Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial

BACKGROUND

Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear.

OBJECTIVE

This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty.

METHODS

This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ≥60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time × group) effects on the outcomes.

RESULTS

In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2%), had completed primary education (152/293, 52.1%), were married (167/293, 57.2%), lived with friends (127/293, 43.3%), and had no VR experience (232/293, 79.5%). In the intervention group, 81.6% (119/146) of participants attended >80% (13/16, 81%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7% to 5/146, 3%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes.

CONCLUSIONS

VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817.

It Is Not Just a Matter of Motivation: The Role of Self-Control in Promoting Physical Activity in Older Adults-A Bayesian Mediation Model

This study aimed to understand how psychological factors affect regular exercise in older adults, hypothesising that trait self-control mediates the relationship between motivation types (intrinsic, extrinsic, and amotivation) and exercise time. In this cross-sectional study, 430 older adults (mean age = 68.8 ± 6.72) completed questionnaires regarding their perceived trait self-control, motivation towards leisure activities, and level of physical activity. A Bayesian mediation analysis was performed, controlling for demographics. We documented positive direct (c' = 0.021, 95%CI [0.001, 0.043]) and indirect (ab = 0.028, 95%CI [0.014, 0.043]) effects of intrinsic motivation on exercise, a fully mediated indirect effect of extrinsic motivation on exercise (ab = 0.027, 95%CI [0.011, 0.046]), and negative direct (c' = -0.281, 95%CI [-0.368, -0.194]) and indirect (ab = -0.161, 95%CI [-0.221, -0.105]) effects of amotivation on exercise. There was no direct association between extrinsic motivation and exercise (c' = 0.013, 95% CI [-0.013, 0.037]). In conclusion, trait self-control mediates motivation to influence exercise behaviour in older adults. Intrinsically motivated individuals resist sedentary living and show higher self-control, while extrinsically motivated ones rely on self-control and are more susceptible to non-adherence during mental fatigue. High amotivation is linked to less exercise and reduced self-control, suggesting potential non-compliance with structured exercise interventions.

Randomized controlled trials of non-pharmacological interventions for healthy seniors: Effects on cognitive decline, brain plasticity and activities of daily living-A 23-year scoping review

Little is known about the simultaneous effects of non-pharmacological interventions (NPI) on healthy older adults' behavior and brain plasticity, as measured by psychometric instruments and magnetic resonance imaging (MRI). The purpose of this scoping review was to compile an extensive list of randomized controlled trials published from January 1, 2000, to August 31, 2023, of NPI for mitigating and countervailing age-related physical and cognitive decline and associated cerebral degeneration in healthy elderly populations with a mean age of 55 and over. After inventorying the NPI that met our criteria, we divided them into six classes: single-domain cognitive, multi-domain cognitive, physical aerobic, physical non-aerobic, combined cognitive and physical aerobic, and combined cognitive and physical non-aerobic. The ultimate purpose of these NPI was to enhance individual autonomy and well-being by bolstering functional capacity that might transfer to activities of daily living. The insights from this study can be a starting point for new research and inform social, public health, and economic policies. The PRISMA extension for scoping reviews (PRISMA-ScR) checklist served as the framework for this scoping review, which includes 70 studies. Results indicate that medium- and long-term interventions combining non-aerobic physical exercise and multi-domain cognitive interventions best stimulate neuroplasticity and protect against age-related decline and that outcomes may transfer to activities of daily living.

Changes in cardiovascular health and white matter integrity with aerobic exercise, cognitive and combined training in physically inactive healthy late-middle-aged adults: the "Projecte Moviment" randomized controlled trial

INTRODUCTION

This is a 12-weeks randomized controlled trial examining the effects of aerobic exercise (AE), computerized cognitive training (CCT) and their combination (COMB). We aim to investigate their impact on cardiovascular health and white matter (WM) integrity and how they contribute to the cognitive benefits.

METHODS

109 participants were recruited and 82 (62% female; age = 58.38 ± 5.47) finished the intervention with > 80% adherence. We report changes in cardiovascular risk factors and WM integrity (fractional anisotropy (FA); mean diffusivity (MD)), how they might be related to changes in physical activity, age and sex, and their potential role as mediators in cognitive improvements.

RESULTS

A decrease in BMI (SMD = - 0.32, p = 0.039), waist circumference (SMD = - 0.42, p = 0.003) and diastolic blood pressure (DBP) (SMD = - 0.42, p = 0.006) in the AE group and a decrease in BMI (SMD = - 0.34, p = 0.031) and DBP (SMD = - 0.32, p = 0.034) in the COMB group compared to the waitlist control group was observed. We also found decreased global MD in the CCT group (SMD = - 0.34; p = 0.032) and significant intervention-related changes in FA and MD in the frontal and temporal lobes in the COMB group.

CONCLUSIONS

We found changes in anthropometric measures that suggest initial benefits on cardiovascular health after only 12 weeks of AE and changes in WM microstructure in the CCT and COMB groups. These results add evidence of the clinical relevance of lifestyle interventions and the potential benefits when combining them.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT031123900.

Intrinsic functional brain connectivity changes following aerobic exercise, computerized cognitive training, and their combination in physically inactive healthy late-middle-aged adults: the Projecte Moviment

Lifestyle interventions have positive neuroprotective effects in aging. However, there are still open questions about how changes in resting-state functional connectivity (rsFC) contribute to cognitive improvements. The Projecte Moviment is a 12-week randomized controlled trial of a multimodal data acquisition protocol that investigated the effects of aerobic exercise (AE), computerized cognitive training (CCT), and their combination (COMB). An initial list of 109 participants was recruited from which a total of 82 participants (62% female; age = 58.38 ± 5.47) finished the intervention with a level of adherence > 80%. Only in the COMB group, we revealed an extended network of 33 connections that involved an increased and decreased rsFC within and between the aDMN/pDMN and a reduced rsFC between the bilateral supplementary motor areas and the right thalamus. No global and especially local rsFC changes due to any intervention mediated the cognitive benefits detected in the AE and COMB groups. Projecte Moviment provides evidence of the clinical relevance of lifestyle interventions and the potential benefits when combining them.

The Effect of Cognitive Training with Neurofeedback on Cognitive Function in Healthy Adults: A Systematic Review and Meta-Analysis

Background: Cognitive training aims to improve cognitive function through cognitive tasks or training games. Neurofeedback is a technique to monitor brain signals with either visual or auditory feedback. Previous studies suggest that a combination of cognitive training and neurofeedback has a superior effect on cognitive functions compared with cognitive training alone. However, no systematic reviews and meta-analyses of the benefits of cognitive training with neurofeedback (CTNF) exist. The purpose of this study was to examine the beneficial effects of CTNF in healthy adults using a systematic review and multilevel meta-analysis. Methods: PubMed, Scopus, PsychoINFO, and MEDLINE were searched for research papers reporting the results of interventions using CTNF. Results: After an initial screening of 234 records, three studies using near-infrared spectroscopy (NIRS) and one study using electroencephalography were extracted from the database. We performed a multi-level meta-analysis with three NIRS studies including 166 participants (mean ages ranged from 21.43 to 65.96 years). A multi-level meta-analysis revealed that CTNF has a beneficial effect on the episodic, long-term, and working memory domains. Conclusions: Although three studies were included in the systematic review and meta-analysis, our results indicate that CTNF using NIRS would lead to improvements in memory functioning.

Effects of exergame and bicycle exercise intervention on blood pressure and executive function in older adults with hypertension: A three-group randomized controlled study

Management of hypertension and prevention of cognitive decline are challenging public health problems. However, the effects of exergame intervention on blood pressure (BP) remain to be explored, and whether exergame intervention is an effective alternative to traditional physical exercise intervention for older adults with hypertension remains to be demonstrated. This study aimed to explore the effectiveness of moderate-intensity exergame intervention and bicycle exercise training on BP and executive function in older hypertensive patients. A total of 128 participants were randomly assigned to the exergame intervention group (n = 41), bicycle exercise intervention group (n = 44), and control group (n = 43). The intervention groups exercised for 60 min, 3 times per week, for 16 weeks, while the control group maintained their normal lifestyle. The results revealed that there were no significant differences between two intervention groups and control group in systolic BP and diastolic BP changes (ps > 0.05). Both intervention groups demonstrated significant improvements in working memory when compared with control group (exergame intervention group: -461.9 ms, p = 0.025; bicycle exercise intervention group: -470.1 ms, p = 0.021). There were no significant differences in systolic BP, diastolic BP, or working memory between the two intervention groups after 16 weeks of training (ps > 0.05). No difference in inhibition or cognitive flexibility was observed between the intervention and control groups (ps > 0.05). The current results showed that moderate-intensity exergame intervention did not produce significant benefits in reducing BP, but yielded similar beneficial effects in working memory to that of bicycle exercise intervention. More studies are needed on whether exergame intervention has the potential to be a promising supplemental therapeutic tool for older adults with hypertension.

Does the combination of exercise and cognitive training improve working memory in older adults? A systematic review and meta-analysis

Background

Cognitive functioning is dependent on working memory and a decline in working memory is the main cause of cognitive aging. Many studies have suggested that physical exercise or cognitive intervention can effectively improve working memory in the elderly. However, it is still unknown whether a combination of exercise and cognitive training (CECT) is more effective than either intervention alone. The present systematic review and meta-analysis were undertaken to evaluate the effect of CECT on working memory in the elderly.

Methods

The review was registered in the International Prospective Systematic Review (PROSPERO, CRD42021290138). Systematic searches were conducted on Web of Science, Elsevier Science, PubMed and Google Scholar. The data were extracted according to the PICOS framework. Comprehensive meta-analysis (CMA) software was used to perform the meta-analysis, moderator analysis and publication bias testing.

Results

The current meta-analysis included 21 randomized controlled trials (RCT). Results showed that CECT had a significantly greater impact on working memory in older adults compared to no intervention groups (SMD = 0.29, 95% CI [0.14-0.44], p < 0.01), with no significant difference between CECT and exercise (SMD = 0.16, 95% CI [-0.04-0.35], p = 0.12) or cognitive intervention alone (SMD = 0.08, 95% CI [-0.13-0.30], p = 0.44). Furthermore, the positive effect of CECT was moderated by intervention frequency and cognitive state.

Conclusions

The CECT can effectively improve working memory of older adults, but the effect of CECT compared to single intervention needs to be further explored.

Artificial Cognitive Systems Applied in Executive Function Stimulation and Rehabilitation Programs: A Systematic Review

This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13369-022-07292-5.

Comparison of Dual Task Training Versus Aerobics Training in Improving Cognition in Healthy Elderly Population

Background Cognitive impairments, particularly in old age, are pervasive and occur because of both normal and pathological senescence. Engaging in some routine bodily activities combined with activities that stimulate cognitive skills appears beneficial in increasing cognitive resistance to degenerative processes of the brain. Dual-task training (DTT) by combining motor and cognitive activities causes improvement, particularly in executive function, working memory and divided attention, whereas aerobic exercise training (AET) plays an important role in improving executive function, attention, and memory. In this study, we attempted to compare the efficiency of DTT versus AT in improving cognitive function in healthy older individuals. Methods Forty healthy older adults between 60 and 70 years of age who met the inclusion criteria participated in this study. They were randomly split into two groups A and B. Group A (64.05±3.17 years) received DTT three times a week, whereas group B (65.50±3.44 years) received AT five times a week. Both training programs were conducted for six weeks. Cognitive function was assessed using Trail Making Test (TMT)-A, TMT-B, and Montreal Cognitive Assessment (MoCA). The assessment was done at baseline (first day of intervention), on completion of the third week, and again at the end of the training session i.e., the sixth week. The Chi-square test and the student's paired and unpaired t-tests were used for statistical analysis with a level of significance P<0.05. Discussion and result Betterment in cognitive functions was evident after six weeks of DTT and AET. Post-intervention improvements were noted in TMT-A, TMT-B, and MoCA scores in both groups A and B (P>0.0001). However, the difference between the pre and post-intervention scores was greater for group A compared to group B indicative of remarkable improvements in cognitive function in group A. Conclusion The current study demonstrated that both DTT and AET are notably efficient in improving cognitive function in a healthy elderly population. However, in comparison, DTT was significantly more effective than AET (P<0.05). This shows that six weeks of DTT is effective in improving cognitive function and slowing age-associated cognitive decline in older adults.

Auditory Cognitive Training Improves Brain Plasticity in Healthy Older Adults: Evidence From a Randomized Controlled Trial

The number of older adults is increasing globally. Aging is associated with cognitive and sensory decline. Additionally, declined auditory performance and cognitive function affect the quality of life of older adults. Therefore, it is important to develop an intervention method to improve both auditory and cognitive performances. The current study aimed to investigate the beneficial effects of auditory and cognitive training on auditory ability and cognitive functions in healthy older adults. Fifty healthy older adults were randomly divided into four training groups-an auditory-cognitive training group (AC training; n = 13), an auditory training group (A training; n = 13), a cognitive training group (C training; n = 14), and an active control group (n = 12). During the training period, we reduced the sound intensity level in AC and A training groups and increase training task difficulty in AC, A, and C training groups based on participants' performance. Cognitive function measures [digit-cancelation test (D-CAT); logical memory (LM); digit span (DS)], auditory measures [pure-tone audiometry (PTA)], and magnetic resonance imaging (MRI) scans were performed before and after the training periods. We found three key findings. First, the AC training group showed difference between other training groups (A, C, and active control training groups) in regional gray matter volume (rGMV) in the right dorsolateral prefrontal cortex, the left inferior temporal gyrus (L. ITG), the left superior frontal gyrus, the left orbitofrontal cortex, the right cerebellum (lobule 7 Crus 1). Second, the auditory training factor groups (ATFGs, the AC and A training groups) improved auditory measures and increased the rGMV and functional connectivity (FC) in the left temporal pole compared to the non-ATFGs (the C training group and active control group). Third, the cognitive training factor groups (CTFGs; the AC and C training groups) showed statistically significant improvement in cognitive performances in LM and D-CAT compared to the non-CTFGs (the A training group and active control group). Therefore, the auditory training factor and cognitive training factor would be useful in enhancing the quality of life of older adults. The current AC training study, the plasticity of the brain structure was observed after 4 weeks of training.

What Is Targeted When We Train Working Memory? Evidence From a Meta-Analysis of the Neural Correlates of Working Memory Training Using Activation Likelihood Estimation

Working memory (WM) is the system responsible for maintaining and manipulating information, in the face of ongoing distraction. In turn, WM span is perceived to be an individual-differences construct reflecting the limited capacity of this system. Recently, however, there has been some evidence to suggest that WM capacity can increase through training, raising the possibility that training can functionally alter the neural structures supporting WM. To address the hypothesis that the neural substrates underlying WM are targeted by training, we conducted a meta-analysis of functional magnetic resonance imaging (fMRI) studies of WM training using Activation Likelihood Estimation (ALE). Our results demonstrate that WM training is associated exclusively with decreases in blood oxygenation level-dependent (BOLD) responses in clusters within the fronto-parietal system that underlie WM, including the bilateral inferior parietal lobule (BA 39/40), middle (BA 9) and superior (BA 6) frontal gyri, and medial frontal gyrus bordering on the cingulate gyrus (BA 8/32). We discuss the various psychological and physiological mechanisms that could be responsible for the observed reductions in the BOLD signal in relation to WM training, and consider their implications for the construct of WM span as a limited resource.

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.

Cognitive Training with Neurofeedback Using NIRS Improved Cognitive Functions in Young Adults: Evidence from a Randomized Controlled Trial

(1) Background: A previous study has shown that cognitive training with neurofeedback (CT-NF) using down-regulation improves cognitive functions in young adults. Neurofeedback has two strategies for manipulating brain activity (down-regulation and upregulation). However, the benefit of CT-NF with the upregulation of cognitive functions is still unknown. In this study, we investigated whether the upregulation of CT-NF improves a wide range of cognitive functions compared to cognitive training alone. (2) Methods: In this double-blinded randomized control trial (RCT), 60 young adults were randomly assigned to one of three groups: CT-NF group, CT alone group, and an active control (ACT) group who played a puzzle game. Participants in the three groups used the same device (tablet PC and 2ch NIRS (near-infrared spectroscopy)) and performed the training game for 20 min every day for four weeks. We measured brain activity during training in all groups, but only CT-NFs received NF. We also measured a wide range of cognitive functions before and after the intervention period. (3) Results: The CT-NF groups showed superior beneficial effects on episodic memory, working memory, and attention compared to the CT alone and ACT groups. In addition, the CT-NF group showed an increase in brain activity during CT, which was associated with improvements in cognitive function. (4) Discussion: This study first demonstrated that the CT-NF using the upregulation strategy has beneficial effects on cognitive functions compared to the CT alone. Our results suggest that greater brain activities during CT would enhance a benefit from CT.

Gamified Dual-Task Training for Individuals with Parkinson Disease: An Exploratory Study on Feasibility, Safety, and Efficacy

Objectives: The feasibility and safety of the use of neurorehabilitation technology (SMARTfit^® Trainer system) by physical therapists in implementing a gamified physical-cognitive dual-task training (DTT) paradigm for individuals with Parkinson disease (IWPD) was examined. Additionally, the efficacy of this gamified DTT was compared to physical single-task training (STT), both of which were optimized using physio-motivational factors, on changes in motor and cognitive outcomes, and self-assessed disability in activities of daily living. Methods: Using a cross-over study design, eight participants with mild-to-moderate idiopathic PD (including one with mild cognitive impairment) completed both training conditions (i.e., gamified DTT and STT). For each training condition, the participants attended 2–3 sessions per week over 8.8 weeks on average, with the total amount of training being equivalent to 24 1 h sessions. A washout period averaging 11.5 weeks was inserted between training conditions. STT consisted of task-oriented training involving the practice of functional tasks, whereas for gamified DTT, the same task-oriented training was implemented simultaneously with varied cognitive games using an interactive training system (SMARTfit^®). Both training conditions were optimized through continual adaptation to ensure the use of challenging tasks and to provide autonomy support. Training hours, heart rate, and adverse events were measured to assess the feasibility and safety of the gamified DTT protocol. Motor and cognitive function as well as perceived disability were assessed before and after each training condition. Results: Gamified DTT was feasible and safe for this cohort. Across participants, significant improvements were achieved in more outcome measures after gamified DTT than they were after STT. Individually, participants with specific demographic and clinical characteristics responded differently to the two training conditions. Conclusion: Physical therapists’ utilization of technology with versatile hardware configurations and customizable software application selections was feasible and safe for implementing a tailor-made intervention and for adapting it in real-time to meet the individualized, evolving training needs of IWPD. Specifically in comparison to optimized STT, there was a preliminary signal of efficacy for gamified DTT in improving motor and cognitive function as well as perceived disability in IWPD.

Pilot testing of Dual-task Zumba Gold (DTZ) for community-dwelling people with mild cognitive impairment: A mixed-methods study

Dual-tasking (e.g., enrichment of physical activities with mental exercises) is an innovative strategy to enhance older adults' cognition. Meanwhile, Zumba is a popular dance program, but research is limited about its utility on older people or those with mild cognitive impairment (MCI). This study assessed the feasibility of a new intervention called dual-task Zumba Gold (DTZ) for people with MCI. A mixed-methods feasibility study involving ten people aged ≥55 years with MCI was conducted from December 2020 to March 2021. Nine participants completed the study (90%) with high intervention acceptability. Program adherence (90.3%) and implementation fidelity (92.2%) were high. Participants also expressed the program's benefits, challenges, and facilitators. Moreover, pilot test results suggested improvements in global cognition (Z=-2.680; p=0.007), quality of life (Z=-2.688; p=0.008), and mobility (Z=-2.333; p=0.020). Hence, DTZ is feasible and acceptable for people with MCI, offering potential multidomain effects. Future randomized controlled studies should confirm these outcomes.