Addressing issues related to geropsychiatry and the well-being of older adults Aging Matters

How Exercise Influences Cognitive Performance

When Mild Cognitive Impairment Exists
A Literature Review
ABSTRACT
Older adults who present with mild
cognitive impairment (MCI) have an
increased risk of developing more
advanced dementia. However, no
pharmacological treatment cur-
rently exists to slow the progres-
sion of or reverse MCI. The purpose
of the current systematic review is
to summarize evidence surround-
ing the impact of exercise interven-
tions on the cognitive performance
levels of community-dwelling older

2015 Shutterstock.com/StockLite
adults with MCI. Computerized data-
base and ancestry search strategies
located distinct intervention trials
between 1990 and 2015. Results in-

dicated that physical exercise may
benefit cognitive function among
older adults who have MCI, including
improvements in global cognition,
executive function, memory, atten-
tion, and processing speed. Physical
exercise may also positively impact
the physiology of the aging brain.
However, evidence surrounding the
characteristics of effective physical
exercise interventions in terms of ex-
ercise type, intensity, duration, and
frequency remains limited. [Journal
of Psychosocial Nursing and Mental
Health Services, 54(1), 25-35.]
T
he U.S. population of
individuals 65 and older is
expected to increase greatly
in upcoming decades, from 43 to
92 million by 2060 (U.S. Cen-
sus Bureau, 2012). Prevalence of
dementia and other cognitive dis-
orders is predicted to rise substan-
tially. Major population-based stud-
ies reported an average prevalence of
mild cognitive impairment (MCI) of
18.9% (Das et al., 2007; Di Carlo et
al., 2007; Lopez et al., 2003; Palmer,
Bckman, Winblad, & Fratiglioni,
2008; Petersen et al., 2014; Purser,
Fillenbaum, Pieper, & Wallace,
2005). Average incidence rates are
47.9 (range = 21.5 to 71.3) per 1,000
individuals per year (Ward, Arrighi,
Michels, & Cedarbaum, 2012). Older
adults who present with MCI have a
greater risk of developing dementia
(Petersen et al., 2014), with a con-
version rate of 10% to 40% per year
to Alzheimers disease. With a world-
wide aging population, the societal
impact of MCI is rising. No pharma-
cological treatment currently exists
to slow the progression of or reverse
MCI (Petersen et al., 2014). Given
the high prevalence and conversion
rate to dementia, identifying effec-
tive nonpharmacological approaches
to maintain or improve cognition
is urgent to control the epidemic of
dementia. The current article focuses

Yun Cai, AGPCNP-BC, MS; and Kathleen Abrahamson, PhD, RN

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016 25

Aging Matters
on the effect of physical exercise on
cognitive performance.
The definition of exercise is inten-
tional physical activity for improving
health and fitness, based on the
American College of Sports Medicine
position stand (Garber et al., 2011).
Epidemiological studies have proposed
that physical exercise is associated
with various cognitive benefits (Hamer
& Chida, 2009; Kramer et al., 1999).
Physical exercise reduces cognitive
decline associated with aging and may
reduce the risk for MCI and dementia
in older adults who maintain higher
levels of physical activity (Hamer &
Chida, 2009; Kramer et al., 1999).
However, cognitive benefits of physical
exercise among older adults with MCI
are still unclear.
A number of mechanisms exist by
which exercise may impact the aging
brain (Kirk-Sanchez & McGough,
2014). Exercise has a demonstrated
impact on cardiovascular function,
and multiple cardiovascular risk fac-
tors, such as hypertension and circula-
tory health, are associated with risk for
cognitive decline (Grodstein, 2007).
Increased risk for cognitive impair-
ment has also been linked to diabetes,
depression, and high levels of inflam-
matory markersconditions that
may be impacted by level of physical
activity (Nelson et al., 2007). Exercise
may also increase the release of protec-
tive agents, such as neurotrophins, and
impact the nervous system and brain
physiology in ways that promote cog-
nitive performance (Erickson et al.,
2011; Rasmussen et al., 2009; Seifert et
al., 2010; Vaynman & Gomez-Pinilla,
2005).
There is an established body of
literature surrounding the influence
of interventions focused on physical
experience on cognitive function in
older adults with and without cognitive
impairment. The purpose of the cur-
rent article is to systematically describe
what is known regarding the impact of
exercise interventions on community-
dwelling older adults with identified
26
MCI and provide insight regarding
the impact this evidence can have on
nursing and primary care practice.
METHOD
A review of studies published from
1990 to 2015 was conducted. Data-
bases searched included CINAHL,
PubMed, PsycINFO, SportDiscus, and
Cochrane Library. Medical Subject
Headings used in the search included
MCI/cognitive impairment, cognition
disorders, exercise, or physical therapy
modalities. Searches were limited to
English language and human studies
in all databases and clinical trials in
PubMed. In addition, relevant sources
cited in identified publications were
included in the review (ancestry
method). The Preferred Reporting
Items for Systematic Reviews and
Meta-Analyses guidelines provided
a structure for manuscript review
(Moher, Liberati, Tetzlaff, & Alt-
man, 2009). Articles were included
if: (a) participants were community-
dwelling adults 60 or older; (b) par-
ticipants had MCI; (c) experimental
or quasi-experimental studies were
reported; (d) physical exercise or
physical therapy interventions were
described; and (e) cognitive perfor-
mance was directly measured as an
outcome.
The current authors defined MCI
using a combination of four major
definitions from the Mayo Clinic
(Petersen, 2004; Winblad et al.,
2004), National Institute on Aging
Alzheimers Association workgroup
(Albert et al., 2011), and fifth edi-
tion of the Diagnostic and Statistical
Manual of Mental Disorders (Ameri-
can Psychiatric Association, 2013).
Core clinical criteria according to
these definitions include: (a) self- or
informant-reported memory or cogni-
tive complaint; (b) objective memory
or cognitive impairment; (c) essen-
tially preserved general cognitive
functioning; (d) preserved indepen-
dence in functional abilities; and
(e) no dementia diagnosis (Petersen
et al., 2014). Although older adults
are usually defined as those 65 and
older, it is common to find research
articles defining the cutoff as 55 to 60
(Baker et al., 2010; Lam et al., 2012;
Lautenschlager et al., 2008). Thus, the
current authors established age 60 as
the cutoff for the inclusion of studies.
The Table displays the identified
studies designs (i.e., publication year,
country, study design, and sample
[number, background demographic
characteristics]), intervention char-
acteristics (i.e., setting, duration,
delivery mode, theoretical framework,
cognitive measures, and time points),
and key cognitive findings. Studies
were arranged by type of interven-
tions: aerobic exercise, Tai Chi exer-
cise, functional task exercise, resis-
tance training, and multicomponent
physical training.
RESULTS
Search Outcome
The initial computerized search
yielded 387 citations. After screening
abstracts, 19 duplicates and 355 arti-
cles that did not meet inclusion crite-
ria were rejected. Reasons for exclusion
were primarily because participants did
not have MCI or were institutional-
ized, studies were nonexperimental,
studies had nonphysical interventions,
or cognitive performance was not mea-
sured. One additional study was identi-
fied through ancestry searches on pre-
viously published review articles and
all potential primary studies. A total of
13 studies were included in the current
review.
Sample Characteristics
Four of 13 studies were conducted in
the United States, with the remaining
nine conducted in Japan, Hong Kong/
China, Australia, Canada, Brazil, and
Spain. The 13 studies represented a
total of 1,171 participants with mean
ages from 70 to 78. Study samples
ranged from 11 to 389. The range of the
percentage of males was 0% to 63%,
with an average of 38%.
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 TABLE
STUDY CHARACTERISTICS AND FINDINGS BY TYPE OF EXERCISE INTERVENTIONa
Author/Location/
Study Design Sample Characteristics Intervention Measures/Time Points Findings
Aerobic Exercise
Baker et al., 2010/ N = 29 (TX n = 19; VA memory clinic and local YMCA EF by SDMT, verbal Intervention versus control: no
United States/RCT control n = 10) High-intensity aerobic exercise at fluency, Stroop, TMT-B, and significant findings at 3 months
Ages 55 to 85 (average = 70 75% to 85% of HR reserve; 45 to 60 task switching For women, improved
years) minutes/day, 4 days/week Memory by story recall, performance on multiple tests of
48% male Control: stretching activities, list learning, and DMS EF at 6 months
Mean MMSE (25.6 to 28.6); HR 50% Baseline and 3 and 6 For men, a favorable effect
mean DRS Duration = 6 months months only on TMT-B performance
Doi et al., 2013/ N = 16 Setting unclear Changes in oxy-Hb in the During DTW versus NW:
Japan/uncontrolled Age >65 (average = 75 years) DTW and NW sessions: NW-1, prefrontal area higher oxy-Hb values

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016

pretestposttest 63% male DTW-1, NW-2, DTW-2, NW-3, DTW-3; EF by Stroop interference Oxy-Hb in LIFG but not RIFG
MMSE >23; without ADL 60 seconds each Baseline, posttest was significantly correlated with
impairment Duration = one session EF during DTW; no significant
correlation during NW
Lautenschlager et al., N = 170 (TX n = 85; Participants homes Cognition by ADAS-Cog Intervention versus control
2008/Australia/RCT control n = 85) Home-based physical activity Baseline, post- over time: greater improvement
Ages 60 to 77 (average = 69 motivation program, three 50-minute intervention, and 12- and of ADAS-Cog scores
years) sessions/week; workbook, physical 18-month follow up
58% male activity diary, newsletters, and
SMC only, aMCI, or non-aMCI telephone calls
Education and usual care
Duration = 6 months
van Uffelen, N = 152 (TX n = 77; Community centers Cognitive functions by Intervention versus control: no
Chinapaw, van control n = 75) Group-based moderate-intensity AVLT, SCWT-A, DSST, and VFT significant effect of walking on
Mechelen, & Ages 70 to 80 (average = 74 to walking, twice weekly Baseline and 6 and 12 cognition at 6 or 12 months
Hopman-Rock, 2008/ 76 years) Low-intensity placebo activity months
Australia/RCT 56% male program
SMC, MMSE 24, and Duration = 12 months
objective memory impairment
(10 WLT delayed recall 5 and %
savings 100)
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TABLE (CONTINUED)
STUDY CHARACTERISTICS AND FINDINGS BY TYPE OF EXERCISE INTERVENTIONa
Author/Location/
Study Design Sample Characteristics
Varela, Ayan, N = 48 (TX1 n = 17; TX2
Cancela, & Martin, n = 15; control n = 15)
2012/Spain/RCT Age >65 (average = 78
(pilot study) years)
44% male
Clinical diagnosis of MCI;
mean MMSE = 20 to 22
Chang et al., 2011/ N = 11
United States/ Average age = 85
uncontrolled 9% male
pretestposttest MMSE (15 to 27), Digit
(pilot study) Symbol-Coding on the
WAIS-III (6), Digit Span on
the WAIS-III (6), Stroop
Color and Word test (39),
or Hopkins Verbal Learning
Test (39)
With chronic pain;
without depression
Lam et al., 2012/ N = 389 (TX n = 171;
Hong Kong/RCT control n = 218)
Age >65 (average = 77 to
78 years)
24% male
CDR 0.5 or aMCI
Li, Harmer, Liu, & N = 46 (TX n = 22;
Chou, 2014/United control n = 24)
States/non-RCT Age 65 (average = 76
(pilot study) years)
30% male
MMSE = 20 to 25
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Intervention
Residential care homes
TX1: supervised aerobic exercise Baseline and 3- and
(cycling) at 40% of HR reserve;
three 30-minute sessions/week
TX2: same aerobic exercise at
60% of HR reserve
Control: recreational activities
Duration = 3 months
Tai Chi Exercise
Senior centers and residential
complexes
Sun-style 12 from Tai Chi; 20 to
40 minutes/session twice per week
Duration = 15 weeks
Community centers, residential
homes, or participants homes
24 forms simplified Tai Chi; 30
minutes/day, 3 days/week
Control: stretching and toning
exercise
Duration = 12 months
Senior centers
TJQMBB; 60-minute session
twice/week
Control: usual daily physical
activity
Duration = 14 weeks
Measures/Time Points Findings
Cognition by MMSE Interventions versus control: no significant
between-group difference on MMSE at 3- or
Aging Matters
6-month follow up 6-month follow up
Cognitive function by Posttest versus pretest: no significant
the five screening tools, difference in cognition; a significant dose-
and physical and mental response relationship
function by SF-36
Baseline and 15 weeks
Cognitive functions by No change in MMSE scores in both groups
ADAS-Cog, digit span, delay Intervention versus control
recall, CVFT, TMT, and MMSE at 12 months: no significant between-group
Baseline and 5, 9, and difference on any cognition parameters
12 months Intervention versus control at
12 months, completers
only: greater improvement in delayed recall
Global cognitive function Intervention versus control
by MMSE at post-intervention: greater improvement
Baseline, post- on MMSE scores
intervention
 TABLE (CONTINUED)
STUDY CHARACTERISTICS AND FINDINGS BY TYPE OF EXERCISE INTERVENTIONa

Author/Location/
Study Design Sample Characteristics
Tsai, Chang, Beck, N = 55 (TX n = 28;
Kuo, & Keefe, 2013/ control n = 27)
United States/RCT Age >60 (average = 79 years)
(pilot study) 27% male
Ethnicity: 93% Caucasian
MMSE = 18 to 28 and OA
Law, Barnett, Yau, N = 83 (TX n = 43;
& Gray, 2014/Hong control n = 40)
Kong/RCT Age >60 (average = 74 years)
Intervention
Senior centers and residential
complexes
Sun-style Tai Chi classes,
3 sessions/week
Control: health and culture classes
Duration = 20 weeks
Functional Task Exercise
Outpatient clinic
Functional task exercise
Control: active cognitive training
Measures/Time Points Findings
Cognitive functions by Intervention versus control
MMSE post-intervention: no significant
Baseline, every 4 weeks, difference in MMSE (p = 0.096)
and post-intervention
Cognition by NCSE, CVVLT, Intervention versus control
CVFT, TMT-A, and TMT-B post-intervention and
Baseline, post- 6-month follow up: greater

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016

40% male Duration = 10 weeks intervention, and 6-month general cognitive functions,
SMC or suspected CI follow up memory, and EF
Resistance Training
Nagamatsu, Handy, N = 77 (TX1 n = 26; TX2 n = 24; Setting unclear EF by Stroop and TMT TX1 versus control post-
Hsu, Voss, & Liu- control n = 27) TX1: resistance training (stretching, Working memory by intervention: greater improved
Ambrose, 2012/ Age = 70 to 80 (average = 75 range of motion, balance exercise, verbal digits tests performance on the Stroop Test
Canada/RCT years) relaxation techniques); 60 minutes, Associative memory by and associative memory task
0% male twice per week memorizing face-scene pairs TX2 versus control post-
MoCA (<26/30) and SMC TX2: aerobic training (outdoor Everyday problem-solving intervention: no significant effect
walking program); 60 minutes, twice ability by Everyday Problem on cognitive function measures
per week Test
Control: balance and tone training; Baseline, post-
60 minutes, twice per week intervention
Duration = 6 months
Multicomponent Physical Training
Nascimento et N = 45 (TX n = 24; Setting unclear Cognitive functions by Intervention versus control
al., 2015/Brazil/ control n = 21) Multimodal physical training MoCA post-intervention: improved
CT (randomization Age >60 (average = 66 to 69 (muscular resistance, aerobic fitness, Peripheral concentrations cognitive functions, especially
unclear) years) motor coordination/balance) at of BDNF the EF, and significantly
41% male 60% to 80% of max HR; three 1-hour Baseline, post- increased peripheral BDNF level
MCI reported by participants sessions per week intervention
and caregivers; without Control: usual activity
depression Duration = 4 months
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TABLE (CONTINUED)
STUDY CHARACTERISTICS AND FINDINGS BY TYPE OF EXERCISE INTERVENTIONa

Author/Location/
Study Design Sample Characteristics Intervention Measures/Time Points Findings
Suzuki et al., 2013/ N = 50 (TX n = 25; Community center Cognitive functions by Intervention versus control
Aging Matters

Japan/RCT control n = 25) Supervised multicomponent MMSE, WMS-LM, DSC, LVFT over time from baseline
Age 65 to 93 exercise (aerobic exercises, muscle and SCWT to 12 months: greater
(average = 75 years) strength training, postural balance Baseline and 6 and 12 improvements on MMSE, logical
54% male retraining); 90 minutes/day, months memory of immediate recall
aMCI 2 days/week (WMS-LM I), and LVFT
Control: three sessions of
education classes regarding health
but not exercise-specific
Duration = 12 months

Note. RCT = randomized controlled trial; TX = intervention group; MMSE = Mini-Mental State Examination; DRS = Dementia Rating Scale; YMCA = Young Mens Christian Associations;
HR = heart rate; EF = executive function; SDMT = Symbol Digit Modalities Test; TMT-B = Trail Making Test B; DMS = delayed-match-to-sample; ADL = activities of daily living; DTW = dual-task
walking; NW = normal walking; oxy-Hb = oxygenated hemoglobin; LIFG = left inferior frontal gyrus; RIFG = right inferior frontal gyrus; SMC = subjective memory complaints; aMCI = amnestic-
mild cognitive impairment; ADAS-Cog = Change in Alzheimer Disease Assessment Scale-Cognitive Subscale; WLT = word learning test; AVLT = auditory verbal learning test; SCWT-A = Stroop
color word test-abridged; DSST = digit symbol substitution test; VFT = verbal fluency test; WAIS-III = Wechsler Adult Intelligence Scale (3rd ed.); SF-36 = Short Form-36; CDR = clinical dementia
rating; CVFT = category verbal fluency test; TJQMBB = Tai Ji Quan: Moving for Better Balance; OA = osteoarthritis; NCSE = Chinese version of Neurobehavioral Cognitive Status Examination;
CVVLT = Chinese version verbal learning test; TMT-A = Trail Making Test A; MoCA = Montreal Cognitive Assessment; BDNF = brain-derived neurotrophic factor; WMS-LM = Logical Memory
subtest of the Wechsler Memory Scale-Revised; DSC = digit symbol coding; LVFT = letter and categorical verbal fluency test; SCWT = Stroop color word test.
a
Unless otherwise stated, all reported findings are significant at p < 0.05.

of 78.2%.
studies (Table).

activities (Table).
Methodological Attributes

ence, the study also delivered a social

Suzuki et al., 2013). In control groups,
Voss, & Liu-Ambrose, 2012). The

tion (nine of 13 studies), followed by

physical activity, and recreational
and/or toning training, nonexercise-
activity, stretching exercise, balance
porated resistance training, aerobic
et al., 2014). One study used resistance
single-limb movements, simultaneous
exercise (e.g., walking) as the targeted
Five of 13 studies used aerobic
randomized controlled trials (RCTs),

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executive function (seven studies,)
nitive outcome was global cogni-
The most common measured cog-
calls, which comprised information on

time management, barriers to activity,

exercise programs, rewards, goal setting,
a manual, newsletters, and telephone
intervention package via workshop,
cognitive theorybased behavioral
utes per week of moderate-intensity
physical activity. To enhance adher-
ticipants to perform at least 150 min-
program that aimed to encourage par-
nitive training, low-intensity placebo
related health education, active cog-
activities used included usual daily
training) (Nascimento et al., 2014;
exercise, and coordination/balance
ponent physical training (i.e., incor-
remaining two studies used multicom-
training only (Nagamatsu, Handy, Hsu,
body midline crossing exercises) (Law
hand movements, task switching, and
tional task exercises (i.e., incorporated
exercise. One study conducted func-
intervention. Four studies used Tai Chi
two were uncontrolled pretestposttest
two were non-RCTs, and the remaining

(2008) reported a high adherence rate

alized home-based physical activity
2008). The study provided an individu-
nitive theory) (Lautenschlager et al.,
behavior theorybased (i.e., social cog-

and safe exercise. Lautenschlager et al.

Only one of 13 studies was health
Of 13 studies included, nine were

verbal learning and memory (five
studies), and memory (i.e., delay or
immediate recalls) (four studies). Other
cognitive outcomes included attention,
visual attention and task switching,
processing speed, and brain activation
measured by peripheral oxyhemoglobin
or brain-derived neurotrophic factor
(BDNP) level.
Intervention settings included com-
munity settings, participants homes,
or both. Intervention setting was not
clearly described in three studies. Nine
studies (69%) had an intervention
duration of 6 months and ranged from
10 weeks to 6 months; the remaining
four interventions lasted 12 months.
Ten (77%) studies measured cogni-
tive performance immediately post-
intervention, whereas only three
measured follow-up outcomes at 3 or
12 months post-intervention (Table).
Efficacy of Interventions
In general, nine (69%) of 13 studies
reported some positive findings on
cognitive improvement in global cog-
nition, executive function, and/or
memory (Table).
Global Cognition
Nine (69%) of 13 studies exam-
ined the effect of physical exercise
on global cognition using the Mini-
Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975),
Alzheimers Disease Assessment
Scale cognitive subscale (ADAS-
Cog; Rosen, Mohs, & Davis, 1984),
Clinical Dementia Rating Sum of
Boxes (Morris, 1997), Chinese version
of Neurobehavioral Cognitive Status
Examination (NCSE; Man, Chung, &
Mak, 2009), and Montreal Cognitive
Assessment (MoCA; Nasreddine et al.,
2005) (Table).
A positive effect was observed in five
(56%) of these nine studies (Table).
The study by Li, Harmer, Liu, and Chou
(2014) was a pilot RCT on the effect of
a 14-week Tai Chi Quan: Moving for
Better Balance program on global cog-
nitive function, with a total sample of
Journal of Psychosocial Nursing Vol. 54, No. 1, 2016
44 older adults. An Australian study
randomized 170 participants with
MCI for either a 6-month home-based
physical activity motivation program
(50-minute sessions, three times per
week) or an education group. At the
end of the intervention, the exer-
cise group showed an improvement
of 0.26 points on the ADAS-Cog,
whereas the control group showed a
decrease of 1.04 points (Lautenschlager
et al., 2008). Another RCT in Hong
Kong/China studied the effect of a
10-week functional task exercise pro-
gram on cognition as compared to an
active control group (existing cognitive
training) (Law, Barnett, Yau, & Gray,
2014). The program comprised 13 ses-
sions of 30-minute simulated functional
task exercises. After the intervention,
participants showed an improvement
on global cognitive function measured
by the NCSE. Suzuki et al. (2013)
examined the effects of a 12-month
multicomponent exercise program
(90 minutes per day, 2 days per week;
aerobic exercise, strength training, bal-
ance, and dual tasking) in Japan. After
the intervention, participants showed
an improvement on the MMSE but not
on the ADAS-Cog. A recent non-RCT
reported positive results for a 4-month
multimodal physical training program
(muscular resistance, aerobic fitness,
and motor coordination/balance) on
general cognitive function (especially
executive function) measured by the
MoCA (Nascimento et al., 2014).
In contrast, the remaining four studies
did not yield significant improvements
on global cognitive function post-
intervention. A RCT with a large sample
(N = 389) conducted in Hong Kong/
China did not show improvements
on the MMSE or ADAS-Cog after a
12-month Tai Chi exercise program (at
least 30 minutes per day, 3 days per week)
(Lam et al., 2012). Two other RCTs were
pilot studies with samples of 55 (Tsai,
Chang, Beck, Kuo, & Keefe, 2013) and
48 (Varela, Ayan, Cancela, & Martin,
2012). Tsai et al. (2013) led 20-week
sun-style Tai Chi classes (three sessions
Aging Matters
per week) in the intervention group
and controlled with health and culture
classes. Varela et al. (2012) conducted
a supervised aerobic exercise program
(low- and moderate-intensity cycling) for
3 months. The remaining study was an
uncontrolled pretestposttest study with
a sample of only 11 older adults involved
in a 15-week sun-style Tai Chi program
(20 to 40 minutes per session, two times
per week) (Chang et al., 2011).
Executive Function, Memory, Attention,
and Other Cognitive Domains
Seven (54%) of 13 studies evaluated
the effects of exercise on executive
function. Four (57%) of these seven
studies found modest positive effects.
Commonly used assessment tools
included the verbal fluency test (Troyer,
Moscovitch, & Winocur, 1997), Stroop
Color and Word Test (Stroop, 1992),
and Trail Making Tests A and/or B
(TMT; Reitan, 1958). Seven (54%)
of 13 studies tested the effects of exer-
cise on memory, which was measured
by story recall, list learning, delayed
match-to-sample, Hopkins verbal
learning test, auditory verbal learning
test, and digit span test. Four (57%)
of these seven studies demonstrated
efficacy (Table).
In a RCT, Baker et al. (2010)
examined the effect of a 6-month high-
intensity aerobic exercise on executive
function and memory (45 to 60 min-
utes, four times per week). Favorable
effects of physical exercise were found
in all executive function measures
(i.e., verbal fluency, TMT-B, and task
switching) among female participants
at the end of the intervention, whereas
for males, there was a favorable effect
only on TMT-B performance. No
improvement on memory was found.
In contrast, another RCT reported
positive findings on memory (delayed
recall) and negative findings on execu-
tive function at the end of a 12-month
Tai Chi program (Lam et al., 2012).
Three other RCTs reported con-
sistent negative findings on executive
function and memory for a 12-month
31
Aging Matters
multicomponent exercise program
(Suzuki et al., 2013), 10-week func-
tional task exercise program (Law et
al., 2014), and 6-month resistance
training program (Nagamatsu et al.,
2012) post-intervention. The details of
the studies by Suzuki et al. (2013) and
Law et al. (2014) are discussed above.
Nagamatsu et al. (2012) conducted a
RCT in Canada comparing the effects
of resistance and aerobic training inter-
ventions with an active control group
(balance and tone training), with the
same training doses (60 minutes per
session, twice per week). They found
that, as compared to the control group,
Stroop test and associative memory
task performance improved in the resis-
tance training group post-intervention,
but not in the aerobic training group.
Physical exercise may benefit older adults with mild
cognitive impairment, including improvement in...
global cognition, executive function, memory,
attention, and processing speed.
Two pretestposttest studies with
small samples did not yield improve-
ments in executive function or
memory performance (Chang et al.,
2011; Doi et al., 2013). The study by
Chang et al. (2011) is discussed above.
Doi et al. (2013) provided a walking
intervention in Japan with alternated
normal walking and dual-tasking
walking (i.e., walking while per-
forming a verbal letter fluency task).
Changes in oxyhemoglobin levels
were recorded while participants per-
formed the normal walking and dual-
tasking walking tests. The authors
found that oxyhemoglobin levels were
higher during dual-tasking walking
than normal walking, and the level in
the left inferior frontal gyrus was sig-
nificantly correlated with executive
function during dual-tasking walking
but not during normal walking.
Another objective measurement was
the peripheral BDNF measured in the
32
study by Nascimento et al. (2014).
Significant increases in the peripheral
concentration of BDNP and cogni-
tive functions were observed after
the 16-week period of multimodal
physical training, whereas no signifi-
cant changes were observed in the
control group. In another RCT, van
Uffelen, Chinapaw, van Mechelen,
and Hopman-Rock (2008) tested the
efficacy of a 12-month group-based,
moderate-intensity walking program
as compared to a low-intensity placebo
activity program among 152 older
adults. The authors did not find
intervention effects on immediate and
delayed recall and executive function
post-intervention.
Attention and processing speed were
less commonly measured in included
studies. Two studies (one pretestposttest
and one RCT) reported negative find-
ings on attention after a 15-week Tai
Chi program (Chang et al., 2011) and
a 12-month moderate-intensity walk-
ing program (van Uffelen et al., 2008).
Similarly, three studies that measured
processing speed did not yield efficacy
(Chang et al., 2011; Suzuki et al., 2013;
van Uffelen et al., 2008).
DISCUSSION
Physical exercise programs in the
current review comprised several
different types of exercise, including
aerobic exercise, resistance training,
functional task exercise, multicom-
ponent exercise, and a mindbody
exercise (i.e., Tai Chi) that was also
considered a multicomponent exer-
cise (Li et al., 2014). Results indicated
that physical exercise may benefit
older adults with MCI, including im-
provement in the areas of global cog-
nition, executive function, memory,
attention, and processing speed. The
current findings of improved global
cognition and executive function
after aerobic exercise interventions
are consistent with previous review
articles (Cooper, Li, Lyketsos, & Liv-
ingston, 2013; Hahn & Andel, 2011;
Langa & Levine, 2014; Teixeira et al.,
2012). The current article adds new
evidence that other types of exercise
(i.e., resistance training, functional
task exercise, and multicomponent
exercise) may have positive effects not
only on global cognition and execu-
tive function, but also on memory and
brain activation. However, currently,
specific evidence to direct primary
care practitioners toward recommend-
ing an exercise type, intensity, dura-
tion, and frequency to impact cogni-
tive function is limited.
In many studies, exercise inten-
sity was high (up to moderate in-
tensity), but training session atten-
dance or participants acceptance of
the exercise intervention was rarely
described. Duration of the interven-
tions was relatively short, from 10
weeks to 6 months. Participants
adherence to exercise after the in-
tervention period and maintenance
of positive effects on cognition were
not examined in the included stud-
ies, and could be a significant issue
when implementing these interven-
tions in community settings. Many
cognitive tests were used to measure
cognitive outcomes. Tests measur-
ing global cognitive function, ex-
ecutive function, and memory were
most commonly used. Recent studies
have started examining the effects of
physical exercise on specific cogni-
tive domains in addition to general
cognitive function. More research
is needed to measure the impact of
community-based exercise interven-
tions using tools that are accessible
to the primary care nurse or physi-
cian, and targeting the aspects of
cognition that are most meaningful
to older adults with MCI.
Copyright SLACK Incorporated

LIMITATIONS
Findings in the current review
should be interpreted in the context of
several limitations. First, the rigor of
the included studies varied. Given the
limited amount of research targeting
community-dwelling older adults with
MCI, the search was not limited to
only RCTs. Instead, non-RCTs and
pretestposttest studies were included
to achieve a broader view. For exam-
ple, Chang et al.s (2011) study found a
trend of positive effect of Tai Chi exer-
cise on global cognition, cognitive pro-
cessing speed, and memory. However,
the small-scale, pretestposttest study
might not have had enough power to
detect the effect of Tai Chi on cogni-
tive function, especially specific cog-
nitive domains. Second, participants
ages and health conditions may affect
study results. For example, participants
in Chang et al.s (2011) study were of
old age (average = 85 years) and had
a chronic pain condition. These facts
may interfere with the compliance of
exercise intervention and detection of
cognitive changes post-intervention.
Similar issues were found in another
small-scale RCT with a comparable
study design (Tsai et al., 2013). In ad-
dition, gender-specific intervention
effect was analyzed in only one (19%)
study (Baker et al., 2010). Relatively
small samples in most studies limited
their ability to analyze the gender dif-
ference of intervention effects on cog-
nitive function.
Third, median adherence (<75%) to
exercise programs was reported in most
studies. For example, van Uffelen et al.
(2008) reported a 63% adherence rate
among 152 participants in a 12-month
walking program. In addition, the ad-
herence rate of female participants
was as low as 45% in comparison to
75% for males. Overall, 20% of par-
ticipants did not attend any interven-
tion session, but were still included in
final analyses of intervention effects.
An additional analysis including com-
pleters may only be helpful to present
more accurate results. Intervention
Journal of Psychosocial Nursing Vol. 54, No. 1, 2016
fidelity control was described in only
two studies (Li et al., 2014; Tsai et al.,
2013). For example, Li et al. (2014)
stated that the intervention teaching
protocol was monitored by the first
author per criteria described in the
article. Fourth, inclusion criteria of
MCI participants were inconsistent.
As discussed previously, MCI is a con-
cept in evolution. Some studies found
that participants were not diagnosed
correctly at baseline when they might
have dementia already, which might
have blurred the effects of the physical
exercise intervention on cognitive
changes. Many studies also did not
report participants baseline physical
activity levels. For example, some
studies found that most participants
experienced moderate-intensity exer-
cise at baseline, which may result in
less sensitivity to an exercise interven-
tion of a similar intensity (van Uffelen
et al., 2008; Varela et al., 2012).
In the current review, only one
intervention was guided by health
behavior theoretical frameworks to
encourage participant adherence to
an exercise program. Recent meta-
analyses show that interventions
strongly guided by health behavior
theory significantly impact physi-
cal activity outcomes of participants
(Gourlan et al., 2014; Young, Plot-
nikoff, Collins, Callister, & Morgan,
2014). For example, when examining
social cognitive theorybased physical
activity interventions, this health be-
havior theory explained 31% of vari-
ance in physical activity (Young et al.,
2014). However, mechanisms that ex-
plain these larger effects are not clear
(Gourlan et al., 2014; Young et al.,
2014). Theory-based strategies may
be developed with greater care, fidel-
ity, and structure. In the implementa-
tion of exercise interventions among
older adults, motivational/supportive
contacts guided by health behavior
theories may increase participants ad-
herence to exercise programs.
The mixed findings of these studies
indicate more primary research is
Aging Matters
needed. To further understand the
effect of physical exercise on cogni-
tive function, RCTs with large sam-
ples are needed. Physical exercise
interventions guided by health be-
havior theories may be helpful in im-
proving adherence during or after in-
terventions. Future large studies may
include gender as a predictor variable
to better understand sex differences
on intervention effects. Intervention
durations of >6 months with follow-
up data are needed to explore long-
term effects of exercise interventions
on cognitive function and mainte-
nance of positive effects over time.
IMPLICATIONS FOR NURSES
Nurses are the largest segment of
the health care workforce and, despite
the potential that nursing care may
have on impacting the outcomes of
exercise-focused interventions, nurses
were involved in only one of 13 studies.
Public health and community health
and home care nurses are well suited
to provide exercise interventions to
community-dwelling older adults
because they (a) see patients in their
natural environment and can involve
families and community members in
the intervention; (b) have education
that has emphasized the need to estab-
lish a trustful relationship with patients
and provide individualized exercise
plans; and (c) have ongoing contact
with patients over an extended period
of time, which may help motivate
patients to better adhere to interven-
tions. Thus, evidence encouraging the
use of exercise interventions with the
MCI population could potentially ben-
efit from research specifically aimed at
nursing practice.
CONCLUSION
The causal effect of physical exer-
cise interventions on cognitive perfor-
mance in community-dwelling older
adults is unclear due to insufficient
evidence. It remains unclear which
intervention characteristics are more
effective in terms of exercise type,
33
Aging Matters
intensity, and duration. Future rig-
orously designed, large intervention
studies with longer durations are
needed to explore the effect of physi-
cal exercise programs on cognitive
performance in older adults with MCI.
Theory-based interventions with
sex difference and follow-up data are
preferred. Moreover, clearly reported
intervention design, participants
baseline activity level, compliance,
acceptance, and intervention fidelity
control should be encouraged to fa-
cilitate appropriate interpretation of
future studies.
REFERENCES
Albert, M.S., DeKosky, S.T., Dickson, D., Dubois,
B., Feldman, H.H., Fox, N.C.,...Phelps,
C.H. (2011). The diagnosis of mild cogni-
tive impairment due to Alzheimers disease:
Recommendations from the National In-
stitute on AgingAlzheimers Association
workgroups on diagnostic guidelines for
Alzheimers disease. Alzheimers & Dementia,
7, 270-279. doi:10.1016/j.jalz.2011.03.008
American Psychiatric Association. (2013). Diag-
nostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Baker, L.D., Frank, L.L., Foster-Schubert, K.,
Green, P.S., Wilkinson, C.W., McTiernan,
A.,Craft, S. (2010). Aerobic exercise
improves cognition for older adults with glu-
cose intolerance, a risk factor for Alzheimers
disease. Journal of Alzheimers Disease, 22, 569-
579. doi:10.3233/jad-2010-100768
Chang, J.Y., Tsai, P.F., Beck, C., Hagen, J.L., Huff,
D.C., Anand, K.J.,Beuscher, L. (2011).
The effect of tai chi on cognition in elders
with cognitive impairment. Medsurg Nursing,
20, 63-70.
Cooper, C., Li, R., Lyketsos, C., & Livingston,
G. (2013). Treatment for mild cognitive
impairment: Systematic review. British Journal
of Psychiatry, 203, 255-264. doi:10.1192/bjp.
bp.113.127811
Das, S.K., Bose, P., Biswas, A., Dutt, A.,
Banerjee, T.K., Hazra, A.M.,Roy, T.
(2007). An epidemiologic study of mild
cognitive impairment in Kolkata, India.
Neurology, 68, 2019-2026. doi:10.1212/01.
wnl.0000264424.76759.e6
Di Carlo, A., Lamassa, M., Baldereschi, M.,
Inzitari, M., Scafato, E., Farchi, G., &
Inzitari, D. (2007). CIND and MCI in
the Italian elderly: Frequency, vascular
risk factors, progression to dementia. Neu-
rology, 68, 1909-1916. doi:10.1212/01.
wnl.0000263132.99055.0d
Doi, T., Makizako, H., Shimada, H., Park, H.,
34
Tsutsumimoto, K., Uemura, K., & Suzuki,
T. (2013). Brain activation during dual-task
walking and executive function among older
adults with mild cognitive impairment: A
fNIRS study. Aging Clinical and Experimental
Research, 25, 539-544. doi:10.1007/s40520-
013-0119-5
Erickson, K.I., Voss, M.W., Prakash, R.S., Basak,
C., Szabo, A., Chaddock, L.,Kramer, A.F.
(2011). Exercise training increases size of
hippocampus and improves memory. Proceed-
ings of the National Academy of Sciences of the
United States of America, 108, 3017-3022.
doi:10.1073/pnas.1015950108
Folstein, M.F., Folstein, S.E., & McHugh, P.R.
(1975). Mini-mental state. A practical
method for grading the cognitive state of
patients for the clinician. Journal of Psychiatric
Research, 12, 189-198.
Garber, C.E., Blissmer, B., Deschenes, M.R.,
Franklin, B.A., Lamonte, M.J., Lee, I.M.,
Swain, D.P. (2011). American College of
Sports Medicine position stand. Quantity
and quality of exercise for developing and
maintaining cardiorespiratory, musculoskel-
etal, and neuromotor fitness in apparently
healthy adults: Guidance for prescribing
exercise. Medicine and Science in Sports
and Exercise, 43, 1334-1359. doi:10.1249/
MSS.0b013e318213fefb
Gourlan, M., Bernard, P., Bortholon, C., Romain,
A., Lareyre, O., Carayol, M.,Boich, J.
(2014). Efficacy of theory-based interven-
tions to promote physical activity. A meta-
analysis of randomised controlled trials.
Health Psychology Review, 1-74. doi:10.1080/
17437199.2014.981777
Grodstein, F. (2007). Cardiovascular risk fac-
tors and cognitive function. Alzheimers
& Dementia, 3, S16-S22. doi:10.1016/j.
jalz.2007.01.001
Hahn, E.A., & Andel, R. (2011). Nonpharma-
cological therapies for behavioral and cogni-
tive symptoms of mild cognitive impairment.
Journal of Aging and Health, 23, 1223-1245.
doi:10.1177/0898264311422745
Hamer, M., & Chida, Y. (2009). Physical activity
and risk of neurodegenerative disease: A
systematic review of prospective evidence.
Psychological Medicine, 39, 3-11. doi:10.1017/
s0033291708003681
Kirk-Sanchez, N.J., & McGough, E.L. (2014).
Physical exercise and cognitive performance
in the elderly: Current perspectives. Clinical
Interventions in Aging, 9, 51-62. doi:10.2147/
cia.s39506
Kramer, A.F., Hahn, S., Cohen, N.J., Banich,
M.T., McAuley, E., Harrison, C.R.,
Colcombe, A. (1999). Ageing, fitness and
neurocognitive function. Nature, 400, 418-
419. doi:10.1038/22682
Lam, L.C., Chau, R.C., Wong, B.M., Fung, A.W.,
Tam, C.W., Leung, G.T.,Chan, W.M.
(2012). A 1-year randomized controlled trial
comparing mind body exercise (Tai Chi)
with stretching and toning exercise on cogni-
tive function in older Chinese adults at risk
of cognitive decline. Journal of the American
Medical Directors Association, 13, 568.e515-
e520. doi:10.1016/j.jamda.2012.03.008
Langa, K.M., & Levine, D.A. (2014). The
diagnosis and management of mild cogni-
tive impairment: A clinical review. Journal of
the American Medical Association, 312, 2551-
2561. doi:10.1001/jama.2014.13806
Lautenschlager, N.T., Cox, K.L., Flicker, L.,
Foster, J.K., van Bockxmeer, F.M., Xiao, J.,
Almeida, O.P. (2008). Effect of physical
activity on cognitive function in older adults
at risk for Alzheimer disease: A randomized
trial. Journal of the American Medical Associa-
tion, 300, 1027-1037.
Law, L.L., Barnett, F., Yau, M.K., & Gray, M.A.
(2014). Effects of functional tasks exercise
on older adults with cognitive impairment
at risk of Alzheimers disease: A randomised
controlled trial. Age and Ageing, 43, 813-820.
doi:10.1093/ageing/afu055
Li, F., Harmer, P., Liu, Y., & Chou, L.S. (2014).
Tai Ji Quan and global cognitive func-
tion in older adults with cognitive impair-
ment: A pilot study. Archives of Gerontology
and Geriatrics, 58, 434-439. doi:10.1016/j.
archger.2013.12.003
Lopez, O.L., Jagust, W.J., DeKosky, S.T., Becker,
J.T., Fitzpatrick, A., Dulberg, C.,Kuller,
L.H. (2003). Prevalence and classification
of mild cognitive impairment in the Car-
diovascular Health Study Cognition Study:
Part 1. Archives of Neurology, 60, 1385-1389.
doi:10.1001/archneur.60.10.1385
Man, D.W., Chung, J.C., & Mak, M.K. (2009).
Development and validation of the Online
Rivermead Behavioral Memory Test
(OL-RBMT) for people with stroke. Neuro-
Rehabilitation, 24, 231-236. doi:10.3233/nre-
2009-0473
Moher, D., Liberati, A., Tetzlaff, J., & Altman,
D.G. (2009). Preferred reporting items for
systematic reviews and meta-analyses: The
PRISMA statement. British Medical Journal,
339, b2535. doi:10.1136/bmj.b2535
Morris, J.C. (1997). Clinical dementia rating:
A reliable and valid diagnostic and staging
measure for dementia of the Alzheimer type.
International Psychogeriatrics, 9(Suppl. 1),
173-176.
Nagamatsu, L.S., Handy, T.C., Hsu, C.L., Voss,
M., & Liu-Ambrose, T. (2012). Resistance
training promotes cognitive and func-
tional brain plasticity in seniors with prob-
able mild cognitive impairment. Archives of
Internal Medicine, 172, 666-668. doi:10.1001/
archinternmed.2012.379
Nascimento, C.M., Pereira, J.R., de Andrade,
L.P., Garuffi, M., Talib, L.L., Forlenza,
O.V.,Stella, F. (2014). Physical exercise
in MCI elderly promotes reduction of pro-
Copyright SLACK Incorporated

inflammatory cytokines and improvements
on cognition and BDNF peripheral levels.
Current Alzheimer Research, 11, 799-805.
Nasreddine, Z.S., Phillips, N.A., Bedirian, V.,
Charbonneau, S., Whitehead, V., Collin, I.,...
Chertkow, H. (2005). The Montreal Cogni-
tive Assessment, MoCA: A brief screening
tool for mild cognitive impairment. Journal of
the American Geriatrics Society, 53, 695-699.
doi:10.1111/j.1532-5415.2005.53221.x
Nelson, M.E., Rejeski, W.J., Blair, S.N., Duncan,
P.W., Judge, J.O., King, A.C.,Castaneda-
Sceppa, C. (2007). Physical activity and
public health in older adults: Recom-
mendation from the American College of
Sports Medicine and the American Heart
Association. Circulation, 116, 1094-1105.
doi:10.1161/circulationaha.107.185650
Palmer, K., Bckman, L., Winblad, B., &
Fratiglioni, L. (2008). Mild cognitive
impairment in the general population:
Occurrence and progression to Alzheimer
disease. American Journal of Geriatric
Psychiatry, 16, 603-611. doi:10.1097/
JGP.0b013e3181753a64
Petersen, R.C. (2004). Mild cognitive impair-
ment as a diagnostic entity. Journal of Internal
Medicine, 256, 183-194. doi:10.1111/j.1365-
2796.2004.01388.x
Petersen, R.C., Caracciolo, B., Brayne, C.,
Gauthier, S., Jelic, V., & Fratiglioni, L.
(2014). Mild cognitive impairment: A con-
cept in evolution. Journal of Internal Medicine,
275, 214-228. doi:10.1111/joim.12190
Purser, J.L., Fillenbaum, G.G., Pieper, C.F., &
Wallace, R.B. (2005). Mild cognitive impair-
ment and 10-year trajectories of disability in
the Iowa Established Populations for Epide-
miologic Studies of the Elderly cohort. Journal
of the American Geriatrics Society, 53, 1966-
1972. doi:10.1111/j.1532-5415.2005.53566.x
Rasmussen, P., Brassard, P., Adser, H., Pedersen,
M.V., Leick, L., Hart, E.,Pilegaard, H.
(2009). Evidence for a release of brain-derived
neurotrophic factor from the brain during
exercise. Experimental Physiology, 94, 1062-
1069. doi:10.1113/expphysiol.2009.048512
Reitan, R.M. (1958). Validity of the Trail Mak-
ing Test as an indicator of organic brain dam-
Journal of Psychosocial Nursing Vol. 54, No. 1, 2016
age. Perceptual and Motor Skills, 8, 271-276.
doi:10.2466/pms.8.7.271-276
Rosen, W.G., Mohs, R.C., & Davis, K.L. (1984).
A new rating scale for Alzheimers disease.
American Journal of Psychiatry, 141, 1356-
1364.
Seifert, T., Brassard, P., Wissenberg, M.,
Rasmussen, P., Nordby, P., Stallknecht, B.,
Secher, N.H. (2010). Endurance training
enhances BDNF release from the human
brain. American Journal of Physiology, 298,
R372-R377. doi:10.1152/ajpregu.00525.2009
Stroop, J.R. (1992). Studies of interfer-
ence in serial verbal reactions. Journal of
Experimental Psychology: General, 121, 15-23.
doi:10.1037/0096-3445.121.1.15
Suzuki, T., Shimada, H., Makizako, H., Doi, T.,
Yoshida, D., Ito, K.,Kato, T. (2013). A
randomized controlled trial of multicompo-
nent exercise in older adults with mild cog-
nitive impairment. PLoS One, 8, e61483.
doi:10.1371/journal.pone.0061483
Teixeira, C.V.L., Gobbi, L.T.B., Corazza, D.I.,
Stella, F., Costa, J.L.R., & Gobbi, S. (2012).
Non-pharmacological interventions on cog-
nitive functions in older people with mild
cognitive impairment (MCI). Archives of
Gerontology and Geriatrics, 54, 175-180.
Troyer, A.K., Moscovitch, M., & Winocur, G.
(1997). Clustering and switching as two
components of verbal fluency: Evidence from
younger and older healthy adults. Neuropsy-
chology, 11, 138-146.
Tsai, P.F., Chang, J.Y., Beck, C., Kuo, Y.F., &
Keefe, F.J. (2013). A pilot cluster-randomized
trial of a 20-week Tai Chi program in elders
with cognitive impairment and osteoarthritic
knee: Effects on pain and other health
outcomes. Journal of Pain and Symptom
Management, 45, 660-669. doi:10.1016/j.
jpainsymman.2012.04.009
U.S. Census Bureau. (2012). U.S. Census
Bureau projections show a slower growing,
older, more diverse nation a half century from
now. Retrieved from http://www.census.
gov/newsroom/releases/archives/population/
cb12-243.html
van Uffelen, J.G.Z., Chinapaw, M.J.M., van
Mechelen, W., & Hopman-Rock, M. (2008).
Aging Matters
Walking or vitamin B for cognition in older
adults with mild cognitive impairment? A
randomised controlled trial. British Journal
of Sports Medicine, 42, 344-351. doi:10.1136/
bjsm.2007.044735
Varela, S., Ayan, C., Cancela, J.M., & Martin, V.
(2012). Effects of two different intensities of
aerobic exercise on elderly people with mild
cognitive impairment: A randomized pilot
study. Clinical Rehabilitation, 26, 442-450.
doi:10.1177/0269215511425835
Vaynman, S., & Gomez-Pinilla, F. (2005).
License to run: Exercise impacts functional
plasticity in the intact and injured central
nervous system by using neurotrophins. Neu-
rorehabilitation and Neural Repair, 19, 283-295.
doi:10.1177/1545968305280753
Ward, A., Arrighi, H.M., Michels, S., &
Cedarbaum, J.M. (2012). Mild cognitive
impairment: Disparity of incidence and prev-
alence estimates. Alzheimers & Dementia, 8,
14-21. doi:10.1016/j.jalz.2011.01.002
Winblad, B., Palmer, K., Kivipelto, M., Jelic, V.,
Fratiglioni, L., Wahlund, L.O.,...Petersen,
R.C. (2004). Mild cognitive impairment
beyond controversies, towards a consensus:
Report of the International Working Group
on Mild Cognitive Impairment. Journal of
Internal Medicine, 256, 240-246. doi:10.1111/
j.1365-2796.2004.01380.x
Young, M.D., Plotnikoff, R.C., Collins, C.E.,
Callister, R., & Morgan, P.J. (2014). Social
cognitive theory and physical activity: A
systematic review and meta-analysis. Obesity
Reviews, 15, 983-995. doi:10.1111/obr.12225
Ms. Cai is DNP Student, and Dr. Abrahamson
is Assistant Professor, School of Nursing, Purdue
University, West Lafayette, Indiana.
The authors have disclosed no potential
conflicts of interest, financial or otherwise.
Address correspondence to Kathleen
Abrahamson, PhD, RN, Assistant Professor,
School of Nursing, Purdue University, 502 North
University Street, West Lafayette, IN 47907; e-mail:
kaabraha@purdue.edu.
Received: August 1, 2015
Accepted: October 13, 2015
doi:10.3928/02793695-20151109-03
35