The Enhanced Interactive Physical and Cognitive Exercise System (iPACESTM v2.0): Pilot Clinical Trial of an In-Home iPad-Based Neuro-Exergame for Mild Cognitive Impairment (MCI)

Effect of home-based and remotely supervised combined exercise and cognitive intervention on older adults with mild cognitive impairment (COGITO): study protocol for a randomised controlled trial

INTRODUCTION

Mild cognitive impairment (MCI) is an intermediate phase between normal cognitive ageing and dementia and poses a serious threat to public health worldwide; however, it might be reversible, representing the best opportunity for secondary prevention against serious cognitive impairment. As a non-pharmacological intervention for those patients, interventions that combine physical exercise and cognitive training, whether delivered simultaneously or sequentially, may have superior effects on various cognitive domains, including global cognition, memory, executive function and attention. The supportive evidence remains incomplete. This study aims to assess the effectiveness of a combined exercise and cognitive intervention in Chinese older adults with mild cognitive impairment (COGITO), empowered by digital therapy and guided by the Health Action Process Model and the Theory of Planned Behaviour (HAPA-TPB theory) in a home-based setting.

METHODS AND ANALYSIS

This study is a randomised controlled, assessor-blinded multi-centre study. Four parallel groups will include a total of 160 patients, receiving either a combined exercise and cognitive intervention, an isolated exercise intervention, an isolated cognitive intervention or only health education. These interventions will be conducted at least twice a week for 50 min each session, over 3 months. All interventions will be delivered at home and remotely monitored through RehabApp and Mini-programme, along with an arm-worn heart rate telemetry device. Specifically, supervisors will receive participants' real-time training diaries, heart rates or other online monitoring data and then provide weekly telephone calls and monthly home visits to encourage participants to complete their tasks and address any difficulties based on their training information. Eligible participants are community-dwelling patients with no regular exercise habit and diagnosed with MCI. The primary outcome is cognitive function assessed by the Alzheimer's Disease Assessment Scale-Cognitive (ADAS-Cog) and Community Screening Instrument for Dementia (CSI-D), with baseline and three follow-up assessments. Secondary outcomes include quality of life, physical fitness, sleep quality, intrinsic capacity, frailty, social support, adherence, cost-effectiveness and cost-benefit.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board of Peking University. Research findings will be presented to stakeholders and published in peer-reviewed journals and at provincial, national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300073900.

The Best of Two Worlds to Promote Healthy Cognitive Aging: Definition and Classification Approach of Hybrid Physical Training Interventions

A healthy lifestyle can be an important prerequisite to prevent or at least delay the onset of dementia. However, the large number of physically inactive adults underscores the need for developing and evaluating intervention approaches aimed at improving adherence to a physically active lifestyle. In this regard, hybrid physical training, which usually combines center- and home-based physical exercise sessions and has proven successful in rehabilitative settings, could offer a promising approach to preserving cognitive health in the aging population. Despite its potential, research in this area is limited as hybrid physical training interventions have been underused in promoting healthy cognitive aging. Furthermore, the absence of a universally accepted definition or a classification framework for hybrid physical training interventions poses a challenge to future progress in this direction. To address this gap, this article informs the reader about hybrid physical training by providing a definition and classification approach of different types, discussing their specific advantages and disadvantages, and offering recommendations for future research. Specifically, we focus on applying digital technologies to deliver home-based exercises, as their use holds significant potential for reaching underserved and marginalized groups, such as older adults with mobility impairments living in rural areas.

The AUstralian multidomain Approach to Reduce dementia Risk by prOtecting brain health With lifestyle intervention study (AU-ARROW): A study protocol for a single-blind, multi-site, randomized controlled trial

INTRODUCTION

The Finnish Geriatric Intervention Study (FINGER) led to the global dementia risk reduction initiative: World-Wide FINGERS (WW-FINGERS). As part of WW-FINGERS, the Australian AU-ARROW study mirrors aspects of FINGER, as well as US-POINTER.

METHOD

AU-ARROW is a randomized, single-blind, multisite, 2-year clinical trial (n = 600; aged 55-79). The multimodal lifestyle intervention group will engage in aerobic exercise, resistance training and stretching, dietary advice to encourage MIND diet adherence, BrainHQ cognitive training, and medical monitoring and health education. The Health Education and Coaching group will receive occasional health education sessions. The primary outcome measure is the change in a global composite cognitive score. Extra value will emanate from blood biomarker analysis, positron emission tomography (PET) imaging, brain magnetic resonance imaging (MRI), and retinal biomarker tests.

DISCUSSION

The finalized AU-ARROW protocol is expected to allow development of an evidence-based innovative treatment plan to reduce cognitive decline and dementia risk, and effective transfer of research outcomes into Australian health policy.

Highlights

Study protocol for a single-blind, randomized controlled trial, the AU-ARROW Study.The AU-ARROW Study is a member of the World-Wide FINGERS (WW-FINGERS) initiative.AU-ARROW's primary outcome measure is change in a global composite cognitive score.Extra significance from amyloid PET imaging, brain MRI, and retinal biomarker tests.Leading to development of an innovative treatment plan to reduce cognitive decline.

Effects of combined dietary intervention and physical-cognitive exercise on cognitive function and cardiometabolic health of postmenopausal women with obesity: a randomized controlled trial

BACKGROUND

Postmenopausal women with obesity are markedly at risk of cognitive impairment and several health issues. Emerging evidence demonstrated that both diet and exercise, particularly physical-cognitive exercise are involved in cognitive and health benefits. However, the comparative effect of diet, exercise, and combined interventions in postmenopausal women with obesity on cognition and cardiometabolic health is still lacking. Identifying the effective health promotion program and understanding changes in cardiometabolic health linking these interventions to cognition would have important medical implications. This RCT aimed to examine the effect of single and combined interventions of diet and exercise on cognitive function and cardiometabolic health in postmenopausal women with obesity.

METHODS

Ninety-two postmenopausal women with obesity were randomly assigned to diet group (intermittent fasting 2 days/week, 3 months), exercise group (physical-cognitive exercise 3 days/week, 3 months), combined group, or control group (n = 23/group). All cognitive outcomes and cardiometabolic outcomes were measured at baseline and post-3 months. Primary outcomes were executive functions, memory, and plasma BDNF levels. Secondary outcomes were global cognition, attention, language domain, plasma adiponectin levels, IL-6 levels, metabolic parameters, and physical function.

RESULTS

At the end of the 3-month intervention, the exercise and combined group demonstrated significant memory improvement which was accompanied by significant improvements in plasma BDNF level, insulin levels, HOMA-IR, %body fat, and muscle strength when compared to controls (p < 0.05). Only the combined intervention group demonstrated a significant improvement in executive function and increased plasma adiponectin levels when compared to control (p < 0.05). Surprisingly, no cognitive improvement was observed in the diet group (p > 0.05). Significant reduction in cholesterol levels was shown in the diet and combined groups when compared to controls (p < 0.05). Among the three intervention groups, there were no significant differences in all cognitive outcomes and cardiometabolic outcomes (p > 0.05). However, all three intervention groups showed significant improvements in plasma BDNF levels, weight, BMI, WHR, fat mass, and predicted VO2 max, when compared to control (p < 0.05).

CONCLUSION

These findings suggest that combined physical-cognitive exercise and dietary intervention are promising interventions to improve cognition and obesity-related complications of postmenopausal women with obesity.

TRIAL REGISTRATION

NCT04768725 ( https://clinicaltrials.gov ) 24th February 2021.

Acceptability Assessment of an Executive Function Training Game FISHERMAN for Older Adults

Objective: In recent years, an increasing number of gamification tools have been developed for older adults; however, few studies have explored the acceptability of these tools after initial use and sustained use in older adults. In the current study, we focus on "FISHERMAN," an executive function training game containing a cognitive game and an exergame, with the aim of investigating and comparing the acceptability of both versions of "FISHERMAN" after initial use and 3 months of sustained use in older adults. Materials and Methods: Seventy-six older adults were randomly assigned to the cognitive game training group or the exergame training group. Participants completed two 1-hour sessions per week for 12 weeks. Acceptability was evaluated through a validated, 7-point, self-rating, Interactive Technology Art Installation Technology Acceptance Model Questionnaire after the first and last training sessions, with higher ratings representing higher acceptability. The questionnaire included 22 items and 9 acceptability dimensions: usage behavior, intention to use, perceived usefulness, perceived ease of use, perceived playfulness, subjective norm, image, output quality, and result demonstrability. Descriptive statistics were conducted to evaluate acceptability after initial and sustained use. Two-way (time: initial use and sustained use; group: cognitive game group and exergame group) repeated ANOVAs were conducted to investigate the differences in acceptability. Post hoc, within-group, paired-sample t test analyses were performed to evaluate changes in game acceptability for each group over time. Results: After initial use and 3 months of sustained use, the average scores for overall acceptability and individual dimensions exceeded 5.5 of 7 points in both groups. The two groups presented different changes from initial use to sustained use. The overall acceptability, usage behavior, perceived usefulness, and perceived ease of use were significantly improved after training within the cognitive game group, while perceived playfulness was significantly reduced within the exergame group. Conclusions: The current study provided preliminary evidence that older adults had high acceptability for both the cognitive game and exergame versions of "FISHERMAN." After sustained use, acceptability of the cognitive game increased and acceptability of the exergame decreased, highlighting the importance of assessing game acceptability after initial and sustained use.

A thematic review on therapeutic toys and games for the elderly with Alzheimer's disease

PURPOSE

Alzheimer's disease (AD) is a common and devastating neurological ailment that affects millions of the elderly worldwide. Therapeutic toys and games have emerged as potential non-pharmacological interventions for AD. However, despite a growing number of documents on the subject, research on the future direction of therapeutic toys and games for AD remains scarce. To address this gap, this study aims to (1) map the future trends of therapeutic toys and games for AD and (2) identify the categories and design characteristics.

MATERIALS AND METHODS

Using a thematic review framework, a systematic literature search was conducted in two electronic databases (Scopus and WoS) using established criteria. Thematic analysis was done using ATLAS.ti 23 to identify prominent themes, patterns and trends.

RESULTS

A total of 180 documents were found. Twenty-five articles met the inclusion criteria. A thematic review of these 25 articles identified 13 initial codes, which were been clustered into four themes: detection and evaluation; intervention; toy/game category; and design characteristics. The word "Cognitive" appears most frequently in documents according to word cloud.

CONCLUSIONS

Therapeutic toys and games are used to detect and as an intervention for AD. Most of the current studies focused on specific cognitive functions. More research is needed about play therapy for neuropsychiatric symptoms. This thematic review also proposed a conceptual framework for designing toys and games tailored to the needs of the elderly with AD, offering valuable insights to future researchers focusing on this domain.

Alexa, let's train now! - A systematic review and classification approach to digital and home-based physical training interventions aiming to support healthy cognitive aging

BACKGROUND

There is mounting evidence that regular physical activity is an important prerequisite for healthy cognitive aging. Consequently, the finding that almost one-third of the adult population does not reach the recommended level of regular physical activity calls for further public health actions. In this context, digital and home-based physical training interventions might be a promising alternative to center-based intervention programs. Thus, this systematic review aimed to summarize the current state of the literature on the effects of digital and home-based physical training interventions on adult cognitive performance.

METHODS

In this pre-registered systematic review (PROSPERO; ID: CRD42022320031), 5 electronic databases (PubMed, Web of Science, PsycInfo, SPORTDiscus, and Cochrane Library) were searched by 2 independent researchers (FH and PT) to identify eligible studies investigating the effects of digital and home-based physical training interventions on cognitive performance in adults. The systematic literature search yielded 8258 records (extra 17 records from other sources), of which 27 controlled trials were considered relevant. Two reviewers (FH and PT) independently extracted data and assessed the risk of bias using a modified version of the Tool for the assEssment of Study qualiTy and reporting in EXercise (TESTEX scale).

RESULTS

Of the 27 reviewed studies, 15 reported positive effects on cognitive and motor-cognitive outcomes (i.e., performance improvements in measures of executive functions, working memory, and choice stepping reaction test), and a considerable heterogeneity concerning study-related, population-related, and intervention-related characteristics was noticed. A more detailed analysis suggests that, in particular, interventions using online classes and technology-based exercise devices (i.e., step-based exergames) can improve cognitive performance in healthy older adults. Approximately one-half of the reviewed studies were rated as having a high risk of bias with respect to completion adherence (≤85%) and monitoring of the level of regular physical activity in the control group.

CONCLUSION

The current state of evidence concerning the effectiveness of digital and home-based physical training interventions is mixed overall, though there is limited evidence that specific types of digital and home-based physical training interventions (e.g., online classes and step-based exergames) can be an effective strategy for improving cognitive performance in older adults. However, due to the limited number of available studies, future high-quality studies are needed to buttress this assumption empirically and to allow for more solid and nuanced conclusions.

Exergames improve cognitive function in older adults and their possible mechanisms: A systematic review

Objective

The degree of aging in China is deepening, leading to cognitive decline and seriously affecting the health status of the elderly. This article explores the benefits of exergames in improving cognitive function in older adults through a literature review, with aim of contributing to the development of healthy aging.

Methods

Using PubMed, Web of Science, CNKI, dimensional spectrum, search for research papers from 2005 to April 2023 by using keywords such as a somatosensory game, cognitive function, execute function, working memory, aged and suppression control. PEDro Scale was used to check the quality of the literature.

Results

A total of 16 papers were included in the review. Exergames improve the executive function of the elderly and support the relationship between exergames and cognitive performance in older adults. From a mechanistic perspective, somatosensory play promotes signal transduction of brain neurotrophin, thereby protecting the structure and function of neurons in specific brain regions and delays the decline of executive function in older adults as much as possible.

Conclusions

It is recommended to use exergames as an intervention measure for the physical and mental health preservation of older adults. Suggest adopting personalised exergames in the future to explore the impact of cognitive and physical functions in elderly people, as well as measurable changes in brain structure.

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.

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.

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.

Design Considerations for an Exergame-Based Training Intervention for Older Adults With Mild Neurocognitive Disorder: Qualitative Study Including Focus Groups With Experts and Health Care Professionals and Individual Semistructured In-depth Patient Interviews

BACKGROUND

Exergames have attracted growing interest in the prevention and treatment of neurocognitive disorders. The most effective exergame and training components (ie, exercise and training variables such as frequency, intensity, duration, or volume of training and type and content of specific exergame scenarios) however remain to be established for older adults with mild neurocognitive disorders (mNCDs). Regarding the design and development of novel exergame-based training concepts, it seems of crucial importance to explicitly include the intended users' perspective by adopting an interactive and participatory design that includes end users throughout different iterative cycles of development.

OBJECTIVE

This study aimed to determine the capabilities, treatment preferences, and motivators for the training of older adults with mNCD and the perspectives of individuals on training goals and settings and requirements for exergame and training components.

METHODS

A qualitative study including expert focus groups and individual semistructured in-depth patient interviews was conducted. Data were transcribed to a written format to perform qualitative content analysis using QCAmap software.

RESULTS

In total, 10 experts and health care professionals (80% females) and 8 older adults with mNCD (38% females; mean age 82.4, SD 6.2 years) were recruited until data saturation was observed.

CONCLUSIONS

The psychosocial consequences of patients' self-perceived cognitive deterioration might be more burdensome than the cognitive changes themselves. Older adults with mNCD prefer integrative forms of training (such as exergaming) and are primarily motivated by enjoyment or fun in exercising and the effectiveness of the training. Putting the synthesized perspectives of training goals, settings, and requirements for exergames and training components into context, our considerations point to opportunities for improvement in research and rehabilitation, either by adapting existing exergames to patients with mNCDs or by developing novel exergames and exergame-based training concepts specifically tailored to meet patient requirements and needs.

The Effects of Combined Physical and Cognitive Interventions on Direct and Indirect Fall Outcomes for the Elderly with Mild Cognitive Impairment: A Systematic Review

This review was intended to determine the effectiveness of physical and cognitive training (PCT) on falls and fall-related factors and cognitive function among community-dwelling elderly people with mild cognitive impairment (MCI). A systematic literature search was performed of the MEDLINE, CINAHL, Web of Sciences, Scopus, ProQuest, Embase, and Google Scholar databases for articles published from 2010 to 2020. The studies that combined PCT to assess their impacts on fall outcomes both directly and indirectly were included. Study quality was assessed using the standardized JBI Critical Appraisal Tool for RCTs. The standardized data extraction tool from JBI-MAStARI was used to extract data of included studies. Seven RCTs involving 740 participants were included. The overall fall incidence did not significantly decrease after the interventions. However, PCT significantly impacted the cognitive function and physical activities of elderly people with MCI, particularly improving their balancing ability, gait speed, muscular strength, and executive functions. This study indicated that combining PCT improves balance ability, gait speed, and executive functioning in the elderly with MCI, which may help to minimize fall occurrence.

Virtual reality and mental health in older adults: a systematic review

IMPORTANCE

Virtual reality (VR) is a promising tool with the potential to enhance care of cognitive and affective disorders in the aging population. VR has been implemented in clinical settings with adolescents and children; however, it has been less studied in the geriatric population.

OBJECTIVE

The objective of this study is to determine the existing levels of evidence for VR use in clinical settings and identify areas where more evidence may guide translation of existing VR interventions for older adults.

DESIGN AND MEASUREMENTS

We conducted a systematic review in PubMed and Web of Science in November 2019 for peer-reviewed journal articles on VR technology and its applications in older adults. We reviewed article content and extracted the number of study participants, study population, goal of the investigation, the level of evidence, and categorized articles based on the indication of the VR technology and the study population.

RESULTS

The database search yielded 1554 total results, and 55 articles were included in the final synthesis. The most represented study design was cross-sectional, and the most common study population was subjects with cognitive impairment. Articles fell into three categories for VR Indication: Testing, Training, and Screening. There was a wide variety of VR environments used across studies.

CONCLUSIONS

Existing evidence offers support for VR as a screening and training tool for cognitive impairment in older adults. VR-based tasks demonstrated validity comparable to some paper-based assessments of cognition, though more work is needed to refine diagnostic specificity. The variety of VR environments used shows a need for standardization before comparisons can be made across VR simulations. Future studies should address key issues such as usability, data privacy, and confidentiality. Since most literature was generated from high-income countries (HICs), it remains unclear how this may be translated to other parts of the world.

The Effectiveness of e-Health Solutions for Aging With Cognitive Impairment: A Systematic Review

Background and Objectives

e-Health solutions are an innovative approach to support aging with cognitive impairment. Because technology is developing at a fast pace, the aim of this review was to present an overview of the research regarding the effectiveness of these solutions. Moreover, the availability of these solutions was examined.

Research Design and Methods

Systematic searches were conducted in 7 databases. Full texts of potentially relevant references were assessed by 2 reviewers, and discrepancies were solved through discussion. Data on study characteristics, technology type, application domain, availability, outcomes, and effects were extracted. A categorization exercise and narrative synthesis were conducted.

Results

In total, 72 studies describing 70 e-Health solutions were identified. The majority of solutions comprised cognitive training for older adults, followed by educational and supportive web platforms for caregivers. Outcomes included mainly measures of cognition, psychosocial functioning, caregiving processes, caregiver–care receiver relationship, and activities of daily living. Positive effects of cognitive training technologies were observed on cognitive functioning of older adults, as well as those of supportive web platforms on behavioral and psychological symptoms of dementia and caregiver self-efficacy. The effects of these solutions on depression in both target groups were inconclusive. The methodological quality of the studies was moderate to good. However, some important limitations were observed.

Discussion and Implications

The review identified cognitive training solutions and supportive web platforms as the most effective on a limited number of outcomes. Although other solutions seem promising, further research has to overcome methodological issues. Furthermore, solutions for leisure and reminiscence and outcomes specifically related to independent living deserve more attention.

Virtual Reality (VR)-Based Environmental Enrichment in Older Adults with Mild Cognitive Impairment (MCI) and Mild Dementia

Background: Despite an alarming rise in the global prevalence of dementia, the available modalities for improving cognition and mental wellbeing of dementia patients remain limited. Environmental enrichment is an experimental paradigm that has shown promising anti-depressive and memory-enhancing effects in pre-clinical studies. However, its clinical utility has remained limited due to the lack of effective implementation strategies. Objective: The primary objective of this study was to evaluate the usability (tolerability and interactivity) of a long-term virtual reality (VR)- based environmental enrichment training program in older adults with mild cognitive impairment (MCI) and mild dementia. A secondary objective was to assess the effect of VR-based environmental enrichment on stabilization of cognitive functioning and improvement of mental wellbeing in older adults with MCI and mild dementia. Methods: A total of seven participants (four patients with MCI and three with mild dementia) received biweekly VR-based environmental enrichment over a course of 6 months. The tolerability and interactivity of the participants in the VR training was serially assessed via virtual reality sickness questionnaire (VRSQ) and recording of input-error ratio. Cognitive functioning was assessed through Montreal cognitive assessment (MoCA) before and after the study. Mental wellbeing was assessed through Warwick-Edinburgh Mental Well Being Scale (WEMWBS). Results: VR-based environmental enrichment was well-tolerated by the patients with significant decrease in VRSQ scores (p < 0.01) and input-error ratio (p < 0.001) overtime. VR training was also effective in stabilization of MoCA scores over the course of therapy (non-significant difference in the MoCA scores before and after the therapy) and was associated with a trend (p < 0.1) towards improvement in WEMWBS scores between the first and the last assessments. Qualitative observations by the care-givers further corroborated a noticeable improvement in mental wellbeing of patients. Conclusions: This pilot study shows that VR can be a feasible, tolerable, and potentially effective tool in long-term support of older adults with MCI and mild dementia.

Effects of Combined Physical Movement Activity and Multifaceted Cognitive Training in Older People with Mild Neurocognitive Disorder in a Rural Community: A Randomized Control Trial

INTRODUCTION

Cognitive deterioration in older people with mild neurocognitive disorders (mNCD) increases the risk of progress to major NCD. Health professionals worldwide are trying to find strategies for prevention. There is a limited number of studies that deal with cultural conditions in northern Thailand.

OBJECTIVES

This study aimed to investigate the effects of a combination of physical movement activity and multifaceted cognitive training on cognitive function in older people with mNCD.

METHODS

A randomized control trial involving 70 mNCD people, according to DSM-5 criteria, was conducted on an intervention group and a control group (n = 35 each). The program for the intervention group included 24 sessions (twice a week). The outcome measures on cognitive function were assessed before and after the intervention by means of composite cognitive measures for older people, i.e., the Trail-Making Test (TMT), Digit Span (DS), Verbal Fluency (VF), Word-List Learning (WLL), and Block Design (BD).

RESULTS

The combined intervention enhanced cognitive function. TMT-A was significantly improved in the intervention group. There were significant improvements in DS sequence scores, letter verbal fluency (LVF), and category verbal fluency (CVF). Comparing the groups, there were significant differences in LVF including immediate and delayed recall. BD improved significantly in the intervention group.

CONCLUSIONS

The combined intervention appeared to be effective in delaying/preventing cognitive deterioration and cognitive functional decline in people with mNCD. Further studies on a variation of treatments suited to cultural conditions and their effects are needed. Trials in other communities are also recommended.

Can Exergames Be Improved to Better Enhance Behavioral Adaptability in Older Adults? An Ecological Dynamics Perspective

Finding effective training solutions to attenuate the alterations of behavior and cognition in the growing number of older adults is an important challenge for Science and Society. By offering 3D computer-simulated environments to combine perceptual-motor and cognitive exercise, exergames are promising in this respect. However, a careful analysis of meta-analytic reviews suggests that they failed to be more effective than conventional motor-cognitive training. We analyzed the reasons for this situation, and we proposed new directions to design new, conceptually grounded, exergames. Consistent with the evolutionary neuroscience approach, we contend that new solutions should better combine high level of metabolic activity with (neuro)muscular, physical, perceptual-motor, and cognitive stimulations. According to the Ecological Dynamics rationale, we assume that new exergames should act at the agent-environment scale to allow individuals to explore, discover, and adapt to immersive and informationally rich environments that should include cognitively challenging tasks, while being representative of daily living situations.

Effects of Two Physical Training Programs on the Cognitive Status of a Group of Older Adults in Chile

Introduction: The effect of two physical training methods on older adults should be investigated in greater depth and its results shared with the community. Objective: To determine the effects of two types of physical training on the functional features associated with the cognitive state and the effect on a physiological mediator of growth hormone (IGF-1) in older women. Material and Methods: Quasi-experimental study that included 12 weeks of training in two groups divided into resistance and aerobic training. The study included a population of 113 women aged 69.39 ± 6.48 years from Talcahuano, Chile. All participants were randomly assigned to either group. The MINIMENTAL test was used to examine the executive functions of cognitive state and blood concentration of IGF-1, which was also used to examine neurotrophic factors. For the assessment of physical condition, an indirect test was used for the maximum mass displaced in one repetition (1RM) by the limbs and the TM6 test to estimate maximal oxygen consumption. Results: Significant differences between the groups with respect to the total score obtained in the MINIMENTAL test (EG1 = 28.13 ± 2.26; EG2 = 28.57 ± 1.83 and CG = 23.47 ± 2.80; ANOVA; p = 0.000) were observed. A post hoc analysis revealed no significant differences when examining executive functions individually between groups (Bonferroni; p > 0.05). An increase in the neurotrophic factor IGF-1 was also recorded in the training groups (EG1 p = 0.014 and EG2 p = 0.005). The pre- and post-test showed large differences in magnitude in the resistance training group (ES = 0.9; 20.41% change). Conclusion: Both workouts produce an overall improvement in the functions associated with cognitive status and increase blood concentrations of IGF-1 in older adults.

Virtual reality in neurorehabilitation: a review of its effects on multiple cognitive domains

INTRODUCTION

Neurological diseases frequently cause adult-onset disability and have increased the demand for rehabilitative interventions. Neurorehabilitation has been progressively relying on computer-assisted programs and, more recently, on virtual reality (VR). Current reviews explore VR-based neurorehabilitation for assessing and treating the most common neurological pathologies. However, none of them explored specifically the impact of VR on multiple cognitive domains.

AREAS COVERED

The present work is a review of 6 years of literature (2015-2020) on VR in neurorehabilitation with the purpose of analyzing its effects on memory, attention, executive functions, language, and visuospatial ability.

EXPERT OPINION

Our review suggests that VR-based neurorehabilitation showed encouraging results for executive functions and visuospatial abilities particularly for both acute and neurodegenerative conditions. Conversely, memory, and attention outcomes are conflicting, and language did not show significant improvements following VR-based rehabilitation. Within five years, it is plausible that VR-based intervention would be provided in standalone and mobile-based platforms that won't need a PC to work, with reduced latency and improved user interaction.

Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study

BACKGROUND

The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants' motivations to adopt these technologies.

OBJECTIVE

This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework.

METHODS

A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S₁-BrainGame, S₂-CarRace, and S₃-Exergame). Each session included an identical sequence of activities (t₁-Baseline, t₂-Picture encode, t₃-Play, t₄-Stroop test, t₅-Play, and t₆-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire.

RESULTS

Session×activity effects were significant on all ambulatory measures (χ²₁₀>20; P<.001) other than cortisol (P=.37). Compared with S₁ and S₂, S₃ was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S₁, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S₃. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (χ²₁>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group.

CONCLUSIONS

Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed.

Are We There Yet? Immersive Virtual Reality to Improve Cognitive Function in Dementia and Mild Cognitive Impairment

Background and Objectives

Cognitive training therapies may delay cognitive deterioration in dementia. There is potential to enhance delivery through immersive virtual reality (IVR), as removing potential distractors for cognitively impaired individuals can enhance their experience, resulting in increased engagement. Evidence in this field is emerging and not yet synthesized. We aimed to summarize research investigating the use of IVR in dementia to evaluate the current extent of use, acceptability, feasibility, and potential effectiveness. We also aimed to identify gaps in current research and to create a set of recommendations in utilizing this therapy.

Research Design and Methods

A systematic literature review was conducted. Our review was registered with PROSPERO, registration number: CRD42019122295. We undertook searches of five databases, article references, and citations. Key authors in the field of health care VR were also contacted to identify additional papers. Articles were assessed for inclusion by two researchers independently. Data were extracted using standardized forms.

Results

Our search identified a total of 2,824 citations, following screening for duplicates and application of inclusion and exclusion criteria, five studies were included for analysis. Included studies were heterogeneous, with small sample sizes and mixed outcomes.

Discussion and Implications

We were unable to reach definitive conclusions over the use, acceptability, and effectiveness of IVR for dementia and mild cognitive impairment. Future studies should focus on ensuring their interventions are truly immersive, developing more robust controls and account for the rapid rate of obsolescence in digital technologies.

Effects of Traditional vs. iPad-Enhanced Aerobic Exercise on Wayfinding Efficacy and Cognition: A Pilot Randomized Controlled Trial

The purpose of this pilot study was to test the feasibility and efficacy of an iPad-enhanced aerobic exercise intervention designed to enhance wayfinding efficacy and performance and relevant cognitive functioning among middle-aged adults at risk for cognitive impairment. Twenty-seven low active adults (21 females) aged 45 to 62 years (51.22 ± 5.20) participated in a ten-week randomized controlled trial. Participants were randomized to an iPad-enhanced aerobic exercise group (experimental group) or an aerobic exercise-only group (control group) following baseline assessment. Both groups exercised at 50% to 75% of age-predicted heart rate maximum for 30 to 50 min/d, 2 d/wk for 10 weeks. During aerobic exercise, the experimental group engaged in virtual tours delivered via iPad. Baseline and post-intervention assessments of wayfinding self-efficacy, wayfinding task performance, cognitive functioning, electroencephalogram (EEG), and psychosocial questionnaires were administered. The results suggest that ten weeks of iPad-enhanced, moderately intense aerobic exercise had specific effects on wayfinding self-efficacy; however, no statistical differences were found between groups on the behavioral wayfinding task or spatial memory performance at follow-up. Performance scores on an inhibitory attentional-control cognitive assessment revealed significant differences between groups, favoring the experimental group (p < 0.05). Virtual reality-enhanced aerobic exercise may prove to be an effective method for improving cognitive function and increasing confidence to navigate real-world scenarios among individuals at risk of cognitive impairment.

Non-Aβ-Dependent Factors Associated with Global Cognitive and Physical Function in Alzheimer's Disease: A Pilot Multivariate Analysis

Recent literature highlights the importance of identifying factors associated with mild cognitive impairment (MCI) and Alzheimer’s Disease (AD). Actual validated biomarkers include neuroimaging and cerebrospinal fluid assessments; however, we investigated non-Aβ-dependent factors associated with dementia in 12 MCI and 30 AD patients. Patients were assessed for global cognitive function (Mini-Mental state examination—MMSE), physical function (Physical Performance Test—PPT), exercise capacity (6-min walking test—6MWT), maximal oxygen uptake (VO₂max), brain volume, vascular function (flow-mediated dilation—FMD), inflammatory status (tumor necrosis factor—α ,TNF- α, interleukin-6, -10 and -15) and neurotrophin receptors (p75NTR and Tropomyosin receptor kinase A -TrkA). Baseline multifactorial information was submitted to two separate backward stepwise regression analyses to identify the variables associated with cognitive and physical decline in demented patients. A multivariate regression was then applied to verify the stepwise regression. The results indicated that the combination of 6MWT and VO₂max was associated with both global cognitive and physical function (MMSE = 11.384 + (0.00599 × 6MWT) − (0.235 × VO₂max)); (PPT = 1.848 + (0.0264 × 6MWT) + (19.693 × VO₂max)). These results may offer important information that might help to identify specific targets for therapeutic strategies (NIH Clinical trial identification number NCT03034746).