Online lifestyle trial shows improved cognition in older adults

A clinical trial has shown that an internet-delivered lifestyle intervention has resulted in significantly better cognition in older adults.

The team, led by Professor Henry Brodaty AO, Co-Director of the University of New South Wales (UNSW) Centre for Healthy Brain Ageing (CHeBA), calculated a global cognition score from online tests that measured memory, reasoning and speed of information processing, and published their findings in Nature Medicine.

The landmark trial, known as Maintain Your Brain, is the largest internet-based trial ever conducted to attempt to prevent cognitive decline and dementia.

The researchers recruited over 6,000 participants aged 55–77 for the trial through the Sax Institute’s 45 and Up Study, to target modifiable risk factors for dementia in general and Alzheimer’s disease in particular. Participants were without dementia but carried at least two of the major risk factors for dementia.

Half of the participants received an active intervention that included personalized coaching in two to four modules—physical activity, brain training, nutrition or depression/anxiety—depending on their risk factors, while the control group received publicly available information. A Mediterranean diet with limited meat and dairy, an increase in moderate-vigorous intensity exercises, and specific types of computerized brain training were among the changes that led to an improved cognition score.

The trial directly or indirectly tackled several of the 14 modifiable risk factors reported by The Lancet Commission, accounting for approximately 45% of the risk of dementia.

The researchers say the findings have international significance.

“This intervention is scalable with the potential for population-level roll out that may delay cognitive decline in the general community. We could essentially reduce worldwide dementia prevalence if this trial were implemented for the wider population,” says Professor Brodaty.

The greatest benefit to date in preventing cognitive decline

The trial incorporated participants from metropolitan, rural and remote areas, and assessed an online lifestyle intervention to prevent cognitive decline over a three-year period, with follow-ups done at the end of each year. The team split participants into two groups.

The trial specifically tested whether improving lifestyle behaviors could slow cognitive decline.

Professor Brodaty says, “The outcome was a resounding yes—we can improve cognition over three years, and therefore likely enhance resilience to dementia. Both groups improved, but the intervention group demonstrated the greatest benefit to date in a randomized control trial to prevent cognitive decline.”

Bowral resident Paddy Goldsmith, 82, who participated in Maintain Your Brain, believes the trial has significantly benefited her and her husband Geoff. Together they have continued to adhere to the nutrition guidelines and found that the brain training improved their concentration.

“I continue to do weekly balance and strength training as well as online brain training, which I would never have done without the knowledge learned in the trial,” says Paddy.

Evidence to support a tailored prevention program

The findings recommend personalizing prevention efforts and suggest that interventions focused on just one modifiable risk factor, for example physical inactivity, are less effective in preventing dementia.

“Previous trials have largely not tailored interventions to match dementia risk factors of individual participants,” says Prof. Brodaty. “Our findings suggest personalizing interventions and targeting a broad range of lifestyle factors are important for success.”

Chair of CHeBA’s Advisory Committee, Ita Buttrose AC OBE, says this is a moment to be celebrated.

“We now have clear evidence to support a national dementia prevention program,” says Buttrose. “Previously, Australia has been a leader in prevention, particularly with smoking, skin cancer and HIV minimization, but we have dropped the ball. Dementia is a prime example of where we can and must act now.

“This evidence demonstrates significant benefits to improving cognition and potentially delaying the onset of dementia. It is now time for Australia to think seriously about long term goals, to acknowledge the evidence and embrace the need for investment in prevention,” says Buttrose.

Findings may be even more significant

The estimate of the intervention effect is considered conservative, given the control group and the group that received personalized coaching both improved.

Through assessing self-reported change from baseline to the year three follow-up, researchers also noted significant improvements in aerobic activity, strength training, diet and depression scores.

“If we were able to compare the intervention with a control group that received no information at all, we would likely find out that the benefits of this trial would be even greater,” says Prof. Brodaty. “Participants aged 55–65 showed greater benefit than those aged 66–77, suggesting we should consider starting prevention programs earlier.”

This trial has several strengths, particularly in terms of the large population sample size and methodology. Limitations exist, including that participants were more likely to have a university education, better self-rated quality of life and a family history of Alzheimer’s disease. There was also a lack of ethno-racial diversity among participants.

Prof. Brodaty says this research offers new hope for prevention of dementia.

“Future developments could focus on cultural adaptation, particularly targeting groups from lower socio-economic backgrounds and those with less education.”

The intervention modules were:

• Physical activity, steered by University of Sydney’s Professor Maria Fiatarone Singh—participants were advised to do 300 minutes of moderate intensity exercise or 150 minutes of vigorous intensity exercise per week as well as two days of moderate-vigorous intensity strength training per week, and daily balance training;

• Nutrition, steered by Professor Maria Fiatarone Singh—participants were advised to follow a Mediterranean diet by consuming unprocessed plant foods including vegetables, fruits, legumes, grains, nuts/seeds and extra virgin olive oil, moderate amounts of fish and shellfish, and low intake of meat, dairy, eggs and animal fats;

• Brain training, steered by UNSW’s Professor Michael Valenzuela—this training targeted seven cognitive domains (verbal executive, verbal memory, visual executive, visual memory, visual attention, speed and working memory) and allocated three 45-minute sessions each week across the first 10 weeks and then monthly sessions;

• Peace of mind, steered by Scientia Professor Gavin Andrews and Dr. Michael Millard from the Clinical Research Unit for Anxiety and Depression (CRUfAD) at St Vincent’s Hospital—participants received training via ThisWayUp, a digital mental health program based on the principles of cognitive behavioral therapy aimed at reducing or preventing depression and anxiety.