronic databases were searched to identify eligible reviews published between January 2015 and April 2021.

RESULTS

A total of 30 systematic reviews were identified and included in the overview. The most frequent type of exercise for the intervention group was multimodal exercises. Mind-body exercises, exergames, dance intervention and aerobic exercise were other exercise types. Most of the reviews reported that exercise is significantly effective for improving activities of daily living (SMD 95%CI, from 0.27 to 1.44), walking (SMD 95%CI, from 0.08 to 2.23), balance (SMD 95%CI, from 0.37 to 2.24) and visuospatial function (SMD 95%CI, from 0.16 to 0.51), which are among the most leading determinants of independent living in individuals with dementia or mild cognitive impairment.

CONCLUSION

Evidence has shown that exercise (especially multicomponent exercise programmes including cognitive, physical and multitasking exercises) with sufficient intensity improves the activities of daily living skills. Exercise also improves walking, balance and visual processing, which can provide a more independent life for people with dementia and mild cognitive impairment. Cognitively impaired people should therefore be encouraged to exercise regularly in order to be more independent.

Supplemental data for this article is available online at http://dx.doi.org/10.1080/13607863.2021.2019192.

The effects of aerobic exercise and transcranial direct current stimulation on cognitive function in older adults with and without cognitive impairment: A systematic review and meta-analysis

BACKGROUND

Aerobic exercise (AE) may slow age-related cognitive decline. However, such cognition-sparing effects are not uniform across cognitive domains and studies. Transcranial direct current stimulation (tDCS) is a form of non-invasive brain stimulation and is also emerging as a potential alternative to pharmaceutical therapies. Like AE, the effectiveness of tDCS is also inconsistent for reducing cognitive impairment in ageing. The unexplored possibility exists that pairing AE and tDCS could produce synergistic effects and reciprocally augment cognition-improving effects in older individuals with and without cognitive impairments. Previous research found such synergistic effects on cognition when cognitive training is paired with tDCS in older individuals with and without mild cognitive impairment (MCI) or dementia.

AIM

The purpose of this systematic review with meta-analysis was to explore if pairing AE with tDCS could augment singular effects of AE and tDCS on global cognition (GC), working memory (WM) and executive function (EF) in older individuals with or without MCI and dementia.

METHODS

Using a PRISMA-based systematic review, we compiled studies that examined the effects of AE alone, tDCS alone, and AE and tDCS combined on cognitive function in older individuals with and without mild cognitive impairment (MCI) or dementia. Using a PICOS approach, we systematically searched PubMed, Scopus and Web of Science searches up to December 2021, we focused on 'MoCA', 'MMSE', 'Mini-Cog' (measures) and 'cognition', 'cognitive function', 'cognitive', 'cognitive performance', 'executive function', 'executive process', 'attention', 'memory', 'memory performance' (outcome terms). We included only randomized controlled trials (RTC) in humans if available in English full text over the past 20 years, with participants' age over 60. We assessed the methodological quality of the included studies (RTC) by the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Overall, 68 studies were included in the meta-analyses. AE (ES = 0.56 [95% CI: 0.28-0.83], p = 0.01) and tDCS (ES = 0.69 [95% CI: 0.12-1.26], p = 0.02) improved GC in all three groups of older adults combined (healthy, MCI, demented). In healthy population, AE improved GC (ES = 0.46 [95% CI: 0.22-0.69], p = 0.01) and EF (ES = 0.27 [95% CI: 0.05-0.49], p = 0.02). AE improved GC in older adults with MCI (ES = 0.76 [95% CI: 0.21-1.32], p = 0.01). tDCS improved GC (ES = 0.69 [90% CI: 0.12-1.26], p = 0.02), all three cognitive function (GC, WM and EF) combined in older adults with dementia (ES = 1.12 [95% CI: 0.04-2.19], p = 0.04) and improved cognitive function in older adults overall (ES = 0.69 [95% CI: 0.20-1,18], p = 0.01).

CONCLUSION

Our systematic review with meta-analysis provided evidence that beyond the cardiovascular and fitness benefits of AE, pairing AE with tDCS may have the potential to slow symptom progression of cognitive decline in MCI and dementia. Future studies will examine the hypothesis of this present review that a potentiating effect would incrementally improve cognition with increasing severity of cognitive impairment.

Conditions required to ensure successful detection and management of mild cognitive impairment in primary care: A Delphi consultation study in China

Objective

Detection and management of mild cognitive impairment (MCI) in primary care has been recognized internationally as one of the strategies that can be employed to delay the development of dementia. However, little is known about what role primary care should play. This study aimed to develop a checklist of conditions necessary for successfully detecting and managing mild cognitive impairment in primary care in China.

Methods

This study employed the Delphi method to establish expert consensus on the conditions required for successfully detecting and managing MCI in primary care in China. Twenty-four experts who specialized in general practice, public health, neuropsychology, or community health service management rated the importance of pre-defined conditions (44 items measuring providers' preparedness, patient engagement, and system support in line with the Chronic Care Model). The degree of consensus among the experts was measured using four indicators: median ≥ 4, mean ≥3.5, Co-efficient of Variance < 0.25, and retention in the checklist required ≥ 80% agreement with a rating of important or essential. The checklist and descriptions of the conditions were revised according to the experts' feedback and then sent out for repeated consultations along with a summary of the results of the previous round of consultations. Consensus was achieved after the second round of consultations, which was completed by 22 of the experts.

Results

The experts endorsed a checklist of 47 conditions required for successful detection and management of MCI in primary care in China. These conditions were categorized into four domains: prepared general practitioners (17 items), engaged patients (15 items), organizational efforts (11 items), and environmental support (4 items).

Conclusions

Successful detection and management of MCI in primary care in China requires a dedicated and competent workforce of general practitioners, as well as the engagement of patients and family caregivers. Adequate support from healthcare organizations, health system arrangements, and the broader society is needed to enable effective interactions between general practitioners and patients and efficient delivery of the services required to detect and manage MCI.

Multicomponent exercise program effects on fitness and cognitive function of elderlies with mild cognitive impairment: Involvement of oxidative stress and BDNF

Regular exercise has been shown to be one of the most important lifestyle influences on improving functional performance, and decreasing morbidity and all-cause mortality among older people. However, although there is some evidence on the effects of aerobic training on oxidative stress, there is little information regarding the effects of multicomponent exercise (dual-task training) and combination of exercise with cognitive stimulation on oxidative stress. In this context, the aim of this study was to verify the effects of a multicomponent exercise program on physical fitness and cognitive function in the elderly with mild cognitive impairment and determine the role of oxidative stress and brain-derived neurotrophic factor (BDNF). At baseline, 37 elderly nursing home residents with mild cognitive impairment were divided into two groups: the control group (CG, n = 12, 81.8 years) and the experimental group (EG, n = 25, 83.2 years). These elderlies followed multicomponent exercise training for 24 weeks, with two sessions per week and 45–50 min per session. The exercises included both aerobic and strength exercises, considering functional movements and light to moderate intensity. Cognitive stimulation comprehended exercises based on word games, puzzles, mathematical calculations, forward and backward counting, computer exercises, exergames, and games on a balanced platform. Physical assessments (weight, height, and body mass index), health and functional parameters (fitness tests: chair stand, arm curls, chair sit-and-reach, eight feet up-and-go, back scratch, 6-min walking, feet together, semi-tandem, and full tandem), lipid profile (total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides), measures of lipid peroxidation damage, thiobarbituric acid reactive substances (TBARS), total antioxidant capacity (TAC), and BDNF were measured in plasma, based on which analyses were performed before and after the 24 weeks of the multicomponent exercise intervention. The results showed an overall improvement in physical and functional performance. Regarding biochemical measures, multicomponent exercises lead to a significant decrease in oxidative damage. The results indicate that multicomponent exercise training induces benefits in functional capacity and reduces damage due to oxidative stress.

Development of a Combined Exercise and Cognitive Stimulation Intervention for People with Mild Cognitive Impairment-Designing the MEMO_MOVE PROGRAM

Dementia patients are at high risk for the decline of both physical and cognitive capacities, resulting in an increased risk of the loss of autonomy. Exercise is regarded as a non-pharmacological therapy for dementia, considering the potential benefits of preventing cognitive decline and improving physical fitness. In this paper, we aim to describe the different design stages for an exercise program combined with cognitive stimulation for a population with mild cognitive impairment, i.e., the MEMO_MOVE program.

METHODS

The intervention design followed the Medical Research Council's guidelines for complex interventions and was structured according to the six steps in quality intervention development (6SQuID). The intervention was described considering the Template for Intervention Description and Replication (TIDieR). In order to establish the intervention characteristics, a literature review was conducted to collate and analyze previous work, which provided a summary the type of exercise that should be implemented among this population.

RESULTS

The MEMO_MOVE program was structured and described, regarding (i) inclusion of a cognitive stimulation component; (ii) the kind of cognitive stimulation; and (iii) the type of exercise, duration, frequency, intensity, and program length.

CONCLUSIONS

A systematic step-by-step process design was followed to create a specific intervention to promote physical fitness and cognitive stimulation in individuals with mild dementia.

Effectiveness and acceptability of non-pharmacological interventions in people with mild cognitive impairment: Overview of systematic reviews and network meta-analysis

BACKGROUND

To explore effectiveness and acceptability of non-pharmacological interventions in mild cognitive impairment (MCI).

METHODS

Overview of systematic reviews and network meta-analysis were conducted. Systematic reviews (SRs) were searched via seven databases from June 2015 to June 2020. Randomized controlled trials (RCTs) were retrieved. The Methodological quality was assessed by AMSTAR 2 and RoB 2. Outcomes were effectiveness and acceptability measured by standardized mean differences (SMDs) and odd ratios (ORs) with 95% confidence interval (CI). Pairwise meta-analysis was first conducted, followed by network meta-analysis.

RESULTS

A total of 22 SRs and 42 RCTs with 4401 participants were included. The methodological quality of included SRs and RCTs were moderate. There were four interventions, with three types of physical activity (aerobic, muscle-strengthening, and mind-body), three types of cognitive (rehearsal-based, compensatory, and mixed), multicomponent (physical and cognitive component), and nutrition intervention. No significant inconsistency was identified. Regarding intervention effectiveness, muscle-strengthening (SMDs 0.87, 95% CI 0.31-1.43; rank 1), mind-body (0.76, 0.38-1.14; rank 2) and aerobic (0.34, 0.13-0.50; rank 3) were significantly better than the control group and there was no significant difference among these types of intervention . Cognitive intervention of rehearsal-based (1.33, 0.30-2.35; rank 1) and mixed (0.55, 0.00-1.11; rank 2) were significantly better than the control group and there was no significant difference among these types of intervention. Multicomponent intervention (0.32, 0.02-0.62) were significantly better than the control group but not better than the single component group. Regarding acceptability, there was no significant difference among types of intervention.

CONCLUSION

Physical activity, cognitive, and multicomponent intervention could be provided regardless of their types and acceptability due to their effectiveness on improved cognitive function for people with MCI.

Effects of a multicomponent day-care program on cerebral blood flow in patients with mild cognitive impairment

BACKGROUND

Mild cognitive impairment (MCI) is a prodromal phase of dementia and is considered an important period for intervention to prevent conversion to dementia. It has been well established that multicomponent day-care programs including exercise training, cognitive intervention and music therapy have beneficial effects on cognition, but the effects on cerebral blood flow (CBF) in MCI remain unknown. This study examined whether a multicomponent day-care program would have beneficial effects on the longitudinal changes of CBF in MCI patients.

METHODS

Participants were 24 patients with MCI attending a day-care program; they underwent two ⁹⁹ mTc-ethyl cysteinate dimer single photon emission computed tomography scans during the study period. We evaluated the association between the changes of regional cerebral blood flow and the attendance rate.

RESULTS

There was a significant negative correlation between the reduction of regional CBF in the right parietal region and the attendance rate. We found no significant relation between the baseline CBF images and the attendance rate.

CONCLUSIONS

Our results suggest that continuous participation in a multicomponent day-care program might prevent reduction in brain activity in patients with MCI.

Community-based group physical activity and/or nutrition interventions to promote mobility in older adults: an umbrella review

BACKGROUND

Physical activity and a healthy diet are important in helping to maintain mobility with aging. This umbrella review aims to identify group-based physical activity and/or nutrition interventions for community-dwelling older adults that improve mobility-related outcomes.

METHODS

Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Sociological Abstracts) were searched from inception to December 2021. Eligibility criteria included systematic reviews exploring the effectiveness of physical activity or structured exercise, alone or combined with nutrition interventions on mobility-related outcomes (aerobic capacity, physical function, balance, falls/safety, muscle strength, health-related quality of life/wellbeing). Interventions must have been delivered in a group setting to community-dwelling older adults aged 55+. Two reviewers independently performed eligibility screening, critical appraisal (using AMSTAR 2) and data extraction. The GRADE approach was used to reflect the certainty of evidence based on the size of the effect within each mobility-related outcome category. Older adult/provider research partners informed data synthesis and results presentation.

RESULTS

In total, 62 systematic reviews (1 high, 21 moderate, 40 low/critically low quality) were identified; 53 included physical activity only, and nine included both physical activity and nutritional supplements. No reviews included nutrition interventions alone. Combined aerobic/resistance, general physical activity, and mind-body exercise all improved physical function and balance (moderate-high certainty). Aerobic/resistance training improved aerobic capacity (high certainty). Resistance training and general physical activity improved muscle strength (moderate certainty). Aerobic/resistance training and general physical activity are likely to reduce falls among older adults (moderate certainty). There was no evidence of benefit for nutritional supplementation with physical activity.

CONCLUSIONS

Group-based physical activity interventions that combine aerobic and resistance, general PA and mind-body exercise can improve measures of mobility in community-dwelling older adults. We found no reviews focused on nutrition only, highlighting a gap in the literature.

The Effectiveness of Multicomponent Intervention on Daily Functioning among the Community-Dwelling Elderly: A Systematic Review

The deterioration of physical and cognitive functioning in the elderly is an impairment to their independent self-management and to improving their ability to perform daily functions. Nurses should support the elderly to experience a healthy and a successful aging process by preventing dependence on daily functioning and understanding the care assistance that such persons need. This study aimed to gain insight into the evidence on the effectiveness of multicomponent intervention on the activities of daily living (ADL) and instrumental activities of daily living (IADL) among the community-dwelling elderly without cognitive impairment. The design is a systematic review of a randomized controlled trial. The language of the published literature was English, and the search period was from January 2000 to December 2020. Articles were included under the PICO (population, intervention, comparison, and outcome) framework for: (a) community-dwelling elderly without cognitive impairment; (b) multicomponent intervention; (c) comparison group who did not receive the intervention; and (d) measurement of the effect of ADL and IADL. A total of 4413 references were found, 6 studies were included. Most studies (n = 5) reported that the multicomponent intervention exerted a beneficial effect on ADL and IADL. Only one study showed the highest methodology and reporting quality in the Cochrane review. Common components of the programs included: occupational therapy, physical therapy, exercise, memory training, cognitive–behavioral therapy, interdisciplinary intervention, and cognitive training. Multicomponent intervention may be a beneficial way to improve dependence on ADL and IADL as an important area of functional evaluation in the elderly. Considering the physical condition of the elderly, multicomponent interventions, including physical activity, exercise, occupational therapy, and especially individually customized coaching related to ADL and IADL training, may be useful.

Strength-Cognitive Training: A Systemic Review in Adults and Older Adults, and Guidelines to Promote "Strength Exergaming" Innovations

Background

Despite functional and cognitive benefits, few adults and older adults do strength training twice per week with sufficient intensity. Exercise-based active video games (exergaming) may amplify the cognitive benefits of exercise and increase adherence and motivation toward training. However, the benefits of a well-defined and monitored dose of strength training, executed simultaneously or sequentially with a cognitive element, has received little attention. In this study we have two aims: First, to systematically gather the available evidence; second, to suggest possible ways to promote strength exergaming innovations.

Methods

We systematically reviewed randomized controlled trials using simultaneous or sequent combined strength and cognitive training or strength exergaming to improve cognitive or functional outcomes in adults and older adults.

Results

After screening 1,785 studies (Google Scholar, ACM Digital Library, IEEE Xplore Library, PsycARTICLES, Scopus, Cochrane Library and PubMed) we found three eligible studies. Of the two studies using sequent strength and cognitive training, one showed improved functionality, but the other showed negative effects on cognition. The third study using simultaneous intervention, reported a positive influence on both cognition and function, when compared with either strength training alone or a control group. Moderate level of evidence was showed on GRADE analysis.

Conclusion

The existing little evidence suggests that strength and cognitive training improves cognition and function in adults and older adults. The following suggestions may help to promote further innovation: (1) ensure minimal dosage of strength training (30-60 min, 2 × /week), (2) use machine-based strength training devices to control volume and intensity (to prevent cognitive components from interfering with strength training), (3) include power training by using cognitive tasks requiring rapid reactions, and (4) add cognitive memory tasks (to extend the cognitive benefits of strength training per se), and (5) include motivational exergame elements to increase adherence.

Associations of Multidomain Interventions With Improvements in Cognition in Mild Cognitive Impairment: A Systematic Review and Meta-analysis

IMPORTANCE

Older adults with mild cognitive impairment (MCI) have the highest risk of progressing to dementia. Evidence suggests that nonpharmacological, single-domain interventions can prevent or delay progressive declines, but it is unclear whether greater cognitive benefits arise from multidomain interventions.

OBJECTIVE

To determine whether multidomain interventions, composed of 2 or more interventions, are associated with greater improvements in cognition among older adults with MCI than a single intervention on its own.

DATA SOURCES

MEDLINE, Embase, PsycInfo, AgeLine, CINAHL, and Cochrane Central Register of Controlled Trials were systematically searched from database inception to December 20, 2021.

STUDY SELECTION

Included studies contained (1) an MCI diagnosis; (2) nonpharmacological, multidomain interventions that were compared with a single active control; (3) older adults aged 65 years and older; and (4) randomized clinical trials.

DATA EXTRACTION AND SYNTHESIS

Data were screened and extracted by 3 independent reviewers. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, random-effects meta-analyses were used to calculate effect sizes from the standardized mean difference (SMD) and 95% CIs.

MAIN OUTCOMES AND MEASURES

Postintervention cognitive test scores in 7 cognitive domains were compared between single-domain and multidomain groups. Exposure to the intervention was analyzed.

RESULTS

A total of 28 studies published between 2011 and 2021, including 2711 older adults with MCI, reported greater effect sizes in the multidomain group for global cognition (SMD, 0.41; 95% CI, 0.23-0.59; P < .001), executive function (SMD, 0.20; 95% CI, 0.04-0.36; P = .01), memory (SMD, 0.29; 95% CI, 0.14-0.45; P < .001), and verbal fluency (SMD, 0.30; 95% CI, 0.12-0.49; P = .001). The Mini-Mental State Examination (SMD, 0.40; 95% CI, 0.17-0.64; P < .001), category verbal fluency test (SMD, 0.34; 95% CI, 0.13-0.56; P = .002), Trail Making Test-B (SMD, 0.46; 95% CI, 0.13-0.80; P = .007), and Wechsler Memory Scale-Logical Memory I (SMD, 0.47; 95% CI, 0.15-0.80; P < .001) and II (SMD, 0.26; 95% CI, 0.07-0.45; P < .001) favored the multidomain group. Exposure to the intervention varied between studies: the mean (SD) duration was 71.3 (36.0) minutes for 19.8 (14.6) weeks with sessions taking place 2.5 (1.1) times per week, and all interventions lasted less than 1 year.

CONCLUSIONS AND RELEVANCE

In this study, short-term multidomain interventions (<1 year) were associated with improvements in global cognition, executive function, memory, and verbal fluency compared with single interventions in older adults with MCI.

The Effects of Combined Cognitive-Physical Interventions on Cognitive Functioning in Healthy Older Adults: A Systematic Review and Multilevel Meta-Analysis

Research has shown that both physical exercise and cognitive training help to maintain cognition in older adults. The question is whether combined training might produce additive effects when the group comparisons are equated in terms of exercise intensity and modality. We conducted a systematic electronic search in MEDLINE, PsycInfo, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify relevant studies published up to February 2021. Seven hundred and eighty-three effect sizes were obtained from 50 published intervention studies, involving 6,164 healthy older adults, and submitted to a three-level meta-analysis. Results showed that combined training produced a small advantage in comparison to single cognitive training on executive functions, whereas both types of training achieved similar effects on attention, memory, language, processing speed, and global cognition. Combined training achieved higher training gains in balance than single physical training, indicating a transfer from cognitive training to balance. Performing cognitive and physical exercise simultaneously, and interactive training (e.g., exergames, square stepping) produced the largest gains in executive functions, speed, and global cognition, as well as the largest improvements in physical functions. Aerobic training was associated with higher effects in attention and fitness, whereas non-aerobic training produced larger effects in global cognition and balance. For all cognitive and physical outcomes, training resulted more advantageous when performed in a social context, even though individual training obtained similar results in balance as group training.

Systematic Review Registration:www.crd.york.ac.uk/prospero/, identifier: CRD42020175632.

Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: A systematic review and network meta-analysis

BACKGROUND

Exercise is a promising nonpharmacological therapy for cognitive dysfunction, but it is unclear which type of exercise is most effective. The objective of this study was to compare and rank the effectiveness of various exercise interventions on cognitive function in patients with mild cognitive impairment (MCI) or dementia and to examine the effects of exercise on the symptoms relevant to cognitive impairment.

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, SPORTDiscus, and PsycInfo through September 2019 and included randomized controlled trials that examined the effectiveness of exercise interventions in patients with MCI or dementia. Primary outcomes included global cognition, executive cognition, and memory cognition. Secondary outcomes included activities of daily living, neuropsychiatric symptoms, and quality of life. Pairwise analyses and network meta-analyses were performed using a random effects model.

RESULTS

A total of 73 articles from 71 trials with 5606 participants were included. All types of exercise were effective in increasing or maintaining global cognition, and resistance exercise had the highest probability of being the most effective intervention in slowing the decrease in global cognition (standard mean difference (SMD) = 1.05, 95% confidence interval (95%CI): 0.56-1.54), executive function (SMD = 0.85, 95%CI: 0.21-1.49), and memory function (SMD = 0.32, 95%CI: 0.01-0.63) in patients with cognitive dysfunction. Subgroup analyses for patients with MCI revealed different effects, and multicomponent exercise was most likely to be the optimal exercise therapy for preventing the decline of global cognition (SMD = 0.99, 95%CI: 0.44-1.54) and executive function (SMD = 0.72, 95%CI: 0.06-1.38). However, only resistance exercise showed significant effects on memory function for patients with MCI (SMD = 0.35, 95%CI: 0.01-0.69). Exercise interventions also showed various effects on the secondary outcomes.

CONCLUSION

Resistance exercise has the highest probability of being the optimal exercise type for slowing cognitive decline in patients with cognitive dysfunction, especially in patients with dementia. Multicomponent exercise tends to be most effective in protecting global cognition and executive function in patients with MCI.

Aging Adults' Motivation to Use Embodied Conversational Agents in Instrumental Activities of Daily Living: Results of Latent Profile Analysis

The rapidly increasing share of ageing adults in the population drives the need and interest in assistive technology, as it has the potential to support ageing individuals in living independently and safely. However, technological development rarely reflects how needs, preferences, and interests develop in different ways while ageing. It often follows the strategy of “what is possible” rather than “what is needed” and “what preferred”. As part of personalized assistive technology, embodied conversational agents (ECAs) can offer mechanisms to adapt the technological advances with the stakeholders’ expectations. The present study explored the motivation among ageing adults regarding technology use in multiple domains of activities of daily living. Participants responded to the questionnaire on the perceived importance of instrumental activities of daily living and acceptance of the idea of using ECAs to support them. Latent profile analysis revealed four profiles regarding the motivation to use ECAs (i.e., a low motivation profile, two selective motivation profiles with an emphasis on physical and psychological well-being, and a high motivation profile). Profiles were compared in terms of their acceptance of ECA usage in various life domains. The results increase the knowledge needed in the development of assistive technology adapted to the expectations of ageing adults.

Which Exercise Interventions Can Most Effectively Improve Reactive Balance in Older Adults? A Systematic Review and Network Meta-Analysis

BACKGROUND

Reactive balance is the last line of defense to prevent a fall when the body loses stability, and beneficial effects of various exercise-based interventions on reactive balance in older adults have been reported. However, their pooled evidence on the relative effects has yet to be described.

OBJECTIVE

To review and evaluate the comparative effectiveness of various exercise-based interventions on reactive balance in older adults.

METHODS

Nine electronic databases and reference lists were searched from inception to August 2021. Eligibility criteria according to PICOS criteria were as follows: (1) population: older adults with the mean age of 65 years or above; (2) intervention and comparison: at least two distinct exercise interventions or one exercise intervention with a no-exercise controlled intervention (NE) compared in each trial; (3) outcome: at least one measure of reactive balance; (4) study: randomized controlled trial. The main network meta-analysis was performed on data from the entire older adult population, involving all clinical conditions as well as healthy older adults. Subgroup analyses stratified by characteristics of participants (healthy only) and reactive balance outcomes (simulated slip or trip while walking, simulated forward falls, being pushed or pulled, and movable platform) were also conducted.

RESULTS

Thirty-nine RCTs (n = 1388) investigating 17 different types of exercise interventions were included in the network meta-analysis. Reactive balance training as a single intervention presented the highest probability (surface under the cumulative ranking (SUCRA) score) of being the best intervention for improving reactive balance and the greatest relative effects vs. NE in the entire sample involving all clinical conditions [SUCRA = 0.9; mean difference (95% Credible Interval): 2.7 (1.0 to 4.3)]. The results were not affected by characteristics of participants (i.e., healthy older adults only) or reactive balance outcomes.

SUMMARY/CONCLUSION

The findings from the NMA suggest that a task-specific reactive balance exercise could be the optimal intervention for improving reactive balance in older adults, and power training can be considered as a secondary training exercise.

Leisure activities and instrumental activities of daily living: A 3-year cohort study from the Japan Gerontological Evaluation Study

AIM

We prospectively examined the association between leisure activities and changes in instrumental activities of daily living (IADL) among participants of the Japan Gerontological Evaluation Study (JAGES).

METHODS

We analyzed data collected from 49 732 JAGES participants (23 359 men and 26 373 women), aged ≥65 years, from 24 municipalities in Japan.

MEASUREMENTS

Baseline data were obtained for 25 types of leisure activities in which the cohort members participated. Baseline (2010) and follow-up (2013) data on IADL were collected - the outcome indicated changes in IADL scores from 2010 to 2013. We regressed changes in IADL scores from the 2010 to 2013 to the number of leisure activities.

RESULTS

Older adults who engaged in more leisure activities had higher changes in IADL scores than those who engaged in fewer leisure activities: the β values (95% confidence interval [CI]) of the IADL scores were 0.001 [-0.04-0.04], 0.04 [0.01-0.08], 0.09 [0.05-0.13], 0.09 [0.05-0.14], 0.08 [0.02-0.13], and 0.13 [0.07-0.18] for having one, two, three, four, five, and more than six types of leisure activities (P for trend <0.001), respectively. Similar associations were found for different types of leisure activities, including predominantly physical and cultural activities. Statistically significant linear trends were obtained among the group, solitary, and other leisure activity subgroups (P for trend <0.05).

CONCLUSIONS

Encouraging engagement in leisure activities may promote maintenance of IADL among older populations. Different types of leisure activities appear to have similar positive impacts on IADL. Geriatr Gerontol Int 2021; ••: ••-••.

Multi-component cognitive intervention for older adults with mixed cognitive levels: implementation and preliminary effectiveness in real-world settings

BACKGROUND

In most controlled studies of multi-component cognitive intervention, participants' cognitive levels are homogenous, which is contrary to real-world settings. There is a lack of research studying the implementation of evidence-based cognitive intervention in communities. This study describes the implementation and preliminary effectiveness of a Multi-component Cognitive Intervention using Simulated Everyday Tasks (MCI-SET) for older adults with different cognitive levels in real-world settings.

METHODS

Single group, pre-intervention assessment, post-intervention assessment, and 3-month follow-up research design. MCI-SET consists of 12 two-hour weekly sessions that include motor-cognitive tasks, cognitive training, and cognitive rehabilitation. One hundred and thirty participants, > = 65 and frail, dependence on > = one instrumental daily activity, or with confirmed dementia, from eight community centers were included. The primary outcome is general cognition (Montreal Cognitive Assessment-Taiwan, MoCA-T). Secondary outcomes are memory (Miami Prospective Memory Test, Digits Forward, Digits Backward), attention (Color Trail Test-Part 1), executive function (Color Trail Test-Part 2), and general function (Kihon Checklist-Taiwan).

RESULTS

Pre-intervention workshop for group leaders, standardized activity protocols, on-site observation, and ten weekly conferences were conducted to ensure implementation fidelity. MCI-SET had an 85% retention rate and 96% attendance rate. The participants had a mean age of 78.26 ± 7.00 and a mean MoCA-T score of 12.55 ± 7.43. 73% were female. General cognition (Hedges' g = 0.31), attention (Hedges' g = 0.23), and general function (Hedges' g = 0.31), showed significant post-intervention improvement with small effect size. Follow-ups showed maintained improvement in general cognition (Hedges' g = 0.33), and delayed effect on attention (Hedges' g = 0.20), short-term memory (Hedges' g = 0.38), and executive function (Hedges' g = 0.40). Regression analysis indicated that the intervention settings (day care centers vs neighborhood centers), the pre-intervention cognitive levels, and the pre-intervention general function of the participants were not associated with the outcomes.

CONCLUSIONS

MCI-SET is feasible and can improve the cognitive skills and general functions of older adults with heterogeneous cognitive skills or disabilities. It is essential to tailor programs to fit the interests of the participants and the culture of local communities. Group leaders must also have the skills to adjust the cognitive demands of the tasks to meet the heterogeneous cognitive levels of participants.

TRIAL REGISTRATION

This study was retrospectively registered at clinicaltrials.gov (Identifier: NCT04615169 ).

Effects of Semi-Immersive Virtual Reality-Based Cognitive Training Combined with Locomotor Activity on Cognitive Function and Gait Ability in Community-Dwelling Older Adults

This study aimed to investigate the effects of semi-immersive virtual reality-based cognitive training (VRCT) combined with locomotor activity on cognitive function, balance, and gait ability in older adults. Eighteen community-dwelling older adults participated in this study. Subjects who met the selection criteria were assigned to an experimental group (n = 9) and a control group (n = 9). The experimental group received VRCT combined with locomotor activity for 30 min a day, three times a week, for 6 weeks. The control group received tabletop activity-based cognitive training for the same amount of time. Before and after the training, the Korean Mini-Mental State Examination (K-MMSE), Trail Making Test (TMT; A and B), and Digit Span Test (DST; forward and backward) were used to evaluate cognitive function; and the Timed Up and Go (TUG) test and 10-m Walking Test (10MWT) were used to evaluate the improvement in the balance and gait ability parameters. After the intervention, the experimental group showed a significantly greater improvement in the TMT-A (p = 0.045) and DST-backward (p = 0.012) scores compared with the control group. Regarding the gait ability variable, the experimental group showed a significant improvement in the 10MWT test (p = 0.001). This study confirmed that semi-immersive VRCT combined with locomotor activity is useful for improving cognitive function and gait ability in older adults. Therefore, VRCT combined with locomotor activity can be used as a simultaneous intervention for cognitive rehabilitation and functional capacity improvement in older adults.

Individual Differences in the Effects of Physical Activity on Cognitive Function in People with Mild to Moderate Dementia

The aim of this study was to investigate whether the effect of physical activity on cognitive function in persons with dementia is moderated by patient characteristics as Apolipoprotein E and dementia type. We included 101 individuals with dementia and calculated the reliable change index to determine the change in global cognition, executive function, episodic memory, working memory, and processing speed before and after a 12-week exercise training. We found a higher treatment-related benefit in episodic memory in persons with non-Alzheimer’s disease compared to persons with Alzheimer’s disease, and in executive function in individuals with better baseline cognitive function.

Physical and Cognitive Training to Enhance Intensive Care Unit Survivors' Cognition: A Mapping Review

PURPOSE

The aim of this study was to examine current literature regarding effects of physical or cognitive training and simultaneous (dual-task) physical and cognitive training on cognition in adults surviving an intensive care unit (ICU) stay.

DESIGN

Systematic mapping.

METHODS

A literature search was conducted to examine effects of physical and/or cognitive training on cognitive processes.

RESULTS

Few studies targeted adults surviving ICU. Independently, physical and cognitive interventions improved cognition in healthy older adults with and without cognitive impairment. Simultaneous interventions may improve executive function. Small sample size and heterogeneity of interventions limited the ability to make inferences.

CONCLUSION

Literature supports positive effects of single- and dual-task training on recovering cognition in adults. This training could benefit ICU survivors who need to regain cognitive function and prevent future decline.

RELEVANCE TO PRACTICE

With the growing number of ICU survivors experiencing cognitive deficits, it is essential to develop and test interventions that restore cognitive function in this understudied population.

Combined physical and cognitive training for older adults with and without cognitive impairment: A systematic review and network meta-analysis of randomized controlled trials

Combining physical exercise with cognitive training is a popular intervention in dementia prevention trials and guidelines. However, it remains unclear what combination strategies are most beneficial for cognitive and physical outcomes. We aimed to compare the efficacy of the three main types of combination strategies (simultaneous, sequential or exergaming) to either intervention alone or control in older adults. Randomized controlled trials of combined cognitive and physical training were included in multivariate and network meta-analyses. In cognitively healthy older adults and mild cognitive impairment, the effect of any combined intervention relative to control was small and statistically significant for overall cognitive (k = 41, Hedges' g = 0.22, 95 % CI 0.14 to 0.30) and physical function (k = 32, g = 0.25, 95 % CI 0.13 to 0.37). Simultaneous training was the most efficacious approach for cognition, followed by sequential combinations and cognitive training alone, and significantly better than physical exercise. For physical outcomes, simultaneous and sequential training showed comparable efficacy as exercise alone and significantly exceeded all other control conditions. Exergaming ranked low for both outcomes. Our findings suggest that simultaneously and sequentially combined interventions are efficacious for promoting cognitive alongside physical health in older adults, and therefore should be preferred over implementation of single-domain training.

Effects of multimodal agility-like exercise training compared to inactive controls and alternative training on physical performance in older adults: a systematic review and meta-analysis

Background

Multimodal exercise training (MT) as a time-efficient training modality promotes a wide range of physical dimensions. Incorporating agility-like training aspects (coordination, changes of direction and velocity) into MT may further enhance physical outcomes highly relevant for activities of daily living. This meta-analysis investigated the effects of multimodal agility-like exercise training (MAT) on physical and cognitive performance compared to inactive (IC) and active controls (AC) in older adults.

Methods

Literature search was conducted in four health-related databases (PubMed, SCOPUS, SPORTDiscus and Web of Science). Randomized controlled trials with pre-post testing applying MAT (including aspects of training with at least two different traditional domains: strength, balance, endurance) and an agility-like component in community-dwelling older adults were screened for eligibility. Standardized mean differences (SMD) adjusting for small sample sizes (hedges’ g) were used to extract main outcomes (strength, gait, balance, mobility, endurance, cognition). Statistical analysis was conducted using a random effects inverse-variance model.

Results

Twenty trials with 1632 older adults were included. All effects were significantly in favour of MAT compared to IC: Strength, mobility and endurance revealed large overall effects (SMD: 0.88, 0.84, 1.82). Balance showed moderate effects (SMD: 0.6). Small overall effects were observed for gait (SMD: 0.41). Few data were available to compare MAT vs. AC with negligible or small effects in favour of MAT. Funnel plots did not reveal clear funnel shapes, indicating a potential risk of bias.

Conclusions

MAT may serve as a time-efficient training modality to induce positive effects in different physical domains. Compared to isolated training, MAT allows equal effect sizes at lower overall training volumes. More studies are needed to investigate the potential value of MAT with systematic training and load control, especially compared to other exercise-based interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11556-021-00256-y.

Dual-Task Exercise to Improve Cognition and Functional Capacity of Healthy Older Adults

Background

It has been suggested that physical inactivity and lack of stimulating cognitive activity are the two most significant modifiable risk factors to impair cognitive function. Although many studies that investigated the cognitive effects of physical exercise and cognitive stimuli in dual-task conditions showed improved cognitive performance, others have not confirmed these findings. The main aim of the present work is to analyze the effects of a dual-task multimodal physical exercise training, at moderate intensity, and cognitive stimulation on cognitive and physical function in healthy older adults.

Methods

This clinical trial was registered on the Brazilian Registry of Clinical Trials (RBR-9zrx3d). Here we tested the effects of a dual-task multimodal physical exercise training, at moderate intensity, on cognitive and physical function and quality of life in community dwelling older adults. The training protocol included 24 group sessions, 2/week, per 75 min. Cognition was assessed using CANTAB automated neuropsychological tests and Functional Capacity to Exercise tests. Performance was compared from baseline to post intervention and to a non-exercise control group using Mixed Linear Model for repeated measures.

Results

Control (CG) and dual-task (DTEx) groups progressed differentially over time on performance of episodic memory, sustained visual attention, functional mobility, cardiorespiratory fitness, lower limbs strength resistance, agility, quality of life and dual-task performance with significant improved DTEx performance. Control group did not show any significant changes on these tests except for showing a reduction in dual-task performance.

Conclusion

We suggest that the dual-task combination of multisensory cognitive stimulation and multimodal moderate physical exercise training, twice a week, may be adopted as an effective program to reduce progression of age-related cognitive decline and improve physical fitness and quality of life on healthy older adults.

Clinical Trial Registration

Brazilian Registry of Clinical Trials: https://ensaiosclinicos.gov.br/rg/RBR-9zrx3d -UTN code: U1111-1233-6349.

Effects of exergames and cognitive-motor dual-task training on cognitive, physical and dual-task functions in cognitively healthy older adults: An overview

This overview aims to summarize the effectiveness of cognitive-motor dual-task and exergame interventions on cognitive, physical and dual-task functions in healthy older adults, as well as the feasibility, safety, adherence, transfer and retention of benefits of these interventions. We searched for systematic reviews or meta-analyses assessing the effects of cognitive-motor dual-task and exergame interventions on cognitive, physical and dual-task functions in cognitively healthy older adults through eight databases (CDSR (Cochrane), MEDLINE (PubMed), Scopus, EMBASE, CINAHL, PsycINFO, ProQuest and SportDiscus). Two reviewers performed the selection, data extraction and risk of bias evaluation independently (PROSPERO ID: CRD42019143185). Eighteen reviews were included in this overview. Overall, positive effects of cognitive-motor dual-task interventions on cognitive, physical and dual-task functions, as well as exergames on cognitive functions only, were observed in cognitively healthy older adults. In contrast, the effects of exergames on physical functions are more controversial, and their effects on dual-task functions have not been studied. The feasibility, safety, adherence, transfer and retention of benefits for both intervention types are still unclear. Future studies should follow more rigorous methodological standards in order to improve the quality of evidence and provide guidelines for the use of cognitive-motor dual-task and exergame interventions in older adults.

The Potential of Immersive Virtual Reality for Cognitive Training in Elderly

The number of elderly is growing rapidly, including those that struggle with cognitive decline and, consequently, activities of daily living. Developing interventions that slow down cognitive decline would greatly benefit the autonomy of these elderly, as well as their caretakers. Virtual reality (VR) is an immersive and interactive human-computer interface with real-time simulation that is suggested to be a promising tool to improve cognitive functioning. This literature review discusses the features of immersive VR, including its opportunities and limitations, that are of special relevance for improving cognition in elderly. First, the high flexibility of VR allows for personalized and safe training of potentially harmful situations and isolated aspects of tasks. Second, VR's dynamic and real-time feedback on performance provides a labor-extensive tool for caretakers in elderly care. Third, the acquisition of high resolution data enables the exposure of subtle changes over time, relevant for detecting the nature and extent of cognitive changes in elderly, including those with dementia. Fourth, immersive VR has been related to cybersickness. Finally, VR is immersive and enables the perception and expression of emotions, motor behaviors, and multiple senses. Aged subjects are found to have sparing of emotional learning and show increased reliance on multisensory integration for learning. Moreover, they experience high levels of flow, motivation, and presence in VR setups. Despite the clear potential of immersive VR, the studies available are small scale and have not been replicated. The digital illiteracy of elderly and healthcare personnel form an additional barrier for implementation. Hence, while replication of outcomes and standardization of VR interventions is required before it can be used in standard care, VR may provide a particularly effective tool for training cognition in elderly.

Effects of simultaneous cognitive and aerobic exercise training on dual-task walking performance in healthy older adults: results from a pilot randomized controlled trial

Background

The ability to walk and perform cognitive tasks simultaneously is a key aspect of daily life. Performance declines in these dual-tasks may be associated with early signs of neurodegenerative disease and increased risk of falls. Thus, interventions to improve dual-task walking performance are of great interest for promoting healthy aging. Here, we present results of a pilot randomized controlled trial (RCT) to evaluate the effects of a simultaneous aerobic exercise and cognitive training intervention on dual-task walking performance in healthy older adults.

Methods

Community-dwelling, healthy older adults were recruited to participate in a 12-week RCT. Participants were randomized into one of four groups (n = 74): 1) cognitive training (COG), 2) aerobic exercise (EX), 3) combined aerobic exercise and cognitive training (EXCOG), and 4) video-watching control (CON). The COG and EXCOG groups both used a tablet-based cognitive training program that challenged aspects of executive cognitive function, memory, and processing speed. Performance on a dual-task walking test (DTWT; serial subtraction during two-minute walk) was assessed by researchers blinded to groupings before the intervention, and at 6 and 12 weeks. We included all participants randomized with baseline measurements in an intention to treat analysis using linear mixed effects models.

Results

We found a significant group by time interaction for cognitive performance on the DTWT (p = 0.039). Specifically, participants in the EXCOG, EX, and COG groups significantly improved on the cognitive aspect of the DTWT following the full 12-week intervention (p = 3.5e-7, p = 0.048, p = 0.048, respectively). The improvements in EXCOG were twice as large as in the other groups, and were significant at 6 weeks (p = 0.019). The CON group did not show a significant change in cognitive performance on the DTWT, and no group significantly altered dual-task gait measures following the intervention.

Conclusions

A simultaneous aerobic exercise and cognitive training intervention significantly improved cognitive performance during a DTWT in healthy older adults. Despite no change in DTWT gait measures, significant improvements in cognitive performance indicate that further investigation in a larger RCT is warranted.

Trial registration

Clinicaltrials.gov, NCT04120792, Retrospectively Registered 08 October 2019.