Efficacy of short-term intensive home-based cognitive training combined with physical exercise in older adults: a single-arm trial

Efficacy of short-term intensive home-based cognitive training combined with physical exercise in older adults: a single-arm trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of short-term intensive home-based cognitive training combined with physical exercise in older adults: a single-arm trial Ikhyun Lim, Seyoung Shin, Hongseok Baek, EunYoung Park, Jeong Min Hong, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3927684/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Previous studies note the significant effects of Cognitive Training (CT) on older adults, but achieving consensus on optimal dosage is challenging due to intervention protocol heterogeneity. Short-term training seems preferable for clinical use due to potential elderly dropout during long-term intervention Aims To evaluate the efficacy of 4-week intensive home-based cognitive and physical training on personal function in older adults. Methods This prospective single-arm intervention study enrolled older adults aged ≥65 years who were capable of independently performing activities of daily living. Adults with a Mini-Mental Status Examination (MMSE) score of <24 points, a history of any brain injury, or difficulty in continuing the intervention were excluded. The training program comprised 1–2-hour cognitive tasks and 1-hour physical exercise for 5 days per week for 4 consecutive weeks. The MMSE, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Berg Balance Scale (BBS), and modified Barthel Index (MBI) scores were assessed before and after the intervention. Functional outcomes were analyzed according to compliance level. Results Twenty-five participants were enrolled and completed the trial. After the intervention, functional improvements were observed, along with significantly increased MMSE, RBANS-attention, BBS, and MBI scores ( Ps< 0.05). The high-compliance group showed greater increment in RBANS-memory and BBS scores than the low-compliance group ( Ps< 0.05). Discussion The intervention in this study might have contributed to ADL in ambulation and bathing by enhancing the balance function Conclusion Short-term intensive cognitive training combined with physical exercise seems to be effective in enhancing multifaceted functional status in older adults. Cognitive training Physical training Older adult Activities of daily living Figures Figure 1 Figure 2 Introduction The elderly population is increasingly growing globally. With aging, the cognitive function progressively declines, eventually leading to dependence in daily living [ 1 ]. Previous large long-term follow-up study involving community-living older adults reported that 69.5% of elderly experienced difficulty in performing at least one instrumental activity of daily living (ADL) [ 2 ]. Several clinical trials conducted on the elderly have demonstrated the significant effects of training-based interventions on functional loss in those with or without neurological disorders [ 3 – 7 ]. A recent systematic review suggested that cognitive training (CT) for patients with Alzheimer’s disease might result in substantial global cognitive improvement [ 3 ]. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability study showed that long-term multi-domain intervention consisting of CT and physical exercise not only was beneficial for cognitive function but also reduced the risk of new chronic disease occurrence in older people [ 4 – 6 ]. A meta-analysis of combined cognitive and physical training for cognitively impaired or non-impaired older adults showed that combined interventions were significantly effective in improving overall cognitive and physical function [ 7 ]. The amount and method of delivering interventional contents are important issues for training aimed at enhancing the cognitive ability of older adults. Owing to high heterogeneity in intervention protocols, reaching a consensus on the optimal CT dose is difficult. With respect to the duration, short-term training is preferable for clinical application because of the possible drop-out in the elderly during a long-term intervention. In previous clinical studies targeting older adults without cognitive impairment, the duration varied from 2 weeks to 2 years (3–180 sessions), and the intervention dose per session ranged from 30 minutes to 2 hours [ 7 – 9 ]. A short-term trial involving cognitively healthy participants showed that a protocol of 48-hour intervention with a 8-week duration was the most intensive and that multi-domain CT had a beneficial effect on executive function [ 10 ]. Kanaan et al. reported that short-term intensive CT for 40–50 hours over 2 weeks was feasible and effectively induced cognitive improvement in patients with early-stage Alzheimer’s disease [ 11 ]. Based on previous studies, short-term intensive CT appears to be acceptable and beneficial for older adults with or without known cognitive disorder. Moreover, regarding methods of delivering the training content, which is closely associated with the place of practicing the interventions, attempts to provide training at home are increasing. During the COVID-19 pandemic, the demand on home-based interventions for vulnerable older adults or patients susceptible to infection has increased [ 12 , 13 ]. Considering this, investigating the effectiveness of short-term home-based cognitive interventions is necessary. The present study aimed to evaluate the improvement in cognitive function and daily living capability of older adults without current disabilities after a 4-week short-term home-based CT program combined with physical exercise (20 sessions for 4 weeks, with a dose of 40–60 hours in total). By adopting a shorter duration and similar or longer total intervention hours for the program than those in previous studies, we conducted a clinical investigation with a more intensive protocol than before. Materials and methods Participants This prospective single-arm intervention study was conducted from September 25 to November 6, 2020. The opportunity to participate in this study was open to the town residents of Yangcheon-gu in Seoul, Korea. The inclusion criteria were as follows: adults aged ≥ 65 years who were capable of independently performing usual ADL and who provided informed consent for this study. In order to exclude adults with noticeable risks of cognitive impairment, the following exclusion criteria were applied: (i) a Mini-Mental Status Examination (MMSE) score of < 24 points [ 14 ]; (ii) a history of any possible cause of brain dysfunction such as stroke, brain tumor, dementia, cerebral palsy, or Parkinsonism; and (iii) difficulty in continuing the intervention of this study because of poor systemic condition or medical diseases, as judged by the principal investigator of this study. As this was a preliminary study, our target number for the analysis was 25 participants without a control group. Considering a dropout rate of 20%, the total target number of participants was 29. This study was conducted in accordance with the relevant guidelines and regulations, particularly the Declaration of Helsinki, and was approved by the Institutional Review Board of CHA Bundang Medical Center (IRB file no.: 2020-09-005). Written and informed consent was obtained from all participants. Content of the training program The intervention program comprised cognitive and physical training tasks, and performance was recorded in a workbook for personal use. The workbook used in this study and its contents were developed by our research team, which consisted of rehabilitation medicine physicians, psychologists, occupational therapists, and physical therapists. As for the creation of the content of CT, protocols established by the clinical practice team of CHA Bundang Medical Center and existing papers on CT were referred to and combined [ 9 , 15 – 19 ]. A physical exercise program was developed based on previous reports regarding exercise programs for patients with dementia [ 20 – 23 ], and gymnastic video content produced by the Educational Broadcasting System, a Korean public broadcaster, was used [ 24 ]. As for the performance of tasks of a day, each session required 60–120 minutes for CT and 60 minutes for physical exercise. The following tasks for CT focused on practice memory, attention, and mental flexibility: visual memory activity (CT-1), auditory memory tasks (CT-2), short-term memory tasks (CT-3), memory recall tasks (CT-4), and visual and auditory attention tasks (CT-5). Physical exercise involved stretching, muscle strength training, and coordination training. There was no strict order in performing the cognitive and physical tasks, and it was considered completed once the set amount of time per day had elapsed. The combined training program was intended to be practiced daily during weekdays for 4 consecutive weeks. Training that could not be performed during weekdays was recommended to be supplemented on weekends, and a schedule of 5 days per week was fulfilled. Detailed information about the workbook and exercise program is presented in Supplementary Method, Supplementary Tables 1 and 2, and Supplementary Fig. 1. Implementation of training and content delivery To begin with the training, all participants were informed by the study team about the purpose of the study, content, and detailed methods of conducting the training for 2 hours. Subsequently, each participant was provided with a workbook, which contained approximately 200 pages (including schedules, cognitive tasks, pages for diary, and guidelines needed to be filled up for 4 weeks), to carry out the paper-and-pencil-based tasks. Additionally, recorded instrumental audio and video materials were distributed to the participants on a daily basis to perform the tasks via a smartphone messenger service. Following the completion of the 4-week intervention, the rate of practice was assessed according to the written records was assessed with error rates in records of the workbook. Furthermore, given that CT-1 and CT-3 did not have grading standards, the performance rate was evaluated by calculating the success rates of CT-2, CT-4, and CT-5. A social worker from a local public welfare center visited the homes of participants who asked for help, and the researchers contacted the participants daily through phone calls and text messages to encourage and monitor consistent participation. Outcome measures Outcome assessments were conducted before and after the 4-week intervention using approved nationality-specific versions of standardized functional measures. In particular, the MMSE [ 25 ] and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) [ 26 ] were used to evaluate cognitive function. The Berg Balance Scale (BBS) [ 27 ] was used to assess balance and gross motor ability, whereas the modified Barthel Index (MBI) [ 28 ] was used to evaluate capabilities in ADL indipendency. The RBANS consists of five domain indices: (i) immediate memory (list learning and story memory), (ii) visuospatial/constructional ability (figure copy and line orientation), (iii) language (naming and semantic fluency), (iv) attention (digit span and coding), and (v) delayed memory. With the RBANS, one of the four types (namely, A, B, C, and D) was utilized to avoid a learning effect by repeated measurement with a relatively short-term interval. In this study, the participants were randomly divided into two groups to conduct an initial evaluation with type A or C test, respectively, and post-intervention evaluation was performed using other types of test. As baseline assessment, outcomes were assessed within 2 weeks prior to the start of the training program. Post-intervention assessments were conducted within 1 week after the end of the program. Medical doctors evaluated cognitive and physical abilities after securing inter-rater reliability for measurements with intra-class coefficient > 0.9. An expert clinical psychologist also conducted part of the cognitive evaluation. The analyses included not only the total measurement scores but also the RBANS, MMSE, and MBI subscores. When conducting post-intervention functional assessments, the evaluator was blinded to the baseline scores. After 4 weeks of training, feedback regarding the program was obtained from the participants. The participants were instructed to fill in a questionnaire focusing on satisfaction and comfort levels, which comprised ten questions about the following four subjective domains [ 29 ]: (i) satisfaction, (ii) pressure/tension, (iii) value/usefulness, and (iv) willingness to continue the program (Supplementary Table 3). For each detailed item constituting the CT, the implementation rate was calculated as “number of completed pages / total number of pages,” and the success rate was determined as “number of correct answers / total number of questions.” As for physical activity, the participants were telephone-surveyed about the implementation of exercises as percentage. For the analysis of the effect of practice on the outcomes, the participants were divided into two groups (namely, the high-compliance [HC] group and low-compliance [LC] group) according to the median value of the implementation rate for each CT and physical exercise task. Data analysis Data analysis was performed using SPSS software version 27.0 for Windows (IBM Corp., Armonk, NY, USA). The difference in functional scores before and after the intervention was analyzed using the paired t -test or Wilcoxon signed-rank test according to the result of normality test. The influencing effect of the implementation rate of cognitive and physical training tasks as well as the success rate on outcomes was examined using the Mann-Whitney test. All analyses were considered significant at an uncorrected threshold of P < 0.05. Results Baseline characteristics A total of 27 adults (5 men and 22 women) were enrolled in the study from September 25 to October 5, 2020. Two female participants withdrew after screening visits. All 25 participants started the training program on October 5, 2020, which ended on October 30, 2020 (Fig. 1 ). Subsequently, all of them underwent a follow-up evaluation on November 4 or 6, 2020. The average age (mean ± standard deviation) of participants who completed the study was 72.88 ± 4.68 years (range, 65–87 years; men, 76.00 ± 6.36 years; women, 72.10 ± 4.00 years), with 8.60 ± 3.46 years of education (range, 5–18 years; men, 9.00 ± 3.08 years; women, 8.50 ± 3.62 years). The demographic characteristics of the participants are detailed in Table 1 . Table 1 Demographic characteristics of the participants ( N = 25) Characteristic Value Age, years 72.88 ± 4.68 (65–87) Sex (male/female), n 5/20 Education, years 8.60 ± 3.46 (5–18)* Medical illness, n (%) Hypertension Diabetes mellitus Hyperlipidemia Depression Osteoporosis 15 (60%) 3 (12%) 13 (52%) 3 (12%) 4 (16%) * Values are presented as mean ± SD (range) or as number (%) Outcomes of the cognitive and physical training intervention After training, the total MMSE, MBI, and BBS scores significantly increased from 27.32 ± 1.66 to 27.96 ± 1.37 ( Ps < 0.05), from 97.08 ± 2.53 to 98.56 ± 1.69 ( Ps < 0.05), and from 54.68 ± 1.65 to 55.08 ± 1.50 ( Ps < 0.05), respectively (Fig. 2 ). The total RBANS score did not significantly change (96.72 ± 15.40 to 98.20 ± 16.59, Ps = 0.655); however, the attention domain of RBANS subscore showed a significant positive change (99.60 ± 11.12 to 103.12 ± 11.58, Ps < 0.05). Furthermore, the attention/calculation domain of MMSE score significantly increased from 4.16 ± 0.99 to 4.60 ± 0.65 ( Ps < 0.05). Among the MBI subscores, the bathing (4.64 ± 0.49 to 4.92 ± 0.28, Ps < 0.05) and ambulation (14.04 ± 1.43 to 14.76 ± 0.83, Ps < 0.05) scores significantly increased (Table 2 ). Table 2 Subscore analysis of cognitive and ADL tests Pre-intervention Post-intervention p -value RBANS total (40–160) 96.72 ± 15.40 98.20 ± 16.59 0.655 Short memory 99.68 ± 12.56 97.08 ± 12.02 0.345 Visuospatial 96.40 ± 13.19 99.40 ± 12.64 0.256 Language 91.60 ± 20.33 92.96 ± 18.98 0.775 Attention 99.60 ± 11.12 103.12 ± 11.58 0.015* Delayed memory 97.24 ± 12.84 96.80 ± 12.49 0.853 MMSE total (0–30) 27.32 ± 1.65 27.96 ± 1.37 0.023* Orientation time 4.80 ± 0.41 4.72 ± 0.46 0.480 Orientation place 4.72 ± 0.46 4.92 ± 0.28 0.059 Registration 2.08 ± 0.76 3.00 ± 0.00 1.000 Attention and calculation 4.16 ± 0.99 4.60 ± 0.65 0.013* Recall 2.08 ± 0.76 2.00 ± 0.96 0.773 Language and visuospatial 8.56 ± 0.65 8.72 ± 0.54 0.206 MBI total (0–100) 97.08 ± 2.53 98.56 ± 1.69 0.001* Hygiene 5.00 ± 0.00 5.00 ± 0.00 1.000 Bathing 4.64 ± 0.49 4.92 ± 0.28 0.008* Feeding 9.92 ± 0.40 10.00 ± 0.00 0.317 Toilet 10.00 ± 0.00 10.00 ± 0.00 1.000 Stair 8.72 ± 0.98 8.88 ± 1.01 0.157 Dressing 10.00 ± 0.00 10.00 ± 0.00 1.000 Bowel 10.00 ± 0.00 10.00 ± 0.00 1.000 Bladder 9.76 ± 0.66 10.00 ± 0.00 0.083 Ambulation 14.04 ± 1.43 14.76 ± 0.83 0.014* Transfer 15.00 ± 0.00 15.00 ± 0.00 1.000 All values are presented as mean ± SD * P < 0.05 Wilcoxon signed rank test was performed for MMSE and MBI total and subscores, whereas paired t -test was performed for RBANS total and subscores MMSE Mini-Mental Status Examination, RBANS Repeatable Battery for the Assessment of Neuropsychological Status Analysis according to cognitive task compliance and success rate The CT implementation rate varied from 30–100% (mean ± standard deviation: 87.20 ± 20.31%, median: 100%). Therefore, the participants were divided into two groups: the HC group, which implemented all tasks ( n = 15, 100%), and the LC group, which did not fully implement all tasks ( n = 10, 68.00 ± 20.44%). The HC group exhibited significantly higher increments in scores for the short memory (HC 2.87 ± 12.9 vs. LC -10.8 ± 10.1, Ps < 0.05) and delayed memory (HC 3.80 ± 10.6 vs. LC -6.80 ± 11.0, Ps < 0.05) domains of RBANS and total BBS (HC 0.67 ± 0.72 vs. LC 0.00 ± 0.47, Ps < 0.05) than the LC group (Table 3 ). Table 3 Change in the score according to the cognitive task performance rate Total Low-compliance group ( n = 10) High-compliance group ( n = 15) p -value (HC vs. LC) △RBANS total 1.48 ± 16.0 -5.80 ± 16.4 6.33 ± 14.9 0.101 △Short memory -2.60 ± 13.2 -10.8 ± 10.1 2.87 ± 12.9 0.014* △Visuospatial 3.00 ± 12.6 1.20 ± 12.3 4.20 ± 13.5 0.522 △Language 1.36 ± 23.1 -6.60 ± 28.9 6.67 ± 18.4 0.173 △Attention 3.52 ± 6.56 5.40 ± 6.85 2.27 ± 6.51 0.273 △Delayed memory -0.44 ± 11.5 -6.80 ± 11.0 3.80 ± 10.6 0.036* △MMSE total 0.64 ± 1.16 0.70 ± 1.16 0.60 ± 1.24 0.642 △Orientation time -0.08 ± 0.56 -0.20 ± 0.63 0.00 ± 0.53 0.381 △Orientation place 0.20 ± 0.49 0.30 ± 0.48 0.13 ± 0.52 0.436 △Registration 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △Attention and calculation 0.44 ± 0.75 0.60 ± 0.70 0.33 ± 0.82 0.282 △Recall -0.08 ± 1.02 -0.10 ± 0.88 -0.07 ± 1.16 0.928 △Language and visuospatial 0.16 ± 0.61 0.10 ± 0.88 0.20 ± 0.41 0.461 △MBI total 1.48 ± 1.60 1.10 ± 1.60 1.73 ± 1.67 0.299 △Hygiene 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △Bathing 0.28 ± 0.46 0.20 ± 0.42 0.33 ± 0.49 0.476 △Feeding 0.08 ± 0.40 0.00 ± 0.00 0.13 ± 0.52 0.414 △Toilet 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △Stair 0.16 ± 0.55 0.00 ± 0.00 0.27 ± 0.70 0.238 △Dressing 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △Bowel 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △Bladder 0.24 ± 0.66 0.60 ± 0.97 0.00 ± 0.00 0.077 △Ambulation 0.72 ± 1.31 0.30 ± 0.95 1.00 ± 1.46 0.190 △Transfer 0.00 ± 0.00 0.00 ± 0.00 0.00 ± 0.00 1.000 △BBS total 0.40 ± 0.69 0.00 ± 0.47 0.67 ± 0.72 0.019* All values are presented as mean ± SD * P < 0.05 Mann-Whitney test was performed MMSE Mini-Mental Status Examination, RBANS Repeatable Battery for the Assessment of Neuropsychological Status, MBI modified Barthel Index, BBS Berg Balance Scale The implementation and success rates varied according to the tasks. The median success rate for the task of listening to a short article and solving given questions (CT-2, part I) was 58%. In the auditory task in which the participants had to listen and write down words (CT-2, part II), 13 out of 25 participants had median implementation and success rates of 0% for both. The median implementation and success rates were 90.8% and 75.7%, respectively, for the remaining 12 participants. The implementation and success rates for the visual attention task (CT-1) were as high as 100% and 99%, respectively. Satisfaction survey Overall satisfaction results indicated that 88% of participants reported positive responses (“very satisfied” and “satisfied”) (Q1). Furthermore, they expressed positive responses (“very satisfied” [76%] and “satisfied” [72%]) to each questionnaire for the CT and physical exercise programs (Q2 and Q3) (Supplementary Fig. 2). With respect to Q4 and Q5, which pertained to the duration of the entire intervention, 56% and 32% of participants answered that the 4-week intervention was appropriate and long, respectively. In terms of daily program time consumption, 86% answered that it was appropriate. As for responses to the question about pressure and tension, 64% answered that the overall difficulty level of the program was appropriate, whereas 24% expressed that the tasks were difficult (Q6). With respect to the effectiveness of the program in relation to the cognitive, physical, and ADL functions, 64%, 84%, and 76% of participants answered that they were “very satisfied” or “satisfied” for each function (Q7–Q9). Finally, 76% expressed willingness to participate in the program again (Q10). Discussion In this study, the intensive short-term home-based program consisted of CT combined with physical exercise. Variable functions, including attention, balance, and independency in walking and bathing, significantly improved after training in older adults without disability. Analysis of compliance level among the participants revealed that the HC group exhibited greater improvements in memory and balance abilities than the LC group. These results indicated favorable outcome in multifaceted abilities with cognitive and physical training in older adults. Moreover, the use of workbooks for CT and videos to guide the participants in exercise techniques led to a high satisfaction level among the participants. Our findings are in line with the results of previous reports, which also demonstrated the beneficial effects of practicing combined cognitive and physical training on cognitive, motor, and ADL functions despite the short duration of intervention [ 30 , 31 ]. In the present study, increases in the total MMSE score and RBANS-attention score might be accepted as cognitive improvement. Caution in interpreting the total MMSE score is required because unlike the total RBANS score, the MMSE may have a learning effect through repeated testing. Were it not for the RBANS results that indicated a significantly increased score for the attention domain, interpreting the results might be confusing. However, considering the positive results for RBANS, which was developed for short-term follow-up, the intervention could be regarded as more meaningful. The results were also consistent with the findings of a previous systematic review about cognitive-physical interventions for healthy older adults [ 32 ], which showed the efficacy of combined training on the attention domain. This seems meaningful because attention ability is essential for further cognitive processes [ 33 ]. When the participants were divided into two groups according to the compliance level, both the immediate and delayed memory indices of RBANS showed significant improvements in the HC group, whereas the LC group exhibited a decline. Accordingly, we believe that the impact of the intervention is closely related to compliance and that future studies involving additional subgroup analyses should take this into account. In this study, the BBS was used to evaluate gross motor ability and balance, which showed significant improvement after intervention. Moreover, the HC group exhibited more substantial changes than the LC group. The BBS is a powerful tool for discriminating fallers from non- fallers [ 34 ]. Notably, an improvement in balance ability is accompanied by an improvement in attention by the intervention. Attention control is known to be associated with the risk of falls in older adults [ 35 ], and attention control ability has been suggested to be linked to gait performance in older people with a high risk of falls [ 36 ]. It is expected that combined cognitive and physical training may reduce the risk of falls in older adults. As for ADL, our participants showed improvements in their ability to walk and bathe independently. Considering that the BBS scores of patients in this study also improved, the intervention in this study might have contributed to ADL in ambulation and bathing by enhancing the balance function [ 37 ]. Our participants actually expressed that they had previously experienced difficulty in bathing on their own because they needed to hold on to prevent falling; nevertheless, it became possible, as their balance improved throughout the intervention. A previous randomized controlled trial and systematic review also reported that cognitive and physical training led to increased total Barthel Index scores; however, there was no item-by-item analysis [ 38 , 39 ]. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) project [ 40 , 41 ] showed that reasoning training preserved the instrumental ADL function in older adults, which remained even at 10 years after the intervention. It remains unclear how CT causes structural or functional changes in the brain. Structural brain volumetric studies reported that CT increased or preserved the gray matter volume [ 42 ]. A meta-analysis showed that CT activated the left middle frontal gyrus, precentral gyrus, and parietal cortex in older adults [ 43 ]. Increased physical activity was also linked to changes in prefrontal and hippocampal blood flow, potentially enhancing attention [ 44 ]. In the young and old, fitness was associated with attention [ 45 ]. While the exact physiological mechanism would be complex, an improvement in attention is accompanied by an improvement in overall physical ability; nonetheless, further studies on this topic are needed. Our study has some limitations. First, this study was a single-arm trial without a control group and had a small sample size with unequal sex ratio. Second, there were discrepancies in the implementation rate according to tasks, which should be considered for the development of the program in the future. Nevertheless, despite the relatively long intervention time at once (about 2–3 hours per day), our participants achieved an overall implementation rate of approximately 100% (median) with the 4-week home-based intervention. Because an appropriate intervention and regular supervision through periodic contact had been previously reported to enhance the participants’ compliance [ 46 ], borrowing this from previous studies was the key to positive effects even in the short term. Due to heterogeneity in intervention methods and periods compared to previous studies, making a direct comparison is challenging. However, we believe that our results demonstrate the feasibility of conducting short-term intensive home-based cognitive and physical training for the elderly. Conclusion Our study revealed that CT combined with physical exercise for older adults could lead to improvements in cognition, physical ability, and ADL. The short duration of intensive combined program was not only highly satisfactory according to the participants but also effective. Further randomized controlled trials with a larger sample size should be conducted to provide stronger evidence regarding the intervention’s effectiveness. Declarations Acknowledgement The authors acknowledge the Korea Educational Broadcasting System, which provided gymnastic video contents and supported participants’ enrollment. Competing interests The authors declare no competing interests. Funding This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number: HI16C1559) and an IITP grant from the Ministry of Science and ICT (2021-0-00742 Development of Core Technology for Whole-body Medical Twin). Author contributions Kim M designed this study and contributed to data interpretation, writing, and critical revision. Lim I and Shin S were involved in data analysis and interpretation, drafting, and critical revision. Kim J, Baek H, Hong J, and Park E helped in the study design and implementation. All authors are accountable for the final version of the article. Data availability statement The datasets used in this study are not publicly available because of patient confidentiality but are available from the corresponding author upon reasonable request. 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PloS one 12:e0170547 Lam FM, Huang M-Z, Liao L-R, Chung RC, Kwok TC, Pang MY (2018) Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of physiotherapy 64:4–15 Fleiner T, Dauth H, Gersie M, Zijlstra W, Haussermann P (2017) Structured physical exercise improves neuropsychiatric symptoms in acute dementia care: a hospital-based RCT. Alzheimer's Research & Therapy 9:1–9 Korea Educational Broadcasting System (2020) 2020 Exercises to rejuvenate the brain. https://home.ebs.co.kr/healthy_life/main Kang Y, Na DL, Hahn S (1997) A validity study on the Korean Mini-Mental State Examination (K-MMSE) in dementia patients. Journal of the Korean neurological association 15:300–308 Park J-O, Koo B-H, Kim J-Y, Bai D-S, Chang M-S, Kim O-L (2021) The Korean Repeatable Battery for the Assessment of Neuropsychological Status-Update: Psychiatric and Neurosurgery Patient Sample Validity. Journal of Korean Neurosurgical Society 64:125 Jung HY, Park JH, Shim JJ, Kim MJ, Hwang MR, Kim SH (2006) Reliability test of Korean version of berg balance scale. Journal of Korean Academy of Rehabilitation Medicine 30:611–618 Jung HY, Park BK, Shin HS, Kang YK, Pyun SB, Paik NJ, Kim SH, Kim TH, Han TR (2007) Development of the Korean version of Modified Barthel Index (K-MBI): multi-center study for subjects with stroke. Journal of Korean Academy of Rehabilitation Medicine 31:283–297 McAuley E, Duncan T, Tammen VV (1989) Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: a confirmatory factor analysis. Res Q Exerc Sport 60:48–58 Srisuwan P, Nakawiro D, Chansirikarnjana S, Kuha O, Chaikongthong P, Suwannagoot T (2020) Effects of a Group-Based 8-Week Multicomponent Cognitive Training on Cognition, Mood and Activities of Daily Living among Healthy Older Adults: A One-Year Follow-Up of a Randomized Controlled Trial. J Prev Alzheimers Dis 7:112–121 Joubert C, Chainay H (2018) Aging brain: the effect of combined cognitive and physical training on cognition as compared to cognitive and physical training alone - a systematic review. Clin Interv Aging 13:1267–1301 Rieker JA, Reales JM, Muiños M, Ballesteros S (2022) The Effects of Combined Cognitive-Physical Interventions on Cognitive Functioning in Healthy Older Adults: A Systematic Review and Multilevel Meta-Analysis. Front Hum Neurosci 16:838968 Sarter M, Givens B, Bruno JP (2001) The cognitive neuroscience of sustained attention: where top-down meets bottom-up. Brain research reviews 35:146–160 Chiu AY, Au-Yeung SS, LO SK (2003) A comparison of four functional tests in discriminating fallers from non-fallers in older people. Disability and rehabilitation 25:45–50 O'Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA (2011) Falls and falls efficacy: the role of sustained attention in older adults. BMC geriatrics 11:1–10 Fernandez NB, Hars M, Trombetti A, Vuilleumier P (2019) Age-related changes in attention control and their relationship with gait performance in older adults with high risk of falls. Neuroimage 189:551–559 Sapmaz M, Mujdeci B (2021) The effect of fear of falling on balance and dual task performance in the elderly. Exp Gerontol 147:111250 Kim M, Shin E, Kim S, Sok S (2022) The Effectiveness of Multicomponent Intervention on Daily Functioning among the Community-Dwelling Elderly: A Systematic Review. Int J Environ Res Public Health 19 Tian R, Jiang Y, Zhang Y, Yan X, Zhou Y, Chen D (2022) Cognitive training program improves cognitive ability and daily living ability in elderly patients with mild cognitive impairment. Aging Clin Exp Res 34:997–1005 Willis SL, Tennstedt SL, Marsiske M et al. (2006) Long-term effects of cognitive training on everyday functional outcomes in older adults. Jama 296:2805–2814 Rebok GW, Ball K, Guey LT et al. (2014) Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. Journal of the American Geriatrics Society 62:16–24 Nguyen L, Murphy K, Andrews G (2019) Cognitive and neural plasticity in old age: A systematic review of evidence from executive functions cognitive training. Ageing Res Rev 53:100912 Duda BM, Sweet LH (2020) Functional brain changes associated with cognitive training in healthy older adults: A preliminary ALE meta-analysis. Brain Imaging Behav 14:1247–1262 Erickson KI, Voss MW, Prakash RS et al. (2011) Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 108:3017–3022 Fernandes M. de Sousa A, Medeiros AR, Del Rosso S, Stults-Kolehmainen M, Boullosa DA (2019) The influence of exercise and physical fitness status on attention: a systematic review. International Review of Sport and Exercise Psychology 12:202–234 Sipilä S, Tirkkonen A, Hänninen T et al. (2018) Promoting safe walking among older people: the effects of a physical and cognitive training intervention vs. physical training alone on mobility and falls among older community-dwelling men and women (the PASSWORD study): design and methods of a randomized controlled trial. BMC Geriatrics 18:215 Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterials.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3927684","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271148805,"identity":"3f972a27-5be8-44bf-9fcd-eafbfb0487c6","order_by":0,"name":"Ikhyun Lim","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ikhyun","middleName":"","lastName":"Lim","suffix":""},{"id":271148806,"identity":"dde829d4-71dc-4467-ae66-4dc905b017f0","order_by":1,"name":"Seyoung Shin","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Seyoung","middleName":"","lastName":"Shin","suffix":""},{"id":271148807,"identity":"467f0a9a-43f3-4223-ab69-047fd912b803","order_by":2,"name":"Hongseok Baek","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hongseok","middleName":"","lastName":"Baek","suffix":""},{"id":271148808,"identity":"8cca7d83-9513-4398-a316-e698ee441768","order_by":3,"name":"EunYoung Park","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"EunYoung","middleName":"","lastName":"Park","suffix":""},{"id":271148809,"identity":"3e60a217-0df0-4ded-ae81-e7d2913dfe98","order_by":4,"name":"Jeong Min Hong","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jeong","middleName":"Min","lastName":"Hong","suffix":""},{"id":271148810,"identity":"3ab00975-ef30-4d03-ad00-a922b8d1703f","order_by":5,"name":"Jong Moon Kim","email":"","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jong","middleName":"Moon","lastName":"Kim","suffix":""},{"id":271148811,"identity":"a8b6a28a-c644-4166-9ecd-9dd9c1312044","order_by":6,"name":"MinYoung Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYBACCQbGBoYPDAfAHCCTSC2MM0jUwsDAzEOSFslph9se29TckWdgP/yAceYeIrRISye2G+cce2bYwJNmwLjhGRFa5KQT26RzGw4D3ZTDwPjgALFaLBsO2zfwvyFSizRIC2PD4cQGCaAtG4jRIjk7sU2y59jh5DaJZwYHZxCjReJ2+jOJHzWHbfv5kx8+7CFGCxywATFJGkbBKBgFo2AU4AEAZ942/hHwxEUAAAAASUVORK5CYII=","orcid":"","institution":"CHA Bundang Medical Center, CHA University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"MinYoung","middleName":"","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-02-04 13:16:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3927684/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3927684/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":50818613,"identity":"2817d428-a450-460f-8d73-203a2dc76515","added_by":"auto","created_at":"2024-02-07 20:18:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":318370,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3927684/v1/228c38e2bf1df8f27ae47040.jpeg"},{"id":50817571,"identity":"bd3304a9-7c4d-4d58-826c-0b2a903b1e13","added_by":"auto","created_at":"2024-02-07 20:10:49","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":220818,"visible":true,"origin":"","legend":"\u003cp\u003eChange in the main outcome measures. Mean changes from baseline are shown. Changes in the (\u003cstrong\u003ea\u003c/strong\u003e) MMSE total score, (\u003cstrong\u003eb\u003c/strong\u003e) RBANS total score, (\u003cstrong\u003ec\u003c/strong\u003e) MBI total score, and (\u003cstrong\u003ed\u003c/strong\u003e) BBS total score from baseline values. All values are presented as mean±SD. \u003csup\u003ea\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 in the total participants, \u003csup\u003eb\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 in the high-compliance group, \u003csup\u003ec\u003c/sup\u003e\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 in the low-compliance group. \u003cem\u003eMMSE\u003c/em\u003e Mini-Mental Status Examination, \u003cem\u003eRBANS\u003c/em\u003e Repeatable Battery for the Assessment of Neuropsychological Status, \u003cem\u003eMBI\u003c/em\u003e modified Barthel Index, \u003cem\u003eBBS\u003c/em\u003e Berg Balance Scale\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3927684/v1/a6fed66338b1039436660809.jpeg"},{"id":50863347,"identity":"8d2333dc-8d60-416a-a107-00ead05e29ed","added_by":"auto","created_at":"2024-02-08 14:22:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":475525,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3927684/v1/550ed090-249a-4612-bb8a-5abb9c0a55ec.pdf"},{"id":50817573,"identity":"6a653660-2e25-4af8-9725-81f8c3ae0314","added_by":"auto","created_at":"2024-02-07 20:10:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":5164241,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-3927684/v1/6cec5929ec84c8f4fd3558f7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of short-term intensive home-based cognitive training combined with physical exercise in older adults: a single-arm trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe elderly population is increasingly growing globally. With aging, the cognitive function progressively declines, eventually leading to dependence in daily living [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Previous large long-term follow-up study involving community-living older adults reported that 69.5% of elderly experienced difficulty in performing at least one instrumental activity of daily living (ADL) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral clinical trials conducted on the elderly have demonstrated the significant effects of training-based interventions on functional loss in those with or without neurological disorders [\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A recent systematic review suggested that cognitive training (CT) for patients with Alzheimer\u0026rsquo;s disease might result in substantial global cognitive improvement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability study showed that long-term multi-domain intervention consisting of CT and physical exercise not only was beneficial for cognitive function but also reduced the risk of new chronic disease occurrence in older people [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A meta-analysis of combined cognitive and physical training for cognitively impaired or non-impaired older adults showed that combined interventions were significantly effective in improving overall cognitive and physical function [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe amount and method of delivering interventional contents are important issues for training aimed at enhancing the cognitive ability of older adults. Owing to high heterogeneity in intervention protocols, reaching a consensus on the optimal CT dose is difficult. With respect to the duration, short-term training is preferable for clinical application because of the possible drop-out in the elderly during a long-term intervention. In previous clinical studies targeting older adults without cognitive impairment, the duration varied from 2 weeks to 2 years (3\u0026ndash;180 sessions), and the intervention dose per session ranged from 30 minutes to 2 hours [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A short-term trial involving cognitively healthy participants showed that a protocol of 48-hour intervention with a 8-week duration was the most intensive and that multi-domain CT had a beneficial effect on executive function [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Kanaan et al. reported that short-term intensive CT for 40\u0026ndash;50 hours over 2 weeks was feasible and effectively induced cognitive improvement in patients with early-stage Alzheimer\u0026rsquo;s disease [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on previous studies, short-term intensive CT appears to be acceptable and beneficial for older adults with or without known cognitive disorder. Moreover, regarding methods of delivering the training content, which is closely associated with the place of practicing the interventions, attempts to provide training at home are increasing. During the COVID-19 pandemic, the demand on home-based interventions for vulnerable older adults or patients susceptible to infection has increased [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Considering this, investigating the effectiveness of short-term home-based cognitive interventions is necessary.\u003c/p\u003e \u003cp\u003eThe present study aimed to evaluate the improvement in cognitive function and daily living capability of older adults without current disabilities after a 4-week short-term home-based CT program combined with physical exercise (20 sessions for 4 weeks, with a dose of 40\u0026ndash;60 hours in total). By adopting a shorter duration and similar or longer total intervention hours for the program than those in previous studies, we conducted a clinical investigation with a more intensive protocol than before.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis prospective single-arm intervention study was conducted from September 25 to November 6, 2020. The opportunity to participate in this study was open to the town residents of Yangcheon-gu in Seoul, Korea. The inclusion criteria were as follows: adults aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years who were capable of independently performing usual ADL and who provided informed consent for this study. In order to exclude adults with noticeable risks of cognitive impairment, the following exclusion criteria were applied: (i) a Mini-Mental Status Examination (MMSE) score of \u0026lt;\u0026thinsp;24 points [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; (ii) a history of any possible cause of brain dysfunction such as stroke, brain tumor, dementia, cerebral palsy, or Parkinsonism; and (iii) difficulty in continuing the intervention of this study because of poor systemic condition or medical diseases, as judged by the principal investigator of this study. As this was a preliminary study, our target number for the analysis was 25 participants without a control group. Considering a dropout rate of 20%, the total target number of participants was 29.\u003c/p\u003e \u003cp\u003e This study was conducted in accordance with the relevant guidelines and regulations, particularly the Declaration of Helsinki, and was approved by the Institutional Review Board of CHA Bundang Medical Center (IRB file no.: 2020-09-005). Written and informed consent was obtained from all participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eContent of the training program\u003c/h2\u003e \u003cp\u003eThe intervention program comprised cognitive and physical training tasks, and performance was recorded in a workbook for personal use. The workbook used in this study and its contents were developed by our research team, which consisted of rehabilitation medicine physicians, psychologists, occupational therapists, and physical therapists.\u003c/p\u003e \u003cp\u003eAs for the creation of the content of CT, protocols established by the clinical practice team of CHA Bundang Medical Center and existing papers on CT were referred to and combined [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A physical exercise program was developed based on previous reports regarding exercise programs for patients with dementia [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and gymnastic video content produced by the Educational Broadcasting System, a Korean public broadcaster, was used [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs for the performance of tasks of a day, each session required 60\u0026ndash;120 minutes for CT and 60 minutes for physical exercise. The following tasks for CT focused on practice memory, attention, and mental flexibility: visual memory activity (CT-1), auditory memory tasks (CT-2), short-term memory tasks (CT-3), memory recall tasks (CT-4), and visual and auditory attention tasks (CT-5). Physical exercise involved stretching, muscle strength training, and coordination training. There was no strict order in performing the cognitive and physical tasks, and it was considered completed once the set amount of time per day had elapsed. The combined training program was intended to be practiced daily during weekdays for 4 consecutive weeks. Training that could not be performed during weekdays was recommended to be supplemented on weekends, and a schedule of 5 days per week was fulfilled. Detailed information about the workbook and exercise program is presented in Supplementary Method, Supplementary Tables\u0026nbsp;1 and 2, and Supplementary Fig.\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eImplementation of training and content delivery\u003c/h2\u003e \u003cp\u003eTo begin with the training, all participants were informed by the study team about the purpose of the study, content, and detailed methods of conducting the training for 2 hours. Subsequently, each participant was provided with a workbook, which contained approximately 200 pages (including schedules, cognitive tasks, pages for diary, and guidelines needed to be filled up for 4 weeks), to carry out the paper-and-pencil-based tasks. Additionally, recorded instrumental audio and video materials were distributed to the participants on a daily basis to perform the tasks via a smartphone messenger service. Following the completion of the 4-week intervention, the rate of practice was assessed according to the written records was assessed with error rates in records of the workbook. Furthermore, given that CT-1 and CT-3 did not have grading standards, the performance rate was evaluated by calculating the success rates of CT-2, CT-4, and CT-5. A social worker from a local public welfare center visited the homes of participants who asked for help, and the researchers contacted the participants daily through phone calls and text messages to encourage and monitor consistent participation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003e Outcome assessments were conducted before and after the 4-week intervention using approved nationality-specific versions of standardized functional measures. In particular, the MMSE [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] were used to evaluate cognitive function. The Berg Balance Scale (BBS) [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] was used to assess balance and gross motor ability, whereas the modified Barthel Index (MBI) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] was used to evaluate capabilities in ADL indipendency. The RBANS consists of five domain indices: (i) immediate memory (list learning and story memory), (ii) visuospatial/constructional ability (figure copy and line orientation), (iii) language (naming and semantic fluency), (iv) attention (digit span and coding), and (v) delayed memory. With the RBANS, one of the four types (namely, A, B, C, and D) was utilized to avoid a learning effect by repeated measurement with a relatively short-term interval. In this study, the participants were randomly divided into two groups to conduct an initial evaluation with type A or C test, respectively, and post-intervention evaluation was performed using other types of test.\u003c/p\u003e \u003cp\u003eAs baseline assessment, outcomes were assessed within 2 weeks prior to the start of the training program. Post-intervention assessments were conducted within 1 week after the end of the program. Medical doctors evaluated cognitive and physical abilities after securing inter-rater reliability for measurements with intra-class coefficient\u0026thinsp;\u0026gt;\u0026thinsp;0.9. An expert clinical psychologist also conducted part of the cognitive evaluation. The analyses included not only the total measurement scores but also the RBANS, MMSE, and MBI subscores. When conducting post-intervention functional assessments, the evaluator was blinded to the baseline scores.\u003c/p\u003e \u003cp\u003eAfter 4 weeks of training, feedback regarding the program was obtained from the participants. The participants were instructed to fill in a questionnaire focusing on satisfaction and comfort levels, which comprised ten questions about the following four subjective domains [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]: (i) satisfaction, (ii) pressure/tension, (iii) value/usefulness, and (iv) willingness to continue the program (Supplementary Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eFor each detailed item constituting the CT, the implementation rate was calculated as \u0026ldquo;number of completed pages / total number of pages,\u0026rdquo; and the success rate was determined as \u0026ldquo;number of correct answers / total number of questions.\u0026rdquo; As for physical activity, the participants were telephone-surveyed about the implementation of exercises as percentage. For the analysis of the effect of practice on the outcomes, the participants were divided into two groups (namely, the high-compliance [HC] group and low-compliance [LC] group) according to the median value of the implementation rate for each CT and physical exercise task.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analysis was performed using SPSS software version 27.0 for Windows (IBM Corp., Armonk, NY, USA). The difference in functional scores before and after the intervention was analyzed using the paired \u003cem\u003et\u003c/em\u003e-test or Wilcoxon signed-rank test according to the result of normality test. The influencing effect of the implementation rate of cognitive and physical training tasks as well as the success rate on outcomes was examined using the Mann-Whitney test. All analyses were considered significant at an uncorrected threshold of \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eA total of 27 adults (5 men and 22 women) were enrolled in the study from September 25 to October 5, 2020. Two female participants withdrew after screening visits. All 25 participants started the training program on October 5, 2020, which ended on October 30, 2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequently, all of them underwent a follow-up evaluation on November 4 or 6, 2020. The average age (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation) of participants who completed the study was 72.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68 years (range, 65\u0026ndash;87 years; men, 76.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.36 years; women, 72.10\u0026thinsp;\u0026plusmn;\u0026thinsp;4.00 years), with 8.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46 years of education (range, 5\u0026ndash;18 years; men, 9.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08 years; women, 8.50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62 years). The demographic characteristics of the participants are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of the participants (\u003cem\u003eN\u0026thinsp;=\u003c/em\u003e\u0026thinsp;25)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.88\u0026thinsp;\u0026plusmn;\u0026thinsp;4.68 (65\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female), \u003cem\u003en\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46 (5\u0026ndash;18)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical illness, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003cp\u003eDiabetes mellitus\u003c/p\u003e \u003cp\u003eHyperlipidemia\u003c/p\u003e \u003cp\u003eDepression\u003c/p\u003e \u003cp\u003eOsteoporosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (60%)\u003c/p\u003e \u003cp\u003e3 (12%)\u003c/p\u003e \u003cp\u003e13 (52%)\u003c/p\u003e \u003cp\u003e3 (12%)\u003c/p\u003e \u003cp\u003e4 (16%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* Values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range) or as number (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes of the cognitive and physical training intervention\u003c/h2\u003e \u003cp\u003eAfter training, the total MMSE, MBI, and BBS scores significantly increased from 27.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66 to 27.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37 (\u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), from 97.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53 to 98.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69 (\u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and from 54.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65 to 55.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.50 (\u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The total RBANS score did not significantly change (96.72\u0026thinsp;\u0026plusmn;\u0026thinsp;15.40 to 98.20\u0026thinsp;\u0026plusmn;\u0026thinsp;16.59, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.655); however, the attention domain of RBANS subscore showed a significant positive change (99.60\u0026thinsp;\u0026plusmn;\u0026thinsp;11.12 to 103.12\u0026thinsp;\u0026plusmn;\u0026thinsp;11.58, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, the attention/calculation domain of MMSE score significantly increased from 4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 to 4.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65 (\u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among the MBI subscores, the bathing (4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 to 4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and ambulation (14.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43 to 14.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) scores significantly increased (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubscore analysis of cognitive and ADL tests\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBANS total (40\u0026ndash;160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e96.72\u0026thinsp;\u0026plusmn;\u0026thinsp;15.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e98.20\u0026thinsp;\u0026plusmn;\u0026thinsp;16.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.655\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e99.68\u0026thinsp;\u0026plusmn;\u0026thinsp;12.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e97.08\u0026thinsp;\u0026plusmn;\u0026thinsp;12.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisuospatial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e96.40\u0026thinsp;\u0026plusmn;\u0026thinsp;13.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e99.40\u0026thinsp;\u0026plusmn;\u0026thinsp;12.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e91.60\u0026thinsp;\u0026plusmn;\u0026thinsp;20.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e92.96\u0026thinsp;\u0026plusmn;\u0026thinsp;18.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e99.60\u0026thinsp;\u0026plusmn;\u0026thinsp;11.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e103.12\u0026thinsp;\u0026plusmn;\u0026thinsp;11.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelayed memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e97.24\u0026thinsp;\u0026plusmn;\u0026thinsp;12.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e96.80\u0026thinsp;\u0026plusmn;\u0026thinsp;12.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.853\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE total (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e27.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.96\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.023*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrientation place\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttention and calculation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e2.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLanguage and visuospatial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMBI total (0\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e97.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e98.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e4.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.008*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToilet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e8.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.157\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDressing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBowel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBladder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.04\u0026thinsp;\u0026plusmn;\u0026thinsp;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e14.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eWilcoxon signed rank test was performed for MMSE and MBI total and subscores, whereas paired \u003cem\u003et\u003c/em\u003e-test was performed for RBANS total and subscores\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eMMSE\u003c/em\u003e Mini-Mental Status Examination, \u003cem\u003eRBANS\u003c/em\u003e Repeatable Battery for the Assessment of Neuropsychological Status\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis according to cognitive task compliance and success rate\u003c/h2\u003e \u003cp\u003eThe CT implementation rate varied from 30\u0026ndash;100% (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation: 87.20\u0026thinsp;\u0026plusmn;\u0026thinsp;20.31%, median: 100%). Therefore, the participants were divided into two groups: the HC group, which implemented all tasks (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15, 100%), and the LC group, which did not fully implement all tasks (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10, 68.00\u0026thinsp;\u0026plusmn;\u0026thinsp;20.44%). The HC group exhibited significantly higher increments in scores for the short memory (HC 2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9 vs. LC -10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and delayed memory (HC 3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6 vs. LC -6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) domains of RBANS and total BBS (HC 0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 vs. LC 0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47, \u003cem\u003ePs\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) than the LC group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChange in the score according to the cognitive task performance rate\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow-compliance group\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh-compliance group\u003c/p\u003e \u003cp\u003e(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003cp\u003e(HC vs. LC)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△RBANS total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-5.80\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;14.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Short memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-2.60\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Visuospatial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.00\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.20\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.20\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Language\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-6.60\u0026thinsp;\u0026plusmn;\u0026thinsp;28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.67\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Attention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.52\u0026thinsp;\u0026plusmn;\u0026thinsp;6.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;6.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Delayed memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-6.80\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e3.80\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.036*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△MMSE total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.70\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Orientation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.381\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Orientation place\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Registration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Attention and calculation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Recall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e-0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e-0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e-0.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Language and visuospatial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△MBI total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.10\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Hygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Bathing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.476\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Feeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Toilet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Stair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Dressing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Bowel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Bladder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Ambulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.30\u0026thinsp;\u0026plusmn;\u0026thinsp;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△Transfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e△BBS total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.019*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAll values are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eMann-Whitney test was performed\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eMMSE\u003c/em\u003e Mini-Mental Status Examination, \u003cem\u003eRBANS\u003c/em\u003e Repeatable Battery for the Assessment of Neuropsychological Status, \u003cem\u003eMBI\u003c/em\u003e modified Barthel Index, \u003cem\u003eBBS\u003c/em\u003e Berg Balance Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe implementation and success rates varied according to the tasks. The median success rate for the task of listening to a short article and solving given questions (CT-2, part I) was 58%. In the auditory task in which the participants had to listen and write down words (CT-2, part II), 13 out of 25 participants had median implementation and success rates of 0% for both. The median implementation and success rates were 90.8% and 75.7%, respectively, for the remaining 12 participants. The implementation and success rates for the visual attention task (CT-1) were as high as 100% and 99%, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSatisfaction survey\u003c/h2\u003e \u003cp\u003eOverall satisfaction results indicated that 88% of participants reported positive responses (\u0026ldquo;very satisfied\u0026rdquo; and \u0026ldquo;satisfied\u0026rdquo;) (Q1). Furthermore, they expressed positive responses (\u0026ldquo;very satisfied\u0026rdquo; [76%] and \u0026ldquo;satisfied\u0026rdquo; [72%]) to each questionnaire for the CT and physical exercise programs (Q2 and Q3) (Supplementary Fig.\u0026nbsp;2). With respect to Q4 and Q5, which pertained to the duration of the entire intervention, 56% and 32% of participants answered that the 4-week intervention was appropriate and long, respectively. In terms of daily program time consumption, 86% answered that it was appropriate. As for responses to the question about pressure and tension, 64% answered that the overall difficulty level of the program was appropriate, whereas 24% expressed that the tasks were difficult (Q6). With respect to the effectiveness of the program in relation to the cognitive, physical, and ADL functions, 64%, 84%, and 76% of participants answered that they were \u0026ldquo;very satisfied\u0026rdquo; or \u0026ldquo;satisfied\u0026rdquo; for each function (Q7\u0026ndash;Q9). Finally, 76% expressed willingness to participate in the program again (Q10).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the intensive short-term home-based program consisted of CT combined with physical exercise. Variable functions, including attention, balance, and independency in walking and bathing, significantly improved after training in older adults without disability. Analysis of compliance level among the participants revealed that the HC group exhibited greater improvements in memory and balance abilities than the LC group. These results indicated favorable outcome in multifaceted abilities with cognitive and physical training in older adults. Moreover, the use of workbooks for CT and videos to guide the participants in exercise techniques led to a high satisfaction level among the participants.\u003c/p\u003e \u003cp\u003eOur findings are in line with the results of previous reports, which also demonstrated the beneficial effects of practicing combined cognitive and physical training on cognitive, motor, and ADL functions despite the short duration of intervention [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the present study, increases in the total MMSE score and RBANS-attention score might be accepted as cognitive improvement. Caution in interpreting the total MMSE score is required because unlike the total RBANS score, the MMSE may have a learning effect through repeated testing. Were it not for the RBANS results that indicated a significantly increased score for the attention domain, interpreting the results might be confusing. However, considering the positive results for RBANS, which was developed for short-term follow-up, the intervention could be regarded as more meaningful. The results were also consistent with the findings of a previous systematic review about cognitive-physical interventions for healthy older adults [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], which showed the efficacy of combined training on the attention domain. This seems meaningful because attention ability is essential for further cognitive processes [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. When the participants were divided into two groups according to the compliance level, both the immediate and delayed memory indices of RBANS showed significant improvements in the HC group, whereas the LC group exhibited a decline. Accordingly, we believe that the impact of the intervention is closely related to compliance and that future studies involving additional subgroup analyses should take this into account.\u003c/p\u003e \u003cp\u003eIn this study, the BBS was used to evaluate gross motor ability and balance, which showed significant improvement after intervention. Moreover, the HC group exhibited more substantial changes than the LC group. The BBS is a powerful tool for discriminating fallers from non- fallers [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Notably, an improvement in balance ability is accompanied by an improvement in attention by the intervention. Attention control is known to be associated with the risk of falls in older adults [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and attention control ability has been suggested to be linked to gait performance in older people with a high risk of falls [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It is expected that combined cognitive and physical training may reduce the risk of falls in older adults.\u003c/p\u003e \u003cp\u003e As for ADL, our participants showed improvements in their ability to walk and bathe independently. Considering that the BBS scores of patients in this study also improved, the intervention in this study might have contributed to ADL in ambulation and bathing by enhancing the balance function [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Our participants actually expressed that they had previously experienced difficulty in bathing on their own because they needed to hold on to prevent falling; nevertheless, it became possible, as their balance improved throughout the intervention. A previous randomized controlled trial and systematic review also reported that cognitive and physical training led to increased total Barthel Index scores; however, there was no item-by-item analysis [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) project [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] showed that reasoning training preserved the instrumental ADL function in older adults, which remained even at 10 years after the intervention.\u003c/p\u003e \u003cp\u003eIt remains unclear how CT causes structural or functional changes in the brain. Structural brain volumetric studies reported that CT increased or preserved the gray matter volume [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A meta-analysis showed that CT activated the left middle frontal gyrus, precentral gyrus, and parietal cortex in older adults [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Increased physical activity was also linked to changes in prefrontal and hippocampal blood flow, potentially enhancing attention [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. In the young and old, fitness was associated with attention [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. While the exact physiological mechanism would be complex, an improvement in attention is accompanied by an improvement in overall physical ability; nonetheless, further studies on this topic are needed.\u003c/p\u003e \u003cp\u003eOur study has some limitations. First, this study was a single-arm trial without a control group and had a small sample size with unequal sex ratio. Second, there were discrepancies in the implementation rate according to tasks, which should be considered for the development of the program in the future. Nevertheless, despite the relatively long intervention time at once (about 2\u0026ndash;3 hours per day), our participants achieved an overall implementation rate of approximately 100% (median) with the 4-week home-based intervention. Because an appropriate intervention and regular supervision through periodic contact had been previously reported to enhance the participants\u0026rsquo; compliance [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], borrowing this from previous studies was the key to positive effects even in the short term. Due to heterogeneity in intervention methods and periods compared to previous studies, making a direct comparison is challenging. However, we believe that our results demonstrate the feasibility of conducting short-term intensive home-based cognitive and physical training for the elderly.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study revealed that CT combined with physical exercise for older adults could lead to improvements in cognition, physical ability, and ADL. The short duration of intensive combined program was not only highly satisfactory according to the participants but also effective. Further randomized controlled trials with a larger sample size should be conducted to provide stronger evidence regarding the intervention\u0026rsquo;s effectiveness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u0026nbsp;\u003c/strong\u003eThe authors acknowledge the Korea Educational Broadcasting System, which provided gymnastic video contents and supported participants\u0026rsquo; enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eThis research was supported by a grant of the Korea Health Technology R\u0026amp;D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health \u0026amp; Welfare, Republic of Korea (grant number: HI16C1559) \u0026nbsp;and an IITP grant from the Ministry of Science and ICT (2021-0-00742 Development of Core Technology for Whole-body Medical Twin).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eKim M designed this study and contributed to data interpretation,\u0026nbsp;writing, and critical revision.\u0026nbsp;Lim I and Shin S were involved in data analysis and interpretation, drafting, and critical revision. Kim J, Baek H, Hong J, and Park E helped in the study design and implementation. All authors are accountable for the final version of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u0026nbsp;\u003c/strong\u003eThe datasets used in this study are not publicly available because of patient confidentiality but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003eFor this type of article, informed consent is not needed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHan L, Gill TM, Jones BL, Allore HG (2016) Cognitive aging trajectories and burdens of disability, hospitalization and nursing home admission among community-living older persons. 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Disability and rehabilitation 25:45\u0026ndash;50\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Halloran AM, P\u0026eacute;nard N, Galli A, Fan CW, Robertson IH, Kenny RA (2011) Falls and falls efficacy: the role of sustained attention in older adults. BMC geriatrics 11:1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandez NB, Hars M, Trombetti A, Vuilleumier P (2019) Age-related changes in attention control and their relationship with gait performance in older adults with high risk of falls. Neuroimage 189:551\u0026ndash;559\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSapmaz M, Mujdeci B (2021) The effect of fear of falling on balance and dual task performance in the elderly. 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(2014) Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. Journal of the American Geriatrics Society 62:16\u0026ndash;24\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen L, Murphy K, Andrews G (2019) Cognitive and neural plasticity in old age: A systematic review of evidence from executive functions cognitive training. Ageing Res Rev 53:100912\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuda BM, Sweet LH (2020) Functional brain changes associated with cognitive training in healthy older adults: A preliminary ALE meta-analysis. Brain Imaging Behav 14:1247\u0026ndash;1262\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErickson KI, Voss MW, Prakash RS et al. (2011) Exercise training increases size of hippocampus and improves memory. Proc Natl Acad Sci U S A 108:3017\u0026ndash;3022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernandes M. de Sousa A, Medeiros AR, Del Rosso S, Stults-Kolehmainen M, Boullosa DA (2019) The influence of exercise and physical fitness status on attention: a systematic review. International Review of Sport and Exercise Psychology 12:202\u0026ndash;234\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSipil\u0026auml; S, Tirkkonen A, H\u0026auml;nninen T et al. (2018) Promoting safe walking among older people: the effects of a physical and cognitive training intervention vs. physical training alone on mobility and falls among older community-dwelling men and women (the PASSWORD study): design and methods of a randomized controlled trial. BMC Geriatrics 18:215\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cognitive training, Physical training, Older adult, Activities of daily living","lastPublishedDoi":"10.21203/rs.3.rs-3927684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3927684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003ePrevious studies note the significant effects of Cognitive Training (CT) on older adults, but achieving consensus on optimal dosage is challenging due to intervention protocol heterogeneity. Short-term training seems preferable for clinical use due to potential elderly dropout during long-term intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e To evaluate the efficacy of 4-week intensive home-based cognitive and physical training on personal function in older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eThis prospective single-arm intervention study enrolled older adults aged ≥65 years who were capable of independently performing activities of daily living. Adults with a Mini-Mental Status Examination (MMSE) score of \u0026lt;24 points, a history of any brain injury, or difficulty in continuing the intervention were excluded. The training program comprised 1–2-hour cognitive tasks and 1-hour physical exercise for 5 days per week for 4 consecutive weeks. The MMSE, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Berg Balance Scale (BBS), and modified Barthel Index (MBI) scores were assessed before and after the intervention. Functional outcomes were analyzed according to compliance level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eTwenty-five participants were enrolled and completed the trial. After the intervention, functional improvements were observed, along with significantly increased MMSE, RBANS-attention, BBS, and MBI scores (\u003cem\u003ePs\u0026lt;\u003c/em\u003e0.05). The high-compliance group showed greater increment in RBANS-memory and BBS scores than the low-compliance group (\u003cem\u003ePs\u0026lt;\u003c/em\u003e0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e The intervention in this study might have contributed to ADL in ambulation and bathing by enhancing the balance function\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eShort-term intensive cognitive training combined with physical exercise seems to be effective in enhancing multifaceted functional status in older adults.\u003c/p\u003e","manuscriptTitle":"Efficacy of short-term intensive home-based cognitive training combined with physical exercise in older adults: a single-arm trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-07 20:10:44","doi":"10.21203/rs.3.rs-3927684/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e2c738be-557d-432a-a5c1-885c51a4828e","owner":[],"postedDate":"February 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-08T14:22:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-07 20:10:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3927684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3927684","identity":"rs-3927684","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}