Interventions to Improve Gait in Older Adults with Cognitive Impairment: A Systematic Review

A Review of Recent Advances in Cognitive-Motor Dual-Tasking for Parkinson's Disease Rehabilitation

BACKGROUND

Parkinson's disease is primarily characterized by the degeneration of motor neurons, leading to significant impairments in movement. Initially, physical therapy was predominantly employed to address these motor issues through targeted rehabilitation exercises. However, recent research has indicated that cognitive training can enhance the quality of life for patients with Parkinson's. Consequently, some researchers have posited that the simultaneous engagement in computer-assisted motor and cognitive dual-task (CADT) may yield superior therapeutic outcomes.

METHODS

A comprehensive literature search was performed across various databases, and studies were selected following PRISMA guidelines, focusing on CADT rehabilitation interventions.

RESULTS

Dual-task training enhances Parkinson's disease (PD) rehabilitation by automating movements and minimizing secondary task interference. The inclusion of a sensor system provides real-time feedback to help patients make immediate adjustments during training. Furthermore, CADT promotes more vigorous participation and commitment to training exercises, especially those that are repetitive and can lead to patient boredom and demotivation. Virtual reality-tailored tasks, closely mirroring everyday challenges, facilitate more efficient patient adaptation post-rehabilitation.

CONCLUSIONS

Although the current studies are limited by small sample sizes and low levels, CADT rehabilitation presents as a significant, effective, and potential strategy for PD.

Cognitive control training with domain-general response inhibition does not change children's brains or behavior

Cognitive control is required to organize thoughts and actions and is critical for the pursuit of long-term goals. Childhood cognitive control relates to other domains of cognitive functioning and predicts later-life success and well-being. In this study, we used a randomized controlled trial to test whether cognitive control can be improved through a pre-registered 8-week intervention in 235 children aged 6-13 years targeting response inhibition and whether this leads to changes in multiple behavioral and neural outcomes compared to a response speed training. We show long-lasting improvements of closely related measures of cognitive control at the 1-year follow-up; however, training had no impact on any behavioral outcomes (decision-making, academic achievement, mental health, fluid reasoning and creativity) or neural outcomes (task-dependent and intrinsic brain function and gray and white matter structure). Bayesian analyses provide strong evidence of absent training effects. We conclude that targeted training of response inhibition does little to change children's brains or their behavior.

PEMOCS: theory derivation of a concept for PErsonalized MOtor-Cognitive exergame training in chronic Stroke-a methodological paper with an application example

Background

Coping with residual cognitive and gait impairments is a prominent unmet need in community-dwelling chronic stroke survivors. Motor-cognitive exergames may be promising to address this unmet need. However, many studies have so far implemented motor-cognitive exergame interventions in an unstructured manner and suitable application protocols remain yet unclear. We, therefore, aimed to summarize existing literature on this topic, and developed a training concept for motor-cognitive exergame interventions in chronic stroke.

Methods

The development of the training concept for personalized motor-cognitive exergame training for stroke (PEMOCS) followed Theory Derivation procedures. This comprised (1.1) a thorough (narrative) literature search on long-term stroke rehabilitation; (1.2) a wider literature search beyond the topic of interest to identify analogies, and to induce creativity; (2) the identification of parent theories; (3) the adoption of suitable content or structure of the main parent theory; and (4) the induction of modifications to adapt it to the new field of interest. We also considered several aspects of the "Framework for Developing and Evaluating Complex Interventions" by the Medical Research Council. Specifically, a feasibility study was conducted, and refining actions based on the findings were performed.

Results

A training concept for improving cognitive functions and gait in community-dwelling chronic stroke survivors should consider the principles for neuroplasticity, (motor) skill learning, and training. We suggest using a step-based exergame training for at least 12 weeks, 2-3 times a week for approximately 45 min. Gentile's Taxonomy for Motor Learning was identified as suitable fundament for the personalized progression and variability rules, and extended by a third cognitive dimension. Concepts and models from related fields inspired further additions and modifications to the concept.

Conclusion

We propose the PEMOCS concept for improving cognitive functioning and gait in community-dwelling chronic stroke survivors, which serves as a guide for structuring and implementing motor-cognitive exergame interventions. Future research should focus on developing objective performance parameters that enable personalized progression independent of the chosen exergame type.

Effect of dual-task training on balance in older adults: A systematic review and meta-analysis

PURPOSE

Our review aims to analyze the effect of dual-task training (DTT) on balance in healthy older adults.

METHODS

PubMed, EbscoHost, Web of Science (WOS), Scopus, Cochrane Library, MEDLINE, EBSCO Open Dissertations, ULAKBIM (TR Index) and YOK (Council of Higher Education Thesis Center) databases and the gray literature were searched. The quality of the studies was assessed with the Cochrane Risk of Bias tool and statistical analysis of the data was performed with Comprehensive Meta-Analysis (CMA) software. A funnel plot and Egger's test were used to detect publication bias. Fourteen studies with 691 participants were included.

RESULTS

According to the results of our study, DTT was found to have a significant benefit on balance in older adults than the non-intervention group (standardized mean difference (SMD): -0.691: -1.153, -0.229, 95 % confidence interval (CI)). Furthermore, DTT was superior to different intervention groups in improving balance in older adults (SMD: -0.229: -0.441, -0.016, 95 % CI).

CONCLUSION

The findings of this review suggest that DTT may be an effective intervention to improve balance in healthy older adults.

Functional Lower Extremity Strength Influences Stepping Strategy in Community-Dwelling Older Adults During Single and Dual-Task Walking

As age increases, a decline in lower extremity strength leads to reduced mobility and increased fall risks. This decline outpaces the age-related reduction in muscle mass, resulting in mobility limitations. Older adults with varying degrees of mobility-disability use different stepping strategies. However, the link between functional lower extremity strength and stepping strategy is unknown. Therefore, understanding how age-related reductions in functional lower extremity strength influence stepping strategy is vital to unraveling mobility limitations. Participants were recruited and tested at a local community event, where they were outfitted with IMUs and walked across a pressurized walkway. Our study reveals that older adults with normal strength prefer adjusting their step time during walking tasks, while those with reduced strength do not exhibit a preferred stepping strategy. This study provides valuable insights into the influence of functional lower extremity strength on stepping strategy in community-dwelling older adults during simple and complex walking tasks. These findings could aid in diagnosing gait deviations and developing appropriate treatment or management plans for mobility disability in older adults.

Gait and/or balance disturbances associated with Alzheimer's dementia among older adults with amnestic mild cognitive impairment: A longitudinal observational study

AIMS

To explore whether gait and/or balance disturbances are associated with the onset of Alzheimer's dementia (AD) among older adults with amnestic mild cognitive impairment (MCI).

DESIGN

This study employed a longitudinal retrospective cohort design.

METHODS

We obtained data from the National Alzheimer's Coordinating Center's Uniform Data Set collected from 35 National Institute on Aging Alzheimer's Disease Research Centers between September 2005 and December 2021. The mean age of participants (n = 2692) was 74.5 years with women making up 47.2% of the sample. Risk of incident AD according to baseline gait and/or balance disturbances as measured using the Postural Instability and Gait Disturbance Score, a subscale of the Unified Parkinson's Disease Rating Scale Motor Score, was examined by the Cox proportional hazards regression models adjusting for baseline demographics, medical conditions and study sites. The mean follow-up duration was 4.0 years.

RESULTS

Among all the participants, the presence or the severity of gait and/or balance disturbances was associated with an increased risk of AD. The presence or the severity of gait and/or balance disturbances was associated with a higher risk of Alzheimer's dementia among the subgroups of female and male participants.

CONCLUSION

Gait and/or balance disturbances may increase the risk of developing AD, regardless of sex.

IMPACT

Gait and/or balance disturbances among community-dwelling older adults with amnestic MCI may need to be frequently assessed by nurses to identify potential risk factors for cognitive decline.

NO PATIENT OR PUBLIC CONTRIBUTION

Given the secondary analysis, patients, service users, caregivers or members of the public were not directly involved in this study.

Tango-therapy vs physical exercise in older people with dementia; a randomized controlled trial

BACKGROUND

Dementia is a growing health concern that affects millions of people worldwide. Gait and mobility disorders are often present and represent a major risk factor for falls. The purpose of this study was to investigate the effectiveness of tango-therapy in gait speed, functional mobility, balance, falls, ability to perform activities of daily living and quality of life.

METHODS

A randomised controlled trial with 31 participants living in a specialised dementia unit, aged 65 to 93 years old, who were randomly assigned to tango group (IG) or physical exercise group (CG). The primary outcome was gait speed and Timed Up and Go test. The secondary outcomes include the Short Physical Performance Battery, the ability to perform activities of daily living (Katz Index) and quality of life (Quality of life in Alzheimer Disease). Measurements were performed at baseline, and after one and three months of training.

RESULTS

After 3 months, IG improved gait speed (p = 0.016), implying a statistically significant difference between groups in favour of IG (p = 0.003). CG significantly worsened the time to complete the TUG (p = 0.039). Both groups declined in their ability to perform activities of daily living, being statistically significant only in the CG (p < 0.001).

CONCLUSION

Tango interventions showed efficacy in improving gait speed and in mitigating the decline in functional mobility and ADL skill capacities. Allowing older people with dementia access to non-pharmacological interventions may be a successful strategy to prevent functional decline.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (ID: NCT05744011).

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.

Cognitive-motor interventions based on virtual reality and instrumental activities of daily living (iADL): an overview

Non-invasive, non-pharmacological interventions utilizing virtual reality (VR) represent a promising approach to enhancing cognitive function in patients with degenerative cognitive disorders. Traditional "pen and paper" therapies often lack the practical engagement in everyday activities that older individuals encounter in their environment. These activities pose both cognitive and motor challenges, underscoring the necessity of understanding the outcomes of such combined interventions. This review aimed to assess the advantages of VR applications that integrate cognitive-motor tasks, simulating instrumental activities of daily living (iADLs). We systematically searched five databases-Scopus, Web of Science, Springer Link, IEEE Xplore, and PubMed, from their inception until January 31, 2023. Our review revealed that motor movements, coupled with VR-based cognitive-motor interventions, activate specific brain areas and foster improvements in general cognition, executive function, attention, and memory. VR applications that meld cognitive-motor tasks and simulate iADLs can offer significant benefits to older adults. Enhanced cognitive and motor performance can promote increased independence in daily activities, thereby contributing to improved quality of life.

Executive dysfunction and effectiveness of physical program in older adults: which association?

BACKGROUND

Little is known about the association between executive function and the magnitude of improvement from personalised exercise interventions on gait performance among older-old adults.

AIM

We examined whether the effectiveness of personalised intervention on gait performance is dependent on the patient's baseline dysexecutive syndrome, as assessed by the Frontal Assessment Battery.

METHODS

A total of 175 older community-dwellers (83.57 ± 5.2 years; 70.2% female) were recruited from the day centre for after-care and rehabilitation in the Nantes Ambulatory Centre of the Clinical Gerontology (France), and were followed during a pre-post-intervention, single-arm retrospective design. The intervention consisted of an individual personalised rehabilitation program over a period of 7 weeks, with twice-weekly sessions (45 min each). Gait speed in four conditions (preferred, fast, and under two dual-task conditions), Timed Up and Go test, and handgrip strength test were assessed.

RESULTS

Using a pre-post analysis of covariance, a significant increase in dual-task gait speed while counting (+ 0.10 m/s; + 15%) and in dual-fluency gait speed (+ 0.06 m/s; + 10%), and in Timed Up and Go performance (- 2.9 s; + 17.8%) was observed after the rehabilitation program, regardless the baseline executive status.

DISCUSSION

An individual personalized intervention is effective to improve mobility performance and the dual-task gait speed in older-old adults. The magnitude of those effects is independent of the patient's baseline characteristics including the executive function status.

CONCLUSIONS

Even the most deficient baseline characteristics of patients should not be viewed as clinical barrier for implementing a beneficial individual intervention in high-risk older adults.

Factors Associated with Dual-Fluency Walk Speed Improvement after Rehabilitation in Older Patients

Walk speed measured under dual-task conditions (neurocognitive tasks) could reflect patient performance in real-life. Rehabilitation programs are effective in increasing walk speed, but few studies have evaluated the associations between geriatric factors and rehabilitation efficacy under dual-task conditions. Our objective was to investigate the association between geriatric factors and an increase in dual-task walk speed (threshold of 0.1 m/s), after a multidisciplinary rehabilitation program. We performed a retrospective cohort study that included patients aged 75 years and over, who underwent a complete rehabilitation program and who had a neurocognitive assessment at baseline. The primary outcome was the increase in the dual-task (fluency verbal task) walking speed between pre- and post-rehabilitation assessments. In this study, 145 patients were included, with a mean age of 83.6 years old. After rehabilitation, dual-task walk speed increase in 62 (43%) patients. In multivariate analysis, the following factors were associated with an increase in dual-task walk speed: IADL (OR 2.50, 95% CI [1.26; 4.94], p = 0.009), vitamin D level (OR 0.83, 95% CI [0.72; 0.95], p = 0.008), severe sarcopenia (OR 0.00, 95% CI [0.00; 0.32], p = 0.016), depression (OR 15.85, 95% CI [1.32; 190.40], p = 0.029), number of drugs (OR 1.41, 95% CI [1.04; 1.92], p = 0.027), initial dual-fluency walk speed (OR 0.92, 95% CI [0.86; 0.98], p = 0.014) and time interval between initial and final assessments (OR 0.98, 95% CI [0.96; 1.00], p = 0.06). Identifying patients that are less resilient to rehabilitation may promote a centered-patient approach for an individualized and optimized rehabilitation care.

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.

I Can Step Clearly Now, the TENS Is On: Transcutaneous Electric Nerve Stimulation Decreases Sensorimotor Uncertainty during Stepping Movements

Transcutaneous electric nerve stimulation (TENS) is a method of electrical stimulation that elicits activity in sensory nerves and leads to improvements in the clinical metrics of mobility. However, the underlying perceptual mechanisms leading to this improvement are unknown. The aim of this study was to apply a Bayesian inference model to understand how TENS impacts sensorimotor uncertainty during full body stepping movements. Thirty healthy adults visited the lab on two occasions and completed a motor learning protocol in virtual reality (VR) on both visits. Participants were randomly assigned to one of three groups: TENS on first visit only (TN), TENS on second visit only (NT), or a control group where TENS was not applied on either visit (NN). Using methods of Bayesian inference, we calculated the amount of uncertainty in the participants' center of mass (CoM) position estimates on each visit. We found that groups TN and NT decreased the amount of uncertainty in the CoM position estimates in their second visit while group NN showed no difference. The least amount of uncertainty was seen in the TN group. These results suggest that TENS reduces the amount of uncertainty in sensory information, which may be a cause for the observed benefits with TENS.

Participation in cognitive activities is associated with foot reaction time and gait speed in older adults

BACKGROUND

Given the evidence of the links between cognition and mobility, participation in cognitive activities may benefit neuromotor performance and mobility in older adults.

AIMS

To examine the association between participation in cognitive activities and foot reaction time (RT) and gait speed in community-dwelling older adults.

METHODS

The MOBILIZE Boston Study II (MBSII) re-enrolled 354 community-dwelling older adults aged ≥ 70 years from the original MBS cohort. Of these, 310 completed the performance testing and we excluded three participants who had Parkinson's disease. Cognitive Activities Scale (CAS) assessed participation in 17 cognitive activities. Simple and Choice foot RT (SRT, CRT, msec) and gait speed (m/s) were measured using a sensored GAITRite® gait mat.

RESULTS

The average age of the 307 participants was 84 years; 79% were white and 65% were women. The average CAS score was 25.5 ± 11.7, indicating participation in approximately 26 activities per week on average. The average foot SRT was 245 ± 57msec and average CRT was 323 ± 85msec. Usual-paced gait speed was 0.9 ± 0.3 m/s on average. More frequent participation in cognitive activities was associated with shorter SRT (β = - 0.759, p = 0.015) and CRT (β = - 1.125, p = 0.013), and faster gait speed (β = 0.003, p = 0.026), after adjusting for potential confounders.

DISCUSSION

Participation in cognitively stimulating activities may be beneficial for neuromotor performance and mobility in older adults.

CONCLUSIONS

Prospective and intervention studies are needed to determine whether participation in cognitive activities may prevent mobility decline over time, and thus reduce fall risk.

Short- and long-term effects of different exercise programs on the gait performance of older adults with subjective cognitive decline: A randomized controlled trial

BACKGROUND

Older adults, especially those with cognitive decline, often have poor gait performance, which results in poor clinical outcomes due to falls or decreased daily physical activity. The effects of various exercises on gait performance have been studied, whereas the short-term and long-term effects of different exercise modalities remain unknown.

OBJECTIVE

To compare the short- and long-term effects of aerobic training (AT), resistance training (RT), and combined training (CT) on the gait performance of community-dwelling older adults with subjective cognitive decline (SCD).

DESIGN

A four-arm, randomized controlled trial.

SETTING AND SUBJECTS

388 community-dwelling older adults with SCD (mean age, 72.3 years).

METHODS

Participants attended an exercise or education class twice a week for 26 weeks. 10 gait performance parameters were examined at baseline, post-intervention (Week 26), and after 26 weeks of follow-up (Week 52) using an electronic walkway system.

RESULTS

The mean adherence of exercise sessions was 82.5 to 85.9%. All exercise intervention induced an improvement in gait speed, stride time, cadence, stride length, and double-support time at Week 26 (p < .05), without significant intergroup differences among exercise interventions. However, only RT showed a significant effect on some spatiotemporal gait parameters at Week 52. The analyses for the gait variability parameters showed mild effects of all exercise interventions.

CONCLUSION

All of the exercise programs examined had a positive short-term effect on spatiotemporal gait parameters of older adults with SCD, despite no effect on gait variability parameters. RT are most recommended when long-lasting effects are the primary aim.

Impact of an individual personalised rehabilitation program on mobility performance in older-old people

BACKGROUND

Studies have shown benefits of exercise interventions on preferred and fast gait speed in healthy older adults, but the impact of a personalised rehabilitation program targeting a large cohort of non-disabled older-old adults has rarely been examined.

AIMS

The purpose was to determine whether personalised intervention-related improvements in gait and mobility performance in older-old adults were dependent on cognitive status and/or history of falls.

METHODS

Based on a pre-post design, 483 older-old persons (mean age: 83.3 ± 5.1 years) were followed during a personalised rehabilitation program over a period of 7 weeks, with twice-weekly sessions (45 min each). Gait speed in four conditions (preferred, fast, and under two dual-task conditions), static postural sway, Timed Up and Go test, Five Times Sit to Stand test, the ability to rise from the floor, and handgrip strength test were assessed.

RESULTS

Using a pre-post analysis of covariance, a significant increase in preferred gait speed (+ 20.1%), fast gait speed (+ 15.8%), and dual-task speed while counting (+ 13.4%) was observed after the rehabilitation, regardless of the baseline cognitive status and fall history. Similar improvements in TUG and maximal handgrip force were observed, with a significant reduction of performance time (-19.5%) or an increase of handgrip strength (+ 6.2%).

DISCUSSION

Results suggest the effectiveness of personalised intervention to improve a battery of physical performance measures in older-old adults, even for the frailest participants.

CONCLUSION

Implementing a personalised intervention for targeting the high-risk older-old adults in priority is critical regarding the clinically meaningful change in gait speed.

A Soft Robotic Intervention for Gait Enhancement in Older Adults

Falls continue to be a major safety and health concern for older adults. Researchers reported that increased gait variability was associated with increased fall risks. In the present study, we proposed a novel wearable soft robotic intervention and examined its effects on improving gait variability in older adults. The robotic system used customized pneumatic artificial muscles (PAMs) to provide assistive torque for ankle dorsiflexion during walking. Twelve older adults with low fall risks and twelve with medium-high fall risks participated in an experiment. The participants were asked to walk on a treadmill under no soft robotic intervention, inactive soft robotic intervention, and active soft robotic intervention, and their gait variability during treadmill walking was measured. The results showed that the proposed soft robotic intervention could reduce step length variability for elderly people with medium-high fall risks. These findings provide supporting evidence that the proposed soft robotic intervention could potentially serve as an effective solution to fall prevention for older adults.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

Feasibility and Effectiveness of a Biography-Based Physical Activity Intervention in Institutionalized People With Dementia: Quantitative and Qualitative Results From a Randomized Controlled Trial

The objective of this multicenter randomized controlled trial was to evaluate the feasibility and effectiveness of a physical activity intervention for institutionalized people with dementia, individualized by capacity and biography. The intervention group (n = 34; age: mean = 86.09 years; 79.40% female; mean Mini-Mental State Examination value = 18.59) participated in a multicomponent training program, which included daily activities, dancing, gardening, and sports/games, twice weekly for 3 months. The control group (n = 29; age: mean = 86.34 years; 75.90% female; mean Mini-Mental State Examination value = 19.90) received standard care. Feasibility was evaluated by means of focus groups and feedback questionnaires. Functional performance (Short Physical Performance Battery and Timed Up and Go Test), activities of daily living, and gait were outcomes for effectiveness. A high adherence rate (80.46%) and uniformly positive feedback indicate that the piloted training program is feasible. The results show preliminary effectiveness on functional performance (Short Physical Performance Battery mean t0 = 3.15; mean t1 = 4.50; p = .006) and gait (e.g., velocity mean t0 = 46.97; mean t1 = 58.04; p = .007).

Association Between Gait, Cognition, and Gray Matter Volumes in Mild Cognitive Impairment and Healthy Controls

AIMS

To assess the correlation between cognitive functioning and 3 gait parameters (gait speed, cadence, and stride length) in persons with mild cognitive impairment (MCI) and cognitively healthy controls and investigate linear correlations between gait and gray matter volumes.

MATERIALS AND METHODS

Participants were recruited at IRCCS San Camillo Hospital, Venice, Italy (MCI=43; age-matched controls=43). Participants underwent comprehensive neuropsychological assessment. Gait speed, cadence, and stride length, were assessed with the BTS FREEMG 300 device. Three-dimensional (3D) T1-weighted MR images were acquired using a 1.5 T Philips Achieva MRI system with a Turbo Field Echo sequence.

RESULTS

In MCI there was a positive correlation between gait speed and memory tests (P<0.05). In controls all 3 gait parameters correlated with executive functioning (P<0.01). Temporal and limbic areas (ie, superior temporal gyrus, thalamus and parahippocampal gyrus) were associated with gait parameters in MCI whereas in controls the associations were with frontal areas (ie, middle, inferior, and superior frontal gyrus) and in the cerebellum (anterior and posterior lobe).

CONCLUSIONS

Our results highlight a distinct pattern of association between gray matter volume and gait parameters in MCI patients and controls (temporal areas in MCI and frontal areas in healthy elderly), suggesting a relationship between dementia-related pathology and gait dysfunction.

A novel cognitive-motor exercise program delivered via a tablet to improve mobility in older people with cognitive impairment - StandingTall Cognition and Mobility

BACKGROUND

Evidence-based interventions to improve mobility in older people include balance, strength and cognitive training. Digital technologies provide the opportunity to deliver tailored and progressive programs at home. However, it is unknown if they are effective in older people, especially in those with cognitive impairment.

OBJECTIVE

The aim of this study was to examine the efficacy of a novel tablet-delivered cognitive-motor program on mobility in older people with cognitive impairment.

METHODS

This was a 6-month single-blind randomised controlled trial of older people living in the community with subjective and/or objective cognitive impairment. Participants randomised to the intervention were asked to follow a 120 min per week balance, strength and cognitive training program delivered via an app on an iPad. Both the intervention and control group received monthly phone calls and health fact sheets. The primary outcome measure was gait speed. Secondary measures included dual-task gait speed, balance (step test, FISCIT-4), 5 sit to stand test, cognition (executive function, memory, attention), mood and balance confidence. Adherence, safety, usability and feedback were also measured.

RESULTS

The planned sample size of 110 was not reached due to COVID-19 restrictions. A total of 93 (mean age 72.8 SD 7.0 years) participants were randomised to the two groups. Of these 77 participants returned to the follow-up clinic. In intention-to-treat analysis for gait speed, there was a non-significant improvement favouring the intervention group (β 0.04 m/s 95% CI -0.01, 0.08). There were no significant findings for secondary outcomes. Adherence was excellent (84.5%), usability of the app high (76.7% SD 15.3) and no serious adverse events were reported. Feedback on the app was positive and included suggestions for future updates.

CONCLUSION

Due to COVID-19 the trial was under powered to detect significant results. Despite this, there was a trend towards improvement in the primary outcome measure. The excellent adherence and positive feedback about the app suggest a fully powered trial is warranted.

Kinematic Changes in a Mouse Model of Penetrating Hippocampal Injury and Their Recovery After Intranasal Administration of Endometrial Mesenchymal Stem Cell-Derived Extracellular Vesicles

Locomotion speed changes appear following hippocampal injury. We used a hippocampal penetrating brain injury mouse model to analyze other kinematic changes. We found a significant decrease in locomotion speed in both open-field and tunnel walk tests. We described a new quantitative method that allows us to analyze and compare the displacement curves between mice steps. In the tunnel walk, we marked mice with indelible ink on the knee, ankle, and metatarsus of the left and right hindlimbs to evaluate both in every step. Animals with hippocampal damage exhibit slower locomotion speed in both hindlimbs. In contrast, in the cortical injured group, we observed significant speed decrease only in the right hindlimb. We found changes in the displacement patterns after hippocampal injury. Mesenchymal stem cell-derived extracellular vesicles had been used for the treatment of several diseases in animal models. Here, we evaluated the effects of intranasal administration of endometrial mesenchymal stem cell-derived extracellular vesicles on the outcome after the hippocampal injury. We report the presence of vascular endothelial growth factor, granulocyte–macrophage colony-stimulating factor, and interleukin 6 in these vesicles. We observed locomotion speed and displacement pattern preservation in mice after vesicle treatment. These mice had lower pyknotic cells percentage and a smaller damaged area in comparison with the nontreated group, probably due to angiogenesis, wound repair, and inflammation decrease. Our results build up on the evidence of the hippocampal role in walk control and suggest that the extracellular vesicles could confer neuroprotection to the damaged hippocampus.

The Impact of 12-Week Jaques-Dalcroze Eurhythmics Programme on the Dynamic Agility in Single-Dual-Task Conditions in Older Women: A Randomized Controlled Trial

Background

Progressive degenerative changes in the body of elderly people lead to a decrease in physical and mental fitness. Seniors have a problem with performing tasks that involve both physical and mental health at the same time. The risk of falls increases, the consequences of which in old age may be particularly dangerous. It was decided to investigate the impact of performing exercises involving both physical and mental spheres on the dynamic agility in older women.

Methods

73 women (69.9 ± 3.2) were divided into two groups: intervention (IG, n = 34) and control (CG, n = 39). Individuals with IG participated in the Jaques-Dalcroze Eurhythmics exercise programme for 12 weeks, twice a week for 45 minutes each. Dynamic agility was determined by the Timed Up and Go test, which was conducted both in single-task (TUG_ST) and dual-task (TUG_DT) conditions, where the participant was simultaneously counting down from 60 every 3. The percentage difference between the results of both tests (dual-task cost, DTC) was also determined. Both groups had two measurement sessions: one week before the start of the exercise programme and one week after the end of exercise programme.

Results

After 12 weeks of exercise, IG participants obtained significantly better results in TUG_DT (p < 0.001) and DTC (p = 0.003) tests. During this time, CG participants had significantly worse results in TUG_DT (p < 0.001) and DTC (p < 0.001) tests. In the TUG_ST test, neither IG nor CG achieved a significant change in the result. In each test, a significant interaction between the group assignment and the measurement session was observed: TUG_ST: F = 11.523, η²_P = 0.139, p = 0.001; TUG_DT: F = 60.227, η²_P = 0.458, p < 0.001; DTC: F = 32.382, η²_P = 0.313, p < 0.001.

Conclusion

JDE exercises with a frequency of twice a week, for about 12 weeks, have a significant impact on the improvement of the dynamic agility control in women over 65 years of age.

Metformin Reduces Aging-Related Leaky Gut and Improves Cognitive Function by Beneficially Modulating Gut Microbiome/Goblet Cell/Mucin Axis

Aging-related illnesses are increasing and effective strategies to prevent and/or treat them are lacking. This is because of a poor understanding of therapeutic targets. Low-grade inflammation is often higher in older adults and remains a key risk factor of aging-related morbidities and mortalities. Emerging evidence indicates that abnormal (dysbiotic) gut microbiome and dysfunctional gut permeability (leaky gut) are linked with increased inflammation in older adults. However, currently available drugs do not treat aging-related microbiome dysbiosis and leaky gut, and little is known about the cellular and molecular processes that can be targeted to reduce leaky gut in older adults. Here, we demonstrated that metformin, a safe Food and Drug Administration-approved antidiabetic drug, decreased leaky gut and inflammation in high-fat diet-fed older obese mice, by beneficially modulating the gut microbiota. In addition, metformin increased goblet cell mass and mucin production in the obese older gut, thereby decreasing leaky gut and inflammation. Mechanistically, metformin increased the goblet cell differentiation markers by suppressing Wnt signaling. Our results suggest that metformin can be used as a regimen to prevent and treat aging-related leaky gut and inflammation, especially in obese individuals and people with western-style high-fat dietary lifestyle, by beneficially modulating gut microbiome/goblet cell/mucin biology.

Executive function predicts decline in mobility after a fall: The MYHAT study

BACKGROUND

Evidence suggests that better cognitive functioning is associated with better mobility in older age. It is unknown whether older adults with better cognitive function are more resilient to mobility decline after a fall.

METHODS

Participants from the Monongahela Youghiogheny Healthy Aging Team (MYHAT) study were followed annually for up to 9 years for incident falls. We examined one-year (mean 1.0 year, SD 0.1) change in mobility pre- to post-fall using the Timed Up and Go (TUG) in relation to pre-fall cognition (executive function, attention, memory, and visuospatial function) among incident fallers (n = 598, mean age 79.1, SD = 7.0). Linear regression models tested the association of cognition with change in TUG. Interaction terms were tested to explore if age, sex, body mass index, physical activity, depressive symptoms, or visual acuity modified the associations of cognition and mobility among fallers. The association between cognition and one-year change in TUG was also tested in a comparison sample of non-fallers (n = 442, mean age 76.3, SD = 7.2).

RESULTS

Overall, mobility decline was greater in fallers compared to non-fallers. In fully-adjusted models, higher executive function, but not attention, memory, or visuospatial function, was associated with less decline in mobility among incident fallers. The effect was significantly stronger for those who were older, sedentary, and had lower body mass index. Higher scores in memory tests, but not in other domains, was associated with less mobility decline among non-fallers.

CONCLUSIONS

Higher executive function may offer resilience to mobility decline after a fall, especially among older adults with other risk factors for mobility decline. Future studies should assess whether executive function may be a helpful risk index of fall-related physical functional decline in geriatric settings.

Review of Gait, Cognition, and Fall Risks with Implications for Fall Prevention in Older Adults with Dementia

BACKGROUND

Older people with cognitive impairment are at increased risk of falls; however, fall prevention strategies have limited success in this population. The aim of this paper is to review the literature to inform a theoretical framework for fall prevention in older adults with dementia.

SUMMARY

A narrative review was conducted on fall risk factors in people with cognitive impairment, the relationship between cognition and gait, and their joint impact on the risk of falls. This was used to develop a theoretical framework for fall prevention for people with dementia. Executive function and motor function are closely related as they share neuroanatomy. This close relationship has been confirmed by observational studies including neuroimaging and intervention studies. Executive function is the cognitive domain most commonly associated with gait dysfunction. Attention, sensory integration, and motor planning are the sub-domains of executive function associated with risk of falls through gait dysfunction, whereas cognitive flexibility, judgement, and inhibitory control affect risk of falls through risk-taking behaviour. Key Messages: Gait, cognition, and falls are closely related. The comorbidity and interaction between gait abnormality and cognitive impairment may underpin the high prevalence of falls in older adults with dementia. Gait assessment and cognitive assessment, particularly executive function, should be integrated in fall risk screening. Assessment results should be interpreted and utilised using a multidisciplinary approach; specific strategies such as customised gait training and behavioural modulation should be considered as part of falls prevention for people with dementia.

Occupational therapist use of the 'Timed Up and Go' test in a Memory Clinic to compare performance between cognitive diagnoses and screen for falls risk

INTRODUCTION

Occupational therapists assess older patients attending Memory Clinics to address multiple facets, including memory, activities of daily living function, mobility and falls risk. Identifying deficits in motor and functional abilities represents a crucial and necessary component of cognitive diagnosis. The aim of this research was to compare performance on the TUG between patients with normal (NC), mild cognitive impairment (MCI) and dementia.

METHODS

A prospective single-blind single-centre cohort study was conducted in a Memory Clinic. Patients underwent comprehensive medical assessment, including the Mini Mental Status Examination (MMSE) to determine a cognitive diagnosis. The occupational therapist, blinded to any diagnosis, completed the TUG.

RESULTS

A total of 158 patients aged 60 years and older were recruited. The average TUG was 15.4 s, which was similar between men and women (p = .87). A TUG greater than ≥14 s was significantly associated with the use of a walking aid (p ≤ .001). The TUG increased with age and a slower TUG was associated with a greater number of previous falls (p = .023). The TUG did not significantly differ between patients with dementia, MCI and NC (p = .095). However, there was a significant difference comparing patients with NC and MCI (14.3 s) to those with dementia (16.4 s) (p = .048). There was a significant weak negative correlation between the MMSE and the TUG of -0.253 (p = .003). Univariate models showed that a patient's ability to ambulate independently contributed to 33% of the variance in the TUG, whereas previous falls contributed to 4%, highlighting the importance of physical function and intervention to target this.

CONCLUSION

A simple TUG test should be considered for use by occupational therapists in a Memory Clinic to screen patients at risk of falling. Patients diagnosed with dementia have a significantly slower TUG. However, this tool cannot assist with the early detection of patients with MCI.