Effects of Combined Exercise and Cognitive Interventions on Cognition, Function, and Quality of Life in Dementia Patients

Summary

This retrospective cohort study aimed to evaluate the effects of a 12-week combined exercise and cognitive care pathway. It assessed outcomes in cognitive function, psychological state, functional ability, self-care, and quality of life for dementia patients.

Abstract

This retrospective study aimed to explore the effects of a combined exercise and cognitive care pathway on dementia patients. Data from 80 patients with dementia were analyzed and diagnosed and were admitted to hospital for treatment from October 2022 to October 2024. Based on the care they received, as documented in the medical records, participants were categorized into a control group (conventional treatment and rehabilitation training, 40 cases) and a study group (combined exercise and cognitive care pathway, 40 cases). Data was extracted for a 3-month follow-up period. Data on cognitive function [mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA)], psychological state [Hamilton anxiety and depression scales (HAMA, HAMD)], functional outcomes [Berg balance scale (BBS) and timed up and go test (TUGT)], self-care ability [activities of daily living (ADL)], and quality of life [WHOQOL-BREF] were extracted from patient records at baseline (week 0), at the end of the 12 week care period (week 12), and at 1 or 3 months later. At the end of the 12-week period and throughout the follow-up, the MMSE, MoCA, BBS, ADL, and WHOQOL-BREF scores in both groups had increased from baseline, with the study group showing higher scores than the control group (P < 0.001). The HAMA, HAMD, and TUGT scores in both groups had decreased from baseline, with the study group showing lower scores than the control group (P < 0.001). This retrospective analysis suggests that combined exercise and cognitive care was associated with improvements in the cognitive, psychological, functional outcomes, and self-care abilities of dementia patients, and an associated enhancement in their quality of life.

Introduction

Dementia is a chronic progressive disease characterized by cognitive dysfunction and mental and behavioral abnormalities. It is usually manifested as cognitive dysfunction, progressive memory loss, impaired ability of daily living, and abnormal behavioral and psychological symptoms, mainly affecting the elderly¹. Increasing age, neuronal metabolic disorders, mental stress, and sleep disturbances are among the factors that contribute to the development of dementia². At present, adult dementia can be divided into a variety of types according to different etiology and pathological manifestations, the most common of which are Alzheimer's disease (AD) and vascular dementia (VD), accounting for more than 90% of dementia cases³. AD is mainly characterized by memory loss, decline in learning ability, and impairment in judgment and abstract thinking. In clinical practice, cognitive-enhancing drugs such as cholinesterase inhibitors (e.g., donepezil) and glutamate receptor antagonists (e.g., memantine) are commonly used for treatment⁴. VD is a brain injury caused by cerebrovascular diseases, which is characterized by intellectual impairment and cognitive dysfunction. It is usually treated with oxiracetam, piracetam and other drugs that improve cerebral blood flow or promote brain metabolism⁵. Although drug therapy can alleviate patients' clinical symptoms, the clinical efficacy is not ideal, and have many side effects⁶. Therefore, exploring effective lifestyle intervention measures to improve patients' cognition, psychological function, and living ability levels have important clinical and social value. At present, there is no cure for most cases of dementia in clinical practice, and interventions such as exercise and cognitive training are considered important non-pharmacological approaches for managing symptoms and potentially slowing disease progression^7,8.

Exercise intervention, as a non-pharmacological treatment, plays an important role in improving individual health status. One approach to exercise intervention involves creating a detailed prescription that plans the types, duration, intensity, frequency, and precautions of exercise based on the patient's physical health status. Combining various forms of exercise such as strength training, and balance exercise, it guides individuals to work out in a planned, purposeful, and scientific manner. It not only enhances cardiovascular function, improves brain oxygen supply, and improves physical function, but also promotes the release of neurotransmitters, enhances brain function, improves mental health, and cognitive function^9,10. Cognitive intervention for dementia encompasses a range of evidence-based techniques, such as cognitive stimulation, training, and rehabilitation, aimed at maintaining or improving cognitive functions like memory, attention, and problem-solving¹¹. These interventions are often integrated into holistic care plans. Cognitive stimulation refers to stimulating patients' cognitive interest and participation through novel and interesting information and tasks, thereby promoting the improvement of cognitive function¹²; Cognitive training refers to structured, goal-oriented exercises targeting specific cognitive domains—such as memory, attention, and executive function—tailored to the patient's individual condition¹³; Cognitive rehabilitation is the use of training and rehabilitation measures to help patients recover or improve their cognitive function¹⁴. However, the synergistic or additive potential of combining these two modalities remains less clear compared to single-modality approaches. A combined intervention may address the multifactorial nature of dementia more comprehensively than either approach alone, potentially leading to greater improvements in cognition, function, and quality of life.

While both exercise and cognitive interventions individually show benefit for dementia patients, the optimal methods for combining them into a standardized, yet personalized, clinical care pathway remain less clear. Beyond these, other non-pharmacological approaches such as nutritional support, sleep hygiene management, music and art therapy, and multisensory stimulation have also shown promise in improving symptoms and quality of life in dementia care. However, the integration of exercise and cognitive training represents a particularly potent combination due to their complementary mechanisms of action on brain health and functional capacity. This retrospective study aimed to explore the outcomes associated with a structured, combined exercise and cognitive care program versus conventional care in a hospital rehabilitation setting. Unlike previous studies that often apply exercise or cognitive training in isolation, our research introduces and evaluates a phased, integrated, and personalized protocol that systematically combines both modalities within a real-world clinical pathway. This approach not only addresses the multifactorial nature of dementia but also provides a replicable methodological framework for implementation. By analyzing the implementation and results of this specific protocol, we sought to provide preliminary evidence on its feasibility and associations with patient outcomes, contributing to the understanding of how such combined interventions can be operationalized effectively.

Protocol

This study protocol received approval from the Ethics Committee of The First People's Hospital of Fuyang District, Hangzhou City (Approval No.: Y202207-31A). Written informed consent was obtained from all participants and/or their legal guardians prior to any study procedures. The study was conducted in accordance with the Declaration of Helsinki.

Study subjects and inclusion/exclusion criteria

A retrospective review of records was conducted for patients treated from October 2022 to October 2024. The study identified a total of 80 patients diagnosed with dementia whose records met the inclusion criteria. Diagnosis was ensured through multidisciplinary consultations (neurology, psychiatry, rehabilitation) and was confirmed with electroencephalography (EEG) and head magnetic resonance imaging (MRI) examinations as part of standard care.

The inclusion criteria for this study were as follows: A confirmed diagnosis was made according to established dementia criteria¹⁵, including AD and VD types^16,17, using clinical assessment and neuroimaging. Patients aged ≥ 18 years were included. The existence of cognitive impairment was documented, defined as an MMSE score <24 and/or a MoCA score <26 at screening. Patient’s ability to communicate in Mandarin, understand questionnaire content, and complete survey evaluations were verified through a brief, informal conversational assessment conducted by the research nurse. A stable medical condition was confirmed after routine inpatient treatment, as judged by the attending physician (no acute medical issues requiring immediate intervention for at least 2 weeks). An expected survival period ≥6 months was ensured, based on the physician's clinical judgment considering comorbidities. Tolerance to the study treatment plan was assessed and confirmed. Written informed consent was obtained.

The exclusion criteria for this study were as follows: Patients with congenital cognitive impairment or other serious diseases (e.g., malignant tumors, severe infections) were excluded. Patients who recently experienced significant life changes or psychological trauma were excluded. Patients deemed to have poor compliance based on documented history in their medical records prior to the retrospective review period (e.g., frequent missed appointments, refusal of prescribed therapies during routine care) were excluded. Patients who received similar exercise/cognitive interventions prior to study enrollment were excluded. Patients with a history of drug abuse or dependence within the past year were excluded. Pregnant or lactating women were excluded.

Intervention measures

Control group intervention: Standard clinical treatment and nursing were provided to the patients. Pharmacological treatment was administered as per guidelines. Pharmacological treatment was administered as per established clinical guidelines for dementia management. For patients with AD, Donepezil hydrochloride (5 mg) was prescribed (1 tablet/day, with dosage adjustment after 4 weeks up to a maximum of 2 tablets/day) to enhance cholinergic neurotransmission; Ganlute sodium (150 mg) was also prescribed (3 tablets per dose, twice daily) as a neuroprotective agent aimed at supporting cognitive function. For patients with VD, butylphthalide soft capsules (0.1 g) were prescribed (2 tablets per dose, three times daily) to improve cerebral circulation, and memantine hydrochloride tablets (10 mg) were prescribed (1 tablet per dose, three times daily) to modulate glutamate activity and slow cognitive decline. These medications represent conventional pharmacotherapy aimed at symptom management and slowing disease progression in the respective dementia subtypes. Monitored patients' blood pressure regularly twice daily during hospitalization and weekly post-discharge. Medication, guidance, education, and appropriate sleep schedules were provided. Specifically, a fixed bedtime and wake-up time were advised, and daytime napping was limited to <30 min. Dietary advice was provided: easily digestible meals low in salt, oil, and sugar were recommended; spicy foods, strong coffee, and tea were avoided; and smoking and alcohol were prohibited. Psychological counseling was offered as needed, which included a weekly 15 min supportive conversation with a trained nurse, focusing on active listening, emotional validation, and providing encouragement to reduce psychological burden.

Study group intervention: A combined exercise and cognitive intervention was implemented for 12 weeks, in addition to the standard care provided to the control group. This duration was selected based on previous non-pharmacological intervention studies in dementia, which commonly report observable improvements in cognitive and functional domains within 8 to 12 weeks, and to ensure feasibility of completion and assessment within a controlled hospital rehabilitation program. A professional team was formed including neurologists, geriatricians, nurses, rehabilitation therapists, nutritionists, and psychological counselors. A weekly team meeting was held to review patient progress and adjust plans.

Exercise intervention

A strict cardiovascular disease assessment was conducted using the physical activity readiness questionnaire (PAR-Q) and resting ECG. Individual exercise prescriptions were developed based on the patient's condition, preferences, health status, personality, functional capacity, and specific cognitive deficits. These prescriptions consisted of structured aerobic and balance exercises, as detailed below. Exercises were prescribed using the FITT principle (frequency, intensity, time, type). Patients were instructed to exercise gradually according to ability, more than 1 h after meals, and to avoid fasting. Aerobic exercises (e.g., brisk walking or stationary cycling) and balance training (e.g., simplified Tai Chi or balance drills) were included as the core modalities. The exercise heart rate was controlled at 100–110 beats/min. Patients or caregivers were taught how to measure radial pulse by 15 s and multiply that by four to monitor intensity. A safe environment was ensured, avoiding slippery floors and steep slopes; family accompaniment was required. Aerobic exercises and balance training were included (e.g., brisk walking or stationery cycling at a moderate pace for 30 min; simplified 24 form Tai Chi or seated/standing balance drills like tandem stance). The exercise duration was set to 45–60 min per session (including warm-up and cool-down), four to six times per week. A printed exercise log was provided for patients/ families to record session completion, type, duration, and any adverse events.

Cognitive intervention

Trust was established and preliminary assessments were conducted. (week 1): Patient medical records were reviewed to understand their condition, test results, and drug allergy history. In-depth conversations were held with patients and families to assess daily habits, hobbies, and cognitive/ psychological/ physical changes post-diagnosis. Personalized intervention plans were developed. Cognitive and psychological assessment scales were used for baseline evaluation. Educational lectures were organized for patients and families to explain disease knowledge, using pictures/videos to reinforce memory of daily items. The intervention plan content and goals were explained to gain trust and cooperation. Families were informed of the importance of companionship and helped to establish a daily routine (waking, dining, sleeping, activity times). Dietary advice was provided, recommending a balanced diet rich in fruits, vegetables, and whole grains while limiting processed foods, saturated fats, and added sugars. Additionally, a safe, accessible, comfortable, and quiet intervention environment was ensured. Cognitive intervention was implemented (weeks 2–9). The following training was conducted for 30–40 min per group, three-five groups per session, six times per week. Each session was led by a trained rehabilitation therapist or nurse in a quiet room.

Memory training: Patients were encouraged to recall recent events and tell stories of interest; they were listened to patiently. Music rhythm was used (e.g., playing two-three classic old songs like "The East is Red" and asking the patient to identify the song name or hum along) to aid memory. Common items were displayed (pen, phone, glasses) for 30 s, covered, and the patient was asked the name as many as possible, gradually increasing the number of items. Game tools were utilized (e.g., matching pairs of memory card games, starting with six cards). Simple maps were used for route-finding exercises (e.g., mark a route from 'bedroom' to 'kitchen' on a floor plan).

Attention training: Patients were guided to complete pattern drawing (e.g., connect-the-dots or copy a simple geometric shape) or follow specific action instructions (e.g., "Clap your hands twice, then tap your shoulder"). Patients were asked to observe and describe a complex, colorful image (e.g., a busy market scene picture) for 2 min. Tracking of a moving object was guided (e.g., a therapist slowly moves a brightly colored ball horizontally and vertically). Simple daily tasks were assigned (e.g., "Sort these socks by color," "Set the table with three utensils"). Puzzles and block games were used (e.g., 20 piece jigsaw puzzles). Pictures of familiar people were presented for identification, gradually reducing the viewing time from 10 s to 3 s per picture.

Intellectual exercise: Patients were guided to participate in puzzles (e.g., Sudoku 4 x 4 grids), number games (e.g., simple arithmetic like 7 + 5), word puzzles (e.g., finding words in a 5 x 5 letter grid), chess (e.g., simplified checkers). Fragmented colored cards were used for shape assembly (e.g., assembled four pieces into a square, progressing to eight pieces for a house shape). Reading simple storybooks, newspapers, magazines, or picture books aloud was encouraged for 5–10 min and then summarizing the main idea was prompted.

Understanding and expression training: A short, simple story was narrated (three-four sentences) and patients were asked to answer specific questions (e.g., “Who went to the store?” “What did they buy?”). Common words of interest were selected, and sentence frames were used (“I want to…”) to create simple sentences, then expanded to compound sentences. Multimedia (images, videos) of daily activities were used (e.g., making tea) to explain steps and the patient was asked to re-tell the process.

Numerical concepts and calculation training: Simple number recognition and counting were practiced (e.g., counting coins from 1 to 10 Yuan). Numerical sorting exercises were guided: Cards numbered “1”, “5”, “9” were provided. The patient was asked to arrange them. Then card number 7 was introduced, and the patient was asked where it belonged. Simple household account calculations were practiced (e.g., “If an apple costs 3 Yuan and you buy two, how much do you pay?”).

Social activities were facilitated (weeks 10–12): Group activities were scheduled twice weekly in a common room. Communication with family, friends, neighbors was encouraged by facilitating a weekly “tea and chat” session with three-four patients. Participation in group activities like chess or dance classes was guided, led by an activity coordinator. Dementia support groups were organized or encouraged by providing contact information for local Alzheimer’s association chapters and an initial group meeting was facilitated.

Intervention was consolidated and discharge was planned (week 12): Sessions were held twice weekly, 30–40 min each. Progress and achievements were reviewed with patients. Effective cognitive methods were summarized. The intervention plan was adjusted and optimized. A post-discharge self-care and rehabilitation plan was developed. Detailed follow-up information was provided (timing, methods) to patients and families. Monitoring was strengthened to ensure continuity of care post-discharge.

Throughout the intervention, abnormal behaviors were monitored (e.g., restlessness, wandering) and potential causes were analyzed (physical discomfort, environmental changes, psychological needs) and corrective measures were taken promptly. Psychological guidance was provided, self-relaxation and expression of thoughts were encouraged, and patient responses were offered to alleviate negative emotions.

Observation indicators and assessment tools

Cognitive function was assessed: The mini-mental state examination (MMSE) was administered. 1 point was scored per correct answer (total 30); higher scores indicate better cognition. The Montreal cognitive assessment (MoCA)¹⁸ was administered at least one day later, covering eight cognitive domains (total 30); scores >26 indicate normal function. Psychological state was assessed using the Hamilton anxiety scale (HAMA) and the Hamilton depression scale (HAMD)¹⁹. Both scales employ a multi-item questionnaire (HAMA: 14 items; HAMD: 17 items) with each item scored from 0 to 4. The HAMA measures the severity of anxiety symptoms, with total scores ≤7 generally considered within the non-clinical range. The HAMD measures the severity of depressive symptoms, with total scores ≤7 similarly indicating an absence of clinically significant depression. Higher scores on both scales indicate greater symptom severity. Functional outcomes were assessed. Balance was evaluated using the Berg balance scale (BBS) (14 items, scored 0–4 each; total 56). Higher scores indicate better balance. The timed up and go test (TUGT)²⁰ was performed: The time taken to stand from a chair, walk 3 m, turn, return, and sit down was recorded. Shorter times indicate better balance/function.

Living ability was assessed: Activities of daily living (ADL)²¹ scale was used. Basic ADL and instrumental ADL were included (covers complex activities, total 0–56). Higher scores indicate better daily living ability. Quality of life was assessed. The WHOQOL-BREF scale²² was administered (24 items across 4 domains: physical, psychological, social, environmental). Each item was scored 1–5; total score 0–120. All assessments were ensured to be performed and interpreted blindly by trained neurologists. Evaluations were conducted at baseline (week 0), post-intervention (week 12), and at one- and three-months post-intervention.

Statistical analysis methods

SPSS 25.0 was used for data analysis. To enhance comparability in this retrospective analysis, a matched-pairs analytical approach was employed. Patients in the study group were individually matched with patients in the control group based on key baseline characteristics known to influence outcomes: age, gender, dementia type, and baseline MMSE score. This created matched pairs for analysis. For continuous variables, normality was assessed using the Shapiro-Wilk test. Data are presented as mean ± standard deviation (SD). Categorical data are presented as number (n) and percentage (%). Baseline characteristics between groups were compared using independent samples t-tests or Mann-Whitney U tests for continuous variables, and chi-square tests for categorical variables. Comparisons between groups were made using independent samples t-tests, within-group changes were analyzed using paired t-tests, multiple groups were compared using ANOVA, and post-hoc comparisons were made using independent samples t-tests. Outliers were defined as data points exceeding 3 standard deviations from the group mean and were excluded from analysis. A P value <0.05 was considered statistically significant.

Results

Cognitive function assessment

The analysis of cognitive function using MMSE and MoCA scales revealed that both groups exhibited improvements from baseline following the intervention. However, the study group demonstrated significantly higher scores compared to the control group at week 12 (MMSE: 18.88 ± 1.76 vs. 14.73 ± 2.04; MoCA: 15.85 ± 1.73 vs. 13.53 ± 1.85, both P < 0.001). These superior outcomes were sustained throughout the follow-up period, with the study group mai...

Discussion

Dementia, influenced by genetic, environmental, and lifestyle factors²³, often progresses subtly, with early mild memory decline frequently overlooked until significant cognitive and functional impairments—such as reduced daily living skills, behavioral changes, or incontinence—appear^24,25,26. Cognitive impairment, a core feature, diminishes patients’ independence and social functioning,...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
ADL Scale (Activities of daily living)	Lawton & Brody Scale	Not applicable	Assesses BADL and IADL abilities
BBS (Berg balance scale)	Not specified	Not applicable	Assesses limb balance (14 items, 0–56 points)
Butylphthalide soft capsules	CSPC NBP Pharmaceutical Co., Ltd.	H20050299	For vascular dementia (VD), 0.1g 3 times/day
Donepezil hydrochloride tablets	Eisai Co., Ltd. / Generic Manufacturer	H20030106	For Alzheimer's disease (AD), 5–10 mg/day
EEG (Electroencephalogram) system	Not specified	Not specified	Used to assist in dementia diagnosis
Gantule sodium tablets	Shanghai Green Valley Pharmaceuticals	H20190031	For AD, 150 mg each time, twice daily
HAMA (Hamilton anxiety rating scale)	Not specified	Not applicable	Assesses anxiety symptoms in dementia patients
HAMD (Hamilton depression rating scale)	Not specified	Not applicable	Assesses depressive symptoms in dementia patients
Head MRI scanner	GE / Siemens / Philips	Not specified	Used to assist in dementia subtype differentiation
Memantine hydrochloride tablets	Merz Pharma GmbH / Generic Manufacturer	H20203134	For VD, 10 mg 3 times/day
MMSE Scale (Mini-mental state exam)	Chinese validated version	Not applicable	Assesses cognitive function (30 point scale)
MoCA Scale (Montreal cognitive assessment)	MoCA Institute & Beijing version	Not applicable	Assesses cognitive domains incl. memory, naming, etc.
SPSS statistics software	IBM	SPSS 25.0	Used for data analysis in the study
TUGT stopwatch	Not specified	Not specified	Used in Timed Up and Go Test (TUGT)
WHOQOL-BREF questionnaire	WHO	Not applicable	Assesses QoL across 4 domains (physical, psych, etc.)