Abstract
[Purpose] We evaluated the effects of a multicomponent intervention for pre-frail and frail older adults and assessed changes in cognitive function and body composition to explore frailty reversibility. [Participants and Methods] A total of 51 community-dwelling older adults aged 70 years or older were classified into the Robust (n=28) and Prefrail/Frail groups (n=23) using the Kihon Checklist. A 3-month intervention combining exercise and cognitive training was implemented. Cognitive function was assessed using the National Center for Geriatrics and Gerontology functional assessment tool, and body composition was measured using bioelectrical impedance analysis. [Results] Compared with the Robust group, the Prefrail/Frail group exhibited significantly improved processing speed, whereas other cognitive function measures showed no significant changes. [Conclusion] These findings suggest that short-term intervention may enhance specific cognitive functions associated with frailty. Further research is needed to clarify the long-term effects.
Keywords: Dementia prevention, Multi-component approach, Frailty
INTRODUCTION
Japan is experiencing rapid aging, leading to an increase in the number of patients with dementia. Previous reports1) have estimated that the prevalence of dementia among individuals aged ≥65 years will be approximately 15% by 2025, while recent data2) indicate a slight decline to 12.9%. However, the rising dementia risk associated with aging remains a significant issue.
Frailty is also gaining attention in Japan, with lectures and community-based prevention activities being conducted. Frailty is prevalent among older adults, with a higher incidence in females than in males, and is influenced by social and regional disparities. Reports estimate the prevalence of frailty at 8.7%, prefrailty at 40.8%, and robustness at 50.5%3).
Therefore, intervention programs targeting frailty and dementia prevention are actively implemented nationwide. Existing studies4,5,6,7) have shown that aerobic exercise and strength training, either alone or in combination, enhance cognitive function. This study examines the effects of a multi-component intervention combining exercise and cognitive tasks in older adults with frailty. A 3-month in multi-component intervention incorporating exercise and cognitive tasks was conducted as part of a caregiving prevention initiative organized by local governments from 2021 to 2023. Participants were classified into the Robust Group and the Prefrailty/Frailty Group using the Kihon Checklist. Cognitive function was assessed before and after the intervention in each group.
This study aims to evaluate the impact of a multi-component intervention on cognitive function in older adults with prefrailty and frailty and to explore the reversibility of frailty.
PARTICIPANTS AND METHODS
The study included 71 older adults aged ≥70 years who enrolled in a 3-month caregiving prevention program in A City (mean age: 72.2 ± 2.6 years, years of education: 12.4 ± 1.8, 20 males, 51 females). Of these, 51 completed both pre- and post-intervention assessments (Fig. 1). Exclusion criteria were: (1) cerebrovascular disease within the past 6 months and (2) a dementia diagnosis, and (3) failure to complete either pre- or post-intervention assessments.
Fig. 1.
Diagrammatic representation of participant selection process.
KCL: Kihon Checklist.
Participants were classified into two groups based on their Kihon Checklist (KCL) scores. The Robust Group (n=28, mean age: 71.8 ± 2.7 years, years of education: 12.4 ± 1.9, 9 males, 19 females) had a KCL score ≤3, while the Prefrailty/Frailty Group (n=23, mean age: 72.2 ± 2.5 years, years of education: 12.8 ± 1.7, 7 males, 16 females) included those with a KCL score ≥4. Participants received oral and written explanations and provided consent.
Cognitive function assessments and body composition measurements were conducted before and after the intervention. The cognitive function assessments were performed using the National Center for Geriatrics and Gerontology Functional Assessment Tool (NCGG-FAT), which has been confirmed for reliability and validity in previous studies8). This tool was used to evaluate word memory, attention, executive function, and processing speed.
Word memory tasks included immediate and delayed recall of a word list. Ten words were displayed sequentially on an iPad at 2-s intervals for memorization. Participants then selected the memorized words from a 30-word list. The immediate recall task was repeated three times, and the average number of correct responses was calculated. The delayed recall task was performed after a set time (approximately 15–20 minutes), requiring participants to write and select memorized words from a 30-word list. The maximum score was 10.
Attention and executive function were assessed using the Trail Making Test-Part A/B (TMT-A/B) on a tablet. In TMT-A, participants sequentially touched numbers from 1 to 15 on the screen, while TMT-B required them to alternate between selecting numbers (1–8) and the hiragana characters “a” to “ki”. The average processing time (in seconds) per character or number was recorded.
Processing speed was evaluated using the Symbol Digit Substitution Test (SDST). Nine symbol-number pairs were displayed on the screen, and participants matched symbols with corresponding numbers from a list at the bottom of the screen. The result was the number of correctly matched symbols within 120 s.
Body composition was assessed using Bioelectrical Impedance Analysis (BIA, MC-780A, TANITA, Tokyo, Japan) with measurements taken in the afternoon at the same time to account for hydration status.
The multi-component intervention was conducted in groups or individually, with a 90-minute session every 2 weeks. The exercise intervention consisted of lower limb, upper limb, and trunk stretching, strength training, and aerobic exercise (30 minutes), combined with cognitive and exercise tasks in seated and standing positions (60 minutes). In the seated multi-component intervention, aerobic exercise included stepping while moving the upper limbs, and cognitive tasks involved performing actions corresponding to specific numbers while counting. Seated exercises also included forward and lateral stepping. Standing exercises incorporated ladder exercises, with participants stepping in specific positions and performing actions while counting corresponding numbers.
This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the International University of Health and Welfare (24-Io-10).
For statistical analysis, data normality was assessed using the Shapiro–Wilk test. Paired t-tests were applied to normally distributed data, while the Wilcoxon signed-rank test was used for non-normally distributed data. Independent t-tests or Mann–Whitney U tests were employed for between-group comparisons. Additionally, effect sizes (Cohen’s d for parametric tests and r for non-parametric tests) were calculated to better understand the clinical relevance of the results. The significance level was set at p<0.05.
RESULTS
Table 1 presents pre- and post-intervention comparisons for the 51 participants. Statistically significant differences were observed in weight (Cohen’s d=0.068), BMI (Cohen’s d=0.047), body fat percentage (BFP) (Cohen’s d=0.153), processing speed (Cohen’s d=0.178), and KCL scores (r=0.296).
Table 1. Comparison of pre- and post-intervention in all participants.
| Pre-intervention | Post-intervention | Effect size (Cohen’s d/r ) | |
| Height (cm) | 154.1 (149.5–158.6) | 153.4 (149.7–160.3) | 0.493 |
| Weight (kg) | 55.3 ± 8.7 | 55.8 ± 8.5* | 0.068 |
| BMI (kg/m2) | 23.0 ± 3.5 | 23.2 ± 3.4* | 0.047 |
| Muscle mass (kg) | 35.2 (32.7–40.4) | 35.1 (32.3–39.9) | 0.390 |
| BFP (%) | 28.6 ± 9.8 | 30.0 ± 9.1* | 0.153 |
| KCL (points) | 3.0 (2.0–6.0) | 3.0 (1.0–5.0)* | 0.296 |
| Processing speed (points) | 65.9 ± 11.7 | 68.0 ± 11.4* | 0.178 |
| Word Memory: immediate recognition (points) | 8.3 (7.7–9.0) | 8.7 (7.3–9.0) | 0.016 |
| Word Memory: delayed recall (points) | 6.0 (5.0–7.0) | 6.0 (4.0–7.0) | 0.045 |
| Word Memory: delayed recognition (points) | 8.0 (7.0–9.0) | 8.0 (7.0–9.0) | 0.012 |
| Attention function: TMT Parts A (s) | 1.3 (1.1–1.5) | 1.2 (1.0–1.4) | 0.133 |
| Executive function: TMT Parts B (s) | 2.0 (1.5–2.5) | 1.9 (1.5–2.4) | 0.031 |
Median (1st Quartile–3rd Quartile). Mean ± SD. *p<0.05. EH: education history; BMI: body mass index; BFP: body fat percentage; KCL: Kihon Checklist.
Table 2 shows the baseline comparison between the Robust and Prefrailty/Frailty Groups, revealing no statistically significant differences except for KCL scores (r=0.862).
Table 2. Comparison of baseline characteristics between the robust and prefrailty/frailty groups.
| Robust group (n=28) | Prefrailty/Frailty group (n=23) | Effect size (Cohen’s d/r) | |
| Age (years) | 70.0 (69.0–75.0) | 70.0 (70.0–75.0) | 0.129 |
| EH (years) | 12.0 (12.0–12.3) | 12.0 (12.0–14.0) | 0.149 |
| Height (cm) | 155.0 ± 7.9 | 155.2 ± 7.8 | 0.028 |
| Weight (kg) | 54.0 ± 8.1 | 56.8 ± 9.3 | 0.334 |
| BMI (kg/m2) | 22.6 ± 3.4 | 23.6 ± 3.6 | 0.295 |
| Muscle mass (kg) | 34.6 (32.4–41.5) | 35.3 (32.8–39.5) | 0.074 |
| BFP (%) | 27.5 ± 10.1 | 29.8 ± 9.4 | 0.231 |
| KCL (points) | 3.0 (1.0–3.0) | 6.0 (5.0–9.0)* | 0.862 |
| Processing speed (points) | 66.0 ± 8.3 | 65.8 ± 15.0 | 0.017 |
| Word Memory: immediate recognition (points) | 8.3 (7.8–8.7) | 8.7 (7.0–9.3) | 0.159 |
| Word Memory: delayed recall (points) | 6.0 (5.0–7.0) | 6.0 (5.0–7.0) | 0.009 |
| Word Memory: delayed recognition (points) | 8.0 (7.0–9.0) | 8.0 (7.0–9.0) | 0.016 |
| Attention function: TMT Parts A (s) | 1.3 (1.1–1.3) | 1.3 (1.0–1.5) | 0.001 |
| Executive function: TMT Parts B (s) | 2.0 (1.5–2.2) | 1.9 (1.5–2.5) | 0.017 |
Median (1st Quartile–3rd Quartile). Mean ± SD. *p<0.05. EH: education history; BMI: body mass index; BFP: body fat percentage; KCL: Kihon Checklist.
Table 3 details pre- and post-intervention comparisons for the Robust Group, showing statistically significant differences in weight (Cohen’s d=0.075), BMI (Cohen’s d=0.051), muscle mass (r=0.381), and BFP (Cohen’s d=0.154). No changes in cognitive function were observed.
Table 3. Comparison of pre- and post-intervention in the robust group.
| Pre-intervention | Post-intervention | Effect size (Cohen’s d/r) | |
| Weight (kg) | 54.0 ± 8.1 | 54.6 ± 7.9* | 0.075 |
| BMI (kg/m2) | 22.6 ± 3.4 | 22.7 ± 3.3* | 0.051 |
| Muscle mass (kg) | 34.6 (32.4–41.5) | 34.7 (32.2–40.5)* | 0.381 |
| BFP (%) | 27.5 ± 10.1 | 29.0 ± 9.2* | 0.154 |
| KCL (points) | 2.0 (1.0–2.0) | 2.0 (1.0–2.0) | 0.181 |
| Processing speed (points) | 66.0 ± 8.3 | 67.6 ± 9.5 | 0.176 |
| Word Memory: immediate recognition (points) | 8.3 ± 0.7 | 8.2 ± 1.1 | 0.065 |
| Word Memory: delayed recall (points) | 6.0 (5.0–7.0) | 5.0 (4.0–7.8) | 0.023 |
| Word Memory: delayed recognition (points) | 8.0 (7.0–9.0) | 8.0 (7.3–9.0) | 0.097 |
| Attention function: TMT Parts A (s) | 1.3 (1.1–1.3) | 1.3 (1.0–1.5) | 0.020 |
| Executive function: TMT Parts B (s) | 2.0 (1.5–2.2) | 1.8 (1.5–2.2) | 0.162 |
Median (1st Quartile–3rd Quartile). Mean ± SD. *p<0.05. EH: education history; BMI: body mass index; BFP: body fat percentage. KCL: Kihon Checklist.
Table 4 presents pre- and post-intervention comparisons for the Prefrailty/Frailty Group. In this group, BFP (Cohen’s d=0.147) significantly increased, processing speed (Cohen’s d=0.181) and KCL (r=0.598) significantly improved, and muscle mass (r=0.452) showed a significant decrease.
Table 4. Comparison of pre- and post-intervention in the prefrailty/frailty group.
| Pre-intervention | Post-intervention | Effect size (Cohen’s d/r) | |
| Weight (kg) | 56.8 ± 9.3 | 57.3 ± 9.1 | 0.061 |
| BMI (kg/m2) | 23.6 ± 3.6 | 23.7 ± 3.5 | 0.042 |
| Muscle mass(kg) | 35.3 (32.8–39.5) | 35.2 (32.6–39.5)* | 0.452 |
| BFP (%) | 29.8 ± 9.4 | 31.2 ± 9.0* | 0.147 |
| KCL (points) | 6.0 (5.0–9.0) | 5.0 (2.0–7.0)* | 0.598 |
| Processing speed (points) | 65.8 ± 15.0 | 68.5 ± 13.5* | 0.181 |
| Word Memory: immediate recognition (points) | 8.7 (7.0–9.3) | 8.7 (7.7–9.3) | 0.093 |
| Word Memory: delayed recall (points) | 6.0 (5.0–7.0) | 6.0 (5.0–6.0) | 0.079 |
| Word Memory: delayed recognition (points) | 8.0 (7.0–9.0) | 8.0 (7.0–9.0) | 0.050 |
| Attention function: TMT Parts A (s) | 1.3 (1.0–1.5) | 1.1 (1.0–1.3) | 0.304 |
| Executive function: TMT Parts B (s) | 1.9 (1.5–2.5) | 2.0 (1.8–2.5) | 0.180 |
Median (1st Quartile–3rd Quartile). *p<0.05. Mean ± SD. EH: education history; BMI: body mass index; BFP: body fat percentage; KCL: Kihon Checklist.
DISCUSSION
This study found that a multi-component intervention combining exercise and cognitive tasks significantly improved cognitive function in the Prefrailty/Frailty Group. Specifically, processing speed improved significantly in the Prefrailty/Frailty Group, while no significant cognitive function changes were observed in the Robust Group.
The study findings indicate that while processing speed improved in the Prefrailty/Frailty Group, no significant changes occurred in other cognitive function measures. Further research is needed to assess the effects of multi-component interventions on overall cognitive function. Previous studies9) have shown that exercise interventions enhance both physical and cognitive function and aerobic exercise10) may improve cognitive processing speed in stroke patients. These results align with prior findings; however, randomized controlled trials with control groups are necessary to verify the independent effects of the intervention. Additionally, studies11) have demonstrated that combined exercise and cognitive tasks improve cognitive function in older adults with mild cognitive impairment (MCI) or dementia.
Based on the finding that cognitive function significantly improved in the Prefrailty/Frailty Group, this study highlights the importance of multi-component interventions for frail older adults. Research11) on patients with MCI has shown that both physical and cognitive interventions contribute to maintaining and improving cognitive function. Furthermore, continuous community support12) has been emphasized as crucial for dementia prevention.
The improvement observed in the Prefrailty/Frailty Group may be partially attributed to the social participation aspect of the intervention. Previous studies13, 14) have shown that social participation enhances the effectiveness of dementia prevention. In this study, interactions during the caregiving prevention event may have provided cognitive stimulation.
This study highlights the need for comprehensive interventions targeting older adults with frailty. Specifically, it underscores the need for a comprehensive intervention model for older adults at high risk of dementia or frailty, through caregiving prevention programs in collaboration with local communities and government agencies. The study findings provide new evidence for dementia prevention and contribute to developing intervention strategies, including participant selection for caregiving prevention events in super-aged societies.
In terms of changes in body composition, there was a significant increase in weight, BMI, BFP, and muscle mass in the Robust Group, whereas in the Prefrail/Frailty Group, there was an increase in BFP but a decrease in muscle mass. This intervention, conducted once every two weeks for 90 minutes, aimed primarily at cognitive improvement, and its effects on body composition may have been influenced by other factors, such as diet and daily activity levels.
While the increase in muscle mass in the Robust Group may help prevent sarcopenia, the muscle loss and BFP increase in the Prefrail/Frailty Group could indicate a higher frailty risk or sarcopenic obesity, requiring further attention. Given the low frequency and intensity of the intervention, it may not have been sufficient to counteract muscle loss in the Prefrail/Frailty Group. Future interventions should consider higher-frequency sessions or the incorporation of resistance training to promote muscle retention. Additionally, external factors such as dietary habits and daily physical activity may have influenced changes in body composition, highlighting the need for a more comprehensive approach in future studies.
This study has several limitations. First, the analysis of the intervention content and participants’ psychosocial factors was insufficient. Second, detailed data on activities outside the dementia prevention classes were not collected. Third, since participants were from a single region, caution is needed when generalizing the findings. Additionally, follow-up studies are necessary to assess the long-term effects of the intervention. Furthermore, this study followed the schedule and duration set by the local government, which assessed the feasibility of a community-based program. While the intervention frequency may seem low, significant improvements were observed in the Pre-frail/Frailty Group. However, an increased frequency may lead to more substantial or sustained improvements. Future studies should explore the impact of varying intervention frequencies to determine the optimal dosage for achieving cognitive and physical benefits.
Funding
The authors received no financial support for this study.
Conflicts of interest
The authors declare no conflicts of interest.
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