Langlois, F., Vu, T.T.M., Chass, K., Dupuis, G., Kergoat, M.J., & Bherer, L., (2012).

Benefits of physical exercise training on cognition and quality of life in frail olderadults. Journals of Gerontology
Series B: Psychological Sciences and Social Sciences, 68(3), 400404, doi:10.1093/geronb/gbs069. Advance Access publication August 28, 2012

Benefits of Physical Exercise Training on Cognition and

Quality of Life in Frail OlderAdults
FrancisLanglois,1,2 Thien Tuong MinhVu,2,3 KathleenChass,2 GillesDupuis,1,4 Marie-JeanneKergoat,2
and LouisBherer1,2

1
Dpartement de psychologie, Universit du Qubec Montral (UQAM), Montral, Canada.
2
Institut universitaire de griatrie de Montral (IUGM), Montral, Canada.
3
Centre hospitalier de luniversit de Montral (CHUM), Montral, Canada.
4
Institut de Cardiologie de Montral, Montral, Canada.

Objectives. Frailty is a state of vulnerability associated with increased risks of fall, hospitalization, cognitive deficits,

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and psychological distress. Studies with healthy senior suggest that physical exercise can help improve cognition and
quality of life. Whether frail older adults can show such benefits remains to be documented.

Method. Atotal of 83 participants aged 6189years were assigned to an exercise-training group (3 times a week for
12 weeks) or a control group (waiting list). Frailty was determined by a complete geriatric examination using specific
criteria. Pre- and post-test measures assessed physical capacity, cognitive performance, and quality of life.

Results. Compared with controls, the intervention group showed significant improvement in physical capacity (func-
tional capacities and physical endurance), cognitive performance (executive functions, processing speed, and working
memory), and quality of life (global quality of life, leisure activities, physical capacity, social/family relationships, and
physical health). Benefits were overall equivalent between frail and nonfrail participants.

Discussion. Physical exercise training leads to improved cognitive functioning and psychological well-being in frail
older adults.

Key Words: AgingFrailtyPhysical exerciseCognitive impairmentQuality of life.

R ecent studies suggest that exercise-training inter-

ventions can lead to significant improvement in cog-
nitive performances (Angevaren, Aufdemkampe, Verhaar,
Aleman, & Vanhees, 2008) and enhanced quality of life
(Elavsky etal., 2005). However, most studies published so
far involved healthy community dwellers with few medi-
cal conditions and no limiting factors for exercise. Whether
exercise interventions can lead to cognitive and psychologi-
cal benefits in patients with chronic diseases and complex
geriatric syndromes remains to be documented.
Frailty is an emerging geriatric syndrome that can
severely limit physical activity and exercise. Frailty refers
to a complex health state of increased vulnerability to stress-
ors due to impairments in multiple systems, and increased
risks of adverse outcomes such as disability, falls, hospi-
talization, and death (Fried etal., 2001). Although concep-
tion and operationalization of frailty might differ (Bergman
etal., 2007), it has gained increased attention among health
professionals as being a frame of reference for risk quantifi-
cation and prognosis in elderly populations (Lekan, 2009).
The prevalence of frailty increases significantly with aging
(Rockwood, Song, & Mitnitski, 2011). In addition to reduced
physical capacity, frail older adults show specific cognitive
deficits in executive functions and processing speed as well
as reduced quality of life (Langlois etal., 2012).
There is urgent need to find intervention approaches that
would reduce the negative impacts of frailty and thereby
lessen its social and economical impacts. This study assessed
the effects of physical exercise training on cognition and
quality of life in frail and nonfrail older adults. Based on
findings that exercise training help enhance physical capac-
ity and endurance in frail older adults (Barreto, 2009; Chin,
van Uffelen, Riphagen, & van Mechelen, 2008), we hypoth-
esized that both frail and nonfrail older adults would show
significant gain on cognition and quality of life.
Method
Participants
Eighty-three participants aged 6189 participated in this
study. They underwent a complete geriatric assessment
to ensure that they could perform a physical exercise pro-
gram at low risk. Participants were excluded if they showed
limitations to undertake a physical exercise program, or
signs of dementia (<25 at the mini-mental state examina-
tion [MMSE]; Folstein, 1975), or depression (>10 at the
Geriatric depression scale; Yesavage etal., 1982).
Participants were categorized as frail if they met at least
two of the three following diagnostic criteria: (a) three of
the five symptoms of frailty, as defined by Fried etal. (2001)

400 The Author 2012. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Received October 27, 2011; Accepted June 26, 2012
Decision Editor: Bob G.Knight, PhD
 PHYSICAL EXERCISE FOR FRAIL OLDER ADULTS 401

Table1. Baseline Characteristics of Participants

Control group (n=36) Training group (n=36) Frail vs. nonfrail Control vs. training
Characteristics Nonfrail (n=19) Frail (n=17) Nonfrail (n=19) Frail (n=17) p Value p Value
Age, M SD 70.955.38 75.414.91 68.745.52 74.476.99 <.001 .25
Female, n (%) 17 (89.47) 13 (76.47) 14 (73.68) 12 (70.59) .41 .26
Education, M SD 13.002.71 12.684.33 15.473.12 13.354.92 .19 .09
Cardiovascular diseases, total M SD 0.790.92 1.531.23 1.111.29 2.121.27 .003 .11
Hypertension, n (%) 7 (36.84) 10 (58.82) 8 (42.11) 14 (82.35) .009 .24
Diabetes mellitus, n (%) 1 (5.26) 4 (23.53) 2 (10.53) 2 (11.76) .21 .72
Dyslipidemia, n (%) 6 (31.58) 7 (41.18) 7 (36.84) 13 (76.47) .04 .10
Heart failure, n (%) 0 (0) 0 (0) 0 (0) 1 (5.88) .29 .32
Arrhythmia, n (%) 1 (5.26) 1 (5.88) 1 (5.26) 2 (11.76) .55 .64
Valvular disease, n (%) 0 (0) 3 (17.65) 1 (5.26) 1 (5.88) .13 .64
Musculoskeletal disorders, total M SD 2.581.61 4.593.06 3.052.97 6.354.86 .001 .15
Head and neck problems, n (%) 4 (21.05) 4 (23.53) 6 (31.58) 6 (35.29) .77 .29
Arthritis, n (%) 11 (57.89) 11 (64.71) 13 (68.42) 13 (76.47) .50 .32

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Osteoporosis, n (%) 5 (26.32) 6 (35.29) 0 (0) 3 (17.65) .15 .02
History of fractures, n (%) 3 (15.79) 6 (35.29) 4 (21.05) 5 (29.41) .17 1.00
Poor standing posture, n (%) 0 (0) 3 (17.65) 0 (0) 4 (23.53) .003 .69
Irregular gait pattern, n (%) 2 (10.53) 4 (23.53) 1 (5.26) 7 (41.18) .01 .55
Gastrointestinal, total M SD 0.631.01 0.941.25 0.681.42 1.591.73 .07 .28
Swallowing difficulty, n (%) 1 (5.26) 1 (5.88) 1 (5.26) 7 (41.18) .03 .04
Pyrosis or reflux, n (%) 2 (10.53) 3 (17.65) 6 (31.58) 5 (29.41) .80 .09
Digestive problems, n (%) 5 (26.32) 6 (35.29) 2 (10.53) 7 (41.18) .06 .60
Pulmonary disease, total M SD 0.47 (0.96) 0.59 (0.94) 0.32 (0.48) 0.65 (1.00) .27 .81
Asthma, n (%) 1 (5.26) 3 (17.65) 1 (5.26) 1 (5.88) .32 .39
COPD, n (%) 2 (10.53) 3 (17.65) 1 (5.26) 1 (5.88) .58 .23
History of depression, n (%) 2 (10.53) 2 (11.76) 5 (26.32) 7 (41.18) .41 .02
Mobility aids, n (%) 1 (5.26) 4 (23.53) 1 (5.26) 4 (23.53) .03 1.00
At least one ADL or IADL disability, n (%) 1 (5.26) 6 (35.29) 2 (10.53) 10 (58.82) <.001 .18
Number of daily medications, M SD 3.742.71 6.123.82 3.792.96 6.712.69 <.001 .66

Notes. ADL=activity of daily living; COPD=chronic obstructive pulmonary disease; IADL=instrumental activity of daily living.
Chi-square tests were used for categorical variables, and ANOVAs were used for continuous variables.

(muscular weakness, slow walking speed, fatigability,
sedentarity, and unintentional weight lost); (b) a score of
28/36 on the modified Physical Performance Test (PPT;
Binder et al., 2004); and (c) identified as frail according
to the geriatricians judgment (mildly frail or worse on the
clinical frailty scale) after assessing the 70 possible deficits
of the frailty index (Rockwood etal., 2005). To be classified
as nonfrail, participants could not meet any of these three
frailty criteria.
This was a matched-control group design in which partic-
ipants were randomly assigned to the control or the training
conditions to form subgroups of three to five participants,
while ensuring that the female-to-male ratio was equivalent
in each group of frail and nonfrail participants.
The physical exercise-training program consisted of
12 weeks of 1-h exercise session 3days a week. Training
was conducted in subgroups of three to five participants to
ensure adequate supervision. Each session included 10min
of warm up exercises (stretching and balancing), 1030min
of aerobic workout (using treadmills, recumbent bikes,
and elliptical), and 10min of strength training, followed
by 10min of cool down exercises. The intensity and dura-
tion of the aerobic exercises were increased individually,
using the modified Borg Rating of Perceived Exertion scale
(010) to reach moderate to hard intensity.
Participants in the control group were instructed to main-
tain their current level of activity during the entire study
period. After participating in the study, they were offered
the opportunity to join a physical training program. Table1
presents baseline demographic and medical characteristics
of participants. There was no significant difference between
the training and control groups at baseline in physical
capacity, cognitive, and quality oflife.
Measures
Pre- and post-test assessments took place within 1 week
before and after the 12-week study period. Physical capac-
ity, cognition, and quality of life, were assessed in the same
order in three different sessions, with 1day of rest between
eachsession.
The physical capacity assessment included the modi-
fied PPT, grip strength (hand-held dynamometer), physical
endurance (6-Minute Walk Test [MWT]), mobility (Timed
Up and Go Test), and gait speed (mean score of comfortable
and maximum gaitspeed).
The cognitive evaluation involved six cognitive domains:
(a) global cognitive functioning (MMSE), (b) abstract verbal
reasoning (Similarities of the Wechsler Adult Intelligence
Scale [WAIS-III]), (c) processing speed (composite score of
the Digit-Symbol Coding subtest of the WAIS-III), the Trail
402 LANGLOIS ET AL.
Making Test (TMT) part A, and the naming and reading
conditions of the modified Stroop Color-Word Test, (d)
working memory (composite score of the Letter-Number
Sequencing and the Digit Span backward subtests of the
WAIS-III), (e) episodic memory (composite score of the
Rey Auditory Verbal Learning Test), and (f) executive
functions (composite score of the TMT part B minus part
A, and the Interference and flexibility conditions of the
modified Stroop Color-Word Test minus the naming and
reading conditions). Composite scores (X) were created
based on an equally unit-weighted approach using z scores:
composite score (X)=mean (z score A, z score B, z score
C, ...). All measures used for each composite score were
highly intercorrelated and were found to measure a specific
cognitive function.
The Quality of Life Systemic Inventory questionnaire
(Duquette, Dupuis, & Perrault, 1994) assessed the capac-
ity to achieve personal goals in 28 life domains (e.g., mari-
tal life, self-esteem, and sleep) and provide quality of life
scores in nine dimensions depicted in Figure1.
StatisticalAnalyses
Given that frail and nonfrail participants differed in baseline
functioning and to allow scores comparison from differ-
ent measurement scales on a common scale, z scores were
computed on raw scores by subtracting individual scores
to the groups mean (pre and post combined), divided by
the groups standard deviation (pre and post combined).
Intervention effects were assessed on z score change
from pre-test to post-test. Z score change provides a reli-
able measure of the intervention effect size, which allows
comparison of both experimental groups (control vs. inter-
vention) and frailty condition (frail vs. nonfrail) using a
standardizedmethod.
Three multivariate analyses of variance (MANOVAs)
were performed on all dependent variables of each dimen-
sion: physical capacity, cognition, and quality of life.
Dependent variables were z score change. Group (interven-
tion vs. control) and frailty (frail vs. nonfrail) were fixed
factors. Follow-up analyses were performed using univari-
ate ANOVAs. Significance level was set at .05. Analyses
were performed with SPSS statistical software, version 16.0
(SPSS Inc., Chicago, IL).
Results
In the intervention group, 36/43 participants completed the
study (3 frail and 4 nonfrail participants dropped out before
completion due to schedule conflict [3], medical [3], or per-
sonal [1] complications). In the control group, 36/40 seniors
completed the study (2 frail and 2 nonfrail participants did
not attend the post-test session). Participants who dropped
out were comparable to those who completed the study
on all physical, cognitive, and psychological measures.
Intent-to-treat analyses performed with the data available
for the 11 participants who did not complete the study did
not modify any of the reportedresults.
Figure1 shows the z score change for each variable of
the three dimensions: physical capacity, cognitive function,
and quality of life.
PhysicalCapacity
Results from the MANOVA showed a significant main effect
of group, F(5, 63)=9.47, p < .001, due to a larger improve-
ment in the training group compared with the control group
in functional capacity (PPT), F(1, 68) = 24.03, p < .001,
and physical endurance (6-MWT), F(1, 68)=4.79, p=.03.
No effect of training was found on gait speed (p = .58),
mobility (p=.26), or grip strength (p=.08). The group
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frailty interaction was not significant, F(5, 63)=1.58, n.s.,
although improvement in functional capacity (PPT) was
larger in frail (z score change=.79) than in nonfrail partici-
pants (z score change=.36). Improvement at the 6-MWT
was equivalent in frail (z score change of .33) and nonfrail
individuals (z score change=.20).
Cognition
A significant main group effect, F(6, 63)=3.27, p=.007,
was observed, due to larger improvement in the training
group in processing speed, F(1, 68)=6.38, p=.014, work-
ing memory, F(1, 68)=4.61, p=.035, and executive func-
tions F(1, 68)=4.45, p=.039. There was no group frailty
interaction, F(6, 63)< 1.Respectively for frail and nonfrail
individuals, z score changes were .24 and .35 in processing
speed, .35 and .13 in working memory, and .36 and .24 in
executive functions.
Quality ofLife
A main group effect was observed in Quality of Life,
F(11, 58)=2.04, p=.04, due to larger gains in the train-
ing group compared with the control group in global qual-
ity of life, F(1, 68)=3.97, p=.05, leisure activities, F(1,
68)=9.13, p=.004, perception of physical capacity, F(1,
68) = 5.76, p = .019, social/family relationships, F(1,
68)=4.41, p=.039, and physical health, F(1, 68)=4.40,
p=.040. No group frailty interaction was found, F(11,
58)< 1.Respectively for frail and nonfrail elders, z score
changes were .09 and .30 in global quality of life, .35 and
.52 in leisure activities, .44 and .34 in perception of physi-
cal capacity, .14 and .35 in social/family relationships, and
.27 and .14 in self-perceived physical health.
Discussion
The effect of a 3-month physical exercise intervention
was assessed in frail and nonfrail older adults on three
dimensions: physical capacity, cognitive performance,
and quality of life. Training-related improvement was
observed in functional capacity, physical endurance,
 PHYSICAL EXERCISE FOR FRAIL OLDER ADULTS 403

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Figure1. Z score change in the training and control groups for each measure of the three dimensions: physical capacity (top panel), cognition (middle panel), and
quality of life (lower panel). *p .05. **p .01. ***p .001.

executive functioning, processing speed, working mem-
ory, and self-reported quality of life in leisure activities,
physical capacity, social/family relationships, and health.
Benefits were overall equivalent in frail and nonfrail
participants.
Improvement in physical capacity replicates past findings
with frails seniors (Chin etal., 2008), although some stud-
ies did not report such benefits (Faber, Bosscher, Chin, &
van Wieringen, 2006). Positive results report here might be
related to individualize adapted training, which might have
maximized training effects. Although past studies reported
exercise-induced improvement in cognition in healthy older
adults (Colcombe & Kramer, 2003), this study is the first
to report enhanced cognitive performances in frail older
adults. Larger gains were observed in executive control,
processing speed, and working memory, all playing a criti-
cal role in everyday activities, such as driving, cooking, or
managing finances.
404 LANGLOIS ET AL.
It is noteworthy that frail older adults tolerated very well
the physical training program designed by a kinesiologist and
the dropout rate was very low (16.3%). This could be due to
the fact that training was individualized and adapted to the
strength and needs of the participant, based on the geriat-
ric examination and a physical therapists assessment. This
might also very well explain the substantial benefits observed
in this study. While the frailty condition improved signifi-
cantly in all dimensions (i.e., physical capacity, cognition,
and quality of life), it is unlikely that only a 3-month exercise
program is sufficient to reverse frailty condition, and this was
not formally assessed in thisstudy.
Future randomized clinical trials including larger sample
sizes and active control groups are required to support the
present findings. Future studies should also assess whether
all executive control mechanisms improve to the same
extent after physical training, as recent reports suggest that
some executive mechanisms might be more age sensitive
than others (Verhaeghen, 2011). Finally, subsequent studies
need to assess whether training-induced cognitive improve-
ments generalize to real life situation.
Funding
F.L. received salary support from the Canadian Institutes of Health
Research (CIHR), and L.B. is supported by the Canadian Research Chair
Program.
Correspondence
Correspondence should be addressed to Louis Bherer, Dpartement
de psychologie, Universit du Qubec Montral (UQAM), CRIUGM,
4545 Queen Mary, Montreal, Quebec, H3W 1W4, Canada. E-mail: bherer.
louis@uqam.ca.
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