Cay Anderson-Hanley

This study investigated whether neuro-exergaming with an interactive physical and cognitive exercise system (iPACES), might alleviate symptoms in college students with symptoms of Attention Deficit Hyperactivity Disorder (sxADHD). It was hypothesized that challenges with attention and executive function, often experienced by those with sxADHD, would improve after an acute bout of pedal-n-play exercise. College students (n = 33; 18 with sxADHD) participated in a 20 min single bout of exercise, pedaling along a virtual pathway (tour), while steering the tablet. Mental exercise included a working memory (focus) task to steer toward assigned locations along the path. An exploratory experimental condition was also embedded in the basic pre/post design, wherein half of the students were randomly assigned collectibles (coins) in the pathway. Cognition was assessed (e.g., paper and digital Stroop, Trails, Digit Span) before and after the acute bout of exercise. Paired t-tests revealed significant improvements in executive function on both paper and electronic Stroop tasks for those with sxADHD, while significant change was also seen on Trails and Digit Span for normative students. Surprisingly, those with sxADHD, assigned to the experimental “multi-tasking” collectible (coin) challenge, performed significantly better on tests of executive functioning than normative peers, who improved more without coins. It is hypothesized that the collectible challenge provided additional mental stimulation or reward needed to increase attentional focus for those with sxADHD, leading to improved performance, post-exercise. While the findings of this study are preliminary, additional research can further explore possible designs for combined, interactive mental and physical exercise challenges, as well as further possible synergistic or differential neural activation, in order to maximize outcomes from the same amount of time exercising. Additionally, future research could examine longer-term use of neuro-exergaming, through a clinical trial, as an alternative to, or in conjunction with, medication for sxADHD treatment and symptom relief.

Background: To enable brief and integrated serial assessment across a national sample, we developed an electronic version of the Trail Making test (eTrails) for remote self‐administration on digital devices. eTrails, a digital, web‐based assessment, mimicking the traditional paper version of Trails B (see demo: https://bit.ly/33DCPGP), in which participants draw a line from a number to a letter in alternating, ascending order, was integrated into the iPACES app. Herein we report on initial validation of eTrails, as compared with the paper Trail Making Test.Method: This initial validation report examined digital trail making data (n = 34 sessions) serially collected from ten MCI and caregiver participants in the iPACES v3 clinical trial (mean age = 70.2, mean years of education = 16.9). Included in analyses were eTrails data for traditional metrics (i.e., overall completion time) and novel digital biomarkers extracted from event‐level data (e.g., # of lifts and pause time). After a baseline tele‐neuropsychological evaluation in which paper Trail Making was administered (Forms A&B), at predetermined study intervals (typically weekly), participants were automatically prompted to complete the eTrails on their iPACES tablet. In the eTrails, participants were presented with one of four randomly selected alternate forms of trail making stimuli (i.e., different spatial configurations of Form B).Result: Overall completion time from eTrails was moderately correlated with both forms of paper‐based trail making completed at baseline (correlation with Paper Trails A: r = .37, p = .030; correlation with Paper Trails B: r = .41, p = .017). Novel digital biomarkers (i.e., # lifts, pause time) were moderately correlated (r’s = 0.59‐0.6, p’s < .001) with the traditional scoring of the eTrails (i.e., assessment completion time in seconds), and though non‐significant, weakly correlated with completion time of paper Trails A (r = 0.20, p = 0.25).Conclusion: These preliminary data provide initial evidence of validity, that eTrails as a serial assessment of subtle cognitive decline can serve as a remote self‐administered digital test for serial assessment of executive function and will be further evaluated in our ongoing iPACES study. Future research may explore the sensitivity of novel digital biomarkers extractable from event‐level data.

Facing an unrelenting rise in dementia cases worldwide, researchers are exploring non-pharmacological ways to ameliorate cognitive decline in later life. Twenty older adults completed assessments before and after a single bout of interactive physical and cognitive exercise, by playing a neuro-exergame that required pedaling and steering to control progress in a tablet-based video game tailored to impact executive function (the interactive Physical and Cognitive Exercise System; iPACES v2). This study explored the cognitive and biomarker outcomes for participants with mild cognitive impairment (MCI) and normative older adults after 20 min of pedal-to-play exercise. Neuropsychological and salivary assessments were performed pre- and post-exercise to assess the impact. Repeated-measures ANOVAs revealed significant interaction effects, with MCI participants experiencing greater changes in executive function and alpha-amylase levels than normative older adults; within-group changes were also significant. This study provides further data regarding cognitive effects and potential mechanisms of action for exercise as an intervention for MCI.

Background: Alzheimer’s and related dementias are on the rise, and older adults and their families are seeking accessible and effective ways to stave off or ameliorate mild cognitive impairment (MCI). Aim: This pilot clinical trial (ClinicalTrials.gov Identifier: 03069391) examined neuropsychological and neurobiological outcomes of interactive physical and mental exercise. Participants and methods: Older adults (MCI and caregivers) were enrolled in a 3-month, in-home trial of a portable neuro-exergame (the interactive Physical and Cognitive Exercise System [iPACES™]), in which they pedaled and steered along a virtual bike path to complete a list of errands (Memory Lane™). Neuropsychological function and salivary biomarkers were measured at pre-, mid-, and posttrial. Ten older adults complied with the recommended use of iPACES (complete dose; ≥2×/wk, 67% of the 15 who also had pre- and postevaluation data). Statistical analyses compared change over time and also change among those with a complete dose vs inadequate dose. Correlations between change in neuropsychological and biomarker measures were also examined. Results: Executive function and verbal memory increased after 3 months (p = 0.01; no significant change was found with an inadequate dose). Change in salivary biomarkers was moderately associated with increasing cognition (cortisol, r = 0.68; IGF-1, r = 0.37). Conclusion: Further research is needed, but these pilot data provide preliminary indications to suggest neuro-exergaming can impact cognitive function, perhaps via neurobiological mechanisms, and as such may provide an effective and practical way to promote healthy aging.

Given increasing longevity worldwide, older adults and caregivers are seeking ways to curb cognitive decline especially for those with mild cognitive impairment (MCI, now mild neurocognitive disorder, mNCD, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V). This quasi-experimental, within-subjects pilot clinical trial was designed to replicate and extend the study of cognitive benefits for MCI by improving upon our prior interactive Physical and Cognitive Exercise Study (iPACES^TM v1.0) by increasing the usability of the neuro-exergame and exploring possible underlying neurobiological mechanisms. Older adults were enrolled in a three-month, in-home trial of a portable neuro-exergame (iPACES™ v2.0) where participants pedaled and steered along a virtual bike path (Memory Lane™). Neuropsychological function was assessed at baseline after component familiarization intervals (e.g., two weeks of exercise-only, game-only, etc.) and after three months of interactive neuro-exergame intervention. Fourteen participants were enrolled in the study and seven completed the final evaluation. Intent-to-treat analyses were conducted with imputed missing data (total n = 14). Significant improvement in executive function (Stroop) was found (d = 0.68, p = 0.02) only. Changes in salivary biomarkers (cortisol and insulin-like growth factor 1; IGF-1) were significantly associated with improved cognition. Further research is needed, but pilot data suggest that a portable in-home neuro-exergame may be an additional, practical tool to fight back against cognitive decline and dementia.

Prior research has found that cognitive benefits of physical exercise and brain health in older adults may be enhanced when mental exercise is interactive simultaneously, as in exergaming. It is unclear whether the cognitive benefit can be maximized by increasing the degree of mental challenge during exercise. This randomized clinical trial (RCT), the Aerobic and Cognitive Exercise Study (ACES) sought to replicate and extend prior findings of added cognitive benefit from exergaming to those with or at risk for mild cognitive impairment (MCI). ACES compares the effects of 6 months of an exer-tour (virtual reality bike rides) with the effects of a more effortful exer-score (pedaling through a videogame to score points). Fourteen community-dwelling older adults meeting screening criteria for MCI (sMCI) were adherent to their assigned exercise for 6 months. The primary outcome was executive function, while secondary outcomes included memory and everyday cognitive function. Exer-tour and exer-score yielded significant moderate effects on executive function (Stroop A/C; d's = 0.51 and 0.47); there was no significant interaction effect. However, after 3 months the exer-tour revealed a significant and moderate effect, while exer-score showed little impact, as did a game-only condition. Both exer-tour and exer-score conditions also resulted in significant improvements in verbal memory. Effects appear to generalize to self-reported everyday cognitive function. Pilot data, including salivary biomarkers and structural MRI, were gathered at baseline and 6 months; exercise dose was associated with increased BDNF as well as increased gray matter volume in the PFC and ACC. Improvement in memory was associated with an increase in the DLPFC. Improved executive function was associated with increased expression of exosomal miRNA-9. Interactive physical and cognitive exercise (both high and low mental challenge) yielded similarly significant cognitive benefit for adherent sMCI exercisers over 6 months. A larger RCT is needed to confirm these findings. Further innovation and clinical trial data are needed to develop accessible, yet engaging and effective interventions to combat cognitive decline for the growing MCI population. ClinicalTrials.gov ID: NCT02237560

Dementia cases are on the rise and researchers seek innovative ways to prevent or ameliorate cognitive impairment in later life. Some research has reported that combining mental and physical exercise may benefit cognition more than either alone. This randomized pilot trial examined the feasibility and cognitive benefit for older adults (n = 30) of a single bout of neuro-exergaming (physical activity with cognitive training) using an interactive physical and cognitive exercise system (iPACES), compared with that of exergaming or neurogaming alone. Intent-to-treat and sensitivity analyses were conducted using repeated-measures ANOVA, controlling for age, sex, and education. A significant interaction effect was found for executive function (Color Trails 2), with a significant improvement in the neuro-exergaming condition. Results demonstrate feasibility for older adults to use a novel and theoretically-derived neuro-exergame, and also provide promising new evidence that neuro-exergaming can yield greater cognitive benefit than either of its component parts.

Dementia cases are increasing worldwide; thus, investigators seek to identify interventions that might prevent or ameliorate cognitive decline in later life. Extensive research confirms the benefits of physical exercise for brain health, yet only a fraction of older adults exercise regularly. Interactive mental and physical exercise, as in aerobic exergaming, not only motivates, but has also been found to yield cognitive benefit above and beyond traditional exercise. This pilot study sought to investigate whether greater cognitive challenge while exergaming would yield differential outcomes in executive function and generalize to everyday functioning. Sixty-four community based older adults (mean age=82) were randomly assigned to pedal a stationary bike, while interactively engaging on-screen with: (1) a low cognitive demand task (bike tour), or (2) a high cognitive demand task (video game). Executive function (indices from Trails, Stroop and Digit Span) was assessed before and after a single-bout and 3-month exercise intervention. Significant group × time interactions were found after a single-bout (Color Trails) and after 3 months of exergaming (Stroop; among 20 adherents). Those in the high cognitive demand group performed better than those in the low cognitive dose condition. Everyday function improved across both exercise conditions. Pilot data indicate that for older adults, cognitive benefit while exergaming increased concomitantly with higher doses of interactive mental challenge. (JINS, 2015,21, 768–779)

The rise in dementia and the evidence of cognitive benefits of exercise for the older adult population together make salient the research into variables affecting cognitive benefit and exercise behavior. One promising avenue for increasing exercise participation has been the introduction of exergaming, a type of exercise that works in combination with virtual reality to enhance both the exercise experience and health outcomes. Past research has revealed that executive function (EF) was related to greater use of self-regulatory strategies, which in turn was related to greater adherence to exercise following an intervention (McAuley et al., 2011). Best et al. (2014) found improvement in EF related to adherence to exercise post- intervention. Anderson-Hanley et al. (2012) found that for older adults aerobic exergaming yielded greater cognitive benefit than traditional exercise alone; however, questions remain as to the possible impact of greater cognitive benefit and other factors on participants’ involvement in exercise following the end of an intervention. The current study presents follow-up data exploring the relationship between change in EF, self-regulation, and exercise adherence in the post-intervention (naturalistic) period. Herein, it was predicted that improvement in EF during an exercise intervention, would predict subsequent exercise with an exergame during the naturalistic window. Contrary to expectations, results suggest that those with EF decline during the intervention used the exergame more frequently. The results of this study contradict previous literature, but suggest an interesting relationship between change in executive function, self-regulation, and exercise behaviors when exergaming is employed, particularly with older adults with some cognitive decline. We hypothesize that other factors may be at work; perhaps expectation of cognitive benefit might act as a unique motivator or caregivers may be instrumental in adherence.

The Fuld Object-Memory Evaluation (FOME) uses multisensory (tactile, visual, and verbal) encoding of objects for assessing memory, with particular clinical and research application in older adults. This preliminary study reports the first known psychometric data on the development of an alternate form of the FOME. Data were drawn from 102 independent-living older adults participating in a larger clinical trial. Seventy participants completed three versions of the shortened administration of the FOME, and comparability of forms was established by significant, moderate intraclass correlation coefficients for immediate and delayed recall scores. Reliable change indexes indicate the new alternate form performs well, with minimal practice or learning effects. Evidence of convergent and discriminant validity was documented using the Rey Auditory Verbal Learning Test, category fluency task, and North American Adult Reading Test. Normative data are provided stratified by age for participants completing at least one of three time points (n = 96). Results of this preliminary study provide evidence for the comparability and construct validity of a new alternate form of the FOME with prior forms. An additional well-validated form of the FOME has practical implications for serial testing often required in clinical practice and research design.