Association of impaired sleep, depressive symptoms and pain with physical activity and exercise intervention adherence

Association of impaired sleep, depressive symptoms and pain with physical activity and exercise intervention adherence | 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 Association of impaired sleep, depressive symptoms and pain with physical activity and exercise intervention adherence Eija Kekkonen, Anette Hall, Riitta Antikainen, Satu Havulinna, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4826880/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Mar, 2025 Read the published version in BMC Geriatrics → Version 1 posted 4 You are reading this latest preprint version Abstract Background Physical activity (PA) and exercise interventions are beneficial for health and can reduce dementia risk. However, there might be barriers to engage in PA, such as sleep problems, depressive symptoms and pain, which are common complaints with older adults. We investigated the association between sleep duration, sleep quality, depressive symptoms, and pain with adherence to exercise intervention and self-reported PA in a 2-year randomized controlled trial using multidomain lifestyle intervention (post-hoc analyses). Methods The FINGER trial included 1259 individuals at risk for dementia, aged 60–77 years who were randomized (1:1) to a multidomain lifestyle intervention (exercise, diet, cognitive training, vascular risk factor management) or a control (regular health advice) group. Logistic regression analyses were used with exercise adherence (adherent: ≥66% participation) or self-reported PA (active: ≥2 times/week) as outcomes, adjusted for relevant baseline characteristics. Data on PA at baseline and at 2-years were available for 1100 participants. Results The intervention group participants sleeping < 6h or ≥ 9h per night were less likely to be adherent compared with the participants sleeping ≥ 7–<8h, (OR 0.46, 95% CI 0.21–0.99 and OR 0.38, 95% CI 0.20–0.74, respectively). The intervention group participants were more likely to be physically active than those in the control group at two years. This intervention benefit did not significantly differ by baseline sleep duration, depressive symptoms, or pain (p > 0.3 for all interactions). Regardless of randomization group, those sleeping < 6h were less likely to be physically active at two years, compared with participants sleeping ≥ 7–<8h (OR 0.36, 95% CI 0.18–0.72). Depressive symptoms or pain were not related to PA at two years. Conclusions Older adults with sleep problems, depressive symptoms or pain may benefit from lifestyle interventions. However, both short and long sleep duration can be barriers to engaging in exercise intervention and should be taken into consideration when aiming to promote PA among older populations at risk of dementia. Trial registration: The FINGER trial was registered at ClinicalTrials.gov with identifier NCT01041989. Physical activity exercise sleep mood pain lifestyle intervention adherence Figures Figure 1 Introduction Older adults meeting physical activity (PA) recommendations have a reduced risk of non-communicable diseases such as cardiovascular disease ( 1 , 2 ) and diabetes ( 3 ). Sufficient PA has been associated with reduced risk of cognitive decline, dementia and Alzheimer’s disease (AD) ( 4 , 5 ). As ageing is associated with a higher risk for several cognitive and other health-related challenges ( 5 , 6 ), it is important to investigate potential barriers to participation in lifestyle intervention programs and maintaining a physically active lifestyle. Sleep problems, depressive symptoms and pain are common complaints in late life ( 7 – 10 ), and they often co-occur ( 11 – 13 ), and can have a negative impact on PA. This impact on PA has been less investigated in the context of intervention studies and most earlier studies have focused primarily on how PA affects sleep, depressive symptoms and pain ( 14 , 15 ). Short-term associations (7–14 days) of sleep on PA have been investigated in older adults in observational studies with inconsistent results ( 16 – 19 ). A 2-year longitudinal study in community-dwelling older adults reported that a prior poor sleep quality predicted lower PA ( 20 ). One 18-week lifestyle intervention study showed that better sleep quality predicted increased PA the following day ( 21 ). Depressive symptoms have been associated with physical inactivity in older populations ( 22 , 23 ). In a longitudinal study, depressive symptoms predicted lower levels of PA after 2 years ( 24 ). A few lifestyle intervention studies have reported lower exercise participation rates in people with increased depressive symptoms ( 25 – 28 ). Pain, due to common age-related musculoskeletal conditions or other causes, has also been linked to lower levels of PA ( 29 – 31 ). However, the associations of impaired sleep or pain on exercise intervention participation have not been previously investigated in the context of dementia prevention. Multidomain lifestyle interventions including exercise are currently emphasized as a promising dementia risk reduction strategy ( 5 , 32 ). The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) was the first large long-term randomized controlled trial to show that a 2-year multidomain lifestyle intervention (combining exercise, diet, cognitive training and vascular risk factor management) had benefits for cognition in older adults at risk for dementia ( 32 ). This study aimed at investigating whether self-reported sleep duration, sleep quality, depressive symptoms and bodily pain at baseline are associated with (i) exercise intervention adherence in people participating in the intervention group exercise program during the trial, and (ii) PA after the 2-year multidomain intervention in all trial participants. Methods Population and intervention FINGER (ClinicalTrials.gov identifier NCT01041989) was a 2-year randomized controlled trial conducted at 6 sites in Finland in 1259 older individuals at-risk for dementia. The detailed protocol and primary results have been previously published ( 33 ). Participants were aged 60–77 years, had a Cardiovascular Risk Factors, Aging and Dementia (CAIDE) risk score ≥ 6 points, and cognitive performance around the mean level or slightly lower than expected for age according to Finnish population norms ( 32 ). Participants with dementia (diagnosed or suspected after clinical evaluation at screening), MMSE < 20 points, or conditions affecting safe participation were excluded. Eligible participants were randomized (1:1) into multidomain intervention and control groups, using a computerized algorithm in blocks of four (two individuals randomly allocated to each group) at each site after baseline by the study nurse. Double blinding was pursued as much as possible: outcome assessors were blinded, and participants were not actively informed about their randomization group. The primary outcome of the FINGER trial was comprehensive neuropsychological test battery (NTB) total score ( 32 ). The control group received general health advice. The intervention group was offered to receive a combination of several intervention components. The exercise component followed international guidelines and included group training sessions at the gym, guided by the study physiotherapists. The training program was individually tailored based on repetition maximum measurements and incorporated progressive muscle strength training (1–3 times/week) and aerobic exercise (2–5 times/week), including exercises to improve postural balance. Other intervention components were nutritional guidance, cognitive training, social stimulation, and monitoring and management of metabolic and vascular risk factors ( 32 , 33 ). Assessment of physical activity, sleep, depressive symptoms, and pain Exercise adherence in the intervention group was defined as the percentage of participation in the offered gym sessions. Participants were considered adherent when they reached at least 66% adherence rate in the exercise training sessions, as previously proposed ( 34 ). PA in all trial participants was assessed as the self-reported frequency of exercise activities lasting at least 20 minutes and having sufficient intensity to cause slight breathlessness and sweating. Based on a previously defined cut-off, participants reporting a frequency of at least two times/week were considered physically active ( 35 ). Self-reported average duration of sleep during the night was categorized as < 6h, ≥ 6–<7h, ≥ 7–<8h, ≥ 8–<9h, and ≥ 9h. The recommended sleep duration for older adults is ≥ 7–<8 hours per night ( 36 ). A composite index of sleep quality was calculated based on seven sleep-related questions (Appendix table 1). A cut-off of ≥ 40/100 was used to define poor sleep quality. Depressive symptoms were assessed using the Zung scale, and cut-off for at least mild depressive symptoms was set to ≥ 40, as previously defined ( 37 – 39 ). Pain was measured as a composite index based on RAND-36 bodily pain scale ( 40 ); cut-off was set to ≥ 40/100 for describing at least average amount of pain that disturbs at least some amount of daily chores and work (Appendix table 1). Statistical analysis Data analyses in this study were post-hoc. A study flowchart with focus on PA and exercise intervention adherence as outcomes is shown in Fig. 1 . Between-group differences in baseline characteristics were analyzed with t-test and one-way ANOVA for normally distributed variables, Mann-Whitney test or Kruskal-Wallis test for non-normally distributed variables, and Chi-Square test for categorical variables. Cross-sectional analyses of associations between sleep duration, sleep quality, depressive symptoms or pain and PA at baseline (active versus inactive) were analyzed using logistic regression models, adjusted for age, sex, education, body mass index (BMI), marital status, self-rated health status, and study site. The analysis of exercise adherence during the intervention included all intervention group participants. Effects of sleep duration, sleep quality, and pain on intervention exercise adherence (adherent versus non-adherent) were analyzed with logistic regression models adjusted for baseline PA, age, sex, education, BMI, marital status, self-rated health status, and study site. For sleep, the recommended duration of 7–8h/night was used as the reference category ( 36 ). The effects of depressive symptoms on exercise adherence have been reported previously ( 25 , 28 ). The analysis of the intervention effect on self-reported PA (active/inactive) at two years and the effect of sleep, depressive symptoms and pain on PA included all intervention and control group participants with PA data available from both baseline and 2-year visits. To assess the intervention effect on PA, logistic regression was conducted with PA after the 2-year trial as dependent variable (active versus inactive) and randomization group as independent variable, adjusted for baseline PA, age, sex, education, BMI, marital status, self-rated health status, and study site. To evaluate whether the effect on PA was modified by baseline sleep duration or quality, depressive symptoms or pain, the following terms were separately added to the logistic regression model: (i) sleep duration and sleep duration×randomization group interaction; (ii) sleep quality and sleep quality×randomization; (iii) depressive symptoms and depressive symptoms×randomization; and (iv) pain and pain×randomization. We report the two-way interactions and the intervention effect stratified by sleep duration, sleep quality, depressive symptoms and pain categories. To further investigate if baseline sleep, depressive symptoms or pain were related to PA after the 2-year trial irrespective of randomization group, we used logistic regression models adjusted for randomization group, baseline PA, age, sex, education, BMI, marital status, self-rated health status and study site (Model 1). Additionally, all the models were adjusted for relevant baseline medications (for sleep problems, depressive symptoms or pain, Model 2), and baseline cognition (total NTB score, Model 3). The same approach was used for models with exercise intervention adherence as outcome. All analyses were conducted using STATA version 14 software, and the significance level was set to 0.05. Results There were 1100 participants (87.4%) who had PA data available at both baseline and 2-year visits (Fig. 1 ). At baseline there were no significant differences between intervention and control groups. Overall, compared with participants who were active at baseline, inactive participants had a higher BMI, worse self-rated health, poorer sleep quality, more pain and more depressive symptoms (Table 1 ). Participants without available PA data (n = 159) were slightly older, had a lower education and cognition, and more pain, with a trend for more often abnormal sleep duration than in participants with available PA data (Appendix table 2). Sleep duration, sleep quality, depressive symptoms and pain were all associated with one another at baseline (Appendix tables 3–4). The associations were U-shaped for sleep duration, i.e. both short and long sleep durations were associated with more depressive symptoms and more bodily pain ( p < 0.001, Appendix table 3). Participants with a poor sleep quality had more depressive symptoms and pain ( p < 0.001), and those with depressive symptoms had more often pronounced pain ( p < 0.001, Appendix table 4). Cross-sectional analyses at baseline showed that participants with depressive symptoms and shorter sleep duration (≥ 6–<7h compared with ≥ 7–<8h/night) were less likely to be physically active: (OR 0.70, 95% CI 0.50–1.00) and (OR 0.66, 95% CI 0.44–1.00), respectively. PA was not significantly associated with sleep duration of < 6h (OR 1.11, 95% CI 0.55–2.25); 8–9h (OR 0.79, 95% CI 0.56–1.10); or ≥ 9h: (OR 0.66, 95% CI 0.40–1.10) compared with ≥ 7–<8h/night. There were also no associations of PA with poor sleep quality: (OR 0.83, 95% CI 0.581.18); or bodily pain: (OR 0.90, 95% CI 0.64–1.25). Table 1 Baseline characteristics of the FINGER participants with available physical activity data at both baseline and 2-year visits Intervention Group N = 546 Control Group N = 554 p value Physically active ≥ 2 times a week N = 786 Physically active < 2 times a week N = 314 p value Age, mean (SD) 68.9 (4.6) 68.5 (4.7) 0.172 68.8 (4.7) 68.5 (4.59) 0.301 Sex, female n (%) 242 (44.3%) 265 (47.8%) 0.243 371 (47.2%) 136 (43.3%) 0.243 Education years, mean (SD) 10.0 (3.5) 10.1 (3.5) 0.816 10.0 (3.4) 10.1 (3.5) 0.986 Body mass index, mean (SD) 28.2 (4.5) 28.0 (5.0) 0.546 27.8 (4.4) 29.2 (5.4) < .001 Self-rated health Poor self-rated health, n (%) 18 (3.3%) 18 (3.3%) 0.492 6 (0.8%) 30 (9.6%) < .001 Average self-rated health, n (%) 204 (37.6%) 189 (34.2%) 257 (32.9%) 136 (43.3%) Excellent or good self-rated health, n (%) 321 (59.1%) 346 (62.6%) 519 (66.4%) 148 (47.1%) Cognition (NTB total score), mean (SD) -0.02 (0.56) 0.05 (0.58) 0.039 0.01 (0.57) 0.02 (0.59) 0.845 Physical activity at least 2 times a week, n (%) 383 (70.2%) 403 (72.7%) 0.340 Average sleep duration during the night Sleep duration of < 6 h 33 (6.0%) 21 (3.8%) 0.532 39 (5.0%) 15 (4.8%) 0.084 Sleep duration of 6–7 h 85 (15.6%) 88 (16.0%) 111 (14.2%) 62 (19.8%) Sleep duration of 7–8 h 190 (34.9%) 197 (35.7%) 292 (37.2%) 95 (30.4%) Sleep duration of 8–9 h 188 (34.5%) 199 (36.0%) 277 (35.3%) 110 (35.1%) Sleep duration of ≥ 9 h 49 (9.0%) 47 (8.5%) 65 (8.3%) 31 (9.9%) Sleep quality index, mean (SD) 25.2 (17.0) 26.0 (17.2) 0.452 24.3 (15.7) 38.8 (19.6) < .001 Depressive symptoms, mean (SD) 34.0 (7.7) 33.8 (7.1) 0.614 33.2 (7.1) 35.6 (7.9) < .001 Bodily pain, mean (SD) 25.3 (22.2) 25.0 (21.3) 0.796 23.6 (20.3) 29.1 (24.7) 0.002 At least 66% exercise intervention adherence (intervention group only) 304 (48.2%) 233 (53.4%) 69 (36.5%) < .001 NTB = Neuropsychological test battery. Numbers are means (SD), unless otherwise specified. P-values are shown from t-test for continues variables and Mann-Whitney test for non-normally distributed variables, and chi square test for categorical variable Association between baseline sleep, depressive symptoms and pain, and exercise intervention adherence Of the intervention group participants 48% adhered with the exercise training program. The adherence varied by sleep duration, with the lowest adherence rates were among the participants with the longest (≥ 9h) and shortest (< 6h) sleep duration, with rates of 32% and 33% respectively. Participants sleeping ≥ 6–<7h, ≥ 7–<8h, ≥ 8–<9h were more often adherent (51%, 52% and 50%, respectively). As expected, adherent participants were also more likely to be physically active after the 2-year intervention (OR 3.37, 95% CI 1.99–5.73). Participants sleeping < 6h or ≥ 9h were significantly less likely to be adherent compared with participants sleeping ≥ 7–<8h, (OR 0.46, 95% CI 0.21–0.99) and (OR 0.38, 95% CI 0.20–0.74), respectively (Model 1, Table 2 ). Restricting the analysis to the participants with the PA data available at both baseline and 2-year visits did not substantially change the results. Further adjustment for sleep medication (Model 2) or baseline cognition (Model 3) resulted in similar findings. The effect of baseline short (< 6) and long (≥ 9h) sleep duration on exercise intervention adherence remained similar in additional analyses adjusting Model 1 for depressive symptoms and pain (OR 0.37, 95%CI 0.16–0.88), and (OR 0.39, 95% CI 0.19–0.80), respectively. Sleep quality or pain were not significantly associated with exercise intervention adherence (Table 2 ). Table 2 The impact of baseline sleep duration and quality, and pain on exercise adherence in the intervention group Model 1. Including all intervention group participants Model 2. Including all intervention group participants Model 3. Including all intervention group participants Intervention group participants with PA information available N OR (95% CI) OR (95% CI) OR (95% CI) N OR (95% CI) Sleep duration < 6 hours 614 0.46 (0.21–0.99) 0.41 (0.21–1.01) 0.46 (0.21–1.01) 536 0.43 (0.19–0.97) Sleep duration ≥ 6–<7 hours 1.18 (0.70–2.01) 1.20 (0.71–2.05) 1.19 (0.70–2.02) 1.13 (0.64–2.02) Sleep duration ≤ 7–<8 hours (ref) 1 1 1 1 Sleep duration ≥ 8–<9 hours 0.85 (0.56–1.29) 0.84 (0.55–1.27) 0.85 (0.56–1.29) 0.79 (0.50–1.24) Sleep duration ≥ 9 hours 0.38 (0.20–0.74) 0.37 (1.9–0.72) 0.39 (0.20–0.75) 0.40 (0.20–0.81) Better sleep quality (index < 40) 615 1 1 1 536 1 Worse sleep quality (index ≥ 40) 1.2 (0.78–1.90) 1.29 (0.81–2.05) 1.22 (0.78–1.91) 1.1 (0.68–1.78) No or mild bodily pain (RAND-36 Bodily pain < 40) 609 1 1 1 533 1 Pronounced bodily pain (RAND-36 Bodily pain ≥ 40) 0.90 (0.59–1.37) 0.80 (0.51–1.24) 0.90 (0.59–1.39) 0.87 (0.55–1.37) ORs (95% CI) are shown from binary logistic regression models with at least 66% exercise adherence to the FINGER multidomain intervention as outcome. Results are shown for all intervention participants, and also only for those who did report physical activity both at baseline and at 2-years. Model 1Adjusted for baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline. Model 2 is adjusted as model 1 and additionally adjusted for medications. Model 3 is adjusted as model 1 and additionally adjusted for cognition. Results for depressive symptoms were reported previously ( 28 ). Association of baseline sleep, depressive symptoms, and pain with PA after the trial Overall, as expected, participants who were physically active at baseline were more likely to be physically active also after the 2-year intervention (OR 7.60, 95% CI 5.51–10.48). PA increased significantly more in the intervention group compared with control group (OR 1.87, 95% CI 1.36–2.55). This intervention benefit on self-reported PA was not significantly different by baseline sleep duration or quality, depressive symptoms, or pain (p > 0.3 for all interactions, Table 3 ). In the analyses stratified by baseline sleep duration, sleep quality, depressive symptoms, or pain (Table 3 ) all ORs for intervention-control differences in 2-year PA indicated a favorable intervention effect on PA irrespective of these baseline characteristics (ORs from 1.68 to 5.46), except for a long sleep duration (OR = 1). Table 3 Impact of baseline sleep duration and quality, depressive symptoms, and pain on the intervention benefit on physical activity Intervention effect on physical activity after the 2-year intervention Baseline characteristic x randomization group interaction N OR 95% CI p-value of the interaction Sleep duration < 6 hours 50 5.46 0.79–37.55 0.711 Sleep duration ≥ 6–<7 hours 169 1.68 0.77–3.66 0.779 Sleep duration ≤ 7–<8 hours (ref) 379 2.15 1.24–3.75 REF Sleep duration ≥ 8–<9 hours 376 2.05 1.16–3.63 0.738 Sleep duration ≥ 9 hours 96 1.00 0.31–3.27 0.322 Better sleep quality (index < 40) 874 1.89 1.33–2.70 0.921 Worse sleep quality (index ≥ 40) 205 1.95 0.98–3.88 No depressive symptoms (Zung score < 40) 842 1.74 1.21–2.49 0.302 At least mild depressive symptoms (Zung score ≥ 40) 217 2.75 1.32–5.69 No or mild bodily pain (RAND-36 Bodily pain < 40) 794 1.70 1.18–2.46 0.421 Pronounced bodily pain (RAND-36 Bodily pain ≥ 40) 280 2.62 1.35–5.08 ORs (95% CI) are shown from stratified logistic regression models with physical activity after 2 years as outcome, and adjusted for randomization group, baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline. Compared with ≥ 7–<8h sleep duration, participants sleeping < 6h at baseline were less likely to be physically active after two years, (OR 0.36, 95% CI 0.18–0.72) (Model 1, Table 4 ). Results were similar after an additional adjustment for sleep medication (Model 2) and baseline cognition (Model 3). Further adjustment of Model 1 for depressive symptoms and pain did not change the results (OR 0.34, 95% CI 0.17–0.67). A similar trend was found for sleep duration ≥ 6–<7h versus ≥ 7–<8h: (OR 0.65, 95% CI 0.41–1.03); and for poor versus better sleep quality (OR 0.68, 95% CI 0.46 − 1.01) (Table 4 ). Other sleep duration categories, depressive symptoms or pain were not significantly associated with PA after 2 years. Table 4 Overall impact of baseline sleep duration and quality, depressive symptoms, and pain on physical activity after 2 years (intervention and control participants combined, including participants with physical activity information available at baseline and at 2-years) Model 1. Model 2. Model 3. N OR (95% CI) OR (95% CI) OR (95% CI) Sleep duration < 6 hours 1079 0.36 (0.18–0.72) 0.36 (0.18–0.73) 0.39 (0.19–0.78) Sleep duration ≥ 6–<7 hours 0.65 (0.41–1.03) 0.65 (0.41–1.03) 0.65 (0.41–1.03) Sleep duration ≤ 7–<8 hours (ref) 1 1 1 Sleep duration ≥ 8–<9 hours 1.00 (0.68–1.46) 0.98 (0.67–1.44) 1.01 (0.69–1.47) Sleep duration ≥ 9 hours 0.89 (0.50–1.59) 0.88 (0.49–1.57) 0.89 (0.50–1.59) Better sleep quality (index < 40) 1079 1 1 1 Worse sleep quality (index ≥ 40) 0.68 (0.46–1.01) 0.71 (0.47–1.06) 0.70 (0.47–1.03) No depressive symptoms (Zung score < 40) 1059 1 1 1 At least mild depressive symptoms (Zung score ≥ 40) 1.06 (0.71–1.58) 1.09 (0.73–1.62) 1.04 (0.70–1.57) No or mild bodily pain (RAND-36 Bodily pain < 40) 1074 1 1 1 Pronounced bodily pain (RAND-36 Bodily pain ≥ 40) 0.90 (0.62–1.30) 0.86 (0.59–1.25) 0.90 (0.61–1.29) ORs (95% CI) are shown from binary logistic regression models with physical activity after 2 years as outcome. Model 1 is adjusted for randomization group, baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline. Model 2 is adjusted as model 1 and additionally adjusted for medications. Model 3 is adjusted as model 1 and additionally adjusted for cognition. Discussion This is, to our knowledge, the first study to investigate the associations of sleep, depressive symptoms and pain with both the exercise intervention adherence and PA after a 2-year multidomain lifestyle intervention trial targeting older adults at risk for dementia. Exercise intervention adherence was lower in participants with both the shortest (< 6h) and longest (≥ 9h) night sleep duration, and by depressive symptoms as previously reported ( 28 ). However, pain did not affect exercise adherence in this study. Self-reported PA after 2 years improved significantly more in the intervention compared with control group. This intervention benefit on PA was not significantly affected by sleep duration or quality, depressive symptoms, or pain level at baseline. This is particularly important since participants with < 6h/night sleep duration were overall less likely to be physically active after 2 years in both randomization groups, and independently of depressive symptoms and pain. A similar trend was also observed for participants with ≥ 6–<7h sleep duration (compared with the recommended ≥ 7–<8h) and those with poor sleep quality. Overall, depressive symptoms or pain were not significantly related to PA after 2 years. The FINGER intervention included a structured and intensive group exercise program at the gym, supervised by a physiotherapist, which may have increased motivation and participation and facilitated an intervention benefit on PA. A large number of previous studies have focused on the beneficial effects of PA on different aspects of sleep ( 18 , 41 ), especially in the context of exercise programs ( 15 ). However, the role of sleep as a determinant of both exercise intervention adherence and overall PA level has not been previously investigated in large, longer-term randomized controlled trials. Previous observational studies have reported links between sleep duration and PA. In a cross-sectional study of older adults, participants reporting short or long sleep, compared to recommended sleep duration, were less likely to be physically active ( 42 ). In a follow-up study of older adults, inadequate sleep duration (more or less than 6-8h per night) was associated with a lower hand-grip strength, and lower levels of PA ( 43 ). Furthermore, results from an accelerometer study showed that long sleep duration was associated with lower PA levels ( 17 ). Prior sleep quality affected later PA level, but not vice versa, in a 2-year follow-up study of community-dwelling older adults ( 20 ). In one short-term (18-week) lifestyle intervention, sleep quality was a predictor for PA in older adults ( 21 ). The associations between sleep, PA and cognition are complex. A sufficient PA level can reduce the risk of cardiovascular disease ( 1 , 2 ) and diabetes ( 3 ), while both short and long sleep duration have been associated with an increased risk for coronary artery disease, stroke, diabetes ( 44 , 45 ), and hypertension ( 45 , 46 ), which are all known to be associated with dementia ( 5 ). Previously, a short sleep duration (≤ 6h/night) in mid-life has been associated with higher incidence of dementia in over a 30-year follow-up study, but in later life long sleep duration has been associated with dementia ( 47 ). The relationship between sleep and dementia is bidirectional as development of AD related pathology can affect sleep structure and vice versa ( 48 ). In the present study among older adults without substantial cognitive impairment but at risk of dementia, findings on baseline sleep, exercise intervention adherence and PA after two years were not modified after adjusting for baseline cognition. People at risk of dementia with difficulties engaging in physical activities and abnormal sleep duration should be given support for both exercise and sleep. Even though exercise is a well-studied non-pharmacological intervention form for poor sleep quality, the impact on abnormal sleep duration is less studied. ( 49 ). In addition, whether sleep problems would be associated with AD related biomarkers or pathology in people at risk of dementia, and whether our findings would also apply to individuals who already have mild cognitive impairment should be investigated in further studies. Having depressive symptoms was associated with poorer exercise intervention adherence in the FINGER trial ( 25 , 34 ). However, we found that participants with depressive symptoms still had an intervention benefit on PA after 2 years. In this intervention all participants had relatively low levels of depressive symptoms, which might have influenced the results. Although pain has been previously associated with lower levels of PA ( 29 , 50 ), in the present study pain did not significantly affect the exercise intervention adherence or PA after the trial, and the participants reporting pain at baseline seemed to also benefit from the FINGER intervention. A key strength of the present study is the large, long-term randomized controlled trial design. The trial targeted older adults with risk factors for dementia, including cardiovascular risk factors, a population for whom the identification of determinants for a physically active lifestyle is particularly important. Furthermore, the exercise training program combined progressive muscle strength training and aerobic exercise was guided by a physiotherapist and was individually tailored. The adherence rate was recorded during the entire trial. The present study has several limitations. PA and sleep measures were self-reported and sleep quality was not measured with a validated questionnaire or sleep registering. The FINGER trial eligibility criteria excluded participants with substantial cognitive impairment, ongoing severe major depression or health conditions preventing safe engagement in the intervention, thus limiting generalizability of the findings to a relatively healthy population. Participants with missing PA data were older, had lower education and cognition, and had more pain and more often abnormal sleep duration, which may have affected the results. Conclusions In conclusion, older adults at risk of dementia who have difficulties with being physically active due to sleep problems may also benefit from lifestyle interventions including exercise. However, as inadequate sleep duration is associated with numerous other health-related issues, short and long sleep duration should be given particular consideration in exercise interventions in people at risk of dementia. Whether sleep management in this population may further improve their ability to be more physically active should be investigated in future trials. Abbreviations AD Alzheimer's disease BMI body mass index CAIDE Cardiovascular Risk Factors, Aging and Dementia FINGER The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability MMSE Mini-Mental State Examination NTB neuropsychological test battery PA Physical activity RAND-36 The RAND 36-Item Health Survey 1.0 Declarations Ethics approval and consent to participate The study was approved by the Coordinating Ethics Committee of Helsinki and Uusimaa Hospital District, and all participants gave written informed consent. Consent for publication Consent for publication is not applicable in this study. Availability of data and materials Data used in this study is not publicly available due to ethical and legal reasons, but the data are available upon request. Those fulfilling the requirements for viewing confidential data as required by the Finnish legislation and the Finnish Institute for Health and Welfare are able to access the data after completion of a material transfer agreement. Requests may be directed to [email protected] . Competing interests The authors declare that they have no competing interests Funding This work was supported by Juho Vainio Foundation (Finland); Finnish Cultural Foundation, North Savo Regional Fund (Finland); UEF doctoral research program to EK (Finland); EU Joint Programme - Neurodegenerative Disease Research (JPND) EURO-FINGERS and Multi-MeMo grants; Ministry of Education and Culture (Finland); Yrjö Jahnsson Foundation (Finland); Alzheimer’s Research and Prevention Foundation (US); Kela (Finland); The Finnish Foundation for Cardiovascular Research (Finland); Alzheimerfonden (Sweden); Swedish Research Council; Region Stockholm (ALF, Sweden); Center for Innovative Medicine (CIMED) at Karolinska Institute (Sweden); Stiftelsen Stockholms sjukhem (Sweden); Knut and Alice Wallenberg Foundation (Sweden); Konung Gustaf V:s och Drottning Victorias Frimurarstiftelse (Sweden); European Research Council [grant 804371]; Swedish research council for health, working life and welfare; Research Council of Finland; NordForsk NJ-FINGERS grant. Authors’ contributions All authors have read and approved of the submission of this manuscript. EK, TN, and AS contributed to the study concept and design. RA, SH, MK, TL, HS, TS, JT, and TN contributed to the planning and acquisition of data. EK, AH and AS were responsible for statistical analysis. All authors contributed to the interpretation of data. All authors contributed to critical revisions of the manuscript for important intellectual content. EK, RA, MK, JK, TL, HS, TS, JT, TN, and AS obtained funding. MK, TN and AS and provided study supervision. References Kraus WE, Powell KE, Haskell WL, Janz KF, Campbell WW, Jakicic JM, et al. Physical Activity, All-Cause and Cardiovascular Mortality, and Cardiovascular Disease. Med Sci Sports Exerc. 2019;51(6):1270–81. Lin X, Zhang X, Guo J, Roberts CK, McKenzie S, Wu WC, et al. Effects of Exercise Training on Cardiorespiratory Fitness and Biomarkers of Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Association. 2015;4(7). 10.1161/JAHA.115.002014 . Kivimaki M, Singh-Manoux A, Pentti J, Sabia S, Nyberg ST, Alfredsson L, et al. Physical inactivity, cardiometabolic disease, and risk of dementia: an individual-participant meta-analysis. BMJ (Clinical Res ed). 2019;365:l1495. Cunningham C, O’Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;30(5):816–27. Livingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, et al. Dementia prevention, intervention, and care. Lancet (British edition). 2017;390(10113):2673–734. Figueira I, Fernandes A, Djordjevic AM, Lopez-Contreras A, Henriques CM, Selman C, et al. Interventions for age-related diseases: Shifting the paradigm. Mech Ageing Dev. 2016;160:69–92. Domenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuro-psychopharmacol Biol Psychiatry. 2019;93:284–90. Gulia KK, Kumar VM. Sleep disorders in the elderly: a growing challenge. Psychogeriatrics: official J Japanese Psychogeriatr Soc. 2018;18(3):155–65. Sjoberg L, Karlsson B, Atti AR, Skoog I, Fratiglioni L, Wang HX. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017;221:123–31. Zis P, Daskalaki A, Bountouni I, Sykioti P, Varrassi G, Paladini A. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging. 2017;12:709–20. Cao X, Chen Z, Wu L, Zhou J. Co-occurrence of chronic pain, depressive symptoms, and poor sleep quality in a health check-up population in China:A multicenter survey. J Affect Disord. 2021;281:792–8. Eslami V, Zimmerman ME, Grewal T, Katz M, Lipton RB. Pain grade and sleep disturbance in older adults: evaluation the role of pain, and stress for depressed and non-depressed individuals. Int J Geriatr Psychiatry. 2016;31(5):450–7. Generaal E, Vogelzangs N, Penninx BW, Dekker J, Insomnia. Sleep Duration, Depressive Symptoms, and the Onset of Chronic Multisite Musculoskeletal Pain. Sleep. 2017;40(1). 10.1093/sleep/zsw030 . Bridle C, Spanjers K, Patel S, Atherton NM, Lamb SE. Effect of exercise on depression severity in older people: systematic review and meta-analysis of randomised controlled trials. Br J psychiatry: J mental Sci. 2012;201(3):180–5. Vanderlinden J, Boen F, Van Uffelen JGZ. Effects of physical activity programs on sleep outcomes in older adults: a systematic review. 17, Int J Behav Nutr Phys Activity. 2020. LAMBIASE M, GABRIEL K, KULLER L. Temporal Relationships between Physical Activity and Sleep in Older Women. Med Sci Sports Exerc. 2013;45(12):2362–8. Mead MP, Baron K, Sorby M, Irish LA. Daily Associations Between Sleep and Physical Activity. Int J Behav Med. 2019;26:562. MITCHELL J, GODBOLE S, MORAN K, MURRAY K, JAMES P, LADEN F, et al. No Evidence of Reciprocal Associations between Daily Sleep and Physical Activity. Med Sci Sports Exerc. 2016;48(10):1950–6. Tang NKY, Sanborn AN. Better quality sleep promotes daytime physical activity in patients with chronic pain? A multilevel analysis of the within-person relationship. PLoS ONE. 2014;9(3):e92158. Holfeld B, Ruthig JC. A Longitudinal Examination of Sleep Quality and Physical Activity in Older Adults. J Appl Gerontol. 2014;33(7):791–807. Dzierzewski JM, Buman MP, Giacobbi PR, Roberts BL, Aiken-Morgan AT, Marsiske M, et al. Exercise and sleep in community‐dwelling older adults: evidence for a reciprocal relationship. J Sleep Res. 2014;23(1):61–8. Achttien R, van Lieshout J, Wensing M, van der Sanden MN, Staal JB. Symptoms of depression are associated with physical inactivity but not modified by gender or the presence of a cardiovascular disease; a cross-sectional study. BMC Cardiovasc Disord. 2019;19(1):95–8. Gomes M, Figueiredo D, Teixeira L, Poveda V, Paul C, Santos-Silva A, et al. Physical inactivity among older adults across Europe based on the SHARE database. Age Ageing. 2017;46(1):71–7. Watts AS, Mortby ME, Burns JM. Depressive symptoms as a barrier to engagement in physical activity in older adults with and without Alzheimer’s disease. PLoS ONE. 2018;13(12):e0208581. Coley N, Ngandu T, Lehtisalo J, Soininen H, Vellas B, Richard E, et al. Alzheimer’s dementia: J Alzheimer’s Association. 2019;15(6):729–41. Adherence to multidomain interventions for dementia prevention: Data from the FINGER and MAPT trials. Flegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS. Adherence to yoga and exercise interventions in a 6-month clinical trial. BMC Complement Altern Med. 2007;7:37–37. Stineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R. Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program. Gerontologist. 2011;51(Suppl 1):59. Neuvonen E, Lehtisalo J, Solomon A, Antikainen R, Havulinna S, Hänninen T et al. Psychosocial determinants for adherence to a healthy lifestyle and intervention participation in the FINGER trial: an exploratory analysis of a randomised clinical trial. Aging Clin Exp Res. 2022. Blyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31(2):160–8. Picorelli AM, Pereira LS, Pereira DS, Felicio D, Sherrington C. Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J physiotherapy. 2014;60(3):151–6. Yarmohammadi S, Saadati HM, Ghaffari M, Ramezankhani A. A systematic review of barriers and motivators to physical activity in elderly adults in Iran and worldwide. Epidemiol health. 2019;41:e2019049. Ngandu T, Lehtisalo J, Solomon A, Levälahti E, Ahtiluoto S, Antikainen R, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet. 2015;385(9984):2255–63. Kivipelto M, Solomon A, Ahtiluoto S, Ngandu T, Lehtisalo J, Antikainen R, et al. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER): study design and progress. Alzheimer’s dementia: J Alzheimer’s Association. 2013;9(6):657–65. Ngandu T, Lehtisalo J, Korkki S, Solomon A, Coley N, Antikainen R et al. The effect of adherence on cognition in a multidomain lifestyle intervention (FINGER). Alzheimer’s dementia: J Alzheimer’s Association. 2021. Kivipelto M, Ngandu T, Laatikainen T, Winblad B, Soininen H, Tuomilehto J. Risk score for the prediction of dementia risk in 20 years among middle aged people: a longitudinal, population-based study. Lancet Neurol. 2006;5(9):735–41. Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al. National Sleep Foundation’s updated sleep duration recommendations: final report. Sleep Health. 2015;1(4):233–43. Dunstan DA, Scott N. Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores. Depression research and treatment. 2018;2018:9250972. Jokelainen J, Timonen M, Keinanen-Kiukaanniemi S, Harkonen P, Jurvelin H, Suija K. Validation of the Zung self-rating depression scale (SDS) in older adults. Scand J Prim Health Care. 2019;37(3):353–7. Zung WW. From art to science. The diagnosis and treatment of depression. Arch Gen Psychiatry. 1973;29(3):328–37. Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med. 2001;33(5):350–7. Chennaoui M, Arnal PJ, Sauvet F, Léger D. Sleep and exercise: A reciprocal issue? Sleep Med Rev. 2014;20:59–72. Scarlett S, Nolan H, Kenny RA, O’Connell MD. Objective Sleep Duration in Older Adults: Results From The Irish Longitudinal Study on Ageing. J Am Geriatr Soc. 2020;68(1):120–8. Morgan K, Hartescu I. Sleep duration and all-cause mortality: links to physical activity and prefrailty in a 27-year follow up of older adults in the UK. Sleep Med. 2019;54:231–7. Jike M, Itani O, Watanabe N, Buysse DJ, Kaneita Y. Long sleep duration and health outcomes: A systematic review, meta-analysis and meta-regression. Sleep Med Rev. 2018;39:25–36. Itani O, Jike M, Watanabe N, Kaneita Y. Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Med. 2016;32:246–56. Wang Y, Mei H, Jiang YR, Sun WQ, Song YJ, Liu SJ, et al. Relationship between Duration of Sleep and Hypertension in Adults: A Meta-Analysis. J Clin Sleep Med. 2015;11(9):1047–56. Sabia S, Fayosse A, Dumurgier J, Hees VTV, Paquet C, Sommerlad A et al. Association of sleep duration in middle and old age with incidence of dementia. 12, Nat Commun. 2021. Wang C, Holtzman DM. Bidirectional relationship between sleep and Alzheimer’s disease: role of amyloid, tau, and other factors. Neuropsychopharmacology: official publication Am Coll Neuropsychopharmacol. 2020;45(1):104–20. Sella E, Toffalini E, Canini L, Borella E. Non-pharmacological interventions targeting sleep quality in older adults: a systematic review and meta-analysis. Aging Ment Health. 2022;1–15. Smith D, Wilkie R, Croft P, Parmar S, McBeth J. Pain and mortality: mechanisms for a relationship. Pain. 2018;159(6):1112–8. Additional Declarations No competing interests reported. Supplementary Files KekkonenFINGERSleepAndPAmanuscriptSupplementarymaterial2024BMC.docx Cite Share Download PDF Status: Published Journal Publication published 29 Mar, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 05 Aug, 2024 Editor assigned by journal 31 Jul, 2024 Submission checks completed at journal 31 Jul, 2024 First submitted to journal 30 Jul, 2024 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4826880","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336064644,"identity":"c9ca06cb-0921-4b34-adc0-fd840b4f7f56","order_by":0,"name":"Eija Kekkonen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIie2RsUoDQRRF7zLFNrNsO8tC/IVdBlbBoL8yYWBt0thZCAkEtFmxVQj5jLSOPEiawTql4g8MpBEsdJIgWM1iZzGne3AP98IDIpH/CIMCDCqxv66AdJq8mj8oFuCGVWFlz4+S3ByUYDhP8eZgh7K4vXt+v1zQgIMlwZZiBi2waZuSv2j5uCTpFQSViqAEHA0HYtyU2ZJGT8hNUDkn6A+4r51y/JnNadL1tjC0fphpSt/Csimp3mGC0J4oq2XRWVny1UXdsR4lv7d641Zn9cO6q7f8+vSIpzPmQor/g9o98xcsnPekwRWRSCQSAb4BF1dF68Aa8ZwAAAAASUVORK5CYII=","orcid":"","institution":"University of Eastern Finland","correspondingAuthor":true,"prefix":"","firstName":"Eija","middleName":"","lastName":"Kekkonen","suffix":""},{"id":336064645,"identity":"1d15219e-d7f9-4609-bd32-664ed480f19e","order_by":1,"name":"Anette Hall","email":"","orcid":"","institution":"University of Eastern Finland","correspondingAuthor":false,"prefix":"","firstName":"Anette","middleName":"","lastName":"Hall","suffix":""},{"id":336064646,"identity":"7a55554c-7f04-446a-a71c-5dac14e61f1b","order_by":2,"name":"Riitta Antikainen","email":"","orcid":"","institution":"University of Oulu","correspondingAuthor":false,"prefix":"","firstName":"Riitta","middleName":"","lastName":"Antikainen","suffix":""},{"id":336064647,"identity":"8cde3cf1-64df-453f-b556-75b18dfc9df4","order_by":3,"name":"Satu Havulinna","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Satu","middleName":"","lastName":"Havulinna","suffix":""},{"id":336064648,"identity":"7adbec19-0241-4527-a609-c81223211ae0","order_by":4,"name":"Miia Kivipelto","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Miia","middleName":"","lastName":"Kivipelto","suffix":""},{"id":336064649,"identity":"6253ee7d-41fb-403d-bb33-29805c864fb0","order_by":5,"name":"Jenni Kulmala","email":"","orcid":"","institution":"Tampere University","correspondingAuthor":false,"prefix":"","firstName":"Jenni","middleName":"","lastName":"Kulmala","suffix":""},{"id":336064650,"identity":"2c44d73c-6045-427d-9fcb-5cc8794c8c8b","order_by":6,"name":"Tiina Laatikainen","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Tiina","middleName":"","lastName":"Laatikainen","suffix":""},{"id":336064651,"identity":"34f43999-61e8-469c-a028-26159acd8f5f","order_by":7,"name":"Teemu Paajanen","email":"","orcid":"","institution":"Finnish Institute of Occupational Health","correspondingAuthor":false,"prefix":"","firstName":"Teemu","middleName":"","lastName":"Paajanen","suffix":""},{"id":336064652,"identity":"4f7e5fd3-94d1-4418-9bcb-4cc27b0a5406","order_by":8,"name":"Shireen Sindi","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Shireen","middleName":"","lastName":"Sindi","suffix":""},{"id":336064653,"identity":"66fb3fdf-f1e8-4298-aa04-d4bbc3613b26","order_by":9,"name":"Hilkka Soininen","email":"","orcid":"","institution":"University of Eastern Finland","correspondingAuthor":false,"prefix":"","firstName":"Hilkka","middleName":"","lastName":"Soininen","suffix":""},{"id":336064654,"identity":"330f9bfe-6a37-4bb3-8007-2695d70af985","order_by":10,"name":"Timo Strandberg","email":"","orcid":"","institution":"University of Oulu","correspondingAuthor":false,"prefix":"","firstName":"Timo","middleName":"","lastName":"Strandberg","suffix":""},{"id":336064655,"identity":"5f9e94e1-8c9d-4c44-972d-9c0deae9dc8e","order_by":11,"name":"Jaakko Tuomilehto","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Jaakko","middleName":"","lastName":"Tuomilehto","suffix":""},{"id":336064656,"identity":"96c1625f-9812-442a-acc6-14217a3e6a63","order_by":12,"name":"Tiia Ngandu","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Tiia","middleName":"","lastName":"Ngandu","suffix":""},{"id":336064657,"identity":"a2e00811-3434-4376-ad1e-a2008f89f17a","order_by":13,"name":"Alina Solomon","email":"","orcid":"","institution":"University of Eastern Finland","correspondingAuthor":false,"prefix":"","firstName":"Alina","middleName":"","lastName":"Solomon","suffix":""}],"badges":[],"createdAt":"2024-07-30 08:14:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4826880/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4826880/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-025-05830-y","type":"published","date":"2025-03-29T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64248237,"identity":"1ffb2b22-31cc-4cf5-b736-e8925715bdbf","added_by":"auto","created_at":"2024-09-10 20:46:51","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":463943,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy flowchart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4826880/v1/622e00bc7a4fa97703cebe9b.jpeg"},{"id":79604789,"identity":"29ac3516-675e-44bc-8764-75e88fbe865d","added_by":"auto","created_at":"2025-03-31 16:05:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1763988,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4826880/v1/11bbca39-3136-4291-b90c-68d2cd3b84ca.pdf"},{"id":64248236,"identity":"89995db5-88bc-45ba-bea0-e4b8d6f8b180","added_by":"auto","created_at":"2024-09-10 20:46:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":39321,"visible":true,"origin":"","legend":"","description":"","filename":"KekkonenFINGERSleepAndPAmanuscriptSupplementarymaterial2024BMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-4826880/v1/e41aca9242be48cf4da5e658.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of impaired sleep, depressive symptoms and pain with physical activity and exercise intervention adherence","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOlder adults meeting physical activity (PA) recommendations have a reduced risk of non-communicable diseases such as cardiovascular disease (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and diabetes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Sufficient PA has been associated with reduced risk of cognitive decline, dementia and Alzheimer\u0026rsquo;s disease (AD) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). As ageing is associated with a higher risk for several cognitive and other health-related challenges (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), it is important to investigate potential barriers to participation in lifestyle intervention programs and maintaining a physically active lifestyle. Sleep problems, depressive symptoms and pain are common complaints in late life (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and they often co-occur (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and can have a negative impact on PA. This impact on PA has been less investigated in the context of intervention studies and most earlier studies have focused primarily on how PA affects sleep, depressive symptoms and pain (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eShort-term associations (7\u0026ndash;14 days) of sleep on PA have been investigated in older adults in observational studies with inconsistent results (\u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A 2-year longitudinal study in community-dwelling older adults reported that a prior poor sleep quality predicted lower PA (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). One 18-week lifestyle intervention study showed that better sleep quality predicted increased PA the following day (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Depressive symptoms have been associated with physical inactivity in older populations (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In a longitudinal study, depressive symptoms predicted lower levels of PA after 2 years (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). A few lifestyle intervention studies have reported lower exercise participation rates in people with increased depressive symptoms (\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Pain, due to common age-related musculoskeletal conditions or other causes, has also been linked to lower levels of PA (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, the associations of impaired sleep or pain on exercise intervention participation have not been previously investigated in the context of dementia prevention.\u003c/p\u003e \u003cp\u003eMultidomain lifestyle interventions including exercise are currently emphasized as a promising dementia risk reduction strategy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) was the first large long-term randomized controlled trial to show that a 2-year multidomain lifestyle intervention (combining exercise, diet, cognitive training and vascular risk factor management) had benefits for cognition in older adults at risk for dementia (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This study aimed at investigating whether self-reported sleep duration, sleep quality, depressive symptoms and bodily pain at baseline are associated with (i) exercise intervention adherence in people participating in the intervention group exercise program during the trial, and (ii) PA after the 2-year multidomain intervention in all trial participants.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation and intervention\u003c/h2\u003e \u003cp\u003eFINGER (ClinicalTrials.gov identifier NCT01041989) was a 2-year randomized controlled trial conducted at 6 sites in Finland in 1259 older individuals at-risk for dementia. The detailed protocol and primary results have been previously published (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Participants were aged 60\u0026ndash;77 years, had a Cardiovascular Risk Factors, Aging and Dementia (CAIDE) risk score\u0026thinsp;\u0026ge;\u0026thinsp;6 points, and cognitive performance around the mean level or slightly lower than expected for age according to Finnish population norms (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Participants with dementia (diagnosed or suspected after clinical evaluation at screening), MMSE\u0026thinsp;\u0026lt;\u0026thinsp;20 points, or conditions affecting safe participation were excluded. Eligible participants were randomized (1:1) into multidomain intervention and control groups, using a computerized algorithm in blocks of four (two individuals randomly allocated to each group) at each site after baseline by the study nurse. Double blinding was pursued as much as possible: outcome assessors were blinded, and participants were not actively informed about their randomization group. The primary outcome of the FINGER trial was comprehensive neuropsychological test battery (NTB) total score (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe control group received general health advice. The intervention group was offered to receive a combination of several intervention components. The exercise component followed international guidelines and included group training sessions at the gym, guided by the study physiotherapists. The training program was individually tailored based on repetition maximum measurements and incorporated progressive muscle strength training (1\u0026ndash;3 times/week) and aerobic exercise (2\u0026ndash;5 times/week), including exercises to improve postural balance. Other intervention components were nutritional guidance, cognitive training, social stimulation, and monitoring and management of metabolic and vascular risk factors (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAssessment of physical activity, sleep, depressive symptoms, and pain\u003c/h2\u003e \u003cp\u003eExercise adherence in the intervention group was defined as the percentage of participation in the offered gym sessions. Participants were considered adherent when they reached at least 66% adherence rate in the exercise training sessions, as previously proposed (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e PA in all trial participants was assessed as the self-reported frequency of exercise activities lasting at least 20 minutes and having sufficient intensity to cause slight breathlessness and sweating. Based on a previously defined cut-off, participants reporting a frequency of at least two times/week were considered physically active (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSelf-reported average duration of sleep during the night was categorized as \u0026lt;\u0026thinsp;6h, \u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7h, \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h, \u0026ge;\u0026thinsp;8\u0026ndash;\u0026lt;9h, and \u0026ge;\u0026thinsp;9h. The recommended sleep duration for older adults is \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8 hours per night (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). A composite index of sleep quality was calculated based on seven sleep-related questions (Appendix table 1). A cut-off of \u0026ge;\u0026thinsp;40/100 was used to define poor sleep quality. Depressive symptoms were assessed using the Zung scale, and cut-off for at least mild depressive symptoms was set to \u0026ge;\u0026thinsp;40, as previously defined (\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Pain was measured as a composite index based on RAND-36 bodily pain scale (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e); cut-off was set to \u0026ge;\u0026thinsp;40/100 for describing at least average amount of pain that disturbs at least some amount of daily chores and work (Appendix table 1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData analyses in this study were post-hoc. A study flowchart with focus on PA and exercise intervention adherence as outcomes is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBetween-group differences in baseline characteristics were analyzed with t-test and one-way ANOVA for normally distributed variables, Mann-Whitney test or Kruskal-Wallis test for non-normally distributed variables, and Chi-Square test for categorical variables. Cross-sectional analyses of associations between sleep duration, sleep quality, depressive symptoms or pain and PA at baseline (active versus inactive) were analyzed using logistic regression models, adjusted for age, sex, education, body mass index (BMI), marital status, self-rated health status, and study site.\u003c/p\u003e \u003cp\u003eThe analysis of exercise adherence during the intervention included all intervention group participants. Effects of sleep duration, sleep quality, and pain on intervention exercise adherence (adherent versus non-adherent) were analyzed with logistic regression models adjusted for baseline PA, age, sex, education, BMI, marital status, self-rated health status, and study site. For sleep, the recommended duration of 7\u0026ndash;8h/night was used as the reference category (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The effects of depressive symptoms on exercise adherence have been reported previously (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe analysis of the intervention effect on self-reported PA (active/inactive) at two years and the effect of sleep, depressive symptoms and pain on PA included all intervention and control group participants with PA data available from both baseline and 2-year visits. To assess the intervention effect on PA, logistic regression was conducted with PA after the 2-year trial as dependent variable (active versus inactive) and randomization group as independent variable, adjusted for baseline PA, age, sex, education, BMI, marital status, self-rated health status, and study site. To evaluate whether the effect on PA was modified by baseline sleep duration or quality, depressive symptoms or pain, the following terms were separately added to the logistic regression model: (i) sleep duration and sleep duration\u0026times;randomization group interaction; (ii) sleep quality and sleep quality\u0026times;randomization; (iii) depressive symptoms and depressive symptoms\u0026times;randomization; and (iv) pain and pain\u0026times;randomization. We report the two-way interactions and the intervention effect stratified by sleep duration, sleep quality, depressive symptoms and pain categories.\u003c/p\u003e \u003cp\u003eTo further investigate if baseline sleep, depressive symptoms or pain were related to PA after the 2-year trial irrespective of randomization group, we used logistic regression models adjusted for randomization group, baseline PA, age, sex, education, BMI, marital status, self-rated health status and study site (Model 1). Additionally, all the models were adjusted for relevant baseline medications (for sleep problems, depressive symptoms or pain, Model 2), and baseline cognition (total NTB score, Model 3). The same approach was used for models with exercise intervention adherence as outcome. All analyses were conducted using STATA version 14 software, and the significance level was set to 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 1100 participants (87.4%) who had PA data available at both baseline and 2-year visits (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At baseline there were no significant differences between intervention and control groups. Overall, compared with participants who were active at baseline, inactive participants had a higher BMI, worse self-rated health, poorer sleep quality, more pain and more depressive symptoms (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Participants without available PA data (n\u0026thinsp;=\u0026thinsp;159) were slightly older, had a lower education and cognition, and more pain, with a trend for more often abnormal sleep duration than in participants with available PA data (Appendix table 2).\u003c/p\u003e \u003cp\u003eSleep duration, sleep quality, depressive symptoms and pain were all associated with one another at baseline (Appendix tables 3\u0026ndash;4). The associations were U-shaped for sleep duration, i.e. both short and long sleep durations were associated with more depressive symptoms and more bodily pain (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Appendix table 3). Participants with a poor sleep quality had more depressive symptoms and pain (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and those with depressive symptoms had more often pronounced pain (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Appendix table 4).\u003c/p\u003e \u003cp\u003eCross-sectional analyses at baseline showed that participants with depressive symptoms and shorter sleep duration (\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7h compared with \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h/night) were less likely to be physically active: (OR 0.70, 95% CI 0.50\u0026ndash;1.00) and (OR 0.66, 95% CI 0.44\u0026ndash;1.00), respectively. PA was not significantly associated with sleep duration of \u0026lt;\u0026thinsp;6h (OR 1.11, 95% CI 0.55\u0026ndash;2.25); 8\u0026ndash;9h (OR 0.79, 95% CI 0.56\u0026ndash;1.10); or \u0026ge;\u0026thinsp;9h: (OR 0.66, 95% CI 0.40\u0026ndash;1.10) compared with \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h/night. There were also no associations of PA with poor sleep quality: (OR 0.83, 95% CI 0.581.18); or bodily pain: (OR 0.90, 95% CI 0.64\u0026ndash;1.25).\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\u003eBaseline characteristics of the FINGER participants with available physical activity data at both baseline and 2-year visits\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\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\u003eIntervention Group\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;546\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;554\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysically active\u0026thinsp;\u0026ge;\u0026thinsp;2 times a week\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;786\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhysically active\u0026thinsp;\u0026lt;\u0026thinsp;2 times a week\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;314\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68.9 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.5 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68.8 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68.5 (4.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, female n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e242 (44.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e265 (47.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e371 (47.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e136 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation years, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.0 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.1 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.816\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.0 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.1 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.986\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.2 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.0 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.546\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.8 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29.2 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-rated health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor self-rated health, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage self-rated health, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e204 (37.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e189 (34.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e257 (32.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e136 (43.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent or good self-rated health, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e321 (59.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e346 (62.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e519 (66.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e148 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognition (NTB total score), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.02 (0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.05 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.01 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02 (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.845\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical activity at least 2 times a week, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e383 (70.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e403 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage sleep duration during the night\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration of \u0026lt;\u0026thinsp;6 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39 (5.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration of 6\u0026ndash;7 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (16.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e111 (14.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration of 7\u0026ndash;8 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e190 (34.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e197 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e292 (37.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e95 (30.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration of 8\u0026ndash;9 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e188 (34.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e199 (36.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e277 (35.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e110 (35.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration of \u0026ge;\u0026thinsp;9 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31 (9.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep quality index, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.2 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.0 (17.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.3 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38.8 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive symptoms, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.0 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.8 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33.2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35.6 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBodily pain, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.3 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.0 (21.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23.6 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29.1 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least 66% exercise intervention adherence (intervention group only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e304 (48.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e233 (53.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69 (36.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNTB\u0026thinsp;=\u0026thinsp;Neuropsychological test battery.\u003c/p\u003e \u003cp\u003eNumbers are means (SD), unless otherwise specified. P-values are shown from t-test for continues variables and Mann-Whitney test for non-normally distributed variables, and chi square test for categorical variable\u003c/p\u003e\n\u003ch3\u003eAssociation between baseline sleep, depressive symptoms and pain, and exercise intervention adherence\u003c/h3\u003e\n\u003cp\u003eOf the intervention group participants 48% adhered with the exercise training program. The adherence varied by sleep duration, with the lowest adherence rates were among the participants with the longest (\u0026ge;\u0026thinsp;9h) and shortest (\u0026lt;\u0026thinsp;6h) sleep duration, with rates of 32% and 33% respectively. Participants sleeping\u0026thinsp;\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7h, \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h, \u0026ge;\u0026thinsp;8\u0026ndash;\u0026lt;9h were more often adherent (51%, 52% and 50%, respectively). As expected, adherent participants were also more likely to be physically active after the 2-year intervention (OR 3.37, 95% CI 1.99\u0026ndash;5.73).\u003c/p\u003e \u003cp\u003eParticipants sleeping\u0026thinsp;\u0026lt;\u0026thinsp;6h or \u0026ge;\u0026thinsp;9h were significantly less likely to be adherent compared with participants sleeping\u0026thinsp;\u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h, (OR 0.46, 95% CI 0.21\u0026ndash;0.99) and (OR 0.38, 95% CI 0.20\u0026ndash;0.74), respectively (Model 1, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Restricting the analysis to the participants with the PA data available at both baseline and 2-year visits did not substantially change the results. Further adjustment for sleep medication (Model 2) or baseline cognition (Model 3) resulted in similar findings. The effect of baseline short (\u0026lt;\u0026thinsp;6) and long (\u0026ge;\u0026thinsp;9h) sleep duration on exercise intervention adherence remained similar in additional analyses adjusting Model 1 for depressive symptoms and pain (OR 0.37, 95%CI 0.16\u0026ndash;0.88), and (OR 0.39, 95% CI 0.19\u0026ndash;0.80), respectively. Sleep quality or pain were not significantly associated with exercise intervention adherence (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003e\u003cb\u003eThe impact of baseline sleep duration and quality, and pain on exercise adherence in the intervention group\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eModel 1.\u003c/p\u003e \u003cp\u003eIncluding all intervention group participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2.\u003c/p\u003e \u003cp\u003eIncluding all intervention group participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModel 3.\u003c/p\u003e \u003cp\u003eIncluding all intervention group participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIntervention group participants with PA information available\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026lt;\u0026thinsp;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e614\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.46\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.21\u0026ndash;0.99)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003cp\u003e(0.21\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003cp\u003e(0.21\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e536\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.43\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.19\u0026ndash;0.97)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003cp\u003e(0.70\u0026ndash;2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003cp\u003e(0.71\u0026ndash;2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003cp\u003e(0.70\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003cp\u003e(0.64\u0026ndash;2.02)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026le;\u0026thinsp;7\u0026ndash;\u0026lt;8 hours (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;8\u0026ndash;\u0026lt;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003cp\u003e(0.56\u0026ndash;1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003cp\u003e(0.55\u0026ndash;1.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003cp\u003e(0.56\u0026ndash;1.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003cp\u003e(0.50\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.38\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.20\u0026ndash;0.74)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.37\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(1.9\u0026ndash;0.72)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.39\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.20\u0026ndash;0.75)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.40\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.20\u0026ndash;0.81)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetter sleep quality (index\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e536\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorse sleep quality (index\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003cp\u003e(0.78\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.29\u003c/p\u003e \u003cp\u003e(0.81\u0026ndash;2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003cp\u003e(0.78\u0026ndash;1.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003cp\u003e(0.68\u0026ndash;1.78)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo or mild bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePronounced bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003cp\u003e(0.59\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003cp\u003e(0.51\u0026ndash;1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003cp\u003e(0.59\u0026ndash;1.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003cp\u003e(0.55\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eORs (95% CI) are shown from binary logistic regression models with at least 66% exercise adherence to the FINGER multidomain intervention as outcome. Results are shown for all intervention participants, and also only for those who did report physical activity both at baseline and at 2-years.\u003c/p\u003e \u003cp\u003eModel 1Adjusted for baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline.\u003c/p\u003e \u003cp\u003eModel 2 is adjusted as model 1 and additionally adjusted for medications.\u003c/p\u003e \u003cp\u003eModel 3 is adjusted as model 1 and additionally adjusted for cognition.\u003c/p\u003e \u003cp\u003eResults for depressive symptoms were reported previously (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAssociation of baseline sleep, depressive symptoms, and pain with PA after the trial\u003c/h2\u003e \u003cp\u003eOverall, as expected, participants who were physically active at baseline were more likely to be physically active also after the 2-year intervention (OR 7.60, 95% CI 5.51\u0026ndash;10.48). PA increased significantly more in the intervention group compared with control group (OR 1.87, 95% CI 1.36\u0026ndash;2.55). This intervention benefit on self-reported PA was not significantly different by baseline sleep duration or quality, depressive symptoms, or pain (p\u0026thinsp;\u0026gt;\u0026thinsp;0.3 for all interactions, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the analyses stratified by baseline sleep duration, sleep quality, depressive symptoms, or pain (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) all ORs for intervention-control differences in 2-year PA indicated a favorable intervention effect on PA irrespective of these baseline characteristics (ORs from 1.68 to 5.46), except for a long sleep duration (OR\u0026thinsp;=\u0026thinsp;1).\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\u003eImpact of baseline sleep duration and quality, depressive symptoms, and pain on the intervention benefit on physical activity\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIntervention effect on physical activity after the 2-year intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBaseline characteristic x\u003c/p\u003e \u003cp\u003erandomization group interaction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value of the interaction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026lt;\u0026thinsp;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.79\u0026ndash;37.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.77\u0026ndash;3.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.779\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026le;\u0026thinsp;7\u0026ndash;\u0026lt;8 hours (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.24\u0026ndash;3.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eREF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;8\u0026ndash;\u0026lt;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.05\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.16\u0026ndash;3.63\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.738\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.31\u0026ndash;3.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetter sleep quality (index\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.89\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.33\u0026ndash;2.70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.921\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorse sleep quality (index\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u0026ndash;3.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo depressive symptoms (Zung score\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e842\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.74\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.21\u0026ndash;2.49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least mild depressive symptoms (Zung score\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.32\u0026ndash;5.69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo or mild bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.18\u0026ndash;2.46\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePronounced bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e2.62\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1.35\u0026ndash;5.08\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eORs (95% CI) are shown from stratified logistic regression models with physical activity after 2 years as outcome, and adjusted for randomization group, baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline.\u003c/p\u003e \u003cp\u003eCompared with \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h sleep duration, participants sleeping\u0026thinsp;\u0026lt;\u0026thinsp;6h at baseline were less likely to be physically active after two years, (OR 0.36, 95% CI 0.18\u0026ndash;0.72) (Model 1, Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Results were similar after an additional adjustment for sleep medication (Model 2) and baseline cognition (Model 3). Further adjustment of Model 1 for depressive symptoms and pain did not change the results (OR 0.34, 95% CI 0.17\u0026ndash;0.67). A similar trend was found for sleep duration\u0026thinsp;\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7h versus \u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h: (OR 0.65, 95% CI 0.41\u0026ndash;1.03); and for poor versus better sleep quality (OR 0.68, 95% CI 0.46 \u0026minus;\u0026thinsp;1.01) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Other sleep duration categories, depressive symptoms or pain were not significantly associated with PA after 2 years.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall impact of baseline sleep duration and quality, depressive symptoms, and pain on physical activity after 2 years (intervention and control participants combined, including participants with physical activity information available at baseline and at 2-years)\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=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" 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\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModel 1.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModel 3.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eOR (95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026lt;\u0026thinsp;6 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e1079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.36\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.18\u0026ndash;0.72)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.36\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.18\u0026ndash;0.73)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.39\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(0.19\u0026ndash;0.78)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003cp\u003e(0.41\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003cp\u003e(0.41\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003cp\u003e(0.41\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026le;\u0026thinsp;7\u0026ndash;\u0026lt;8 hours (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;8\u0026ndash;\u0026lt;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003cp\u003e(0.68\u0026ndash;1.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003cp\u003e(0.67\u0026ndash;1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003cp\u003e(0.69\u0026ndash;1.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep duration\u0026thinsp;\u0026ge;\u0026thinsp;9 hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003cp\u003e(0.50\u0026ndash;1.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003cp\u003e(0.49\u0026ndash;1.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003cp\u003e(0.50\u0026ndash;1.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetter sleep quality (index\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorse sleep quality (index\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003cp\u003e(0.46\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003cp\u003e(0.47\u0026ndash;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003cp\u003e(0.47\u0026ndash;1.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo depressive symptoms (Zung score\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt least mild depressive symptoms (Zung score\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003cp\u003e(0.71\u0026ndash;1.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003cp\u003e(0.73\u0026ndash;1.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003cp\u003e(0.70\u0026ndash;1.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo or mild bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026lt;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePronounced bodily pain (RAND-36 Bodily pain\u0026thinsp;\u0026ge;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003cp\u003e(0.62\u0026ndash;1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003cp\u003e(0.59\u0026ndash;1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003cp\u003e(0.61\u0026ndash;1.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eORs (95% CI) are shown from binary logistic regression models with physical activity after 2 years as outcome. Model 1 is adjusted for randomization group, baseline physical activity, age, sex, education years, BMI, marital status and self-reported current health status at baseline. Model 2 is adjusted as model 1 and additionally adjusted for medications. Model 3 is adjusted as model 1 and additionally adjusted for cognition.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is, to our knowledge, the first study to investigate the associations of sleep, depressive symptoms and pain with both the exercise intervention adherence and PA after a 2-year multidomain lifestyle intervention trial targeting older adults at risk for dementia. Exercise intervention adherence was lower in participants with both the shortest (\u0026lt;\u0026thinsp;6h) and longest (\u0026ge;\u0026thinsp;9h) night sleep duration, and by depressive symptoms as previously reported (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, pain did not affect exercise adherence in this study. Self-reported PA after 2 years improved significantly more in the intervention compared with control group. This intervention benefit on PA was not significantly affected by sleep duration or quality, depressive symptoms, or pain level at baseline. This is particularly important since participants with \u0026lt;\u0026thinsp;6h/night sleep duration were overall less likely to be physically active after 2 years in both randomization groups, and independently of depressive symptoms and pain. A similar trend was also observed for participants with \u0026ge;\u0026thinsp;6\u0026ndash;\u0026lt;7h sleep duration (compared with the recommended\u0026thinsp;\u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h) and those with poor sleep quality. Overall, depressive symptoms or pain were not significantly related to PA after 2 years. The FINGER intervention included a structured and intensive group exercise program at the gym, supervised by a physiotherapist, which may have increased motivation and participation and facilitated an intervention benefit on PA.\u003c/p\u003e \u003cp\u003eA large number of previous studies have focused on the beneficial effects of PA on different aspects of sleep (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), especially in the context of exercise programs (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, the role of sleep as a determinant of both exercise intervention adherence and overall PA level has not been previously investigated in large, longer-term randomized controlled trials. Previous observational studies have reported links between sleep duration and PA. In a cross-sectional study of older adults, participants reporting short or long sleep, compared to recommended sleep duration, were less likely to be physically active (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). In a follow-up study of older adults, inadequate sleep duration (more or less than 6-8h per night) was associated with a lower hand-grip strength, and lower levels of PA (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Furthermore, results from an accelerometer study showed that long sleep duration was associated with lower PA levels (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Prior sleep quality affected later PA level, but not vice versa, in a 2-year follow-up study of community-dwelling older adults (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In one short-term (18-week) lifestyle intervention, sleep quality was a predictor for PA in older adults (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe associations between sleep, PA and cognition are complex. A sufficient PA level can reduce the risk of cardiovascular disease (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and diabetes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), while both short and long sleep duration have been associated with an increased risk for coronary artery disease, stroke, diabetes (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), and hypertension (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), which are all known to be associated with dementia (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Previously, a short sleep duration (\u0026le;\u0026thinsp;6h/night) in mid-life has been associated with higher incidence of dementia in over a 30-year follow-up study, but in later life long sleep duration has been associated with dementia (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The relationship between sleep and dementia is bidirectional as development of AD related pathology can affect sleep structure and vice versa (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). In the present study among older adults without substantial cognitive impairment but at risk of dementia, findings on baseline sleep, exercise intervention adherence and PA after two years were not modified after adjusting for baseline cognition. People at risk of dementia with difficulties engaging in physical activities and abnormal sleep duration should be given support for both exercise and sleep. Even though exercise is a well-studied non-pharmacological intervention form for poor sleep quality, the impact on abnormal sleep duration is less studied. (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). In addition, whether sleep problems would be associated with AD related biomarkers or pathology in people at risk of dementia, and whether our findings would also apply to individuals who already have mild cognitive impairment should be investigated in further studies.\u003c/p\u003e \u003cp\u003eHaving depressive symptoms was associated with poorer exercise intervention adherence in the FINGER trial (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, we found that participants with depressive symptoms still had an intervention benefit on PA after 2 years. In this intervention all participants had relatively low levels of depressive symptoms, which might have influenced the results. Although pain has been previously associated with lower levels of PA (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), in the present study pain did not significantly affect the exercise intervention adherence or PA after the trial, and the participants reporting pain at baseline seemed to also benefit from the FINGER intervention.\u003c/p\u003e \u003cp\u003eA key strength of the present study is the large, long-term randomized controlled trial design. The trial targeted older adults with risk factors for dementia, including cardiovascular risk factors, a population for whom the identification of determinants for a physically active lifestyle is particularly important. Furthermore, the exercise training program combined progressive muscle strength training and aerobic exercise was guided by a physiotherapist and was individually tailored. The adherence rate was recorded during the entire trial.\u003c/p\u003e \u003cp\u003eThe present study has several limitations. PA and sleep measures were self-reported and sleep quality was not measured with a validated questionnaire or sleep registering. The FINGER trial eligibility criteria excluded participants with substantial cognitive impairment, ongoing severe major depression or health conditions preventing safe engagement in the intervention, thus limiting generalizability of the findings to a relatively healthy population. Participants with missing PA data were older, had lower education and cognition, and had more pain and more often abnormal sleep duration, which may have affected the results.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, older adults at risk of dementia who have difficulties with being physically active due to sleep problems may also benefit from lifestyle interventions including exercise. However, as inadequate sleep duration is associated with numerous other health-related issues, short and long sleep duration should be given particular consideration in exercise interventions in people at risk of dementia. Whether sleep management in this population may further improve their ability to be more physically active should be investigated in future trials.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\"\u003e\n \u003cp\u003eAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eAlzheimer\u0026apos;s disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003ebody mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eCAIDE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eCardiovascular Risk Factors, Aging and Dementia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eFINGER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eThe Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eMMSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eMini-Mental State Examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eNTB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eneuropsychological test battery\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\"\u003e\n \u003cp\u003ePA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003ePhysical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"35.34201954397394%\" valign=\"top\"\u003e\n \u003cp\u003eRAND-36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"64.65798045602605%\"\u003e\n \u003cp\u003eThe RAND 36-Item Health Survey 1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Coordinating Ethics Committee of Helsinki and Uusimaa Hospital District, and all participants gave written informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;is not applicable in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData used in this study is not publicly available due to ethical and legal reasons, but the data are available upon request. Those fulfilling the requirements for viewing confidential data as required by the Finnish legislation and the Finnish Institute for Health and Welfare are able to access the data after completion of a material transfer agreement. Requests may be directed to [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Juho Vainio Foundation (Finland); Finnish Cultural Foundation, North Savo Regional Fund (Finland); UEF doctoral research program to EK (Finland); EU Joint Programme - Neurodegenerative Disease Research (JPND) EURO-FINGERS and Multi-MeMo grants; Ministry of Education and Culture (Finland); Yrj\u0026ouml; Jahnsson Foundation (Finland); Alzheimer\u0026rsquo;s Research and Prevention Foundation (US); Kela (Finland); The Finnish Foundation for Cardiovascular Research (Finland); Alzheimerfonden (Sweden); Swedish Research Council; Region Stockholm (ALF, Sweden); Center for Innovative Medicine (CIMED) at Karolinska Institute (Sweden); Stiftelsen Stockholms sjukhem (Sweden); Knut and Alice Wallenberg Foundation (Sweden); Konung Gustaf V:s och Drottning Victorias Frimurarstiftelse (Sweden); European Research Council [grant 804371]; Swedish research council for health, working life and welfare; Research Council of Finland; NordForsk NJ-FINGERS grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved of the submission of this manuscript. EK, TN, and AS contributed to the study concept and design. RA, SH, MK, TL, HS, TS, JT, and TN contributed to the planning and acquisition of data. EK, AH and AS were responsible for statistical analysis. All authors contributed to the interpretation of data. All authors contributed to critical revisions of the manuscript for important intellectual content. EK, RA, MK, JK, TL, HS, TS, JT, TN, and AS obtained funding. MK, TN and AS and provided study supervision.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKraus WE, Powell KE, Haskell WL, Janz KF, Campbell WW, Jakicic JM, et al. Physical Activity, All-Cause and Cardiovascular Mortality, and Cardiovascular Disease. Med Sci Sports Exerc. 2019;51(6):1270\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin X, Zhang X, Guo J, Roberts CK, McKenzie S, Wu WC, et al. Effects of Exercise Training on Cardiorespiratory Fitness and Biomarkers of Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Association. 2015;4(7). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/JAHA.115.002014\u003c/span\u003e\u003cspan address=\"10.1161/JAHA.115.002014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivimaki M, Singh-Manoux A, Pentti J, Sabia S, Nyberg ST, Alfredsson L, et al. Physical inactivity, cardiometabolic disease, and risk of dementia: an individual-participant meta-analysis. BMJ (Clinical Res ed). 2019;365:l1495.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCunningham C, O\u0026rsquo;Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;30(5):816\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLivingston G, Sommerlad A, Orgeta V, Costafreda SG, Huntley J, Ames D, et al. Dementia prevention, intervention, and care. Lancet (British edition). 2017;390(10113):2673\u0026ndash;734.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueira I, Fernandes A, Djordjevic AM, Lopez-Contreras A, Henriques CM, Selman C, et al. Interventions for age-related diseases: Shifting the paradigm. Mech Ageing Dev. 2016;160:69\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDomenichiello AF, Ramsden CE. The silent epidemic of chronic pain in older adults. Prog Neuro-psychopharmacol Biol Psychiatry. 2019;93:284\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGulia KK, Kumar VM. Sleep disorders in the elderly: a growing challenge. Psychogeriatrics: official J Japanese Psychogeriatr Soc. 2018;18(3):155\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSjoberg L, Karlsson B, Atti AR, Skoog I, Fratiglioni L, Wang HX. Prevalence of depression: Comparisons of different depression definitions in population-based samples of older adults. J Affect Disord. 2017;221:123\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZis P, Daskalaki A, Bountouni I, Sykioti P, Varrassi G, Paladini A. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging. 2017;12:709\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao X, Chen Z, Wu L, Zhou J. Co-occurrence of chronic pain, depressive symptoms, and poor sleep quality in a health check-up population in China:A multicenter survey. J Affect Disord. 2021;281:792\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEslami V, Zimmerman ME, Grewal T, Katz M, Lipton RB. Pain grade and sleep disturbance in older adults: evaluation the role of pain, and stress for depressed and non-depressed individuals. Int J Geriatr Psychiatry. 2016;31(5):450\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeneraal E, Vogelzangs N, Penninx BW, Dekker J, Insomnia. Sleep Duration, Depressive Symptoms, and the Onset of Chronic Multisite Musculoskeletal Pain. Sleep. 2017;40(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/sleep/zsw030\u003c/span\u003e\u003cspan address=\"10.1093/sleep/zsw030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBridle C, Spanjers K, Patel S, Atherton NM, Lamb SE. Effect of exercise on depression severity in older people: systematic review and meta-analysis of randomised controlled trials. Br J psychiatry: J mental Sci. 2012;201(3):180\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanderlinden J, Boen F, Van Uffelen JGZ. Effects of physical activity programs on sleep outcomes in older adults: a systematic review. 17, Int J Behav Nutr Phys Activity. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLAMBIASE M, GABRIEL K, KULLER L. Temporal Relationships between Physical Activity and Sleep in Older Women. Med Sci Sports Exerc. 2013;45(12):2362\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMead MP, Baron K, Sorby M, Irish LA. Daily Associations Between Sleep and Physical Activity. Int J Behav Med. 2019;26:562.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMITCHELL J, GODBOLE S, MORAN K, MURRAY K, JAMES P, LADEN F, et al. No Evidence of Reciprocal Associations between Daily Sleep and Physical Activity. Med Sci Sports Exerc. 2016;48(10):1950\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang NKY, Sanborn AN. Better quality sleep promotes daytime physical activity in patients with chronic pain? A multilevel analysis of the within-person relationship. PLoS ONE. 2014;9(3):e92158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolfeld B, Ruthig JC. A Longitudinal Examination of Sleep Quality and Physical Activity in Older Adults. J Appl Gerontol. 2014;33(7):791\u0026ndash;807.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDzierzewski JM, Buman MP, Giacobbi PR, Roberts BL, Aiken-Morgan AT, Marsiske M, et al. Exercise and sleep in community‐dwelling older adults: evidence for a reciprocal relationship. J Sleep Res. 2014;23(1):61\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAchttien R, van Lieshout J, Wensing M, van der Sanden MN, Staal JB. Symptoms of depression are associated with physical inactivity but not modified by gender or the presence of a cardiovascular disease; a cross-sectional study. BMC Cardiovasc Disord. 2019;19(1):95\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGomes M, Figueiredo D, Teixeira L, Poveda V, Paul C, Santos-Silva A, et al. Physical inactivity among older adults across Europe based on the SHARE database. Age Ageing. 2017;46(1):71\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatts AS, Mortby ME, Burns JM. Depressive symptoms as a barrier to engagement in physical activity in older adults with and without Alzheimer\u0026rsquo;s disease. PLoS ONE. 2018;13(12):e0208581.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColey N, Ngandu T, Lehtisalo J, Soininen H, Vellas B, Richard E, et al. Alzheimer\u0026rsquo;s dementia: J Alzheimer\u0026rsquo;s Association. 2019;15(6):729\u0026ndash;41. Adherence to multidomain interventions for dementia prevention: Data from the FINGER and MAPT trials.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS. Adherence to yoga and exercise interventions in a 6-month clinical trial. BMC Complement Altern Med. 2007;7:37\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStineman MG, Strumpf N, Kurichi JE, Charles J, Grisso JA, Jayadevappa R. Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program. Gerontologist. 2011;51(Suppl 1):59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeuvonen E, Lehtisalo J, Solomon A, Antikainen R, Havulinna S, H\u0026auml;nninen T et al. Psychosocial determinants for adherence to a healthy lifestyle and intervention participation in the FINGER trial: an exploratory analysis of a randomised clinical trial. Aging Clin Exp Res. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlyth FM, Noguchi N. Chronic musculoskeletal pain and its impact on older people. Best Pract Res Clin Rheumatol. 2017;31(2):160\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePicorelli AM, Pereira LS, Pereira DS, Felicio D, Sherrington C. Adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review. J physiotherapy. 2014;60(3):151\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYarmohammadi S, Saadati HM, Ghaffari M, Ramezankhani A. A systematic review of barriers and motivators to physical activity in elderly adults in Iran and worldwide. Epidemiol health. 2019;41:e2019049.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgandu T, Lehtisalo J, Solomon A, Lev\u0026auml;lahti E, Ahtiluoto S, Antikainen R, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet. 2015;385(9984):2255\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivipelto M, Solomon A, Ahtiluoto S, Ngandu T, Lehtisalo J, Antikainen R, et al. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER): study design and progress. Alzheimer\u0026rsquo;s dementia: J Alzheimer\u0026rsquo;s Association. 2013;9(6):657\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgandu T, Lehtisalo J, Korkki S, Solomon A, Coley N, Antikainen R et al. The effect of adherence on cognition in a multidomain lifestyle intervention (FINGER). Alzheimer\u0026rsquo;s dementia: J Alzheimer\u0026rsquo;s Association. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivipelto M, Ngandu T, Laatikainen T, Winblad B, Soininen H, Tuomilehto J. Risk score for the prediction of dementia risk in 20 years among middle aged people: a longitudinal, population-based study. Lancet Neurol. 2006;5(9):735\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, et al. National Sleep Foundation\u0026rsquo;s updated sleep duration recommendations: final report. Sleep Health. 2015;1(4):233\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunstan DA, Scott N. Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores. Depression research and treatment. 2018;2018:9250972.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJokelainen J, Timonen M, Keinanen-Kiukaanniemi S, Harkonen P, Jurvelin H, Suija K. Validation of the Zung self-rating depression scale (SDS) in older adults. Scand J Prim Health Care. 2019;37(3):353\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZung WW. From art to science. The diagnosis and treatment of depression. Arch Gen Psychiatry. 1973;29(3):328\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med. 2001;33(5):350\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChennaoui M, Arnal PJ, Sauvet F, L\u0026eacute;ger D. Sleep and exercise: A reciprocal issue? Sleep Med Rev. 2014;20:59\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScarlett S, Nolan H, Kenny RA, O\u0026rsquo;Connell MD. Objective Sleep Duration in Older Adults: Results From The Irish Longitudinal Study on Ageing. J Am Geriatr Soc. 2020;68(1):120\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorgan K, Hartescu I. Sleep duration and all-cause mortality: links to physical activity and prefrailty in a 27-year follow up of older adults in the UK. Sleep Med. 2019;54:231\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJike M, Itani O, Watanabe N, Buysse DJ, Kaneita Y. Long sleep duration and health outcomes: A systematic review, meta-analysis and meta-regression. Sleep Med Rev. 2018;39:25\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItani O, Jike M, Watanabe N, Kaneita Y. Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Med. 2016;32:246\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Y, Mei H, Jiang YR, Sun WQ, Song YJ, Liu SJ, et al. Relationship between Duration of Sleep and Hypertension in Adults: A Meta-Analysis. J Clin Sleep Med. 2015;11(9):1047\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabia S, Fayosse A, Dumurgier J, Hees VTV, Paquet C, Sommerlad A et al. Association of sleep duration in middle and old age with incidence of dementia. 12, Nat Commun. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang C, Holtzman DM. Bidirectional relationship between sleep and Alzheimer\u0026rsquo;s disease: role of amyloid, tau, and other factors. Neuropsychopharmacology: official publication Am Coll Neuropsychopharmacol. 2020;45(1):104\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSella E, Toffalini E, Canini L, Borella E. Non-pharmacological interventions targeting sleep quality in older adults: a systematic review and meta-analysis. Aging Ment Health. 2022;1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith D, Wilkie R, Croft P, Parmar S, McBeth J. Pain and mortality: mechanisms for a relationship. Pain. 2018;159(6):1112\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Physical activity, exercise, sleep, mood, pain, lifestyle intervention, adherence","lastPublishedDoi":"10.21203/rs.3.rs-4826880/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4826880/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePhysical activity (PA) and exercise interventions are beneficial for health and can reduce dementia risk. However, there might be barriers to engage in PA, such as sleep problems, depressive symptoms and pain, which are common complaints with older adults. We investigated the association between sleep duration, sleep quality, depressive symptoms, and pain with adherence to exercise intervention and self-reported PA in a 2-year randomized controlled trial using multidomain lifestyle intervention (post-hoc analyses).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe FINGER trial included 1259 individuals at risk for dementia, aged 60\u0026ndash;77 years who were randomized (1:1) to a multidomain lifestyle intervention (exercise, diet, cognitive training, vascular risk factor management) or a control (regular health advice) group. Logistic regression analyses were used with exercise adherence (adherent: \u0026ge;66% participation) or self-reported PA (active: \u0026ge;2 times/week) as outcomes, adjusted for relevant baseline characteristics. Data on PA at baseline and at 2-years were available for 1100 participants.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe intervention group participants sleeping\u0026thinsp;\u0026lt;\u0026thinsp;6h or \u0026ge;\u0026thinsp;9h per night were less likely to be adherent compared with the participants sleeping\u0026thinsp;\u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h, (OR 0.46, 95% CI 0.21\u0026ndash;0.99 and OR 0.38, 95% CI 0.20\u0026ndash;0.74, respectively). The intervention group participants were more likely to be physically active than those in the control group at two years. This intervention benefit did not significantly differ by baseline sleep duration, depressive symptoms, or pain (p\u0026thinsp;\u0026gt;\u0026thinsp;0.3 for all interactions). Regardless of randomization group, those sleeping\u0026thinsp;\u0026lt;\u0026thinsp;6h were less likely to be physically active at two years, compared with participants sleeping\u0026thinsp;\u0026ge;\u0026thinsp;7\u0026ndash;\u0026lt;8h (OR 0.36, 95% CI 0.18\u0026ndash;0.72). Depressive symptoms or pain were not related to PA at two years.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOlder adults with sleep problems, depressive symptoms or pain may benefit from lifestyle interventions. However, both short and long sleep duration can be barriers to engaging in exercise intervention and should be taken into consideration when aiming to promote PA among older populations at risk of dementia.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e \u003cp\u003eThe FINGER trial was registered at ClinicalTrials.gov with identifier NCT01041989.\u003c/p\u003e","manuscriptTitle":"Association of impaired sleep, depressive symptoms and pain with physical activity and exercise intervention adherence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-10 20:46:46","doi":"10.21203/rs.3.rs-4826880/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-05T09:43:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-31T14:36:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-31T14:35:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2024-07-30T08:12:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"45789e74-a230-4d5a-93d9-bb1a9a753286","owner":[],"postedDate":"September 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:59:00+00:00","versionOfRecord":{"articleIdentity":"rs-4826880","link":"https://doi.org/10.1186/s12877-025-05830-y","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-03-29 15:57:05","publishedOnDateReadable":"March 29th, 2025"},"versionCreatedAt":"2024-09-10 20:46:46","video":"","vorDoi":"10.1186/s12877-025-05830-y","vorDoiUrl":"https://doi.org/10.1186/s12877-025-05830-y","workflowStages":[]},"version":"v1","identity":"rs-4826880","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4826880","identity":"rs-4826880","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}