Systematic Review

Physical and cognitive-based training in healthy older adults: Evidence from a systematic review and meta-analysis

Introduction

Older adults may experience cognitive impairment negatively and directly may impact their self-care, autonomy, health condition, and successful aging.¹ Normal aging is related to daily functional memory complications, as demonstrated by challenges in learning unprecedented names, remembering events that happened the pasts day, and finding a particular word in discussion.² The most important age-related changes are related to cognitive tasks that require fast processing of data, including executive function and working memory.³ A hallmark of cognitive aging is age-related changes in executive function which is associated with major declines in executive function, including reasoning, set-shifting, working memory, and inhibition.^4-6 Executive functions are an important part of our day-to-day life, which can affect some everyday functions, like allowing focused attention, engaging in resolving issues successfully, and planning for the future.⁴ Memory is perhaps the first cognitive function to give several patterns of decrease in some aspects, such as episodic memory.⁷

The progressive trend of cognitive impairment among the older population increased the importance of prevention of cognitive impairment through providing efficient guidelines and strategies. Additionally, there is an increasing body of evidence pointing to preventing or reducing the rate of cognitive impairment by using variant strategies e.g., behavioral training,⁸ mind-body exercise,⁹ and neurofeedback training.^10,11

Neuroimaging also indicated the beneficial effect of mental and physical training on cognitive health. brain-derived neurotropic factor (BDNF) may triggers metabolic, plasticity, learning, and memory processes, plays an important role in excitation of molecular machinery by physical activity. A variety of mechanisms such as regeneration after neuronal injury and prevention of neuronal degeneration are undertaken by BDNF in addition to maintaining and promoting the growth of neurons from neuronal degeneration.

Moreover, the brain plasticity of the mental training has been seen in various procedure, such as cerebral blood flow, grey matter structure and, with matter integrity and energy metabolism. For example Engvig¹² used an intensive memory training program in order to enhance memory skill. Results also revealed memory training may induce short-term structural changes in the structural grey matter and participants’ memory. Scientists come to the conclusion that the different type of physical/mental activity, intensity and duration may be a specify factor in the change in serum concentration of BDNF and regional white matter integrity, and subsequently enhance memory and cognition. Therefore, identifying effective trainings in aging research is critical and necessary.

Additionally, up to the present time, there are some reviews that systematically described trainings in older adults but the number of articles that have examined the different components of cognition is rare, and so in most studies, the effect of mental and physical trainings had not been examined.

The research on physical and mental training over the last 23 years is summarized here to respond; to what types of trainings have been used to affect cognitive outcomes including total cognition, memory, episodic memory, verbal memory, attention, selective attention, sustained attention, executive function, inhibition, mental flexibility, working memory, reasoning, in healthy older adults? This is a fundamental query in the growing field of geriatric health, and the findings should be useful in establishing guidelines and recommendations for health-promoting programs for older adults.

Methods

In this systematic review and meta-analysis, randomized clinical trials (RCTs) published between 2000 and February 6, 2023 were extracted from several electronic databases, including, ProQuest, PubMed, Scopus, Embase, and Web of Science. The study was limited to published papers in the English language that assessed the effects of trainings on cognition function. Those studies that were created to examine the impact of all trainings, excluding medicines, nutritional, advising, and driving training on improving cognition function, were included in this review. The study subjects were healthy older adults who had at least 55 years old.

The search strategy

To warrant the completeness of the included studies, we used Medical Subject Headings (MeSH) and free text words on the 5th online databases (ProQuest, Web of Science, PubMed, Scopus, and Embase) on papers published between 2000 and February 6, 2023. for relevant literature, the following keyword were used: Age, Older, Elder, Movement, Walking, Sports, Yoga, Activity, Exercise, Strengthening, Resistance, Pilates, Tai chi chuan, Brain training, Mental trainings, Executive Function, Attention, Cognition, Memory, Executive, Inhibit, Interference control, Cognition, Memory, Shifting, Mental flexibility, Updating, Planning, Switching, Fluency (see Supplementary file 1).in addition, manual searches were used to identify the additional studies that had not been identified in the initial search. This meta-analysis was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline⁸ (see Supplementary file 2).

Study Selection Criteria

Two authors (F.A. and A.A.T) separately screened the selected studies; the selection was made based on the screening of titles/abstracts. Next, the full texts of the remaining papers were evaluated. Eligibility disagreements were reconciled by initial reviewers and, if necessary, by a third reviewer (Z.J).

Study quality assessment and risk of bias

The methodology quality of the included studies was independently assessed by two reviewers (F.A and A.A.T), and the third reviewer (Z.J) resolved any discrepancy through the Cochrane Collaboration tool⁹ which consisted of six areas. Next, each area was labeled as either low, unclear, or high potential of bias. Additionally, two reviewers evaluated the methodological quality of the contained studies in a separate manner.

Publication bias

The funnel plot of the included papers displayed no document for publication bias. The Egger test results were not considerable for publication bias (P > 0.05) (see Supplementary file 3).

Statistical analysis

The mean differences (MDs) and standard deviation (SD) were computed using Stata software (Sv16). The standardized mean difference is to divide the mean difference by the SD and would compare the studies. All the studies report quantitative data and a weighted mean difference at a 95% confidence interval. Heterogeneity was estimated using statistics I-square:I² and the significance criterion was I² > 50%. The Summary statistics reported were computed using random effects models based on unexplained heterogeneity between the studies. The chi-square test for heterogeneity was used to determine whether of distribution of results was consistent with the assumption that inter-experimental differences were attributable to chance variation alone. The statistical significance level was 0.05. The publication bias has been tested through funnel plots and the Egger regression test.

Results

We identified 680 publications and of the total 407 papers recorded, 35 papers have been included in the meta-analysis (Figure 1).

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Figure 1.

Prisma fallow diagram detailing the search strategy

Figure 1.

Prisma fallow diagram detailing the search strategy

Characteristics of the studies

The studies were categorized into 12 groups including cognitive function, executive function, set-shifting, inhibition, reasoning, working memory, attention, selective attention, memory, delay memory, episodic memory, and verbal memory. All the participants ranged from 55 to more than 80 years of age. Research’s sample sizes in the studies were between 14 to 487 participants (Table 1).

Methodological quality versus risk of bias assessment

A high risk of selection bias due to the absence of allocation concealment (n = 1), performance bias (n = 1), and other sources of bias (n = 2) was shown. Reporting bias (n = 26), attrition bias (n = 22), and a lack of randomization method (n = 21) was unclear for the majority of the included studies (Supplementary file 4).

Effects of trainings on cognition (meta-analysis finding)

The pooled MD for cognition was 0.49 (95% CI = 0.28 to 0.70, I² = 79.3%, P= 0.0001) (Figure 2A). As a result, trainings had a small to larger effect on the executive function (pooled MD: 0.64 (95% CI = 0.26 to 1.02, I² = 86.2%, P = 0.0001) (Figure 2B). In addition, trainings showed small to medium effect on set shifting (pooled MD: 0.37 (95% CI = 0.18 to 0.56, I² = 79.3%, P= 0.0001) (Figure 2C). But trainings had not to effect on inhibitions (Figure 2D). The heterogeneity among studies also was high.

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Figure 2.

Effect of interventions on cognition (A); executive function (B); set shifting (C) and inhibition (D)

Figure 2.

Effect of interventions on cognition (A); executive function (B); set shifting (C) and inhibition (D)

According to Figure 3, trainings were effective in reasoning (pooled MD: 0.40; 95% CI = 0.23 to 0.562, I² = 21.1%, P= 0.224) (Figure 3A) and working memory of older adults (pooled MD: 0.25; 95% CI = 0.07 to 0.44, I² = 53.2%, P= 0.0002; Figure 3B). But trainings showed no effect on attention (Figure 3C) and Selective Attention (Concentration, Figure 3D).

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Figure 3.

Effect of interventions on reasoning (A), working memory (B), attention (C), and selective attention (concentration) (D)

Figure 3.

Effect of interventions on reasoning (A), working memory (B), attention (C), and selective attention (concentration) (D)

Figure 4 indicates that trainings had a small to large effect on Memory (pooled MD: 0.64; 95% CI = 0.25 to 1.04, I² = 87%, P= 0.001) (Figure 4A); Delay memory (pooled MD: 1.18; 95% CI = 0.35 to 2.00, I² = 91.4%, P= 0.001) (Figure 4B); and larger effect on Episode memory (pooled MD: 1.98; 95% CI = 1.20 to 2.77, I² = 92%, P= 0.001) (Figure 4C) of older adults people. But with high heterogeneity and no effect on verbal memory (Figure 4D).

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Figure 4.

Effect of interventions on memory (A); Delay memory (B); Episode memory(C); Verbal memory (D)

Figure 4.

Effect of interventions on memory (A); Delay memory (B); Episode memory(C); Verbal memory (D)

Discussion

As our aim was to investigate the role of physical and mental training as a potential preventive training to improve cognitive function and its sub-domain decay in older persons and also evaluate the quality of available evidence, the analyses prepared explicit evidence that the training had a ‘large’ effect on the improvement of episodic memory. Also, we found that the training had a ‘small to larger’ effect size in cognition, executive function, reasoning, working memory, and memory.

These findings expand prior evidences from a meta-analysis of the single or multi-component physical and mental trainings on cognitive functions. Based on this study and previous results, all types of physical and mental training have been demonstrated to improve cognitive function of healthy aging population.⁴⁷ Our findings also extend the previous findings of the systematic review on the separate and combination of the brain and physical training benefits on improving cognitive functioning in older population,^47,48 while we found studies which claimed the opposite.^49,50 Several possible mechanisms may underlie training-induced enhancements of efficiency that are closely connected to neuroplasticity, chemical transmitter, and change in neuromodulator of central pathway, selectively increasing angiogenesis, synaptogenesis, and neurogenesis.⁵¹ The heterogeneity of the reviewed studies makes the results be interpreted cautiously.

The current study shows a critical extension to the body of literature by examining physical activity and mental training on cognitive function and displays small to large improvements in executive function and small to medium improvement within 3 sub-domains of executive function. Similar to this review, several systematic reviews and training studies have shown an improvement in executive function through aerobic and stretch exercise training,⁵² traditional mental training,⁵³ and cognitive-motor training.⁵⁴ This is in contrast to Shah et al⁵⁵ that did not demonstrate the post-intervention benefits of a combined mental and physical training for executive functions. Limited sample size, differences in the outcome measures, and types of training may be responsible. It may also be assumed that the type of physical activity may be more determinative than the intensity of physical activity in this sub-domain of cognitive function because the training time is equal in both studies.

In addition, the finding of this meta-analysis is comparable to those of the review in terms of the effects of aerobic exercise and combination mind-body training on working memory as another sub-domain of executive function.^56,57 Among the eight reviewed articles, most of the articles (seven out of eight) had mental training but the greatest improvement founded in Fabre et al. study by aerobic and combined mind-body trainings. In contrast, in another meta-analysis, Guo et al showed that mixed training was not superior to physical or mental training alone on executive function.⁵⁸ However, it would be important to interpret in a cautious manner the results in view of the methodological heterogeneity of the studies.in fact, the effectiveness of physical trainings may depend on the nature and length of trainings. Physical activity may greatly increase neurogenesis in the frontal lobe, and mental exercise may decrease the number of neuronal cell deaths.⁵⁹

The results of the current study did not show important benefits from physical activity training in memory function. In contrast, another review by Babaei et al. has shown that physical activity improved neurotrophic factors, mitochondrial biogenesis, and the release of some signaling molecules.⁶⁰ Neuromotor exercise e.g. yoga has been successful in enhancing all types of short and long-term memory in the elderly.⁶¹ These insights can be used to develop future memory enhancement protocols for an aging population.

This study suggests that the separate and combined aerobic and mental training can improve episodic memory in the older population. Based on the findings of Aghjayan et al⁶² and Loprinzi et al⁶³ aerobic exercise may enhance episodic memory. Acute and long-term physical activity has also been displayed to be linked with episodic memory function. According to our finding a systematic review led by Mendonça et al.⁶⁴ Also, physical activity influences cognitive function by spreading BDNF and promoting neuronal growth and survival.⁶⁵

The comprehensive search strategy, measuring different components of cognition, and various pieces of training were major strengths of this review. However, the limitations of the study are mentioned. First, in this study, both physical and mental training results were analyzed in a concurrent manner. As a result, the effects of any type of training cannot be identified alone. It is suggested that each type of training be considered separately for future studies.

Second, the variation in the instruments used to measure the subdomains of cognition function can be identified as a limiting factor. Third, it is very complicated to eliminate the influence of diet, medication, and social support, on the results.

Conclusion

Our findings in this systematic review and meta-analysis show that physical and mental training is a helpful way to improve the mental and executive function of older adults. As a result, emphasizing on physical and mental training programs may improve the quality of life of older adults and let them live more in an independent manner and consequently may guide healthcare providers to set up programs that let elders engage more in physical and mental training programs and also the combined physical and mental training programs may be assumed as a new strategy in the field of geriatric health and gerontology to emphasize on synergetic effects of physical exercise and mental training.

Competing Interests

The authors declare that they have no competing interests.

Ethical Approval

This study was approved by Ethical committee Tabriz University of Medical Sciences (Ethical number: IR.TBZMED.REC.1398.829).

Funding

This research protocol was supported by the Tabriz University of Medical Sciences (grant: IR.TBZMED.REC.1398.829) and by the Iran National Science Foundation (grant: 98021200).

Supplementary Files

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