Abstract
Background: South Africa is an ageing society; in 2024, the elderly population accounted for 9.7% (6.13 million) of the general population. The elderly are at risk of cognitive decline. The primary aim of the study was to assess whether there was a change in cognitive function after a structured exercise programme and, secondarily, to distinguish the effect of a variation in exercise frequency on cognition.
Methods: A study was conducted across five aged care facilities in the eThekwini district. Of the 100 participants, 84 completed the study after being randomly assigned to a uniform supervised programme, exercising two (Group A, N = 45) or three (Group B, N = 39) times per week over a 12-week period. Cognition was measured at baseline and after the exercise intervention using the Short Orientation-Memory-Concentration Test (SOMCT). Cognitive scores pre- and post-intervention were analysed using the Wilcoxon signed-rank test as well as the change in scores between the two exercise frequency groups, using an independent t-test.
Results: The SOMCT improved by one point from a median of four pre-intervention (interquartile range [IQR] = 6) to a median of three post-intervention (IQR = 8) (p = 0.448). Similarly, although reflecting a small effect size (0.114) and not reaching statistical significance (p = 0.603), a slightly larger improvement was observed in the mean memory score change for exercise three times a week (−0.69 ± 5.4) versus twice per week (−0.10 ± 4.8).
Conclusion: The structured exercise programme, and its higher frequency, showed a positive trend of improved cognition, albeit not statistically significant.
Contribution: A structured exercise programme may help improve cognition in the elderly.
Keywords: elderly; aged care facility; South Africa; group exercise; cognition; Short Memory Orientation Concentration Test.
Introduction
Globally, the population aged 60 years and over will reach 2.1 billion by 2050.1,2 South Africa (SA) has the highest proportion of elderly persons in sub-Saharan Africa, and this is projected to rise to over 15 million by the year 2030. A significant increase in chronic diseases is expected to accompany this demographic shift, which poses challenges for healthcare and long-term welfare systems.3
Ageing is a complex phenomenon and includes physical and cognitive decline.4 Muscle mass and strength decrease with age because of increasing inactivity and decreasing levels of growth hormones and testosterone.5,6,7 Cognitive decline or ‘brain ageing’ is thought to occur because of the loss of neurones that are not replaced and a subsequent decline in chemical neurotransmitters.5 This leads to degeneration in the structural and functional integrity of prefrontal and basal ganglia substructures, resulting in cognitive deficits.8
Cognitive impairment in the elderly can be classified as normal cognitive decline with ageing, subjective cognitive impairment, mild cognitive impairment and dementia.9 The decline in cognition is recognised as the transitional state between normal ageing and dementia.10 The effects of cognitive impairment can range from mildly diminished quality of life to a significantly increased risk of poor functioning. Additionally, impaired cognition among the elderly is associated with an increased risk of injuries to themselves or others, a decline in their functional activities of daily living and an increased risk of mortality.11
Apathy is shown to increase with age in the healthy older person, and its presence is considered an early sign of cognitive decline.12 The presence of apathy during ageing may be responsible for hypo-mobility and reduced volition, which contribute significantly to carelessness and, as a consequence, the worsening of comorbidities.12
Structured exercise programmes, including group exercises, are shown to have cognitive benefits and enhance self-efficacy, confidence and overall well-being in the elderly.13 Exercise was found to be protective against cognitive decline.14,15 Some evidence suggests moderate-intensity aerobic exercise is associated with significant improvements in cognitive function, mood regulation and overall well-being in older adults. These benefits are linked to structural and functional changes in the brain, such as increased hippocampal volume and elevated levels of brain-derived neurotrophic factor.14,16,17 Moderate-to-high-intensity resistance training, both in acute and chronic forms, enhances cognitive performance in older adults, particularly in executive functions and visuospatial processing.18 Cognitive benefits, including improvements in information-processing speed, attention and memory, can be sustained through regular training.18 Additionally, physical activity may reduce pro-inflammatory processes and cellular damage secondary to oxidative stress.19
Generally, previous research supports that exercise has a positive benefit on cognition, as supported by a meta-analysis by Zhidong et al.20. However, there is a paucity of local data on the effect of exercise in the rapidly ageing South African population. This study aims to determine the effects of a structured exercise programme and its frequency on the cognitive function of persons aged 60 years and over living independently in aged care facilities. Findings from this study can potentially help to inform healthcare policies and reduce healthcare costs associated with falls and cognitive decline, thus benefiting both the elderly and the larger South African society.
Research methods and design
Study design
This quasi-experimental study was conducted across five aged care facilities in the eThekwini district, SA. The effect of a 12-week structured exercise programme on the biopsychosocial wellness of the elderly was assessed using pre-test and post-test procedures across two groups of participants. This study is an analysis of primary data derived from the research project conducted by a tertiary institution (University of KwaZulu-Natal), entitled ‘Group exercise and its relation to perceived health status, functional fitness, immune and hormonal status of older persons living in aged care facilities within the eThekwini Municipality’. The study comprehensively evaluated multiple domains, including functional fitness, health-related quality of life, immune status (salivary secretory IgA), hormonal markers and cognitive function. Results demonstrated that irrespective of exercise frequency, the structured exercise programme improved functional fitness and health-related quality of life and increased salivary secretory IgA.21,22,23 The current analysis focuses specifically on the cognitive outcomes assessed using the Short Memory Orientation Concentration Test (SOMCT), examining whether the structured exercise intervention conferred cognitive benefits to participants.
Two major state facilities for aged care were purposively selected for inclusion in the study, that is, The Aryan Benevolent Home and The Association for the Aged (TAFTA). The organisations have several old-age facilities within the eThekweni district. For convenience, sites that fell within a 20 km – 30 km radius of central eThekwini were included in the study. The study sample was representative of the resident population at these facilities.
The racial composition of study sites reflects the demographic profiles of the research facilities: The Aryan Benevolent Home has a historically Indian population, while TAFTA historically includes larger proportions of white, people of colour and Indian residents compared to African residents.
Study population and sampling strategy
All persons aged 60 years and over who were independent and non-participants in structured physical activity programmes (including occupational therapy and physiotherapy) for at least 3 months were invited to participate in the study. Participants involved in social events were not excluded, as these constituted unstructured activities across the selected sites. Individuals were excluded if they were < 60 years of age, had undergone hormonal supplementation, were unable to participate based on a medical assessment and were participating in other research or clinical trials.
A structured questionnaire was employed to screen the participants based on demographics (age, sex, race, and marital status), medical history, family history and current medication history. A pre-intervention assessment, including a physical activity readiness evaluation and the International Physical Activity Questionnaire (IPAQ), was conducted by a sports medicine physician to determine eligibility. The IPAQ tool has been well validated in the South African setting.24
Of the 118 initially screened volunteers, 100 were deemed suitable, and 20 participants were recruited from each site. These participants were randomly allocated numbers from 1 to 20. The fishbowl technique25 was used to identify 10 participants for Group A (odd numbers) exercising three times a week (i.e., Monday, Wednesday, and Friday) and Group B (even numbers) exercising two times a week (i.e. Monday and Friday) for 12 weeks.
Intervention
The exercise programme, which combined strength, endurance and balance activities, increased in duration from 50 min to 80 min per session over a 12-week period.21,22,23 Each exercise session began with a warm-up and concluded with a cool-down. Moreover, the exercise sessions were conducted at the same time, as a group under the supervision of an instructor, between 08:00 and 10:00 and at least 60 min after breakfast. Participants had to attend 80% of the exercise sessions to be included in the analysis.
Data collection
Cognition assessments were performed using the SOMCT (Appendix 1), a cognitive screening tool designed to assess an individual’s memory, orientation and concentration.26,27,28 This test is used in clinical and research settings for evaluating cognitive function, especially when screening for cognitive impairment or dementia.26,27,28 Katzman et al.27 assert that the total possible error score in the SOMCT is 28, with an error score of 0–8, which falls within the normal limits. The SOMCT has been used in South African studies.29,30 There is an inverse relationship between the SOMCT score and cognition. This score is determined using the following questionnaire items:
- What year is it now?
- What month is it now?
- Repeat this phrase: John Brown, 42 West Street, Durban.
- About what time is it (within 1 h)?
- Count backwards from 20 to 1.
- Say the months in reverse.
- Repeat the phrase given previously, that is, John Brown, 42 West Street, Durban.
The same test was administered at baseline and immediately after the 12-week programme had ended to compare the pre- and post-intervention results.
Data analysis
Descriptive statistics such as frequency and percentage were used to summarise categorical data, while median and interquartile ranges were used to summarise continuous non-normally distributed data. The IBM SPSS® version 28.0 was used to analyse the data. A p ≤ 0.05 was considered statistically significant.
Comparison of medians for memory scales pre- and post-intervention for the whole sample was achieved using a paired Wilcoxon signed-rank test. Comparison of the two exercise groups for the secondary objective was achieved by subtracting the post-memory score from the pre-memory score to obtain a change in memory score. As the change in memory score was normally distributed, an independent samples t-test was used for comparison of the change in memory scores between the two exercise groups. Effect sizes, classified as small (d = 0.2), medium (d = 0.5) and large (d ≥ 0.8) (Cohen’s D), were reported.
Ethical considerations
Ethical permission for the study was obtained from the University of KwaZulu-Natal (UKZN), Biomedical Research Ethics Committee (BREC) [BE251/11], the Department of Social Development, and each of the five participating aged care facilities. Before enrolment in the study, written informed consent from the participants was obtained. Participation in the study was voluntary, and participants could withdraw from it at any time. Ethical approval for this sub-study was obtained from UKZN BREC (BREC/00005624/2023).
Results
Of the 100 participants enrolled, 84 participants completed the study (Group A, N = 45 and Group B, N = 39), with 16 falling out because of concurrent illnesses or hospital visits. The mean age for the total group was 72.0 (standard deviation [s.d.] ± 8.0) years, and most participants were women (78%). In terms of race, most participants were Indians (75.9%), followed by whites (14.9%), and people of colour (8%), with only one African participant. Just over 50% of the participants were widowed (Table 1).
| TABLE 1: Demographic profile of participants by exercise group and total sample. |
At baseline, 68 (78%) participants had normal memory scores, and 19 (22%) participants had impaired scores. The memory assessment results of the total sample changed from a median score of 4 pre-intervention to a median score of 3 post-intervention, with a lower score indicating better performance. Of the 84 participants who completed the study, 39 (46%) showed an improved memory (decreased score) and 31 (37%) showed a reduction in memory (increased score).
Although these improvements from pre- to post-intervention for memory did not reach statistical significance (p = 0.448), the results suggest a tendency for an improved median memory score, and a greater number of individuals experienced an improved memory score as a result of the supervised exercise programme (Table 2).
| TABLE 2: Memory and concentration measures. |
The mean change in memory score of the two groups is shown in Table 3. The change in memory score among the group that exercised three times a week (0.69) was marginally better than the group exercising two times per week (0.10). The improvement associated with a higher frequency of exercise was larger than that of the group exercising at a lower frequency. However, the effect size observed (0.114) was small, with no statistical significance between the groups (p = 0.603).
| TABLE 3: Change in memory score between groups A and B. |
Discussion
This is one of the few studies to examine the effects of exercise frequency on cognition and memory in a multi-ethnic South African elderly population. Most of the participants were women, widows and of Indian descent. Our study revealed that a structured exercise intervention programme and a higher weekly frequency of exercise (three times a week vs. two times a week) yielded a positive trend of an improved SOMCT memory score, albeit not at a statistically significant level. Some study participants had worsening SOMCT scores; the reasons were not further explored in this study. The exercise intervention was designed to improve strength and endurance, and the SOMCT may not have been sensitive enough to show improvements in cognitive function. Dual tasking, that is, concurrent resistance training and or aerobic training in combination with ‘cognitive tasks’, may have improved cognition.18
A cross-sectional study by Kalula et al.29 conducted with 837 elderly community-dwelling participants in Cape Town, SA, evaluated the association between falls and recurrent falls and predictors of physical activity. The study showed that a higher SOMCT score, which correlates with poorer cognition, was an independent predictor of falls in the elderly, with each point score increase correlating with a 4% increased risk of falls.29 Our study found that exercise intervention was associated with an improved trend of the SOMCT scores, suggesting improved cognition, which we cautiously postulate may reduce fall risk.
These study findings were partially aligned with a South African study by Ramnath et al.31 which explored the relationship between functional status, physical fitness and cognitive performance in physically active older adults. The study among 70 adults (> 65 years of age) assessed functional performance (static, dynamic balance), fitness and cognition and found that a higher level of physical activity, fitness and functional ability was associated with better cognitive performance.
A systematic meta-analysis of 28 studies and 2156 participants by Zhidong et al.20 showed that exercise frequency was typically associated with improved working memory in the elderly. The exercise prescription to achieve optimal improvement was a combination of moderate-intensity Mind-Body Exercise (MBE) or Multi Component Exercise (MCE), performed 3–4 times a week for 45 min – 60 min over a minimum of 12 weeks.20 Compared to our study, we used a shorter duration exercise intervention and frequency, as well as a variation of the exercise prescription. We predominantly utilised a resistance and endurance exercise prescription, whereas Zhidong et al.20 made use of MBE, which entails balance, strength and endurance training and MCE, which is like yoga or Tai chi.
An international study by Yu et al.32 on individual-based exercise intervention among 37 participants over a 12-week period explored the role of exercise frequency on improving cognition and found that moderate or vigorous intensity walking exercise performed once or thrice a week showed similar improvements in cognitive performance in the middle-aged and older population of adults. Similar to our study, more frequent exercise tended to improve cognition scores, but not to a statistically significant extent. The elderly often experience feelings of isolation, loneliness, lack of self-worth and depression and these negative feelings contribute to hypo-mobility, a decline in cognition and worsening comorbidities.9,12 Thus, notwithstanding the limitation of our results, group-based exercise is undoubtedly advantageous as it improves physical fitness, encourages social interaction, thereby improving mental health (of which cognition is an integral part) and overall well-being of the elderly.21,22
The limitations of this study include a relatively small sample size, a limited number of study sites and a study population that was not representative of all ethnic groups in South Africa.
The study participants were medically heterogeneous, with 19 (21.8%) participants screened positive for possible cognitive impairment at baseline according to the SOMCT. The outcome may have been influenced by other potentially confounding variables such as the effect of undiagnosed or poorly controlled comorbidities, chronic medication and the related side effects thereof, the short duration of the study and a female bias in the composition of the overall study group. Furthermore, the SOMCT was administered to the same study participants pre- and post-exercise intervention, and there may be a potential for practice effects, which could influence the results.
The high standard deviations observed in our memory outcome measures reflect the heterogeneous nature of our participant sample and individual variability in response to exercise interventions. This variability, while representative of real-world populations, may have limited our ability to detect statistically significant differences between groups and suggests that larger sample sizes or more targeted participant selection criteria may be beneficial in future trials.
Future studies can be improved by including a larger sample size, inclusive of all ethnic groups and analysis of covariates like age, educational background and concomitant medications. Furthermore, studies can be of longer duration, and participants can be randomised to an intervention, and there can be a control group to detect the effectiveness of the intervention. The exercise prescription can also be tailored to the cognitive impairment. The primary efficacy endpoint can be a formal cognitive function and performance assessment, as opposed to the use of a screening tool like SOMCT.
Conclusion
While our exercise intervention did not result in statistically significant improvement in cognition in the elderly, a positive trend was identified. The potential positive impact of exercise on cognition in the elderly may reduce the health economic burden in resource-limited settings. Longer-term studies are required to observe the effect of exercise, and its frequencies, on cognition in the elderly South African population.
Acknowledgements
The authors would like to acknowledge Tonya Esterhuizen, Associate Professor, Biostatistics Unit, Division of Epidemiology and Biostatistics, Stellenbosch University. The manuscript was submitted in partial fulfilment of the requirements for the Master of Medicine (Internal Medicine) at the School of Clinical Medicine, University of KwaZulu-Natal.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
N.H. conceived and designed the study, analysed and interpreted the data, wrote the manuscript and approved the final version. F.P. conceived and designed the study, analysed and interpreted the data, supervised the writing of the manuscript and approved the final version. J.v.H. analysed and interpreted the data, supervised the writing of the manuscript and approved the final version. S.S.R. conceived and designed the study, analysed and interpreted the data, supervised the writing of the manuscript and approved the final version.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
The data that support the findings of this study are available on request from the corresponding author, N.H. The data are not publicly available due to privacy and ethical reasons.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
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Appendix 1
Short Orientation-Memory-Concentration Test
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