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Original Investigation |

The Mental Activity and eXercise (MAX) Trial:  A Randomized Controlled Trial to Enhance Cognitive Function in Older Adults

Deborah E. Barnes, PhD, MPH; Wendy Santos-Modesitt, MA; Gina Poelke, PhD; Arthur F. Kramer, PhD; Cynthia Castro, PhD; Laura E. Middleton, PhD; Kristine Yaffe, MD
JAMA Intern Med. 2013;173(9):797-804. doi:10.1001/jamainternmed.2013.189.
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Importance The prevalence of cognitive impairment and dementia are projected to rise dramatically during the next 40 years, and strategies for maintaining cognitive function with age are critically needed. Physical or mental activity alone result in relatively small, domain-specific improvements in cognitive function in older adults; combined interventions may have more global effects.

Objective To examine the combined effects of physical plus mental activity on cognitive function in older adults.

Design Randomized controlled trial with a factorial design.

Setting San Francisco, California.

Participants A total of 126 inactive, community-residing older adults with cognitive complaints.

Interventions All participants engaged in home-based mental activity (1 h/d, 3 d/wk) plus class-based physical activity (1 h/d, 3 d/wk) for 12 weeks and were randomized to either mental activity intervention (MA-I; intensive computer) or mental activity control (MA-C; educational DVDs) plus exercise intervention (EX-I; aerobic) or exercise control (EX-C; stretching and toning); a 2 × 2 factorial design was used so that there were 4 groups: MA-I/EX-I, MA-I/EX-C, MA-C/EX-1, and MA-C/EX-C.

Main Outcome Measures Global cognitive change based on a comprehensive neuropsychological test battery.

Results Participants had a mean age of 73.4 years; 62.7% were women, and 34.9% were Hispanic or nonwhite. There were no significant differences between the groups at baseline. Global cognitive scores improved significantly over time (mean, 0.16 SD; P < .001) but did not differ between groups in the comparison between MA-I and MA-C (ignoring exercise, P = .17), the comparison between EX-I and EX-C (ignoring mental activity, P = .74), or across all 4 randomization groups (P = .26).

Conclusions and Relevance In inactive older adults with cognitive complaints, 12 weeks of physical plus mental activity was associated with significant improvements in global cognitive function with no evidence of difference between intervention and active control groups. These findings may reflect practice effects or may suggest that the amount of activity is more important than the type in this subject population.

Trial Registration clinicaltrials.gov Identifier: NCT00522899

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Figures

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Figure 1. Flowchart for the Mental Activity and eXercise (MAX) Trial. The MAX trial used a 2 × 2 factorial design in which participants were first randomized to either the mental activity intervention (intensive computer training) or the mental activity control (educational DVD) group and then to the exercise intervention (aerobic) or exercise control (stretching and toning) group. This design allows comparisons between the mental activity groups (ignoring exercise) and between the exercise groups (ignoring mental activity), as well as assessment of interaction between mental activity and exercise.

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Figure 2. Effects of interventions on composite cognitive score. For the primary outcome of change in the composite cognitive score, scores improved significantly over time but did not differ between the mental activity intervention (MA-I) and mental activity control (MA-C) groups, the exercise intervention (EX-I) and exercise control groups (EX-C) groups, or all 4 randomization groups.

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Figure 3. Change in individual cognitive tests. Cognitive function improved significantly (* P < .05) for the following scores: Digit Symbol Substitution Test (DSST); Trail-Making Test, part A (Trails A); Eriksen Flanker Test (EFT), congruent and incongruent reaction times; Useful Field of View divided attention (UFOV-DA) and selective attention (UFOV-SA); and composite score. Improvements approached statistical significance († P < .10) for Rey Auditory Verbal Learning Test (RAVLT), total words learned; the Trail-Making Test, part B (Trails B); and UFOV processing speed (UFOV-PS).

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Figure 4. Comparison of mental activity intervention (MA-I) vs mental activity control (MA-C) groups in participants with normal and low memory (delayed recall of ≤5 words on the Rey Auditory Verbal Learning Test [approximately 1 SD below the mean]) scores. The 3-way interaction between baseline memory, mental activity group, and time suggests that the MA-I training may have led to greater cognitive improvements than the MA-C training in participants with low memory scores at baseline, although the interaction and the between-group effects only approached statistical significance.

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