Effects of exercise-cognitive dual-task training on elderly patients with cognitive frailty and depression

Abstract

BACKGROUND

Cognitive frailty and depression are prevalent among the elderly, significantly impairing physical and cognitive functions, psychological well-being, and quality of life. Effective interventions are essential to mitigate these adverse effects and enhance overall health outcomes in this population.

AIM

To evaluate the effects of exercise-cognitive dual-task training on frailty, cognitive function, psychological status, and quality of life in elderly patients with cognitive frailty and depression.

METHODS

A retrospective study was conducted on 130 patients with cognitive frailty and depression admitted between December 2021 and December 2023. Patients were divided into a control group receiving routine intervention and an observation group undergoing exercise-cognitive dual-task training in addition to routine care. Frailty, cognitive function, balance and gait, psychological status, and quality of life were assessed before and after the intervention.

RESULTS

After the intervention, the frailty score of the observation group was (5.32 ± 0.69), lower than that of the control group (5.71 ± 0.55). The Montreal cognitive assessment basic scale score in the observation group was (24.06 ± 0.99), higher than the control group (23.43 ± 1.40). The performance oriented mobility assessment score in the observation group was (21.81 ± 1.24), higher than the control group (21.15 ± 1.26). The self-efficacy in the observation group was (28.27 ± 2.66), higher than the control group (30.05 ± 2.66). The anxiety score in the hospital anxiety and depression scale (HADS) for the observation group was (5.86 ± 0.68), lower than the control group (6.21 ± 0.64). The depression score in the HADS for the observation group was (5.67 ± 0.75), lower than the control group (6.27 ± 0.92). Additionally, the scores for each dimension of the 36-item short form survey in the observation group were higher than those in the control group, with statistically significant differences (P < 0.05).

CONCLUSION

Exercise-cognitive dual-task training is beneficial for improving frailty, enhancing cognitive function, and improving psychological status and quality of life in elderly patients with cognitive frailty and depression.

Key Words: Exercise-cognitive dual-task training; Elderly patients; Cognitive frailty; Depression patients; Frailty score; Cognitive function

Core Tip: This study demonstrates that exercise-cognitive dual-task training significantly improves frailty, cognitive function, psychological well-being, and quality of life in elderly patients with cognitive frailty and depression. The intervention combines physical exercises and cognitive tasks, enhancing neuroplasticity and optimizing cognitive-motor integration. Results revealed lower frailty and depression scores and higher cognitive, balance, and quality of life scores in the observation group compared to the control group. These findings underscore the importance of multimodal interventions in geriatric care to mitigate the adverse effects of aging-related cognitive and psychological conditions. Long-term implementation could potentially delay or reverse cognitive frailty progression.

INTRODUCTION

With the acceleration of global aging, the increasing prevalence of cognitive frailty and depressive symptoms among the elderly has become a major challenge in the field of public health[1,2]. Cognitive frailty, characterized by memory decline, attention deficits, and impaired executive function, severely erodes the ability of the elderly to manage daily activities and profoundly affects the quality and depth of their social interactions[3]. Meanwhile, the high incidence of depression in the elderly cannot be ignored, as it often coexists with cognitive frailty, creating a vicious cycle that exacerbates psychological distress and further undermines quality of life[4]. Notably, compared to elderly individuals with intact cognitive function, those suffering from cognitive frailty face a 12-fold increase in disability risk, a 5-fold increase in poor quality of life, and a staggering 5-fold increase in mortality risk[5]. In recent years, scientific research has gradually revealed that regular physical activity is not only crucial for maintaining physical health but also has a profound positive impact on cognitive function and mental health by promoting brain neuroplasticity and optimizing blood circulation[6,7]. Given the potential reversibility of cognitive frailty, early identification, timely diagnosis, and effective intervention are invaluable for delaying the onset and progression of severe outcomes such as dementia and disability[8,9]. Against this backdrop, exercise-cognitive dual-task training, as an innovative and comprehensive intervention strategy, is gaining widespread attention in both academia and clinical practice[10]. This approach combines physical exercise with cognitive challenges, aiming to enhance the flexibility and efficiency of neural connections through dual stimulation effects, potentially promoting cognitive recovery while effectively alleviating depressive symptoms[11]. Existing studies indicate that exercise interventions alone can significantly enhance cognitive abilities in the elderly, and when combined with cognitive tasks, this positive effect may be further amplified[12,13]. However, research specifically addressing the complex comorbidity of cognitive frailty and depression in the elderly remains insufficient, particularly in exploring the specific impacts of exercise-cognitive dual-task training[14,15]. The primary objective of this research is to rigorously investigate the efficacy of combining exercise with cognitive tasks as an intervention for elderly individuals suffering from cognitive frailty and depression. We aim to delineate both the direct outcomes and mechanistic pathways through which this dual-task approach influences cognitive abilities, emotional stability, and overall wellbeing. By establishing a strong evidence base for this therapeutic approach, we hope to expand the arsenal of effective interventions available to geriatric healthcare providers, ultimately leading to more comprehensive and successful treatment strategies for aging patients.

MATERIALS AND METHODS

Study subjects

Initial screening was based on age (60 years and above), gender (unrestricted), and health status (absence of serious cardiovascular diseases, active cancers, etc.). Detailed assessment included medical history collection, physical examination, and cognitive function evaluation [Montreal cognitive assessment (MoCA) scale]. Eligible participants who met the criteria were formally enrolled in the study after signing informed consent forms. This study was approved by the hospital’s ethics committee, and all participants provided written informed consent. Cognitive frailty was assessed using the MoCA scale. Participants scoring below 26 points on the MoCA were defined as cognitively frail. For participants without a formal diagnosis of dementia, additional clinical evaluations were conducted to exclude other conditions that could potentially cause cognitive decline, such as depression and hypothyroidism. All participants underwent detailed medical history collection and physical examinations to ensure they met the definition of cognitive frailty.

Inclusion criteria: (1) Age > 60 years; (2) Meeting the following criteria for cognitive frailty: Subjective cognitive decline reported by the patient or family; Not diagnosed with dementia, with a clinical dementia rating[16] score of 0.5; MoCA[17] score < 26, with an additional point for those with less than 12 years of education; Frailty phenotype score > 3; (3) Presence of depressive state as assessed by the 17-item Hamilton depression scale (HAMD)[18]; (4) Clear consciousness and ability to answer questions independently; and (5) Informed consent and voluntary participation.

Exclusion criteria: (1) Severe aphasia, visual or hearing impairment; (2) Severe organ dysfunction, malignant tumors, or terminal illness; and (3) Acute exacerbations of chronic heart, brain, or lung diseases, neuromuscular skeletal disorders causing limb movement disorders, severe trauma, or other exercise contraindications. A total of 130 patients were included in the retrospective study, divided into an observation group and a control group, with 65 patients each. There were no statistically significant differences in age, gender, education level, and comorbidities between the two groups (P > 0.05), indicating comparability.

Study methods

Control group: The control group received health education and psychological counseling on cognitive frailty, including clinical manifestations, related risk factors, and non-pharmacological prevention measures. After the intervention, dual-task training guidance and intervention were provided to the control group based on personal willingness.

Observation group: In addition to the control group’s interventions, the observation group underwent dual-task intervention combining exercise and cognitive training.

Formation of the exercise-cognitive dual-task training team: The team consisted of 1 doctor, 1 head nurse, 1 rehabilitation therapist, 1 psychological counselor, and 5 nurses. The head nurse served as the team leader, responsible for purchasing materials, personnel training, and quality control. The doctor managed treatment and complications during the intervention; the rehabilitation therapist developed limb exercise and cognitive training content; the psychological counselor provided psychological support; nurses implemented the entire program.

Exercise training: The comprehensive physical exercise program spans 16 weeks, with sessions conducted three times weekly for 30 minutes each. Patients begin in a supine position on a comfortable exercise mat, starting with ankle mobility exercises designed to promote circulation. During these movements, patients extend their legs fully while keeping their back flat against the mat, performing controlled dorsiflexion by drawing their toes toward their shins for 5-10 seconds, followed by plantarflexion pointing away from the body. They complete the ankle sequence with circular mobilization movements, rotating each foot in controlled 360° motions both clockwise and counterclewise, repeating the entire sequence 10-15 times per foot. Following the ankle exercises, patients transition to resistance band training. Using a medium-resistance exercise band, they secure one end around the left foot’s arch while grasping the opposite end with their non-fistula hand. The first resistance exercise involves lifting the left leg approximately 6 inches off the mat and abducting it outward while simultaneously extending the arm in the opposite direction. Patients hold this position for 3-5 seconds before returning to center, completing 12-15 repetitions before switching sides. Proper form is carefully monitored to prevent lower back arching. The next phase involves cross-body resistance movements, maintaining the same band setup but guiding the leg across the body’s midline while extending the opposite arm. This exercise specifically targets the outer thigh muscles and requires maintained controlled breathing throughout the 12-15 repetitions per side. Patients then progress to vertical leg raises, keeping the working leg straight while raising it toward the ceiling until the thigh forms a 90° angle with the torso. This movement is performed for 10-12 repetitions per side, with band resistance adjusted according to individual capability.

The final exercise set focuses on dynamic knee extension without the resistance band. Patients position their left leg with the thigh perpendicular to the mat and the calf parallel to the ground, creating a 90° angle. They slowly extend the knee until the leg is straight, hold for 2-3 seconds, and return to the starting position with control, completing 12-15 repetitions per leg. Throughout the entire exercise session, safety is prioritized through careful monitoring of heart rate, perceived exertion on a 1-10 scale, fatigue levels, and proper hydration, with brief rest periods incorporated between exercises.

Cognitive training: Following the physical exercise component, the cognitive training protocol begins with a structured 15-minute rest period incorporating light stretching, breathing exercises, and hydration, along with a brief cognitive readiness assessment. The main cognitive training session then commences, lasting 30-45 minutes and utilizing tablet-based cognitive stimulation games designed to challenge various mental faculties. This digital training encompasses multiple cognitive domains through carefully selected activities.

The cognitive games begin with pattern recognition and memory exercises, where patients engage in digital puzzle solving with progressive complexity levels, picture sequence memorization, shape and pattern matching exercises, and timed recall challenges. This is followed by executive function training, which includes color-word association tasks, reverse counting exercises (such as counting backward from 100 by 7s), strategic planning games, and digital Gomoku with adaptive difficulty settings. The session concludes with a 15-20 minutes language and creativity segment, featuring a unique seven-word story creation exercise, word association challenges, verbal fluency tasks, and narrative construction exercises.

Throughout the cognitive training, careful attention is paid to progressive difficulty adjustment based on weekly performance assessments. The program incorporates a comprehensive monitoring system tracking completion times, accuracy rates, fatigue levels, strategy development, and creativity in storytelling. This systematic approach ensures that each cognitive domain working memory, visual-spatial processing, executive function, attention span, and processing speed receives appropriate attention and challenge levels. The entire cognitive training program maintains a balance between challenge and achievability, with regular feedback and encouragement provided to maintain patient engagement and motivation throughout the 16-week program.

Evaluation methods

A self-designed general information questionnaire was used to investigate the subjects’ age, gender, education level, height, weight, number of chronic diseases, and daily living abilities.

Frailty status: The Tilburg frailty indicator (TF)[19] was used for assessment. This scale includes three dimensions: Physical frailty, psychological frailty, and social frailty, with 15 items. The scoring range is 0-15; scores > 5 indicate frailty, with higher scores reflecting greater frailty severity.

Cognitive function: The MoCA was used for evaluation. This scale assesses visuospatial processing, naming, memory, attention, language fluency, abstraction, delayed recall, and orientation. The total score ranges from 0 to 30, with higher scores indicating better cognitive levels.

Balance and gait function: The Tinetti performance oriented mobility assessment (POMA)[20] was used for evaluation. This scale includes balance (9 items, 16 points) and gait tests (8 items, 12 points), with a total score of 28. Lower scores indicate poorer motor function.

Self-efficacy: The effect was assessed by comparing changes in the general self-efficacy scale (GSES) scores[21], before and after nursing intervention. This scale includes 10 items, each scored from 1 to 4, with a total score ranging from 10 to 40. Higher scores indicate stronger self-efficacy.

Psychological status: The hospital anxiety and depression scale[18] was used to assess psychological status, with anxiety and depression subscales totaling 14 items. Scores > 8 indicate anxiety or depression.

Quality of life: The 36-item short form survey (SF-36)[22] was used. It includes 36 items across eight dimensions: Physical functioning, role physical, bodily pain, vitality, social functioning, role emotional, mental health, and general health. These dimensions are grouped into physical health (first four) and mental health (last four) to evaluate overall health. Scores range from 0 to 100, with higher scores indicating better quality of life.

Data collection

Demographic and baseline data were collected before the intervention, and data were collected again in the 16^th week of intervention. If participants were unable to fill out the forms themselves, researchers assisted or conducted interviews to objectively record the information.

Statistical analysis

Data were entered using EpiData 3.1 and analyzed with statistical product and service solutions 26.0. Normally distributed data are expressed as mean ± SD, and group comparisons were made using t-tests. Categorical data are presented as frequencies and percentages, with group comparisons using χ² tests. Amos was used to draw a structural equation model of factors affecting frailty. A significance level of P < 0.05 was considered statistically significant.

RESULTS

Comparison of frailty status and cognitive function before and after intervention

Before the intervention, there was no statistically significant difference between the observation and control groups in TF scores (7.80 ± 1.19 vs 7.92 ± 1.17) and MoCA scores (21.20 ± 1.56 vs 20.80 ± 1.48) (P > 0.05). After the intervention, the TF score in the observation group (5.32 ± 0.69) was significantly lower than that of the control group (5.71 ± 0.55), with a statistically significant difference (P < 0.05). The MoCA score in the control group (23.43 ± 1.40) was significantly lower than that of the observation group (24.06 ± 0.99), with a statistically significant difference (P < 0.05), as shown in Table 1.

Table 1 Comparison of Tilburg frailty indicator scores and Montreal cognitive assessment scores before and after intervention in both groups.

Group	TF scores		MoCA scores
	Before intervention	After intervention	Before intervention	After intervention
Trial group (n = 65)	7.80 ± 1.19	5.32 ± 0.69	21.20 ± 1.56	24.06 ± 0.99
Control group (n = 65)	7.92 ± 1.17	5.71 ± 0.55	20.80 ± 1.48	23.43 ± 1.40
t	-0.593	-3.520	1.498	2.889
P value	0.554	0.001	0.137	0.005

TF: Tilburg frailty indicator; MoCA: Montreal cognitive assessment scores.

Comparison of balance and gait function before and after intervention in both groups

Before the intervention, there was no statistically significant difference between the observation and control groups in POMA scores (19.20 ± 1.48 vs 19.58 ± 1.14) and self-efficacy (19.49 ± 4.45 vs 18.47 ± 4.63) (P > 0.05). After the intervention, the POMA scores (21.15 ± 1.26 vs 21.81 ± 1.24) and GSES (28.27 ± 2.66 vs 30.05 ± 2.66) in the control group were significantly lower than those in the observation group, with a statistically significant difference (P < 0.05), as shown in Table 2.

Table 2 Comparison of Tinetti performance oriented mobility assessment and general self-efficacy scale scores before and after intervention in both groups.

Group	POMA scores		GSES scores
	Before intervention	After intervention	Before intervention	After intervention
Trial group (n = 65)	19.20 ± 1.48	21.81 ± 1.24	19.49 ± 4.45	30.05 ± 2.66
Control group (n = 65)	19.58 ± 1.14	21.15 ± 1.26	18.47 ± 4.63	28.27 ± 2.66
t	-1.657	3.126	1.319	3.931
P value	0.100	0.002	0.189	< 0.001

POMA: Tinetti performance oriented mobility assessment; GSES: General self-efficacy scale.

Comparison of psychological status before and after intervention in both groups

Before the intervention, there was no statistically significant difference in HAMD scores for anxiety (8.24 ± 0.68 vs 8.30 ± 0.65) and depression (8.37 ± 0.72 vs 8.51 ± 0.69) between the observation and control groups (P > 0.05). After the intervention, both anxiety (5.86 ± 0.68 vs 6.21 ± 0.64) and depression scores (5.67 ± 0.75 vs 6.27 ± 0.92) significantly decreased, with the observation group scoring lower than the control group. These differences were statistically significant (P < 0.05), as shown in Table 3.

Table 3 Comparison of Hamilton depression scale scores before and after intervention.

Group	Before intervention		After intervention
	Anxiety	Depression	Anxiety	Depression
Trial group (n = 65)	8.24 ± 0.68	8.37 ± 0.72	5.86 ± 0.68	5.67 ± 0.75
Control group (n = 65)	8.30 ± 0.65	8.51 ± 0.69	6.21 ± 0.64	6.27 ± 0.92
t	-0.522	-1.122	-3.030	-4.052
P value	0.603	0.264	0.003	< 0.001

Comparison of quality of life before and after intervention in both groups

Before the intervention, there was no statistically significant difference between the observation and control groups in SF-36 scores for physical functioning (60.60 ± 3.73 vs 59.31 ± 4.02), role physical (61.25 ± 3.52 vs 60.77 ± 3.51), bodily pain (60.11 ± 3.18 vs 60.11 ± 3.18), vitality (61.14 ± 3.30 vs 60.17 ± 3.63), social functioning (58.05 ± 3.37 vs 58.28 ± 3.05), role emotional (58.17 ± 2.69 vs 58.22 ± 3.58), mental health (55.09 ± 2.51 vs 57.80 ± 2.37), and general health (56.91 ± 3.16 vs 57.38 ± 3.17) (P > 0.05). After the intervention, the observation group scored higher than the control group in physical functioning (89.42 ± 5.05 vs 77.25 ± 3.98), role physical (87.72 ± 5.04 vs 78.91 ± 4.02), bodily pain (87.75 ± 5.17 vs 79.75 ± 3.97), vitality (88.23 ± 4.03 vs 78.43 ± 5.17), social functioning (88.69 ± 5.19 vs 78.28 ± 3.37), role emotional (82.85 ± 4.72 vs 79.28 ± 3.37), mental health (87.88 ± 4.64 vs 78.31 ± 3.87), and general health (87.60 ± 4.62 vs 82.49 ± 3.21). These differences were statistically significant (P < 0.05), as shown in Table 4.

Table 4 Comparison of 36-item short form survey scores before and after intervention in both groups.

Items	Before intervention				After intervention
	Trial group	Control group	t	P value	Trial group	Control group	t	P value
Physical function	60.60 ± 3.73	59.31 ± 4.02	1.898	0.060	89.42 ± 5.05	77.25 ± 3.98	15.248	< 0.001
Role physical	61.25 ± 3.52	60.77 ± 3.51	0.772	0.442	87.72 ± 5.04	78.91 ± 4.02	11.019	< 0.001
Bodily pain	60.11 ± 3.18	61.22 ± 3.51	-1.873	0.063	87.75 ± 5.17	79.75 ± 3.97	9.500	< 0.001
Vitality	61.14 ± 3.30	60.17 ± 3.63	1.586	0.115	88.23 ± 4.03	78.43 ± 5.17	8.178	< 0.001
Social function	58.05 ± 3.37	58.28 ± 3.05	-0.409	0.686	88.69 ± 5.19	78.28 ± 3.37	11.282	< 0.001
Mental health	55.09 ± 2.51	57.80 ± 2.37	0.681	0.497	87.88 ± 4.64	78.31 ± 3.87	12.762	< 0.001
Role emotional	58.17 ± 2.69	58.22 ± 3.58	-0.083	0.934	82.85 ± 4.72	79.28 ± 3.37	4.956	< 0.001
General health	56.91 ± 3.16	57.38 ± 3.17	-0.865	0.398	87.60 ± 4.62	82.49 ± 3.21	7.316	< 0.001

Receiver operating characteristic curve analysis of GSES, HAMD, and SF-36 for predicting frailty in elderly patients

The study showed that the goodness of fit for GSES, HAMD, and SF-36 scores was good, with the area under the curve (AUC) being 0.607, 0.588, and 0.700, respectively. The AUC for SF-36 in predicting frailty in elderly patients was significantly higher than that of GSES and HAMD, with a statistically significant difference (P < 0.01, Figure 1).

Figure 1 Receiver operating characteristic curve analysis of general self-efficacy scale, Hamilton depression scale, and 36-item short form survey for predicting frailty in elderly patients. GSES: General self-efficacy scale; SF-36: 36-item short form survey; HADS: Hamilton depression scale.

Structural equation model of factors influencing frailty

Path analysis results showed that self-efficacy and quality of life have a strong direct positive effect on patients’ frailty status, with path coefficients of 1.03 and 0.10, respectively (P < 0.05). Negative emotions have a strong direct negative effect on frailty, with a path coefficient of -0.56 (P < 0.05), as shown in Figure 2.

Figure 2 Structural equation model of factors influencing frailty. Yex1-3 represent cognitive frailty, balance and gait function, and physical frailty; tx1-3 represent physical, emotional, and social dimensions; qx1-2 represent anxiety and depression; zc1-3 represent emotional dimension, motivational dimension, and cognitive dimension. GSES: General self-efficacy scale; SF-36: 36-item short form survey; HADS: Hamilton depression scale; TF: Tilburg frailty indicator.

DISCUSSION

Frailty, cognitive impairment, and depression interact and collectively promote the occurrence and development of cognitive frailty[23]. These three factors form a dynamic process, and targeted interventions for cognitively frail elderly individuals can have positive effects in delaying or even reversing the progression of cognitive frailty[24]. The results of this study show that, compared to the control group, the observation group had reduced TF scores, anxiety, and depression scores, and increased MOCA scores, POMA scores, self-efficacy, and SF-36 scores after the intervention. This indicates that exercise-cognitive dual-task training helps improve frailty, enhance cognitive function and gait balance, and improve psychological state and quality of life. Multimodal interventions can improve the cognitive frailty of the elderly and reduce adverse health outcomes[25]. Dual-tasking involves simultaneously completing two tasks with different goals that can be performed and measured independently. The task integration model suggests that dual-task training effectively integrates two tasks to improve dual-task performance[26]. Exercise-cognitive dual-task training focuses on the interaction between cognitive and muscular behavior control, simulating real-life multitasking scenarios, and improving cognitive and physical functions through mechanisms like neurogenesis and neuronal proliferation[27]. The study results show that exercise-cognitive dual-task training, as a diversified intervention, can improve frailty and reduce anxiety and depression levels in the elderly, consistent with previous research[23]. Menengi Ç et al[11] indicates that exercise-cognitive dual-task training can significantly alter cognitive and activity abilities, enhance functional independence and caregiver well-being, and alleviate anxiety and depression symptoms. The exercise in dual-task training combines the benefits of aerobic, balance, and flexibility training, while cognitive training enhances short-term memory, attention, information processing, and problem-solving abilities[28].

Research indicates that after age 65, brain volume decreases by 0.5% to 1.0% annually, and hippocampal volume decreases by 1% to 2% annually, increasing the risk of cognitive impairment[29]. Additionally, reduced cardiac output, muscle mass, blood circulation, toxin invasion, and decreased oxidase activity lower physical capabilities, making this population prone to frailty[30]. Silva et al[31] found that combining aerobic, resistance, and strength training can improve functional abilities in healthy elderly individuals. In this study, exercise-cognitive dual-task training improved cognitive levels in cognitively frail elderly individuals, similar to findings by Bae et al[32]. The reason is that exercise-cognitive dual-task training uses motor relearning methods, where diverse and repetitive training helps nerve cells establish new synaptic chains, improving central nervous system function. Skeletal muscle is also an important endocrine organ, and exercise training promotes the secretion of cathepsin B, which crosses the blood-brain barrier and induces increased secretion of hippocampal brain-derived neurotrophic factor, regulating synaptic plasticity and neuronal connections, and improving memory[33]. Therefore, long-term dual-task training allows the elderly to allocate limited cognitive capacity to the most important tasks, improving time management and attention-shifting strategies, enhancing the initiation function of cortical executive areas, and significantly improving attention and executive function.

This study observed that patients in the intervention group who underwent a 16-week exercise program combining motor and cognitive dual tasks showed improvements in frailty, gait balance, and self-efficacy. This may be attributed to the exercise regimen developed in this study, which requires coordination of hands and feet for resistance exercises, leading to enhanced lower limb muscle strength, increased walking speed, and effective improvements in physical functionality, flexibility, and balance. Self-efficacy refers to the confidence in one’s ability to successfully perform health behaviors, and it is theoretically grounded in Bandura’s self-efficacy theory, a core concept of social cognitive theory and a psychological domain. Self-efficacy is influenced by physiological and social functions and is associated with frailty and various disabilities[34]. Elderly patients, due to the annual decline in perception and memory, may have incomplete self-management, while good social support, especially mutual communication among peers, can form positive coping strategies, thereby slowing down the overall process of frailty[35]. Therefore, it is suggested that clinical workers should develop appropriate health guidance based on the patient’s condition, enabling patients to achieve goals more easily and gain a sense of accomplishment, reducing frailty. However, the study by Rodrigues et al[36] showed that in healthy elderly people, lower or upper limb strengthening exercises and aerobic exercises (60% of maximum oxygen consumption) had no effect on cognitive status. Therefore, some scholars suggest that in addition to balance and strengthening activities, cognitive activity interventions should also be carried out, which can improve cognitive status more than just exercise alone[37]. Morita et al[38] showed that combining lower limb strengthening exercises with cognitive task training (including simple arithmetic calculations, naming animals, and word generation) can improve cognitive function in elderly patients compared to those who do not engage in exercise. Lee et al[39] showed that a multi-component exercise consisting of stretching, strengthening, balance exercises, aerobic exercises, and dual-task training can improve the cognitive status of elderly people with mild cognitive impairment. Cognitively frail elderly have limited attention resource allocation capabilities, reducing the allocation of attention to posture control, leading to falls[40], studies have shown that motor-cognitive dual-task training can effectively prevent falls in stroke, brain injury, and Parkinson patients, improving their balance function and gait performance[41]. In this study, during the training process, the intervention group performed tasks such as number addition and subtraction or semantic naming while sitting or standing, dual training can optimize cognitive allocation strategies, improve cognitive switching speed, increase the volume of the prefrontal cortex in the elderly, delay the atrophy of brain areas such as the hippocampus, and simultaneously enhance memory and improve the executive functions of the brain[42], motor-cognitive dual-task training focuses on the mutual influence of cognition and muscle behavior control, simulates multi-tasking scenarios in real life, improves the ability of the elderly to complete multiple tasks at the same time, and thereby reduces the risk of falls. In addition, this study shows that negative emotions such as anxiety and depression have a direct negative effect on patient frailty, indicating that the higher the level of anxiety and depression, the less observable the individual’s frailty. In clinical practice, patients often lack understanding of the disease, thinking that exercise will worsen the condition, coupled with a lack of daily living skills, are prone to anxiety, depression and other negative emotions, and are reluctant to cooperate with rehabilitation training, making patients less motivated and affecting rehabilitation motivation[43]. Considering the structural equation model and clinical practice experience, when nursing patients, attention should be paid to the social support and negative emotions of patients, and their psychological support should be strengthened to help them reduce the negative effects of adverse emotions.

Recent neuroscientific evidence provides deeper insights into the neurobiological mechanisms underlying the effectiveness of exercise-cognitive dual-task training. Beyond the established pathways of cathepsin B and brain-derived neurotrophic factor, this training approach appears to trigger multiple complementary neural processes. Exercise induces the release of myokines from contracting skeletal muscles, which can cross the blood-brain barrier and promote neuroplasticity in key cognitive areas. Simultaneously, the cognitive demands of dual-tasking activate the prefrontal-parietal network, enhancing neural efficiency through increased dendritic branching and synaptogenesis. The concurrent activation of motor and cognitive circuits during dual-task training appears to strengthen the connectivity between the cerebellum and prefrontal cortex, improving both motor learning and executive function. Furthermore, this integrated training approach has been shown to upregulate the expression of synaptic proteins and increase the density of dendritic spines in the hippocampus, particularly in the CA1 and CA3 regions critical for spatial memory and pattern recognition. The simultaneous engagement of physical and cognitive processes also promotes increased cerebral blood flow and enhanced glucose metabolism in the anterior cingulate cortex and dorsolateral prefrontal cortex, areas crucial for attention allocation and executive control[44,45]. This neurobiological synergy may explain why dual-task training shows superior outcomes compared to single-domain interventions in improving both physical and cognitive functions in cognitively frail elderly individuals.

CONCLUSION

In summary, motor-cognitive dual-task training has positive clinical significance in improving the frailty status, cognitive function, and physical motor function of elderly patients with cognitive frailty. However, this study has limitations such as a small sample size and convenience sampling leading to insufficient representativeness of the sample. Due to the limitations of the study time, this study did not follow up on the long-term intervention effects of dual-task training on cognitively frail patients. These shortcomings can be improved in future work, such as adopting computerized cognitive training, and through long-term prospective studies to assess the sustained effects of dual-task intervention in improving cognitive frailty, providing stronger evidence for the inclusion of dual-task training in the rehabilitation plan for elderly cognitive frailty.