Mild Neurocognitive Disorder, Social Engagement, and Falls Among Older Primary Care Patients.

OBJECTIVES: (1) To estimate the association between social engagement (SE) and falls; (2) To examine the relation between mild neurocognitive disorder (MNCD) and falls by different levels of SE. DESIGN: We performed a secondary data analysis using prospective cohort study design. SETTING: Primary care. PARTICIPANTS: A total of 425 older adult primary care patients at risk for mobility decline (N=425). As previously reported, at baseline, 42% of participants exhibit MNCD. MAIN OUTCOME MEASURES: The outcome variable was the number of falls during 2 years of follow-up. Exposure variables at baseline included (1) MNCD identified using a cut-off of 1.5 SD below the age-adjusted mean on at least 2 measures within a cognitive performance battery and (2) SE, which was assessed using the social component of the Late-Life Function and Disability Instrument. High SE was defined as having a score ≥ median value (≥49 out of 100). All models were adjusted for age, sex, education, marital status, comorbidities, and pain status. RESULTS: Over 2 years of follow-up, 48% of participants fell at least once. MNCD was associated with a higher rate of falls, adjusting for the covariates (Incidence Rate Ratio=1.6, 95% confidence interval: 1.1-2.3). There was no significant association between MNCD and the rate of falls among people with high SE. In participants with low SE (having a score less than 49.5 out 100), MNCD was associated with a higher rate of falls as compared with participants with no neurocognitive disorder (No-NCD). CONCLUSIONS: Among participants with low SE, MNCD was associated with a higher rate of falls, but not among participants with high SE. The findings suggest that high SE may be protective against falls among older primary care patients with MNCD.

Metabolic Syndrome and Physical Performance: The Moderating Role of Cognition among Middle-to-Older-Aged Adults.

OBJECTIVE: Mobility limitation and cognitive decline are related. Metabolic syndrome (MetS), the clustering of three or more cardiovascular risk factors, is associated with decline in both mobility and cognition. However, the interrelationship among MetS, mobility, and cognition is unknown. This study investigated a proposed pathway where cognition moderates the relationship between MetS and Mobility. METHOD: Adults ages 45-90 years were recruited. MetS risk factors and mobility performance (Short Physical Performance Battery (SPPB) and gait speed) were evaluated. Cognition was assessed using a comprehensive neuropsychological battery. A factor analysis of neuropsychological test scores yielded three factors: executive function, explicit memory, and semantic/contextual memory. Multivariable linear regression models were used to examine the relationship among MetS, mobility, and cognition. RESULTS: Of the 74 participants (average age 61 ± 9 years; 41% female; 69% White), 27 (36%) participants manifested MetS. Mean SPPB score was 10.9 ± 1.2 out of 12 and gait speed was 1.0 ± 0.2 m/s. There were no statistically significant differences in mobility by MetS status. However, increase in any one of the MetS risk factors was associated with decreased mobility performance after adjusting for age and gender (SPPB score: ß (SE) -.17 (0.08), p < .05; gait speed: -.03 (.01), p < .01). Further adjusting for cognitive factors (SPPB score: explicit memory .31 (.14), p = .03; executive function 0.45 (0.13), p < .01; gait speed: explicit memory 0.04 (0.02), p = .03; executive function 0.06 (0.02), p < .01) moderated the relationships between number of metabolic risk factors and mobility. CONCLUSION: The relationship between metabolic risk factors and mobility may be moderated by cognitive performance, specifically through executive function and explicit memory.

Chronic Pain Characteristics and Gait in Older Adults: The MOBILIZE Boston Study II.

OBJECTIVE: To investigate a proposed cognitively-mediated pathway whereby pain contributes to gait impairments by acting as a distractor in community-living older adults. DESIGN: A cross-sectional study of a population-based cohort of older adults. SETTING: Urban and suburban communities in a large metropolitan area. PARTICIPANTS: Community-living participants (N=302) 70 years and older recruited from a previous population-based cohort. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Gait parameters including gait speed, stride length, double support and swing characteristics, and variability were assessed under single- and dual-task conditions involving cognitive challenges (eg, counting backward). A joint pain questionnaire assessed pain distribution in the back and major joints. We examined pain-gait relationships using multivariable linear regression and bootstrapping mediation procedures. RESULTS: Forty-three percent of participants had pain in 2 or more musculoskeletal sites. Pain distribution was related to slower gait speed and other gait characteristics for all gait conditions. Associations persisted after adjustment for age, sex, education, body mass index, medication, and vision. Decrements in gait measures related to pain were comparable with decrements in gait related to dual-task conditions. There were no differences in dual-task cost among the pain distribution groups. Adjusted for confounders, pain-gait relationships appear mediated by selective attention. CONCLUSIONS: These findings suggest that chronic pain contributes to decrements in gait, including slower gait speed, and that it operates through a cognitively-mediated pathway. Further research is needed to understand the mechanisms via pain alters mobility and to develop interventions to improve mobility among older adults with chronic pain.

Effects of Tai Chi on beta endorphin and inflammatory markers in older adults with chronic pain: an exploratory study.

The purpose of this exploratory study was to examine the effects of Tai Chi on blood levels of beta endorphin (ß-endorphin) and inflammatory markers in older adults with chronic pain. Forty community-dwelling older adults with chronic pain were randomized to Tai Chi or light physical exercise, and each offered twice weekly for 12 weeks. Following the 12-week intervention, neither Tai Chi nor light physical exercise changed levels of ß-endorphin and inflammatory markers. However, in older adults who completed 70% or more classes, Tai Chi significantly lowered levels of ß-endorphin (p < 0.05), whereas light physical exercise did not change levels of ß-endorphin. The results suggest that Tai Chi may reduce levels of ß-endorphin in older adults with chronic pain. Future studies are needed to better understand the role of the opioid analgesic system and immune system in regulating pain with aging and the long-term effects of Tai Chi on pain-related biomarkers.

Tai Chi for older adults with chronic multisite pain: a randomized controlled pilot study.

BACKGROUND: Chronic pain is associated with poorer cognition and mobility, and fall risk in older adults. AIMS: To investigate the feasibility of a randomized controlled trial of mind-body exercise (Tai Chi) versus light physical exercise in older adults with multisite pain. METHODS: Adults aged ≥ 65 years with multisite pain who reported falling in the past year or current use of an assistive device were recruited from Boston area communities. Participants were randomized to either a Tai Chi or a light physical exercise program, offered twice weekly for 12 weeks. The primary outcomes were feasibility and acceptability. Secondary outcomes included pain characteristics, cognition, physical function, gait mobility, fear of falling, and fall rate. RESULTS: Of 176 adults screened, 85 were eligible, and 54 consented and enrolled (average age 75 ± 8 years; 96.30% white; 75.93% female). The dropout rate was 18% for Tai Chi and 12% for light physical exercise. For those completing the study, exercise class attendance rate was 76% for Tai Chi and 82% for light physical exercise. There were no significant group differences in most secondary outcomes. Tai Chi significantly lowered pain severity (4.58 ± 1.73 to 3.73 ± 1.79, p < 0.01) and pain interference (4.20 ± 2.53 to 3.16 ± 2.28, p < 0.05), reduced fear of falling (90.82 ± 9.59 to 96.84 ± 10.67, p < 0.05), and improved several single-task and dual-task gait variables, while light physical exercise did not change these measures. DISCUSSION AND CONCLUSIONS: This study demonstrated the feasibility and acceptability of conducting a larger randomized controlled trial in older adults with multisite pain. Study findings and challenges encountered will inform future research.

Potential Benefits of Exergaming for Cognition and Dual-Task Function in Older Adults: A Systematic Review.

This paper provides a systematic review of current research findings using exergaming as a treatment for improving cognition and dual-task function in older adults. A literature search was conducted to collect exergaming intervention studies that were either randomized controlled or uncontrolled studies. Of the seven identified studies (five randomized controlled studies and two uncontrolled studies), three studies focused on cognitive function alone, two studies focused on dual-task function alone, and two studies measured both cognitive function and dual-task function. Current evidence supports that exergaming improves cognitive function and dual-task function, which potentially leads to fall prevention. However, it is unclear whether exergaming, which involves both cognitive input and physical exercise, has additional benefits compared with traditional physical exercise alone. Further studies should include traditional exercise as a control group to identify these potential, additional benefits.

Feasibility and Preliminary Efficacy of Virtual Rehabilitation for Middle and Older Aged Veterans With Mobility Limitations: A Pilot Study.

Objective: To evaluate the feasibility and preliminary efficacy of the transition of an outpatient center-based rehabilitation program for middle and older aged Veterans with mobility limitations to a tele-health platform. Design: Non-randomized non-controlled pilot study including 10 treatment sessions over 8 weeks and assessments at baseline, 8, 16, and 24 weeks. Setting: VA Boston Healthcare System ambulatory care between August 2020 and March 2021. Participants: Veterans aged 50 years and older (n=178) were contacted via letter to participate, and 21 enrolled in the study. Intervention: Participants had virtual intervention sessions with a physical therapist who addressed impairments linked to mobility decline and a coaching program promoting exercise adherence. Main Outcome Measures: Ambulatory Measure for Post-Acute Care (AM-PAC), Phone-FITT, and Self-Efficacy for Exercise (SEE) scale. Results: Completers (n=14, mean age 74.9 years, 86% men) averaged 9.8 out of 10 visits. Changes in the Ambulatory Measure for Post-Acute Care (AM-PAC) exceeded clinically meaningful change after 8 and 24 weeks of treatment, at 4.1 units and 4.3 units respectively. Statistically significant improvements from baseline in AM-PAC and Phone-FITT were observed after 8 weeks of treatment and at 24 weeks. No significant changes were observed in exercise self-efficacy. Conclusions: In this group of veterans, telerehab was feasible and demonstrated preliminary efficacy in both mobility and physical activity, thus justifying further investigation in a larger scale clinical trial.

Changes in Mild Neurocognitive Disorder Status in Mobility Limited Older Primary Care Patients: Implications for Rehabilitative Care.

OBJECTIVE: The aim of the study is to identify potential rehabilitative treatment targets associated with participants' annual cognitive status. DESIGN: A cohort study patients with self-reported mobility limitation who completed neuropsychological, physical performance testing, and questionnaires at baseline to 2-year follow-up were categorized into three groups (persistently cognitively normal, nonpersistent mild neurocognitive disorder, and persistently mild neurocognitive disorder) based on their annual cognitive status using baseline, years 1 and 2 performance on Hopkins Verbal Learning, Trail Making, and Digit Symbol Substitution Tests. Repeated measures multinomial regression analysis was used to examine the differences between groups and associated characteristics. RESULTS: Study included 349 participants (mean age, 76 ± 7) with 57% of participants were persistently cognitively normal, 16% persistently mild neurocognitive disorder, and 27% nonpersistent mild neurocognitive disorder over 2 yrs of follow-up. Faster gait speed (relative risk reduction, 0.64-0.89) was associated with risk reduction and increase in depressive symptoms (relative risk reduction, 1.09-1.12) was associated with greater risk of being classified into the nonpersistent or persistently mild neurocognitive disorder compared with persistently cognitively normal. CONCLUSIONS: Variability across cognitive status over time was observed. Gait speed and depressive symptoms were modifiable risk factors associated with nonpersistent and persistent mild neurocognitive disorder status. This study reinforces the potential benefit of multifaceted rehabilitation for preventing and treating older adults with mobility and/or cognitive problems.

The Live Long Walk Strong Rehabilitation Program Study: Design and Methods.

Objective: To identify attributes targeted by rehabilitative treatment within which improvements lead to short- and long-term changes in mobility. Maintaining independence in mobility is important to many older adults and is associated with critical outcomes such as aging in place, morbidity, and mortality. Design: The Live Long Walk Strong rehabilitation study is a phase 2 single-blind, randomized controlled trial. Setting: Veterans Affairs Boston Healthcare System, outpatient physical therapy. Participants: 198 community-dwelling middle- and older-aged veterans (aged 50 years and older) will be recruited from primary care practices (N=198). Interventions: Comparing a moderate-vigorous intensity physical therapy program of 10 sessions with a waitlist control group. Main Outcome Measure: The primary outcome measure is gait speed. Secondary outcomes include leg strength and power, trunk muscle endurance, gait smoothness, and exercise self-efficacy. Results: Outcomes will be assessed within 2 weeks of intervention completion, at 8 weeks postintervention, and at 16 weeks postintervention. Two-sample t tests will compare mean change in gait speed and target attributes (leg power, trunk muscle endurance, gait smoothness, and exercise self-efficacy) between treatment and control groups. Paired t tests will examine within-person change at subsequent follow-up visits. Multivariable regression analyses will evaluate relationships between dependent and independent variables and potential mediation adjusting for relevant covariates. Conclusions: Results of this study are expected to advance and refine the design of Live Long Walk Strong rehabilitative care and demonstrate its proof of concept and efficacy.

Reliability of Virtual Physical Performance Assessments in Veterans During the COVID-19 Pandemic.

OBJECTIVE: To determine the reliability of 3 physical performance tests performed via a telehealth visit (30-s arm curls test, 30-s chair stand test, 2-min step test) among community-dwelling older veterans. DESIGN: Cross sectional study. SETTING: Virtual. PARTICIPANTS: Veterans (N=55; mean age 75y) who enrolled in Gerofit, a virtual group exercise program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were tested by 2 different assessors at 1 time point. The intraclass correlation coefficient (ICC) with 95% confidence intervals and Bland-Altman plots were used as measures of reliability. To assess generalizability, ICCs were further evaluated by health conditions (type 2 diabetes, arthritis, obesity, depression). RESULTS: Assessments were conducted among 55 participants. The ICC was above 0.98 for all 3 tests across health conditions and Bland-Altman plots indicated that there were no significant systematic errors in the measurement. CONCLUSIONS: The virtual physical performance measures appear to have high reliability and the findings are generalizable across health conditions among veterans. Thus, they are reliable for evaluating physical performance in older veterans in virtual settings.

Evaluating the Feasibility and Effects of a Short-Term Task Specific Power Training With and Without Cognitive Training Among Older Adults With Slow Gait Speed: A Pilot Study.

OBJECTIVE: To investigate the feasibility and efficacy of short-term functional power training and further examine whether the addition of cognitive training targeting sustained attention and inhibitory control would augment the effect on the outcomes. DESIGN: Randomized pilot study. SETTING: Clinical research facility. PARTICIPANTS: Community-dwelling primary care patients (N=25) aged >65 years with mobility limitation within the VA Boston Healthcare System. INTERVENTIONS: Participants were randomly assigned to either functional power training (n=14) or functional power+cognitive training (n=11), offered 3 times a week for 6 weeks. Session durations were either 70 minutes (functional power+cognitive training) or 40 minutes (functional power training). MAIN OUTCOME MEASURES: We evaluated feasibility (dropouts, attendance), mobility performance (Short Physical Performance Battery [SPPB]), leg power [stair climb test]), dynamic balance [figure-of-8], and gait characteristics [gait speed, stance time, step width, swing time, step length, variabilities under single-task and dual-task conditions]). Nonparametric analyses were used to compare overall pre-post changes and between-group differences. RESULTS: Of the 39 veterans screened, 25 were randomized and enrolled. Twenty-one men with a mean age 76±7 years completed the study; 86% were white. Participants had a mean SPPB score of 8.3±1.6 out of 12. For those completing the study, overall attendance was 79%. Among all participants, clinically relevant and/or statistically significant median change in mobility performance (∆1 point), leg power (∆25.0W), dynamic balance (∆-1.1s), and gait characteristics (gait speed [∆0.08s, ∆0.09s], step length [∆1.9cm, ∆3.8cm], and stance time [∆-0.02s, ∆-0.05s] under single- and dual-task, respectively) were observed after 6 weeks of training. There were no statistically significant group differences in dropouts, attendance rate, or any of the outcomes based on cognitive training status. CONCLUSIONS: Short-term functional power training with or without a cognitive training led to clinically meaningful improvements in mobility performance, leg power, dynamic balance, and gait characteristics. These findings add to the body of evidence supporting the benefits of functional power training on clinically relevant outcomes. Additional cognitive training did not have an added effect on the study outcomes from our study. Further research is needed.

Effects of meditation and mind-body exercise on brain-derived neurotrophic factor: A literature review of human experimental studies.

This paper provides a literature review of current studies investigating the effects of meditation and mind-body exercise on peripheral concentrations of brain-derived neurotrophic factor (BDNF), an important mediator of the neuroplasticity of the central nervous system and cognitive function. A literature search was conducted to collect currently published randomized controlled, non-randomized controlled and uncontrolled intervention studies. Fifteen studies were identified; and among these studies, seven were randomized controlled studies, three were non-randomized studies, and five were uncontrolled studies. Current limited evidence tends to support that mindfulness meditation and mind-body exercise (e.g. yoga and tai chi) increase circulating BDNF concentrations in healthy and diseased individuals. It is noteworthy that these findings are based on current studies with a relatively small sample size, or without a randomized controlled design. Further studies are needed to identify a definite effect of meditation or mind-body exercise on BDNF and its role in improving/maintaining brain functions in various populations.

Effects of Exergaming on Cognition and Gait in Older Adults at Risk for Falling.

PURPOSE: To test whether an 8-wk exergaming (EG) program would improve cognition and gait characteristics compared with a traditional physical exercise (TPE) program in older adults at risk for falling. METHODS: A pilot quasi-experimental study was conducted in adults age ≥65 yr at risk for falls, living in senior communities. Participants enrolled (n = 35) in either exercise program offered twice weekly for 8 wk. Cognition and single-task and dual-task gait characteristics were measured before and after the 8-wk exercise intervention. For each outcome, a repeated-measures ANCOVA adjusted for age, gender, and exercise intensity (ratings of perceived exertion, RPE) was used to examine the group-time interaction. RESULTS: Twenty-nine participants (age, 77 ± 7 yr) completed either the EG program (n = 15) or the TPE program (n = 14). Statistically significant group-time interactions were observed in Trail Making Test Part A (P < 0.05) and single-task gait speed, stride length, swing time percentage, and double support percentage (all P < 0.05), and marginal group differences were observed in Mini-Mental State Examination (P = 0.07), all favoring the EG program. There were no statistically significant group differences in dual-task gait measurements except for swing time percentage and double support percentage, favoring the EG program. CONCLUSIONS: An 8-wk EG program for older adults at risk for falls contributed to modest improvements in a number of cognitive measures and single-task but limited improvements in dual-task gait measures, compared with TPE. These findings support the need for larger trials to determine cognitive and mobility benefits related to EG.

Physiological responses and enjoyment of Kinect-based exergames in older adults at risk for falls: A feasibility study.

BACKGROUND: Exergaming has the potential to improve physical function, cognition and dual-task function, and could be an effective new strategy for reducing risk of falling in older adults. OBJECTIVE: To evaluate and test custom Microsoft Kinect-based motion-tracking exergames in older adults at risk for falls. METHODS: Community-dwelling older adults who reported mobility difficulties or had fallen in the past year played three newly developed exergames (Target Trackers, Double Decision, and Visual Sweeps, 5 minutes each) in random order. Heart rate (HR) was measured during, and blood pressures (BPs), rating of perceived exertion (RPE), and rating of the enjoyment were recorded immediately after each exergame. RESULTS: Seven participants (median age 75 y; 4 females) completed the study. There were no adverse events reported during the exergaming session. Exercise HRs and RPEs were statistically significantly higher than resting for all exergames (p< 0.05). The differences were not significant for BPs. Enjoyment ratings ranged from 79.6-90.6% and there were no statistically significant differences between the exergames. CONCLUSIONS: The newly developed exergames were light in exercise intensity and enjoyable for older adults at risk for falls. Future intervention studies are warranted to examine the benefits of exergames for this special population.

Exercise Intensity-Driven Level Design.

Games and experiences designed for virtual or augmented reality usually require the player to move physically to play. This poses substantial challenge for level designers because the player's physical experience in a level will need to be considered, otherwise the level may turn out to be too exhausting or not challenging enough. This paper presents a novel approach to optimize level designs by considering the physical challenge imposed upon the player in completing a level of motion-based games. A game level is represented as an assembly of chunks characterized by the exercise intensity levels they impose on players. We formulate game level synthesis as an optimization problem, where the chunks are assembled in a way to achieve an optimized level of intensity. To allow the synthesis of game levels of varying lengths, we solve the trans-dimensional optimization problem with a Reversible-jump Markov chain Monte Carlo technique. We demonstrate that our approach can be applied to generate game levels for s of motion-based virtual reality games. A user evaluation validates the effectiveness of our approach in generating levels with the desired amount of physical challenge.

Physical Activity Domains/Recommendations and Leukocyte Telomere Length in U.S. Adults.

PURPOSE: The purpose of this study was to examine the associations between different physical activity (PA) domains, PA recommendations, and leukocyte telomere length (LTL) using data from a nationally representative sample of U.S. adults in the National Health and Nutrition Examination Survey, 1999-2002. METHODS: A total of 6933 U.S. adults (3402 men, 3531 women; age range: 20-84 yr) who completed demographic, general health and PA questionnaires and provided a blood sample were included in the analyses. Multivariable-adjusted linear regression models were used to determine associations between PA (domain-specific PA [household/yard work PA, transportation PA, moderate leisure time PA (LTPA), and vigorous LTPA], total moderate PA and PA recommendation groups), and log-transformed LTL adjusting for age, gender, education, cigarette smoking, alcohol consumption, and body mass index. RESULTS: On average, an increase of 1 h·wk of vigorous LTPA was associated with a 0.31% (P < 0.001) longer LTL, and an increase of 1 h·wk of household/yard work PA was associated with a 0.21% (P = 0.03) shorter LTL while adjusted for sociodemographic and health behavior covariates. Neither transportation PA nor moderate LTPA was significantly associated with LTL. In addition, compared with not meeting the PA recommendation (<150 min·wk), exceeding the recommended PA levels (≥300 min·wk) was positively associated with longer LTL (P = 0.04), whereas there was no difference in telomere length between those not meeting versus those meeting the PA recommendation (150-299 min·wk). CONCLUSION: Greater engagement in vigorous LTPA and exceeding the PA recommendation may have a protective effect against telomere shortening. Future studies should examine the association between PA and LTL by exploring potential mediators such as sedentary behavior, genetics, nutrition, and chronic diseases.