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Current Aging Science, 2023, 16, 65-74 65
RESEARCH ARTICLE

Otago Exercise Program Plus Cognitive Dual-task can Reduce Fall Risk,
Improve Cognition and Functioning inhOlder ere Adults
w
l y a ny
e on Lopes or Machado3,4, Pedroe Pugliesi Abdalla3,4, Claúdia
Paula Clara Santos1,2,3,*, Dalmo Roberto s e er Mota3 and Cristina Mesquita1,2
Vanessa Santos5, Sofia Lopeste 1,2,6u, Anabela
y on Correia Martins7, hJorge
i va to a
n
y n yw
r
p d l
n or a
a l e o
1
s on loadSchool
Department of Physiotherapy, u
of Health, sePolytechnic
o ne of Porto, Portugal,heAntónio re Bernardino de Almeida, 400,
r y
peAlmeida, up400, 4200 atePorto,for nRehabilitation Research, w
2
4200 – 072, Porto,
Bernardinor de r
Portugal; CIR - Center
i v o a y n y ESS/PPorto, Portugal, Rua Dr. António

Fo- Faculty oof Sport, University r of Porto t l Laboratory a

3
- 072, Portugal; Research Center in Physical Activity, Health and Leisure
d p n r
(CIAFEL)
u teHealth (ITR), Porto, n al Portugal,d ed Rua Dr. Plácido
(FADEUP)
e
s on
o and
e o91, 4200-450 Porto, Portugal;
for Integrative
re
and Translational Research
ib Preto, University o of São aPaulo, Avenidaudos
4
in Population
t r r s l o y
Costa,
h e School of Nursing

d is Pratice, Portugal;
of Ribeirão
p e 6Departmentu p a te and a nBandeirantes, 3900,
w
14040-902,
y
Ribeirão Preto-SP, Brazil;

or ofdHealth or Sciences (IPSN), riv CESPU, ly rAvenida n Central de Gandra, 1317/4585-

5

b ePolytechnic Institute
Clinical
F
of
p
Diagnostic
t o Gandra, Portugal.
Therapeutic
n
Technologies,
a
School of Health Vale do Sousa,
t 116 Gandra PRD/Portugal;
No Rua u te 7
n al Coimbrad ed Health School s e oPolytechnic
e o of Coimbra, (ESTeSC-IPC),
re
t r a
ib- S. Martinho rdosoBispo,loP.O. Box 7006 3040-854,
LabinSaúde,
u o n h e
Portugal.
y
is pe r up ate an
5 de Outubro Coimbra
w
e d
o r o r i v t o l y a ny
o tb F ed
t a l p ed e on or
N
r i b u Abstract: Background:
s o o
d
n aThe risk of falling u sincreaseso n ewith neuromusculoskeletaleand re cognitive
ist r from l aging. Physical e h
y beneficial effects on thewrisk of falling, but
peare unknown up when associated texercise nshows
changes resulting
d r r i v a a y ny
b e o
the results
o
F edThe objective ofathe p r o
with cognitive
t l a
activity dual-task (DT).
n
t l studyewas d to evaluate the oimpacts oforthe Otago Exercise Program
No u t n d sineolderoadults.
ne ere
Objective:
i b o activitya u
t r
(OEP) plus DT cognitive
r s lo on the risk of falling
p ± 5.7 years) participated e y h
ARTICLE HISTORY
e dis Methods: 36rolder peadultsr u(83.5
o r i v at anin a quasi-experimental
o l y n ywdistributed
Fo ed groups and aa lcontrol r a2) OEP plus DT
study,

o tb in two experimental
(OEPDTG; nu=t12),
p group:
e d t Older 1) OEP (OEPG;
o n n=12), o
N
Received: March 07, 2022
12 weeksriof b
and a controlngroup (CG;
intervention. Theso o a d the risk of falling
n=12).
u sewere oconsidered
adults were
n e asatmultiparameter
evaluated pre- and post-
e re
t r l y h
Revised: May 31, 2022

up(10MWT), evocative ate(Four-Stage),

thresholds for
scoresisof the 10 Meter Walking peThe Four-Stage n Timed Up and Go (TUG), ywSit
Accepted: June 01, 2022

e d r rTest
i v a
10MWT,
o y n
DOI:

o t b Assessment (MoCA),
to Stand Test (STS),
Fo to etestdtheo cognitive impairment.
and Balance
a
r
l p ed t
Test and
o nl or a
the Montreal Cognitive
t sethe oexperimental re
N ibuall groups were n ad ne
10.2174/1874609815666220827143753

t r rs ohomogeneous.
lo u h e
is functional pdifferences, e upin comparison to atheteCG, for y
an10MWT (OEPDTG: p= yw
Results: At baseline, Post-intervention, groups
d r r10MWT (OEPDTG: v p=0.001;
e p= 0.002); i o y an
presented significant
0.002;bOEPG: F o d o p r t n l r
t evocative
l d OEPG:
o
p=0.001);
o
TUG
o
N(OEPDTG:
(OEPDTG: p=0.034); STS (OEPDTG:
b uteintra-group p<0.001; aOEPG: p<0.001)
o n a(pre-post) de wereandobserved s e in allfor
cognitive
n einterven-
MoCA
p<0.019). Significant
tion groups, but noneiin s
i
r The risk of efalling
tCG. rs (Four-Stage)
differences
p lo in experimental t e u
n y o(OEPDTG:
w he
e d was considerably r plowerothan r uCG (83.3%). riva to a ny
groups
33.3%; OEPG: 41.7%)
b F edo p n l y a
otOtago Exercise Program t can reduce thenarisk l of fallinged due to improved e ofunc- or
Conclusion: N u
ib improves cognitive
alone
o a d u s n e
tionality, but adding the dual tasktr rs l o o
isgoes beyond statistics. pe r up te any
also capacity in older adults. The clinical sig-
d r v a
pri d to
nificance of these interventions

t be F o do
e l
Keywords: Physical exercise, double task, cognitive, No elderly, aging, physical i b ut activity. ona ade
i s t r e rs plo
*Address correspondence to this author at the Department of Physiotherapy,eSchool d of Health, Polytechnic
o
p
r ofoPorto, r u Portugal. António Bernardino de Almeida,
tb F ed
No ut
400, 4200 - 072, Porto, Portugal; E-mail: paulaclara@ess.ipp.pt

r i b
d ist
e
1874-6098/23 $65.00+.00 o
t b© 2023 Bentham Science Publishers
N
 66 Current Aging Science, 2023, Vol. 16, No. 1 Santos et al.

1. INTRODUCTION components are related to gait and balance and, of course, to

the risk of falling [47-50]. Motor performance in functional
Falling is the third leading cause of death resulting from
tests reduces the chances of falling when at adequate levels
unintentional injury [1]. In older adults, it represents the
[51].
main cause of fatal and non-fatal injuries [2, 3]. Even when no
eretraining have not shown improvement concerning the
injuries occur, falling advances functional decline, psycholog- However, some studies that combine physical and cogni-
ical stress, and loss of independence [4]. In 2015, direct medi-
w htive
y risk of falling [52, 53], even in older people with mild cog-
ly r an nitive impairment [54, 55], but with improvement after
cal costs for fall-derived injuries were estimated to be more
n
e o ne o
than $50 billion in the United States [5]. From the age of 70
s
years, for every decade, the rate of occurrence of falls doubles e [59]. Anyways, there are no comparative
stroke [56, 57], for multiple sclerosis patients [58], and with
erataxia
u yo
[1]. Evidence suggests that the risk of falling can be reduced
e h
cerebellar
at an
up to 40%, depending on the type of intervention [6].
i v y n yw
studies combining OEP with DT. OEP improved the physi-
p r o
balancet exercises haven been r a l cal and mental function among older adults with cognitive
Resistance training and
al ratio d
e- OR, rangingsfrom o 0.12 too frailty [60]. Hence, our study aims to evaluate the effects of
proved to reduce fallsn(odds d e
o lo[6,a 7]. The OtagouExerciseonPro- adults plus cognitive e re Program on the risk of falling in older
0.30) and related s
r fractures
y
the Otago
h e
Exercise
gram (OEP) is p ethe mostupwidespread fallaprevention te an program that the intervention y w activity in dual tasks. We hypothesize
developedorat Otago r
o Medical School v
ri[8, 9]. tThe o Center for nly cognitive a n increment in the reduction
involving DT brings about an additional
F e d p
l theeNational d o o r of fall indicators com-
Disease Control
t and Prevention, and
a d in reducing
Council on
sethe one re
ibu (35%) onOEP
pared to the sole physical exercise intervention.
Aging America
t r
consider the
r s l o a[10-12].
effective
u h e
y
is peworries p atealongside an w METHODS
risk of falling in older adults The universal
d r r ueveryone, i v 2. MATERIALSyAND
n
ephenomenon
o
of aging
o r
because,
t o l y a
o t b muscle F loss,edthere is an exponential
functional
t a l p growth e d of the 2.1.
e onStudyoType r and Sample
N older adult population
r
u [13].
ib are required s
n
ofor early o a d u e
s oInnthis quasi-experimental study, e re 88 community-dwelling
t r l y h
is of health and pquality e ofulife, p including mental ate anof both sexesyfrom twonDay ywCenter programs were invited to
Urgent strategies mortality and
e d r o r r i v o l
improvement
b [14], which may o
F leadedto reduced mobility t
p and dim- made throughparticipate n posters, a
r folders,
voluntarily. The study’s announcements were
o t
health
t a l e o
e nThe o
Nproved independence [15].uCognitive and neuromusculoskel-
i b o n a d s e Day Center is a and e e
advertisements in the
rdedicated
etal degradation occurs r
t dopamine activity,
in the prefrontal s
cortex l
with o
r whitep matter, and tebasic personal
a reduc- u
community.
y o h
space to solving
d i s e
p ru a a n needs. At the end
y w
of the day, the person re-
tion of overall volume,
r v n
be affects
compared to o o regions [19-22]. pde-ri dknowledge
to nly oexperiencea
turns home. The activities involve personal enhancement,
synaptic density,
t F e d
other brain
l
a de ocultural therapies and o r
Noindependence in dailyibliving ut activities and
personal sharing, providing soci-
This degradation mobility, strength, and balance,
n
o loa degree of udependence, s e e
n and contributing to orthehthose rewith some
creasing
t r r s increas-
e y o
to autonomous people
epreservation
ing the risk of falling [16-18]. i s During
p e
gait, compared
u p to
a t a n y w of
e dsupplementary orarea), or right rivInclusion o lystudyr were n
the person in their family environment.
younger adults, older adults
b
have greater
F
activation
d
of the
p t n a
ot and the left dorsolateral te frontal cortex.nal er;dthe edparticipants swho o o answer
prefrontal region (motor the or- criteria for this age 65 years or old-
N u oare lo“Do a you feel thatu your memory e e
n and/or abilityto tothehthink re
itob the frontal lobe
bitofrontal cortex,
t r r s
had
y o
a positive
e
question
Therefore, cognitive functions relating
d isin an earlier stage p e whenup recently deteriorated?”; a te an being able to stand without y w support;
has
sensitive to the effects of aging
e [19-22]. Executive or function o r v
ri able totoperform autonomous ly walking an for, at least,
compared to other brain areas
t b F d l
and beingp d o n o r
has a metacognitive component,
relevant information, N
o allowing the organization
i b uteadapta- of
o n practice a
e
20 ameters.dExclusion
u s
criteriae were n
no contraindications for e
eof uncontrolled medica-er
decision-making, and favoring
s tr Thus, theer tionpfor s the o
l diabetes and thypertension,
of physical
e
exercise,
y o
use
h
tion to new or more complex situations i[23-27].
d p u a a n y
no difficulty in communi- w
executive function is responsible for e “planning, behaviors,
bgoal-directed or d orcating
initiating,
F p riv toprocedures, andnlless
and understanding
d
y than r
n ad-
a80%
t te pants. na de l o o partici-
No activities, or dual-tasks
sequencing and monitoring complex herence to scheduled sessions by intervention group
u a s e n e
ib in- rso data he
as well as controlling complex
(DT)”. In this mechanism, the executive function truses lowere e u yo
i s e p
p r uor self-reportedivby t
a the older n
a adult at they time ofny w
e d cognitiveFor program
formation processed at lower cortical levels, i.e., basal gan- These obtained from records in the Day Center
b d o p r t o nl or a
and sensory-motor information [28-39].ot
glia, thalamus, and limbic system, which integrate
e a l e d o
ut At institution
request to take part in the study.
N b o d
n one, aparticipants e ne in the
sdistributed
r i s l o u yothe experi-
ist experimental er group
were
Another strategy commonly used with older adults in-
d p u p with the OEPa(OEPG) te anand
volves cognitive and motor DT, which can be an additional
or group r the OEP in rtheiv dual ttask
stimulus as it involves attention in the execution ofbaeprimary
t F
mental
d owith
ticipantstefrom institution two l pformeddtheocontrol (OEPDTG); par-
task. A secondary motor task is performed o
N skills [40-43]. Theibfinal
automatically,
u sample of this a (nd=e 36) ended upgroup
nstudy
(CG).
reducing interference in exclusively cognitive
tr in a balanced o a
rs wayp(nlo= 12) in all groups (OEPDTG,
being dis-
The combination of physical and cognitive training in older istributed e
adults, with or without cognitive impairment, improves bothe d OEPG, andoCG)
p
r (Fig.o1). ru
b F ed
cognitive function and motor performance, compared to
intervention or physical exercise alone [44-46]. TheNbenefits
ot no 2.2. Procedures ut
tr i b
of exercise can be enhanced if combined with DT cognitive Allisparticipants were evaluated two times: pre-and post-
exercises in the domains of executive function, attention, d
e of 50 minutes. In the
application of the OEP, lasting 12 weeks, in two weekly ses-
memory, information processing, and reaction time. These
t bsions
N o experimental groups, participants
 Improve Cognition and Functioning in Older Adults Current Aging Science, 2023, Vol. 16, No. 1 67

e re
wh
y
n ly r an
e o ne o
e
s
u yo h ere
t n yw
r i va to a l y n
l p ed o n or a
a se one re
rs on load u h e
y
r pe r up i v ate an y n yw
Fo ed o r o nl or a
t a l p ed t o
r ibu s on load u se one e re
t r y h
d is
r pe r up i v ate an y ny
w
e o o r t o l a
o tb F ed
t a l p ed e on or
N
rib u
s
n
o loa d u s one e re
t r y h
d is
r pe r up i v ate an y ny
w
e o o r t o l a
o tb F ed
t a l p ed e on or
N
r i b u
s o n a
o
d u s one e re
ist r l te any h
d r pe r up i v a y n yw
e o o r o l a
o tb F ed
t a l p ed t e on or
N
t r ibu r s on load
e us yone h ere
dis r pe r up i v at an y n yw
e o
o dCONSORT Flow Diagram r o
t D, Schulz KF, l a The CONSORT state-
o t b diagram. BasedF in The
Fig. (1). Sample selection
t e a l p indMoher
e o n Altman o r DG.
N
ment: revised recommendations for improvinguthe quality of reports
r ib s o ad
on of parallel-group randomised
u setrials.onLancet
e 2001;357:1191-4. ere
t
isthe OEP, whichpincludes r
e up Anthropometricl n y
te ameasurements wh®(kg) and
were subjected to the applicationdof
r balancing r v a of body mass y
6 warm-up exercises, 5 strengthening e
bexercises. exercises,o11
F d o height (m)
p ri were tobtained
d
o using thely
n r
equipment anSeca – Med-
t teclimbing Kingdom l e 760 and stadiometer o o
Noto carry out the exercise a d(scale e ne222), with an accuracy
exercises, and 2 stretching Since the institutions ical Scales and Measuring Systems, Birmingham, United
do not have a safe place
r i b uof
s o n
o a u s o e re
t r l te an y h
stairs, this was excluded [12, 61, 62]. Detailed
d is protocol
r p rofu1pkg and 1 mm,ivrespectively.
fore
a y ny
w
both physical and cognitive tasks is presented
e o
in Supple-
o r t o l a
tb F ed l p theerisk onolderoadults,
r
2.3.2. Risk of Falling
mentry Table S1.
o t a d of falling among
N b u To n
operformance
measure d
a thresholds well e
s establishede
n in the litera-
func-
r i s o u o he
During all exercises (warm-up, OEP, and stretching),
i s t tional
e r p l t e n y w
mathematical r p r u cognitive action,
OEPDTG was additionally asked to perform cognitive tasks,
namely, memorizing sequences; performing d iva strength, a and resistance ny
ture were used, assessing balance, gait quality, mobility with
be and de-Fo
o p r t o n l y ofrthea
ed limbs. Innthe
or without
ed Balance sTest
calculations, such as adding numbers int ascending
N o naming objects, utlower al Four-Stage
d e o(Four-Stage),
e ofor at
scending order, or basic multiplication;
i b o a u n
r ers uPositions plo are requested yo
balance is assessed in four different positions and held
ist least te aprogressively
places and people displayed on a screen; naming people,
d p
10 seconds.
r a n and
animals, and objects by categories; complementing proverbs
r o of the other;p3)ri One footv o behind the other,
be o indfront t
sequentially as 1) Feet side by side; 2) One foot close but
or traditional songs.
t F al and, d
N o slightly
u tethe toes on thenheel; definally, 4) Unipodal sup-
2.3. Evaluation Tools
t r b
touching
i r s o l o a
d i sport. Participants
p ewho were
u p unable to hold the last two posi-
2.3.1. Selection and Sample Characterization e
tions for at
o rof falling
least 10
o r[29, 30].
seconds (Yes/No) were considered at
b F ed
ot
potential risk
Demographic information and sample characterization
N To evaluate
i b ut walking speed, we applied the 10 Meter-
involved questions about age, diseases, medication, surgical r
WalkingtTest (10MWT). Participants were asked to walk for
procedures, falls, walking aids, and exercise practice. Selec-
d
10 meters is at a comfortable speed, with or without a walking
e
t baid. The time it took participants to travel between the marks
tion criteria were checked based on this initial questionnaire.

N o
 68 Current Aging Science, 2023, Vol. 16, No. 1 Santos et al.

of 2 and 8 meters was timed, not considering the intervals up carried out with IBM SPSS Statistics (Statistical Package for
to 2 meters and after 8 meters, acceleration and deceleration Social Sciences) version 25.0 (Chicago, USA); the signifi-
phases, respectively. This procedure was applied three times, cance level was fixed at p < 0.05.
recording the average of attempts in meters per second (m/s).
re
This test allows for the assessment of functional mobility, hav- 3. RESULTS
e
wh
ing as a reference that a value equal to or greater than 1 m/s
Fig. (1) shows a diagram of the initial selection (n=88) to
but less than 1.25 m/s represents an older adult with some risk
y
nly or an
of falling); when the value is equal to or less than 1 m/s, a fall its final composition (n=36) distributed by the following
prevention program must be started [29, 31, 32]. o groups: OEPG (n=12; female=10); OEPDTG (n=12; fe-

u se timeon(10MWT e ere
male=10) and CG (n=12; female=9). At baseline, all groups
The same test was applied a second
e y -
h
were homogeneous in age (OEPDTG=82.67 ± 8.04; OEPG=
evocative) to test their mobility with
i at application,
vfirst an except
cognitive action. The
that, an
y yw
83.00 ± 4.65; CG=84.92 ± 3.85 years old) and BMI
r o l
dt
test was performed as in the
l p simultaneously, n or (OEPDTG=26.48±3.87; OEPG=25.60 ± 3.26; CG=24.88 ±
their omemory
while the individuals walked
a e e 2.70 kg/m2). Inter- and intra-group comparisons of the pre-
re
was evoked by naming n animals,
that started with rascertainplletter,
d
o oa and so on, thus names of
u
peoples objects
or
o nefor e
and post-intervention risk of falling and cognitive function
h
e the ability y
te plusaancognitive yw
allowing
r pof r u to perform i v agait
tests are shown in Table 1. Previous differences between
n
the evaluation
o y
FoAlthough dnotoyetreference r t test with this nl ra
groups were not found, being homogeneous in age and BMI
task [63].
te a l p foredthe
values
o o
at baseline.
e ne Fig. (2) presents a better
r ibu time compared
variation have beennestablished,
s o tolothe ad conventionalusmode
the difference in
o e re visualization of intragroup and
t
performance
is gives an idea r p
e of theucognitive e nin
trequired y intergroup comparisons w h on the risk of falling and cognitive
d
(10MWT)
r p r
demand
v a a y
bethis motor task.Fo ed o pri d to
performance
r an
nInlytheobeginning,
of older adults.
t l o
e mobility, sebetweene groups with respect
No measures t (TUG), widelynused a to assess re risk of falling and cogni-
there were no significant differences
Timed Up and Go u
ibin seconds thatrsthe o participant a d needs to getu n toethe
t r
the time l o
e threeupmeters, go back,atand e ntive o
y function variables (p>0.05) h
dis with arms,r pwalk wdifferences(Table 1). In POST, the
up from a chair
sit in e tool,orit is possible to i v o a n y
y r a10MWT (p= 0.001);
b the chair. With othis
F d p r assess t groups showed
n l significant in all tests -10MWT

o t agility, and dynamictebalance during a l and etrans- d (p=0.002); o evocative

o TUG (p= 0.034);
strength,
Nfer tasks. Reference values b
gait
uare 10 seconds ofornnormala mobili- d STS e
s groups
(p<0.001);
n e MoCA (p= 0.019). e
r lowerthethan
Specifically, experi-
r i s l o u o h e
ty, between 11 and s
d i14t seconds ether participant
for typical
p u p for
mobility older te
a
mental
CG inan
y presented
the 10MWT (OEPDTG: y
values significantly
w
the

e 33-36]. For d or riv and an(OEPDTG: p= 0.001; OEPG:

p= 0.002; OEPG: p=0.020)
adults, and 14 seconds
b[29,
or more when is at the
p to in the evocative n ly10MWT r
t
risk of falling
o teapplied to evaluate l d
a thede p= 0.015) sande osignificantly o higher in the STS e(OEPDTG:
TheNSit-to-Stand Test (STS)bwas u
i limbs. Participants o n a n
u andyoOEPG reduced e r
inferring that theeindividuals
s t r e r s p lo p<0.001;
t e
OEPG: p<0.001),
h of
resistance and strength of the
i lower
r uagainst 10MWT
were n w
r pand olean va ttests aand increasedythe number nyof repetitions in the
the OEPDTG the execution time in two
asked to get up and sit ind a standard chair, i
be as possible forFo30 seconds. r o l a
the wall, as many ttimes
ofosubjects over 60 years old ed according tonal pSTS
tvary
The nor- d
ecompared to the CG.
2), it was onlyse
onHowever, r in the TUG and MoCA
othe
mative values N
r ib u [1, 38].rso o a d
(Fig. verified that
u than o
e
nthe GC (TUG: OEPDTG obtained
p= 0.030;he
resta-
age and sex (male = 14; female = 12 trepetitions) l tistically betterevalues y
dis pe r up p=0.0015). t suggests ywtraining in
MoCA:
aThis a n a positive impact of DT
e r i v o y n
Fo iseused d o to inducing r l a
2.3.3. Cognitive Screening

o t bAssessment (MoCA) t a l p shorter e d ttimes and betteroncognitive o r activity.

n In theadintragroup analysis seis(Table ne1 andbyFig. 2), the effec- re
The Montreal Cognitive
N in adults with normalibcognitive u otiveness
r s o u o he
distinguish performance ag-
ing or cognitive impairment. The MoCA iassesses s t eight cog-e r p l of the
t e
intervention
n y
identified a significant
wim-
p u a ny
d
orlan- d orto the CG (p<0.001). riv IntotheaMoCA cognitive
provement in the mobility of experimental groups, compared
nitive domains - executive function,evisual-spatial
b
abilities,
F p n ly test,r aOEPDTG
ot orientation - with a utotal te exhibitednsignificantly al dedincreased scores omore than o the OEPG
memory, attention, concentration, working memory,
guage, and temporal and spatial N b o a s e n e only
i
tr was surpass (p=
rs the pcognitive
0.005)
lo decline tthreshold
and the CG (p=0.003),
e u y
being o >26). Ingroup
the to
he
26is indicates e
score possibility of 30 points [16, 64-66]. The MoCA
r uonly a significant n w
applied, considering that a score below d
r pthere owas ivaincrease ain MoCA (p= 0.009). ny
(score the CG,
b e o
F edIn Fig. (3), theaFour-Stage p r t o n l y a
edclassification o to anorevi-
cognitive decline [67, 68].
N ot u t n
l
d s epoints
eafter the
r i b s o of the o
l a u o n
ist intervention. er Thereupwas an evident effect ny interven-
2.4. Statistical Analysis dent involution relative risk of falling (Yes/No)
d p a te of perceived
a
r r v
tion) were used, and data normality was tested bybe
tionobetween o
pri diddnot todiffer
Descriptive statistics (mean, 95% CI, and standard devia-
the experimental groups and the CG (p= 0.039),
t Shapiro-
o OEPG, risk ofufalling F e d l
a group e (p= 0.379).in the relative
Wilk. Quantitative intergroup differences (OEPDTG,
N
although
t in the experimental
the type of intervention
n d
and CG) were indicated (ANOVA, one-way), considering
the time factor (pre-post intervention). The intragroup differ- is
trib e rso ploa
ences of the intervention’s effects were also tested (paired t-e
d 4. DISCUSSION
o r p or u
b
t the 4.1. MainFFindings ed
test) and, for qualitative comparisons of the Four Stages,
N o u t
Chi-Square (χ²) was used to compare proportions with the
rib obtained in our investigation demonstrated
The tresults
s
analysis of adjusted residuals (adjR) localizing differences,
that dthe i application of the Otago Exercise Program (OEP)
and Exact Fisher tests were used. To verify intragroup ho-
mogeneity, the McNemar test was used. All procedures were t b e
No
 Improve Cognition and Functioning in Older Adults Current Aging Science, 2023, Vol. 16, No. 1 69

Table 1. Intra- and inter-group comparison of the variables of fall risk and cognitive function.

Groups

e
OEPDTG OEPG CG

e±rSD
ANOVA
Moments

w h
Mean Mean ± SD Mean ± SD (p)

PREly
ny
10MWT (m/sec)
o n or a 1.00 ± 0.23 0.99 ± 0.24 0.96 ± 0.22 0.889

u se POST o ne 1.22 ± 0.18

ere 1.16 ± 0.15 0.95 ± 0.21 a, b
0.002
t e y h
va to aMcNeman ly
n yw
#
1 m/s
r i a n
<0.001 0.001 0.132
p on o0.51 r ± 0.05
n al ded PRE
s e e e
0.49 ± 0.06
r
0.49 ± 0.06 0.728
o a u o n he± 0.06
ers (m/sec) plo tePOSTany
Evocative 10MWT
w
a, b
0.60 ± 0.06 0.57 0.50 ± 0.06 0.001

r p r u v a y
n <0.001
Functional tests

Fo ed o l pri dMcNeman to
o nly<0.001or a 0.087

i b ut TUG (sec)ona ade PRE use 14.30 ne± 3.18 15.68 ± 2.46 re 15.78 ± 2.59
e
s o o
0.351
t r r l y h
d is
r pe r up i
POST
v ate an 12.61 ± 3.13y 13.56 n y±w2.70 15.66 ± 2.47 a
0.034
e o o r t o l a
tb F e14dsec l pMcNeman d on or 0.001
#

N o u t n a d e s e
0.001
e r
0.732
e
t rib STS (rep) rso lo PRE a u o n h e
is e up te any w
8.00 ± 2.00 8.33 ± 1.97 7.92 ± 1.68 0.850
d p a y
be F or d or POST riv
p d to13.17 ± 2.16 nly13.25 ±r2.38 an 7.92 ± 1.73 a, b
<0.001
t l o o
No ute rep na ade <0.001 e
s e<0.001 0.999 re
#
male=14; female=12

t r i b s o
McNeman
r PREp l o u o n h1.22e
i s e t e n y w
d MoCA
r p ru i v a
23.58 ± 1.62
a 24.42 ± 2.11
y n y
23.25 ± 0.234
e o r o l
Test cognitive

o d ±t1.95 a
t b (0-30 range) F ted POST al p 26.17 on± 1.93 or 24.17 ± 0.83
function

o e
a
25.42 0.019
N u n d s e e r e
26 pointsst
rib e rso ploa 0.001 te u n0.004 y on he
i # McNeman
p OEPG:
dwith Otago program inr dual-task; r u experimental group a Otago program;
a CG: control group;
0.009
y w
e o o r i vwith t o l y 10MWT:n10 Meters Walking Test; TUG:
a
b F difference p moment; POST: moment afterothenintervention; o:rFall𝒙 ±riskDP:thresholds
ted (significance); a:nOEPDTG≠CG;
Note: OEPDTG: experimental group
t
No (p); ANOVA: intergroup al deb:dOEPG≠CG; and:sOEPDTG≠OEPG;
Timed Up and Go; STS: Sit-to-Stand Test; MoCA: Montreal Cognitive Assessment; PRE: initial mean ± standard deviation;
McNeman: intragroup difference
b u o a e n e #

re
considered.

t r i r s l o u y o h e
dis r pe r up i v ate an y n yw
e Fo ed o r o nl or a
o tb t a l p ed t o
N
r ibu s on load u se one e re
t r y h
d is
r pe r up i v ate an y ny
w
e o o r t o l a
o tb F ed
t a l p ed e on or
N ib u n
o loa d s one
i s t r e r s p t e u
n y w he
ed o r p or u r iva to a l y a ny
b F ed p n or
No
t
u t n al ded s e o
e
trib rso ploa e u yon
i s e t n
e d
o r p or u r i va to a
o tb F ed
t a l p ed
N
t ribu r s on load
dis r pe r up
b e F o do
t
o variables (functional tests, te letters A to D) and cognitive function (MoCA,
Fig. (2). Intra- and inter-group comparison of the risk ofN
b u
tri Sit-to-Stand
falling
letter E). OEPDTG: experimental group with Otago program in the dual-task; OEPG:
group; (A) 10MWT: (B) Evocative 10MWT; (C) TUG: Timed Up and Go; (D) d i s
STS:
experimental group with Otago program; CG: control
Test; (E) MoCA: Montreal Cognitive As-
sessment; PRE: initial moment; POST: the moment after the intervention. e
o tb
N
 70 Current Aging Science, 2023, Vol. 16, No. 1 Santos et al.

e re
wh y
n ly r an
e o ne o
e
s
u yo h ere
t n yw
r i va to a l y n
l p ed o n or a
a se one re
rs on load u h e
y
r pe r up i v ate an y n yw
o do pr d t o nl or a variable. PS: significance (p) from Chi-Square (χ²) to
compareFproportions.
Fig. (3). Comparison between groups on the risk of falling (yes/no) in the Four-Stage
te l
a d(|eR| ≥ 1.96 [Z critic]) o
Note: R b
r i =uadjusted Residual;o*n= p<0.05
s o a u se one e re
t
adj

isable to reduce the r l adj

p within 12atweeks, e im- y h

wasd r perisk rofufalling i v an [75]. According to
y
wthese authors, results are justified by the
nisyconsidered a complex mobility task that
e o o r t o fact lthat a
t b tive function. FMost tspecific p riskdof falling involves on differentor
prove functionality, and the OEP with DT improved cogni- TUG
o ed resultsnfor a l the e e reTherefore, it requires spe-
tasks, requiring time to integrate the ca-
N i b u o lo a d u s n e e
(Four-Stage) were
t r reduced to less
r s than half for the interven-
o
pacities of the executive function.
h
y training in subtasks towimprove the overall task, which
d s
tion groups i(OEPDTG: 33.3%;eOEPG: p
p ther group u 41.7%), compared teto ancific
aOEP y However, in our study, we had
e
the CG (83.3%). r
o improved
Furthermore,
o exposed ito
r v t o was not the case
l y inrouraninstudy.
witht b
dual-task F
significantly
e d their cognitivep
l thresh- d
ability significant n
o the CG, o
differences the TUG test between the OEPDT
o t
Nolds (≥ 26). In additionibtouthe statisticalssignificance n aa d e e
s that e seems to be rin e line with the as-
to values greater than
r
the normal cognitive
o decline
l o
group
u
and
o n which
h e
d
t
isperformance p erthe OEPG u p and CG, atetion integration
of the sumption
a n y improves complexwmobility tasks.
a more complete program
y
with executive func-
OEPDTG's superior
e o r improvement
over
o r r iv hand, t o l y n adults is alteredOnand
in aolder
the one
b
the clinical importance
t as functional improvements F ed that DT represent-
of cognitive is empha-
l p d
executive function
o n o r can
sized, as o well
u t n a de lead to the risk
ethalamus,
of
e
falling, so the information
e
processed in the
ed for N b o a s n e r
tri rs plo u yo complex goal-directedhbehaviors, such
these older adults. basal ganglia, and cerebellum to plan, initiate, se-
i s e t e n w
r p and r uLitera- asrivinapair-tasks, a are the important ny
quence, and monitor
e d the Main Findings o o l y
4.2. Relationship Between
b F o d p t n r a
somatosensory information
ture
N ot u te n al er dhand, ed the motor stask
resources to accomplish
e ocan be accomplished
the motor
e o tasks [23-27]. On the oth-
e
rmore
t r ib (MoCA)so
r ob- lotion a or alterationuof sensory o n inferences, stimulating h e
with the reduc-
The significant cognitive improvements
y
served after the intervention of our
dtheis investigationpare e con-up executive functions
r to physi- r i v ate [23-27]. a n
y n yw
b e cognitive o
d o of 4.4.aStrengths r t o nl or a
l p edand
firmed in literature when adding task
cal exercise DT, which texponentiates the F e o
o
Nspeed, increasing attention t
components
uand focus, on ad Weaknesses
se one re
information processing
t r ib[69-72]. r s lo u y h e
is adaptations ptoe randupa non-randomized ate design, an making it ymore difficult ywto
and reducing the risk of falling in older adults The The limitations of the study include the small sample size
12-week exercise program allows for neural
e d r o r i v o l n
o t a
occur, being more evident in individuals
tb
lifestyle [69-72]. Specifically, othese adaptations affectuthe
F ed generalizeathe
with a sedentary
t l presults. e dHowever, on or bias
the investigators
e
chose not
N b
to perform
o n d
randomization
a s
to avoid contamination
n e in an
increase in muscle strength, flexibility, motor reaction
i s tr i time,
e rs ispthat
institution lo it was not possible
where no intervention
t e u was
n y o
performed. Another
w he
p ru ivora thetocognitive
a task wasyadequateny
e dthe cognitiveFor intensity
balance, and increase in bone mineral density recommended limitation to conclude whether the
by loading exercise [69-72]. The benefits of
b d o of the exercises
p r l
nfor r a
component translate into improvement o oft brain plasticity, se- e a l e d o o
N related to planning ibutEven thoughsthere n are noadreferences for itus[6,e62]. ne
for each participant, as sufficiently challenging the DT.
o
r ploof the study,awe yoits character
lective attention, and executive functions
i st e r t e highlight
n
and executing tasks [69-72]. All these factors combined drive
d p u a
or interventionplasting riv 3tmonths,
As for the strength
r o
be limbs, as aolongitudinal
an increase in gait speed in a single DT involving the motor
task, an increase in resistance and strength in the tlower
o and signif- more,uthe F e d l d
a longer pe-
aduringdthee OEP was anotherFurther-
N
riod t inclusion of DT
compared to other
n
studies of this nature [76].
b o loain our study that favored in-
and a decrease in TUG time, justifying the positive
icant differences in the risk of falling assessment tests in par-
s t ri as an innovative e r s feature p
strong
i
r p oonr ucognitive tests after training.
point
ticipants of the two experimental groups [34, 70, 71, 73, 74].
e d creasing performance
o
tb F ed
4.3. Secondary Findings and Connections with Literature
No 4.5. Implications
i b ut for Clinical Practice and Research
r
In the TUG test, our findings did not demonstrate signifi-
cant postintervention differences between the OEPG and the d ista significant
In our study, after 12 weeks of intervention, all groups

b e
showed increase in the final MoCA score. CG
CG for the agility of older people, as noted by Dorfman et al.
t individuals’ improvement can be explained by learning the
No
 Improve Cognition and Functioning in Older Adults Current Aging Science, 2023, Vol. 16, No. 1 71

procedure, facilitating its execution in the second period of HUMAN AND ANIMAL RIGHTS
assessment [64, 77]. Nevertheless, despite all groups show-
No animals were used for studies that are the basis of this
ing significant changes, the OEPDTG, which initially had
research. All the human procedures used were in accordance
the second-best average of the three groups, obtained a sig-
with the ethical standards of the committee responsible for
re
nificant increase compared to the OEPG and the CG in
e human experimentation (institutional and national), and with
wh
postintervention results. The tasks used by the MoCA are
the Helsinki Declaration of 1975, as revised in 2013
like the exercises applied in the DT intervention program.
y
ly r an
(http://ethics.iit.edu/ecodes/node/3931).
Accordingly, OEPDTG besides enjoying benefits in func-
n
e o ne o
tioning, has the expected impact of greater cognitive resolu-
CONSENTeFOR PUBLICATION
e u s
tion capacity [64, 77]. Moreover, OEPDTG favored the op-
y o h er
a t an
timization of mobility training time, enhanced by cognitive
y wstudy started. Participants
All participants read and signed the consent form before
ri v t o
task training. After all, in the context of real life, they are not
ly r ament. n
the could withdraw at any mo-
p d n
al de e o ne o
dissociated.

CONCLUSION rs o n
o a u s o e re
l y h
pe ther uOtago p ate areduces
STANDARDS FOR REPORTING
In this rstudy, ExerciseivProgram
o
n the
y n ywguidelines and methodology were followed.
risk of F o ind older o adults. When pr a cognitive t dual-task nl ra
STROBE
falling
te a l e d o o
was added u
b to theofprogram, n acapacity
ocognitive d e neAVAILABILITY OF DATA
sthree
was increased re AND MATERIALS
t r ichance r s l o u y o h e
up demand,ivperformed ate anin studyThe
and the falling decreased to a third after
d is of intervention. pe Cognitiver y w and/or analyzed during the current
datasets generated
months
r y
to addi- 10.6084/m9.figshare.19310564.v1. n
t betional F
conjunction (dual-task) o dwith
e
o physical training,
l p r brings
d o n l are
o
a in the figshare repository, https://doi.org/
available
r
No it did not favorably
improvements
i butimpact
to cognition
older o na mobility
performance.
a de but im-use ne
In isolation,
e re
t r r s adults’
l o y o h
proved theiris
d
functional tasks. e
r p r up i v ate anFUNDING y w
ny supported by the Portuguese
e o o r t o l a
t b and can beFenhanced d when added atol simple p cog- onfor Science r and Technology (FCT) (Grant num-
The Otago Exercise Program is a strategy well-accepted This work was financially
inoliterature t e e d o
Nnitive demands. b u o n a d Foundation
e e
s UID/DTP/00617/2020
n reCenter in Physical
r i rs l o beruFCT
o [Research
h e
d ist pe r up v a teActivity, a ny Health[Laboratory and Leisure
y w - CIAFEL] and
r ri ITR]). to ly r a n
be o do
LIST OF ABBREVIATIONS LA/P/0064/2020 of Interdisciplinary Research -
t F l p d n
No = Body MassibIndex ute na ade e o ne o
s ere
BMI
= 10 MetertrWalking Test rs
o lo u OFyINTERESTo h
e
disUp and Go r pe or up at author andeclares no yconflict ofnyinterest, w
10MWT CONFLICT
e o d r i v t o l a
TUG
t b
= Timed
F e l p The
d o n o r
financial or

N=o Sit to Stand Test ibut na ade

otherwise.
se one re
STS
t r r s o l o u h e
y
dis Assessment pe r up ate an yw
Four-Stage = Four-Stage Balance Test ACKNOWLEDGEMENTS
= MontrealeCognitive r i v o y n
Fo ed o The rauthors tare grateful to all l participants
n or a and the host
MoCA
o t bGroup t a l p ed o
on load se one re
institutions.
ibu
CG = Control
N s u e
t r r y h
isPhysical Activity pe rREFERENCES up ate an
DT = Dual-Task
d r i v o y yw
nAvailable
MVPA = Moderate to Vigorous e o o r t l a
t b Culturais F ed [2] from: l p ed on or
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