918352

research-article2020
CRE0010.1177/0269215520918352Clinical RehabilitationLipardo and Tsang

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Effects of combined physical and 1­–10

© The Author(s) 2020
Article reuse guidelines:
cognitive training on fall prevention sagepub.com/journals-permissions
DOI: 10.1177/0269215520918352
https://doi.org/10.1177/0269215520918352

and risk reduction in older persons journals.sagepub.com/home/cre

with mild cognitive impairment:

a randomized controlled study

Donald S Lipardo1,2 and William WN Tsang1,3

Abstract
Objective: The aim of this study is to investigate the effects of combined physical and cognitive training
on fall rate and risks of falling in older adults with mild cognitive impairment.
Design: The design of this study was an assessor-blinded, randomized controlled trial.
Setting: The setting for this study is the community from Manila, Philippines.
Subjects: In total, 92 community-dwelling older persons with mild cognitive impairment (aged 60–83)
were randomly allocated to three intervention groups and one waitlist control group.
Interventions: The physical training, cognitive training, and combined physical and cognitive training
intervention programs were delivered for 60 to 90 minutes, one to three times per week for 12 weeks
with six-month follow-up.
Main measures: Participants were assessed at baseline, 12 weeks after baseline, and 36 weeks after
baseline for fall incidence, overall fall risk, dynamic balance, walking speed, and lower limb strength.
Results: No significant difference was observed across time and groups on fall incidence rate at
12 weeks (P = 0.152) and at 36 weeks (P = 0.954). The groups did not statistically differ in other
measures except for a significant improvement in dynamic balance based on Timed Up and Go
Test in the combined physical and cognitive training group (9.0 seconds with P = 0.001) and in the
cognitive training alone group (8.6 seconds with P = 0.012) compared to waitlist group (11.1 seconds)
at 36 weeks.
Conclusion: There was no significant difference among groups on fall rate and risks of falling post-
intervention. Dynamic balance was improved with combined physical and cognitive training and cognitive
training alone. Further research with a larger sample size is needed to establish whether or not the
interventions are effective.

1
 epartment of Rehabilitation Sciences, The Hong Kong
D Corresponding author:
Polytechnic University, Hong Kong, China Professor William WN Tsang, Department of Physiotherapy,
2
Department of Physical Therapy, College of Rehabilitation School of Nursing and Health Studies, The Open University of
Sciences, University of Santo Tomas, Manila, Philippines Hong Kong, Kowloon, Hong Kong, China.
3
Department of Physiotherapy, School of Nursing and Health Email: wntsang@ouhk.edu.hk
Studies, The Open University of Hong Kong, Hong Kong,
China
2 Clinical Rehabilitation 00(0)

Keywords
Mild cognitive impairment, older persons, fall incidence, risk of falls

Received: 6 January 2020; accepted: 21 March 2020

Introduction Declaration of Helsinki and obtained ethical

approval from the Human Subjects Ethics Sub-
Older adults with mild cognitive impairment living
committee of the Hong Kong Polytechnic
in the community fall more frequently with a preva-
University–Department of Rehabilitation Sciences
lence rate that is twice higher compared with their
(HSEARS20170402001) and from the Ethics
cognitively intact peers.1 Mild cognitive impairment
Review Committee of the University of Santo
is considered a predictor and risk factor for falls in
Tomas–College of Rehabilitation Sciences (FI-
community-dwelling older persons.2,3 It is defined as
2017-002). The research protocol was registered
the intermediary state of cognitive decline between
with ClinicalTrials.gov (Identifier: NCT03167840)
the normal aging process and dementia.4
and was previously published.10 The study started
Decreased muscle strength, impaired balance
on May 30, 2017, and ended on August 31, 2018.
control, and slower walking speed in combination
This research did not receive any specific grants.
with advancing age and cognitive decline further
Financial support came from the Research
heighten the risk of falling of older persons with
Studentship Scholarship–Associated Money of the
mild cognitive impairment.5,6 An intervention that
Hong Kong Polytechnic University.
integrates physical exercise and cognitive training
Participants were community-dwelling older per-
into one treatment regimen may be the best
sons, aged 60 or above, with mild cognitive impair-
approach to addressing these risk factors simulta-
ment. They were recruited and screened from
neously and efficiently.7,8 In our published system-
Manila, Philippines, by trained personnel through
atic review, we found evidence that combined
the help of the Office of Senior Citizens Affairs. The
exercise and cognitive rehabilitation improve fall-
diagnosis of mild cognitive impairment was deter-
related factors such as cognitive function, balance
mined by a trained neurologist-psychiatrist. It was
control, and walking speed in older adults with
based on the three criteria of Winblad et al.4 which
mild cognitive impairment.9 However, these are
include the following: (1) cognitive level is not nor-
just indirect measures of fall prevention. More
mal nor demented, (2) decrease in cognitive ability
research is needed to report on the direct effect of
as reported by the older person or caregiver, and (3)
the combined intervention on fall incidence.9
normal performance of basic activities of daily liv-
Hence, the objective of this study was to investi-
ing (ADL) but with slight impairment in instrumen-
gate the effects of combined physical exercise and
tal ADL. As a community-based program, only
cognitive training on fall incidence and fall risks
those who are able to ambulate with or without
among older persons with mild cognitive impairment
assistive devices were included. Only those with
living in the community. We hypothesized that when
signed written consent were allowed to participate.
compared to other treatment programs, integrating
Random assignment was performed by an unbi-
cognitive training while doing physical exercise leads
ased observer not connected with the current study
to lower falls incidence and reduced fall risk in com-
by the traditional random picking sealed names of
munity-dwelling older persons with mild cognitive
participants and intervention groups from separate
impairment (MCI).
containers, to blindly allocate each participant to
one of the four groups.
Methods Measurements were taken by blinded assessors
This is a randomized, parallel-group controlled (1) at baseline, (2) at the conclusion of the inter-
study involving three intervention groups and one vention period (12 weeks after baseline), and (3)
waitlist control group. This study conformed to the six months post-intervention (36  weeks after
Lipardo and Tsang 3
baseline). The assessors were physical therapy and
occupational therapy interns who underwent a
total of 24 hours of training from the primary
investigator. Their inter-rater reliability in all out-
come measures was very high (intraclass correla-
tion coefficient (ICC) range = .90–.99).
Information on fall incidence was collected
from the calendar-diaries of the participants with
confirmation from a relative and from the monthly
follow-up phone calls of a research assistant to
minimize recall bias. A fall is defined as “inadvert-
ently coming to rest on the ground, floor or lower
level, excluding intentional change in position to
rest in furniture, wall or other objects.11
The overall risk for falls was measured using
Physiological Profile Assessment–Short Form.12 It
is composed of five subtests, namely: (1) contrast
sensitivity, (2) knee position sense, (3) knee exten-
sor strength, (4) hand reaction time, and (5) postural
sway. A composite score is derived from these tests,
which is used to determine the level of risk for falls.
The Timed Up and Go Test was used to examine
dynamic balance and functional mobility.13 It is
conducted by recording the time in seconds a par-
ticipant can complete the task of standing up from
a chair, walking a distance of three meters, and
walking back and sitting down on the chair.
The 10-Meter Walk Test was used to examine
walking speed.14 It is computed by dividing the dis-
tance covered in meters by the duration in seconds it
takes the participant to walk that distance. The par-
ticipants walked the distance three times at their pre-
ferred pace and three times also at their fastest pace.
The 30-second Chair Stand Test was used to
determine lower extremity muscle strength.15 It
involves counting the number of times a participant
can stand from a chair within 30 seconds.
The three intervention groups were (1) physical
training alone group, (2) combined physical and
cognitive training group, and (3) cognitive training
alone group. The physical training alone group and
the combined physical and cognitive training group
had the same multicomponent exercise program on
balance, strength, endurance, and flexibility, with no
less than one-third focused on balance training.16,17
Both were conducted three times per week over
12 weeks with sessions that lasted 60 to 90 minutes.
This was done to achieve the minimum requirement
of 40 hours of training to prevent falls.16 In both
groups, progression was individualized in order to
maintain a moderate level of exercise which is 5–6
on a 10-point rating scale of perceived physical
exertion.18
The two groups were supervised by five physio-
therapists, with at least two years of clinical experi-
ence, who had one week of pre-study training to
standardize the implementation of the exercise pro-
grams. However, in comparison to the physical train-
ing alone group, the combined physical and cognitive
training group had cognitive training elements incor-
porated in each type of exercise such as walking with
executive training, sit-to-stand with orientation train-
ing, heel and toe raises with attention training, step-
ping in different directions with memory training,
step-ups with attention training, and graded reaching
in standing with executive training.
The cognitive training alone group was involved
in a set of paper-based cognitive exercises on exec-
utive function, memory, attention, and orientation
training with an emphasis on executive func-
tion.19,20 The group sessions of 60 to 90 minutes
duration were conducted once a week for 12 weeks
based on the recommended optimal duration of
cognitive training.21 The program was facilitated
by five occupational therapists, with at least two
years of clinical experience, who had a weeklong
training to standardize the cognitive training prior
to the commencement of the study.
In all three intervention groups, a therapist–par-
ticipant ratio of 1:5 was followed for proper guid-
ance, close monitoring, and immediate feedback,
and to ensure the safety of the participants. While
the programs were delivered in group sessions, the
progression was individually based. The interven-
tions were delivered in three different enclosed
venues in three separate local communities in
Manila to minimize experimental contamination.
The waitlist control group was instructed to go
on with their usual daily routine, habits, and physi-
cal activity level, and would receive the interven-
tion, combined physical and cognitive training, on
a later date after the completion of all the other
intervention groups.
Collected data were encoded in MS Excel and
evaluated using IBM SPSS Statistics version 23 for
Windows (Armonk, New York, United States).
4 Clinical Rehabilitation 00(0)
Figure 1.  CONSORT flow diagram of the study.
CT: cognitive training; PACT: physical and cognitive training; PT: physical training; WG: waitlist group.
Descriptive statistics were used to summarize demo-
graphic data. The fall incidence rate ratio, computed
as the number of fall events divided by the duration
of falls monitoring for every participant, was used to
compare intergroup fall rates.22
The use of multivariate repeated-measures anal-
ysis of variance (ANOVA) was initially planned to
analyze the group, time, and group–time interac-
tion effects. The assumption of variance equality,
however, was violated (P = 0.007). Therefore, to
compare among group differences at baseline, at
12 weeks and at 36 weeks for data with normal dis-
tribution, the one-way ANOVA was used instead;
otherwise, the Kruskal–Wallis test was employed.
Post hoc analysis to determine differences in pair-
wise group comparisons was performed using
Tukey’s HSD (honestly significant difference) test.
To compare within-group changes across time
for data with normal distribution, the repeated-
measures ANOVA with between-group analysis
was utilized. For non-normal data, Friedman’s
ANOVA was applied. Post hoc analysis for time
effects was conducted using Wilcoxon signed-rank
tests with a Bonferroni correction.
An intention-to-treat analysis, with the last
observation carried forward, was used for missing
data due to dropouts. The P value of <0.05 was
considered significant for all computations.
A priori power analysis was conducted using
statistical software G*Power 3.1.9.2 based on fall
rate as the primary outcome. Utilizing a derived
effect size (Cohen’s d = .39),23 with 80% assumed
power and with 5% Type I error for four groups,
the computed total sample size was 80. Factoring
Lipardo and Tsang 5

Table 1.  Baseline sociodemographic characteristics of the randomization groups.

All (N = 92) PACT (n = 23) PT (n = 23) CT (n = 23) WG (n = 23) P

Demographics
  Age (years), median (IQR) 69 (8.3) 67 (8) 73 (7) 68 (7.5) 68 (8.5) 0.079
  Sex (female), n (%) 73 (79) 16 (70) 22 (96) 18 (78) 17 (74) 0.138
  Education (years), median (IQR) 10 (6) 10 (4) 7 (4) 10 (3.5) 10 (6) 0.089
  BMI (kg/m2), M (SD) 23.9 (5.1) 22.7 (4.7) 22.4 (4.9) 25.1 (5.4) 25.3 (5.1) 0.095
Employment status, n (%)
 Retired 49 (53) 12 (52) 10 (43) 15 (65) 12 (52) 0.562
 Working 15 (16) 2 (9) 5 (22) 3 (13) 5 (22)  
  Did not work 28 (31) 9 (39) 8 (35) 5 (22) 6 (26)  
Civil status, n (%)
 Married 28 (30.4) 8 (35) 6 (26) 6 (26) 8 (35) 0.668
 Widowed 49 (53.3) 11 (48) 13 (57) 14 (61) 11 (48)  
 Single 9 (9.8) 1 (4) 4 (17) 2 (9) 2 (9)  
 Separated 6 (6.5) 3 (13) 0 1 (4) 2 (9)  
Living situation, n (%)
  With companion 92 (99) 23 (100) 23 (100) 22 (96) 23 (100) 0.387
 Alone 1 (1.1) 0 0 1 (4.3) 0  
Lifestyle, n (%)
 Smoker 7 (8) 4 (17) 1 (4) 1 (4) 1 (4) 0.243
  Drink alcoholic beverage 16 (17) 5 (22) 1 (4) 5 (22) 5 (22) 0.304
MoCA (0–30), M (SD) 18.3 (4.6) 17.5 (4.7) 17.0 (4.1) 20.4 (4.9) 18.3 (4.1) 0.066
Fall history (past 12 months)
 0 67 (73) 17 (74) 17 (74) 16 (70) 17 (74) 0.326
 1 14 (15) 4 (17) 3 (13) 3 (13) 4 (17)  
 2 7 (8) 1 (4) 3 (13) 3 (13) 0  
 3 4 (4) 1 (4) 0 1 (4) 2 (9)  

PACT: physical and cognitive training; PT: physical training; CT: cognitive training; WG: waitlist group; IQR: interquartile range;
BMI: body mass index; MoCA: Montreal Cognitive Assessment.

in a 16% dropout rate,23 the sample size was raised
to 93 which meant that at least 23 participants
should be in each group.
Results
From 198 older adults recruited on June to August
2017, 185 consented to participate. After screening
for eligibility, 93 participants were excluded due to
various reasons (Figure 1). A total of 92 partici-
pants, aged 60 to 83 years, with mean (SD) age of
69.5 (5.6) years, were included. The participants’
sociodemographic characteristics are shown in
Table 1. No statistically significant differences were
found for these characteristics among the groups.
Figure 1 also shows the reasons for the attrition of
participants in follow-up assessments. In total, 74
had post-intervention assessment at 12  weeks in
December 2017, and 66 completed the follow-up
assessment at 36 weeks in June 2018. No adverse
events were reported during the duration of the study.
Table 2 presents the compliance of participants
in the three intervention groups. Table 3 shows the
fall incidence rates and causes of falls in all four
groups. From baseline to 12 weeks, 13 falls were
reported. From 12 to 36 weeks follow-up, 20 falls
were reported. There was no statistically signifi-
cant difference in fall incidence rate among the
groups at 12 weeks (P = 0.152) and at 36 weeks
(P = 0.954).
6 Clinical Rehabilitation 00(0)

Table 2.  Compliance in the program among the intervention groups.

Randomization groups

  PACT (n = 23) PT (n = 23) CT (n = 23)

Mean duration of supervised participation (hours), M (SD) 40.0 (5.9) 36.6 (11.8) 12.1 (3.9)
Participant with less than the ideal duration of participation. n (%)a 11 (48) 13 (57) 17 (74)

PACT: physical and cognitive training; PT: physical training; CT: cognitive training.
a
Ideal duration of participation is at least 40 hours for PACT and PT, and at least 12 hours for CT.

Table 3.  Fall prevalence and incidence rates in all randomization groups.

Fall rate Time point Randomization groups

  PACT (n = 23) PT (n = 23) CT (n = 23) WG (n = 23)

Fall prevalence rate over Baseline 6 (26) 6 (26) 7 (30) 6 (26)
past 12 months, n (%)
Number of fall events, 12th week 0 (0) 5 (.762) 3 (.558) 5 (.976)
n (fall incidence rate)a   Trip = 3   Trip = 3   Trip = 2
  Slip = 2   Lost balance = 2
  Knee giving away = 1
36th week 4 (.387) 6 (.610) 5 (.488) 5 (.518)
  Trip = 3   Trip = 3   Trip = 5   Trip = 3
  Slip = 1   Slip = 2   Lost balance = 1
  Lost balance = 1   Knee giving away = 1

PACT: physical and cognitive training; PT: physical training; CT: cognitive training; WG: waitlist group.
a
Computed as new fall events per person-year.

Table 4 shows the comparison of outcomes at
baseline, at 12 weeks, and at 36 weeks in all rand-
omization groups. The four groups are statistically
similar at baseline for all outcome measures.
Significant group effect in overall fall risk was
found at 36 weeks (P = 0.043). Post hoc analysis,
however, did not show significant difference in any
pairwise comparisons. Conversely, there was a sig-
nificant time effect (P = 0.003). Post hoc analysis
revealed that only the combined physical and cog-
nitive training group had a statistically significant
reduction in overall fall risk from baseline to 12th
week (P = 0.009) and from baseline to 36th week
(P = 0.001).
Based on the Timed Up and Go Test for dynamic
balance and mobility, significant group effect was
observed at 36th week (P = 0.001). Post hoc analy-
sis revealed that the combined physical and cogni-
tive training group (P = 0.001) and the cognitive
training alone group (P = 0.012) performed the test
statistically faster compared to waitlist group at
36 weeks. Similarly, time effect was significant for
Timed Up and Go Test (P = 0.004). Post hoc analy-
sis showed that significantly faster test perfor-
mance was observed in the combined physical and
cognitive training group only from baseline to 12th
week (P = 0.002), and from baseline to 36th week
(P < 0.001).
The group–time interaction effect was signifi-
cant for preferred walking pace (P = 0.020) and the
fastest walking pace (P = 0.001). No group effects,
however, were observed in both the preferred and
fastest walking paces with P = 0.065 and P = 0.067,
respectively. The time effect was significant for
preferred walking pace (P = 0.004) and fastest
walking pace (P = 0.004). After post hoc analysis,
no statistically significant improvement was com-
puted in the preferred and fastest walking paces in
all groups from 12th to 36th weeks, except for the
cognitive training alone group (P = 0.023).
Lipardo and Tsang 7

Table 4.  Comparison of outcomes at baseline, at 12 weeks, and at 36 weeks in all randomization groups using the
intention-to-treat method.

Outcome measures Time point Randomization groups Effect sizea

PACT PT CT WG  
PPA, median (IQR)b Baseline 3.34 (2.29) 3.55 (2.62) 2.48 (2.25) 3.14 (2.38) .079
12th week 2.65 (1.68) 3.06 (2.56) 2.23 (2.34) 2.75 (3.35) .058
36th week 2.39 (1.40) 3.08 (1.70) 2.22 (1.44) 2.72 (2.16) .088
TUGT (s), median (IQR)b Baseline 10.7 (2.8) 10.6 (3.0) 9.1 (3.0) 10.6 (4.0) .056
12th week 9.34 (2.0) 10.45 (2.6) 8.91 (2.6) 11.2 (3.5) .056
36th week 9.0 (1.3) 9.6 (1.4) 8.6 (2.0) 11.1 (2.6) .098
10MWT, M (SD)  
  Preferred speed (m/s) Baseline 1.08 (0.17) 0.99 (0.18) 1.13 (0.20) 1.02 (0.23) .082
12th week 1.11 (0.18) 1.09 (0.18) 1.20 (0.24) 1.02 (0.21) .091
36th week 1.13 (0.16) 1.09 (0.18) 1.12 (0.21) 1.01 (0.17) .060
  Fastest speed (m/s) Baseline 1.38 (0.23) 1.24 (0.23) 1.51 (0.30) 1.32 (0.32) .116
12th week 1.41 (0.25) 1.39 (0.24) 1.54 (0.31) 1.33 (0.30) .073
36th week 1.42 (0.24) 1.38 (0.23) 1.47 (0.29) 1.31 (0.28) .054
30sCST, median (IQR) Baseline 13 (3) 13 (3) 15 (5.5) 14 (6) .074
12th week 13 (2) 15 (4.5) 15 (5.5) 15 (5) .062
36th week 14 (2) 15 (3) 16 (5) 13 (4) .067

PACT: physical and cognitive training; PT: physical training; CT: cognitive training; WG: waitlist group; PPA: Physiological Profile
Assessment; IQR: interquartile range; TUGT: Timed Up and Go Test; 10MWT: 10-Meter Walk Test; 30sCST: 30-second Chair
Stand Test.
a
Partial χ2.
b
Lower score means better performance. For other assessment procedures, a higher score means better performance.

No significant group effect was observed in the
30-second Chair Stand Test for lower limb muscle
strength at 12 weeks (P = 0.186) and at 36 weeks
(P = 0.110), but there was a significant time effect
(P < 0.001). Post hoc analysis revealed that only
the physical training alone group had a statistically
significant increase in lower extremity muscle
strength from baseline to 12th week (P < 0.001)
and from baseline to 36th week (P = 0.002).
Discussion
In the present study, we found that integrating
cognitive training while performing physical
exercise did not result in lower falls incidence
among older persons with MCI living in the com-
munity. Among the physical risks for falls, we
found significant between-group differences only
in the dynamic balance and mobility. The com-
bined physical and cognitive training group and
the cognitive training alone group showed better
performance in the Timed Up and Go Test com-
pared to the waitlist group.
Despite registering zero incidences at 12 weeks
and lowest reported fall events at 36 weeks in the
combined physical and cognitive training group,
statistically significant difference in comparison
with other groups was not established. In spite of
the initial sample size and power calculation, the
study may be underpowered to possibly detect a
significant difference in fall incidence. Still, the
non-occurrence of falls and the concomitant reduc-
tion in the overall fall risk based on a significantly
lower composite scores in the Physiological Profile
Assessment in the combined physical and cogni-
tive training group, from baseline to 12 weeks, may
be considered as a noteworthy finding. A mainte-
nance program that will engage older persons to
continue the level of physical and cognitive activi-
ties that they had during the program may be
8 Clinical Rehabilitation 00(0)
recommended to sustain fall prevention and the
reduction in overall fall risk.24
Significantly better dynamic balance and
mobility with faster performance in the Timed Up
and Go Test by the combined physical and cogni-
tive training group and by the cognitive training
alone group compared to the waitlist group is an
important finding. This implies that involvement
in an exercise program with cognitive training or
participation in cognitive training alone is much
better than just doing daily activities in enhancing
functional mobility.25 This could be due to cross-
modality transfer wherein training cognitive func-
tions can influence the performance of physical
functions.26
The lack of significant difference between
groups in the outcome measures may also be due to
the high percentage of participants in each inter-
vention group with less than the expected duration
of participation. Based on published guidelines, at
least 40  hours of physical exercise training is
required to prevent falls in the geriatric popula-
tion16 and about 6 to 20 cognitive training sessions
are recommended to be cost-effective.21 The over-
all attrition rate was 20% at 12 weeks and 28% at
36 weeks. This is in spite of having a mutually
agreed re-assessment schedule.
Greater improvements in outcomes would have
been expected with higher participant compliance
with the program in terms of attendance and the
number of hours rendered.27 Future studies should
set a predefined compliance criterion for inclusion
in data analysis. An intention-to-treat analysis, by
carrying forward the last known data, was
employed to address lost data due to dropouts.
The time point to measure outcomes particu-
larly fall incidence rate was limited to 12 weeks
after baseline to examine the immediate effects and
to 36 weeks after baseline to establish short-term
effects of interventions. A follow-up study to deter-
mine the long-term effects of interventions of at
least one year is warranted.
In conclusion, there was no significant differ-
ence in fall rate and fall-related outcomes among
groups post-intervention except for dynamic bal-
ance which was improved with combined physical
and cognitive training and cognitive training alone.
Further research with larger sample size is needed
to establish whether the interventions are effective
or not. Furthermore, we recommended that pro-
spective experimental studies should have only
two comparison groups to obtain a clearer differ-
ence in outcomes between groups.
Clinical messages
•• Fall incidence was not significantly differ-
ent among the groups at the conclusion of
the intervention period and six months
post-intervention.
•• More studies with larger sample size are
needed to establish the effect of combining
physical and cognitive training in reducing
fall incidence in older persons with mild
cognitive impairment.
Acknowledgements
We wish to thank Patrick Leung (PTRP), Catherine
Escuadra (PTRP, MHPEd), Anne Marie Aseron (MSPT),
Cherry Gabuyo (OTR, MS), Shine Hernandez (OTR,
MHPEd), Archelle Callejo (PTRP), Batch 2018 Bachelor
of Science in Physical Therapy Group 4, and Bachelor of
Science in Occupational Therapy Group 4 of the University
of Santo Tomas–College of Rehabilitation Sciences (UST-
CRS) who assisted in the assessment of the participants;
Dr. Joselito Diaz who examined the participants’ cognitive
function; Kim Medallon (OTRP, MHPEd) for facilitating
the random allocation of the participants; the UST
Simbahayan for providing financial assistance used to buy
the snacks of the participants; and the local officials and
officers of the senior citizen organizations who helped in
the recruitment of participants. Gratitude also goes to the
professional physical therapists and occupational thera-
pists who implemented the interventions namely: Eileen
Lu (PTRP), Janrey Vargas (PTRP), Lester Rojas (PTRP),
Adrian Lim (PTRP), Nikki Ty (OTRP), Raymond Orozco
(OTRP), Gio Becina (OTRP), Bea Hingada (OTRP),
Vaughn Lacsamana (OTRP). We are doubly grateful to
Eileen Lu (PTRP) for language editing the manuscript.
Author Contributions
D.S.L. helped in the study concept and design; acquisi-
tion of data, analysis, and interpretation of data; drafting
of the manuscript; and final revision and approval revi-
sion of the manuscript. W.W.N.T contributed to study
concept and design, analysis and interpretation of data,
drafting of the manuscript, and final revision and
approval revision of the manuscript.
Lipardo and Tsang 9
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Ethical Approval
This study conformed to the Declaration of Helsinki and
obtained ethical approval from the Human Subjects
Ethics Sub-committee of the Hong Kong Polytechnic
University–Department of Rehabilitation Sciences
(HSEARS20170402001) and from the Ethics Review
Committee of the University of Santo Tomas–College of
Rehabilitation Sciences (FI-2017-002). The research
protocol was registered with ClinicalTrials.gov on May
30, 2017 (Identifier: NCT03167840), and published in
BMC Geriatrics, August 2018.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication
of this article: This research did not receive any specific
grant from funding agencies in the public, commercial,
or not-for-profit sectors. Financial support came from
the Research Studentship Scholarship–Associated Money
of the Hong Kong Polytechnic University.
ORCID iD
William WN Tsang https://orcid.org/0000-0002
-3549-2346
References
1. Taylor ME, Lord SR, Delbaere K, et al. Physiological
fall risk factors in cognitively impaired older people: a
one-year prospective study. Dement Geriatr Cogn Disord
2012; 34(3–4): 181–189.
2. Delbaere K, Kochan NA, Close JCT, et al. Mild cognitive
impairment as a predictor of falls in community-dwelling
older people. Am J Geriatr Psychiatry 2012; 20(10):
845–853.
3. Doi T, Shimada H, Park H, et al. Cognitive function and
falling among older adults with mild cognitive impair-
ment and slow gait. Geriatr Gerontol Int 2015; 15(8):
1073–1078.
4. Winblad B, Palmer K, Kivipelto M, et al. Mild cognitive
impairment—beyond controversies, towards a consen-
sus: report of the International Working Group on Mild
Cognitive Impairment. J Intern Med 2004; 256(3): 240–246.
5. Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors
for falls in community-dwelling older people: a system-
atic review and meta-analysis. Epidemiology 2010; 21(5):
658–668.
6. Laughton CA, Slavin M, Katdare K, et al. Aging, muscle
activity, and balance control: physiologic changes associ-
ated with balance impairment. Gait Posture 2003; 18(2):
101–108.
7. Thom JM and Clare L. Rationale for combined exercise
and cognition-focused interventions to improve functional
independence in people with dementia. Gerontology
2011; 57(3): 265–275.
8. Eggenberger P, Theill N, Holenstein S, et al.
Multicomponent physical exercise with simultaneous cog-
nitive training to enhance dual-task walking of older adults:
a secondary analysis of a 6-month randomized controlled
trial with 1-year follow-up. Clin Interv Aging 2015; 10:
1711–1732.
9. Lipardo DS, Aseron AMC, Kwan MM, et al. Effect of exer-
cise and cognitive training on falls and fall-related factors in
older adults with mild cognitive impairment: a systematic
review. Arch Phys Med Rehabil 2017; 98(10): 2079–2096.
10. Lipardo DS and Tsang WWN. Falls prevention through
physical and cognitive training (falls PACT) in older
adults with mild cognitive impairment: a randomized con-
trolled trial protocol. BMC Geriatr 2018; 18(1): 193.
11. World Health Organization. Global reports on falls pre-
vention in older age. Lyon: World Health Organization,
2007.
12. Lord SR, Menz HB and Tiedemann A. A physiological
profile approach to falls risk assessment and prevention.
Phys Ther 2003; 83(3): 237–252.
13. Shumway-Cook A, Brauer S and Woollacott M.
Predicting the probability for falls in community-dwelling
older adults using the Timed Up & Go Test. Phys Ther
2000; 80(9): 896–903.
14. Peel NM, Kuys SS and Klein K. Gait speed as a measure
in geriatric assessment in clinical settings: a systematic
review. J Gerontol A Biol Sci Med Sci 2013; 68(1): 39–46.
15. Jones CJ, Rikli RE and Beam WC. A 30-s chair-stand test
as a measure of lower body strength in community-resid-
ing older adults. Res Q Exerc Sport 1999; 70(2): 113–119.
16. Power V and Clifford AM. Characteristics of optimum
falls prevention exercise programmes for community-
dwelling older adults using the FITT principle. Eur Rev
Aging Phys Act 2013; 10(2): 95–106.
17. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to
prevent falls in older adults: an updated systematic review
and meta-analysis. Br J Sports Med 2016.
18. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA,
et al. American College of Sports Medicine position
stand: exercise and physical activity for older adults. Med
Sci Sports Exerc 2009; 41(7): 1510–1530.
19. Liu XY, Li L, Xiao JQ, et al. Cognitive training in older
adults with mild cognitive impairment. Biomed Environ
Sci 2016; 29(5): 356–364.
20. Vojtkofsky T and Feldman RG. Keep your brain stronger
for longer: 201 brain exercises for people with mild cogni-
tive impairment. New York: The Experiment, LLC, 2015.
21. Jean L, Bergeron ME, Thivierge S, et al. Cognitive inter-
vention programs for individuals with mild cognitive
10 Clinical Rehabilitation 00(0)
impairment: systematic review of the literature. Am J
Geriatr Psychiatry 2010; 18(4): 281–296.
22. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions
for the prevention of falls in older adults: systematic
review and meta-analysis of randomised clinical trials.
BMJ 2004; 328(7441): 680.
23. Trombetti A, Hars M, Herrmann FR, et al. Effect of
music-based multitask training on gait, balance, and fall
risk in elderly people: a randomized controlled trial. Arch
Intern Med 2011; 171(6): 525–533.
24. World Health Organization. Global strategy and action
plan on ageing and health (press release). Geneva: World
Health Organization, 2017.
25. Booth V, Hood V and Kearney F. Interventions incorporat-
ing physical and cognitive elements to reduce falls risk in
cognitively impaired older adults: a systematic review. JBI
Database Syst Rev Implement Rep 2016; 14(5): 110–135.
26. Verghese J, Mahoney J, Ambrose AF, et al. Effect of cog-
nitive remediation on gait in sedentary seniors. J Gerontol
A Biol Sci Med Sci 2010; 65(12): 1338–1343.
27. Freiberger E, Haberle L, Spirduso WW, et al. Long-term
effects of three multicomponent exercise interventions
on physical performance and fall-related psychological
outcomes in community-dwelling older adults: a rand-
omized controlled trial. J Am Geriatr Soc 2012; 60(3):
437–446.