Aging, Neuropsychology, and Cognition

ISSN: 1382-5585 (Print) 1744-4128 (Online) Journal homepage: http://www.tandfonline.com/loi/nanc20

Cognitive function, physical activity, and aging:

Possible biological links and implications for
multimodal interventions

Eduard Kraft

To cite this article: Eduard Kraft (2012) Cognitive function, physical activity, and aging: Possible
biological links and implications for multimodal interventions, Aging, Neuropsychology, and
Cognition, 19:1-2, 248-263, DOI: 10.1080/13825585.2011.645010

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Aging, Neuropsychology, and Cognition, 2012, 19 (1–2), 248–263
http://www.psypress.com/anc
ISSN: 1382-5585 print; 1744-4128 online
http://dx.doi.org/10.1080/13825585.2011.645010

Cognitive function, physical activity,

and aging: Possible biological links and
implications for multimodal interventions
Eduard Kraft1,2
1
Department of Physical Medicine and Rehabilitation, University Hospital,
Ludwig-Maximilian-University Munich, Munich, Germany
2
Parmenides Foundation, Munich, Germany

ABSTRACT
Increasing evidence shows the positive effect of physical activity (PA) on maintaining
cognitive function. Both processes seem intrinsically linked to each other. The most
likely mechanism is a reciprocal stimulation of neuroplasticity. Based on extensive
experimental work on animals and humans, the concept of an enriched environment,
including PA and challenging cognitive tasks, has provided the basis to systematically
assess possible interventions for successful aging. I will use recent findings on brain
mechanisms associated with PA and its effects on higher cognitive function at a sys-
tems and molecular level to demonstrate the need to design effective interventions.
Such interventions should be designed to take advantage of the presumed compensatory
mechanisms of elderly individuals, thereby limiting functional decline in higher cogni-
tive performance in aging people. My review of the most recent relevant publications
concerning this topic supports the notion that it is a promising approach to provide cog-
nitive training and PA in conjunction, since the combination may generate synergistic
beneficial changes than either one individually. Multimodal training programs should
therefore be tested. However, at present there is insufficient evidence to conclude that
multimodal interventions are superior to isolated cognitive or physical exercise inter-
ventions, since major studies addressing this topic are lacking. These studies are needed
to conclusively prove that both strategies will positively interact when used in com-
bined interventions. Finally the use of modern technology for these interventions will
be discussed.
Keywords: Aging; Physical activity; Neuroplasticity; Cognition; Exercise.

Address correspondence to: Eduard Kraft, MD, Department of Physical Medicine and Rehabilitation,
Klinikum Großhadern, Ludwig-Maximilian-University Munich, Marchioninistr. 15, 81377 München,
Germany. E-mail: eduard.kraft@med.uni-muenchen.de

© 2012 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
 COGNITION, PHYSICAL ACTIVITY, AND AGING 249

Increasing evidence shows the important effect of physical activity (PA) on

maintaining cognitive function (see a recent Cochrane review on the subject
by Angevaren, Aufdemkampe, Verhaar, Aleman, & Vanhees, 2008). Both
processes seem intrinsically linked to each other. The most likely mecha-
nism linking both is a reciprocal stimulation of neuroplasticity (Kramer &
Erickson, 2007). Therefore, understanding the effect of PA and exercise on
cognition might be also helpful to elucidate and discuss the mechanism by
which specific brain circuits are able to compensate for ongoing functional
loss.
In the context of the special issue of this volume, the possible mecha-
nisms of neuroplasticity on systems and cellular level induced by PA will be
explored. Important recent publications concerning the theme of this article
will be reviewed. By doing so, several hypotheses will be put forward:

(1) PA and cognitive tasks should be trained in conjunction, since the

combination seems to generate more synergies compared to each of
the components individually. Interventions against aging-related cog-
nitive decline should be designed as multimodal training concepts.
At present, because of lacking data, evidence does not prove nor
refute this hypothesis. However, as this review attempts to illustrate,
there are many hints that it is reasonable to test this further.
(2) Complexity, integrative and social aspects of the respective activity
may influence the effectiveness. Recent evidence points to dancing
as an interesting ‘natural’ intervention combining PA and cogni-
tive challenge. This may open up the space for real world activities
capable of providing combined training.
(3) PA is an important co-variable in compensating for declining higher
order cognition in aging. Furthermore, it is plausible that execu-
tive functions are more susceptible to improvements induced by PA
compared to other basic cognitive domains (Colcombe & Kramer,
2003). This implies a more specific effect of PA on higher-cognition
rather than other basic cognitive domains. Therefore PA might be
also considered to be a tool to indirectly probe the brain mechanisms
underlying the cognitive strategies in elderly to account for declining
executive functions.

Two major concepts are important in this respect. First, the concept of
enriched environment (Milgram, Siwak-Tapp, Araujo, & Head, 2006) and
second, the scaffolding theory forwarded by Park and Reuter-Lorenz (2009).
Whereas previous reviews on PA and its effects on cognition have exten-
sively covered the topic (Kramer, Erickson, & Mcauley, 2008), they have
not addressed the question of the present special issue: the compensatory
250 EDUARD KRAFT

potential of physical exercise and whether physiological mechanisms of

neuroplasticity make it a necessary prerequisite sine qua non, which would
then have to be considered when designing effective interventions to compen-
sate for cognitive decline.

SENSORY-MOTOR PERFORMANCE AND PHYSICAL ACTIVITY

IN OLDER ADULTS
It is an undisputed fact that aging is associated with reduction in sensory-
motor performance and physical fitness leading to reduction of PA in elderly
individuals. This includes aerobic exercise and non-aerobic coordination and
stretching exercise. One of the major contributors to the decline of physical
fitness in aging is the declining sensory-motor performance (Callisaya et al.,
2009). This is caused by the accumulation of concomitant factors of changed
peripheral and sensory processing as well as structural changes of effector
organs, in particular the muscles. Reduced proprioceptive input including tac-
tile acuity, vision and vestibular function pose great challenges to the success-
ful performance of any kind of exercise, increasing the risk for falls and subse-
quent injury such as bone fractures (Kannus, Sievanen, Palvanen, Jarvinen, &
Parkkari, 2005). Slowness of movements is one of the general features of
motor control in aging. This has been consistently reported and is consid-
ered one hallmark of aging associated changes of sensory-motor performance
(Seidler et al., 2010) Furthermore, sarkopenia, referred to as reduction of
muscle mass and volume, is another well described phenomenon in aging.
The excretion of creatinine, reflecting muscle creatinine content, and total
muscle mass decreases by 50% from age 20 to 90 years (Metter et al., 1999).
An additional major finding in older individuals is the increasing need
of attentional and cognitive control in performing previously automatic motor
tasks. This is particularly relevant for motor activities such as walking or
dual task performance and obviously has major implications for maintaining
functioning and participation in social life, since falls are one of the major
risk factors for persistent disability in older people (Tinetti, 2003).
Because postural stability and locomotion have to rely on multimodal
sensory input, namely on proprioceptive, visual and vestibular input, impair-
ment in one or more of those sensory modalities will seriously affect postural
stability and consequently can lead to an increased risk for falls. Independent
of the reduction in sensory-motor performance and control, a reduction of
cardiovascular fitness occurs in aging. Arthrosclerosis is the major problem
affecting the cardiovascular system in aging. These structural changes of the
blood vessels are the basis for the functional changes observed in physical
fitness with aging.
 COGNITION, PHYSICAL ACTIVITY, AND AGING 251

COGNITION IN OLDER ADULTS

Cognitive performance in aging is characterized by a decline in speed of infor-
mation processing and by a reduction of on-line cognitive resources available
to process, store, retrieve, and transform information. There is no uniform
impairment of all cognitive domains in aging. Most of the present issue deals
in detail with some interesting dissociations of different domains and provides
ample space for hypotheses regarding why this might be case and what mech-
anisms are underlying these findings. For instance, some aspects of memory
and attention remain intact. Procedural memory is relatively well preserved
in aging (Mitchell, Brown, & Murphy, 1990).
In general, automatic processes that require little cognitive resources
are largely unaffected in older individuals (Ford et al., 1997). Overall, as is
discussed in detail in the other papers of this special issue, there is a marked
dissociation of higher order cognitive abilities over proportionally well pre-
served in comparison to more basic domains such as episodic memory or
processing speed. It is assumed that compensatory mechanisms contribute to
this disproportional phenomenon.
Research done during the last few years has provided data showing
that whereas older adults may perform a cognitive task at the same level
as younger adults over a broad range of domains including switching and
target detection, there are distinct patterns of neural activity in elderly indi-
viduals. One of the most reliable findings in studies examining task related
brain activity is increases in frontal lobe activations (Cabeza, 2002; Phillips
& Andres, 2010). Based on these findings, Park and Reuter-Lorenz (2009)
proposed the scaffolding theory of aging and cognition to account for this
phenomena. According to their theory, pervasive increased frontal activation
with age is a marker of an adaptive brain that engages in compensatory scaf-
folding in response to the challenges posed by declining neural structures
and function (Park & Reuter-Lorenz, 2009). In contrast, younger people tend
to respond with greater activation of medial temporal lobe structures. This
implies that there are areas of this brain region such as the hippocampus that
can support increasing demands on the cognitive system. However, there are
clear limitations to these compensatory mechanisms. Capell, Gmeindl, and
Reuter-Lorenz (2010) showed that memory load is a strong modulator of the
age differences in frontal lobe activity. The presumed increased activity of
frontal areas occurs only in conditions with low memory load. When there is
high memory load, older people actually under-recruit areas within the dorso-
lateral prefrontal cortex (DLPFC; Cappell et al., 2010). Similar observations
were made by Rajah, Languay, and Valiquette (2010). These authors tested
young and older adults on a relatively easy item recognition task and more
difficult context recognition tasks and compared the respective related brain
activity pattern. Whereas older subjects did not show any increases in activity
252 EDUARD KRAFT

of the DLPFC, young people increased the activity of the DLPFC as the task
demands increased (Rajah et al., 2010). This indicates that over-recruitment
of frontal areas only occurs when upper limits of performance capacity are not
reached. However, the situation might be more complicated, since Leshikar,
Gutchess, Hebrank, Sutton, and Park (2010) did not find such relationship
between increasing task demands and failure to additionally recruit frontal
areas in older individuals.

THE EFFECT OF PHYSICAL ACTIVITY ON COGNITIVE

FUNCTION
There is accumulating experimental evidence to explain the molecular and
metabolic mechanisms by which PA might influence the preservation or
improvement of cognitive abilities. In particular, there is an increasing
amount of research describing effects on angiogenesis, neurogenesis, and
up-regulation of neuroprotective molecules as well as brain volume and func-
tional architecture, which might explain the way by which exercise and PA
acts upon brain structure and function (Anderson, Greenwood, & McCloskey,
2010; Kaliman et al., 2011; Lista & Sorrentino, 2010). Aerobic exercise
promotes angiogenesis in the brain (Black, Isaacs, Anderson, Alcantara, &
Greenough, 1990). New vasculature due to exercise has also been reported in
the motor cortex (Kramer et al., 2008). Exercise has been shown to promote
neurogenesis and also an increasing overall survival of existing neurons. The
first experiments of this kind were conducted by van Praag, Kempermann,
and Gage (1999) and reported increased neurogenesis and cell survival in the
hippocampus of mice exposed to running versus a sedentary control condi-
tion. Importantly, there was a correlation of the rate of cell proliferation in the
dentate gyrus of running mice and the improved performance of navigation
on the Morris water maze (van Praag et al., 1999). When the same authors
studied young and aged mice they found a reversal of the normal decline
in neurogenesis in aged animals. However, sedentary young mice had still
greater neurogenesis than active aged mice and in those younger mice, no
signs of angiogenesis were seen (van Praag, Shubert, Zhao, & Gage, 2005).
The available data suggest a complex relationship between neurogenesis
and exercise in aging people and argue that exercise, at least short-term exer-
cise, may not completely reverse the loss exhibited in the elderly (Kramer
et al., 2008). Furthermore, PA has been shown to affect synaptogenesis by
modification of pre- and postsynaptic compartments (Farmer et al., 2004;
Hu, Ying, Gomez-Pinilla, & Frautschy, 2009). This is of particular rele-
vance concerning the presumed neuroplasticity as the biological mechanism
linking PA with improved cognition. Additionally, a number of molecular
factors such as Insulin like growth factor (IGF-1) and vascular endothelial
 COGNITION, PHYSICAL ACTIVITY, AND AGING 253

growth factor (VEGF), which are affected by exercise, have been impli-
cated in mitigating the effects described in aging. Finally, recent studies
have examined the epigenetic impact of exercise in the hippocampus and
dentate gyrus of rodents (Kaliman et al., 2011). Although the specific mech-
anisms by which epigenetic mechanisms affect brain function and peripheral
tissue are unknown, these findings open up a new field to understand and
possibly influence specifically beneficial effects on cognition. Most of these
effects have been embraced by the neurogenic reserve hypothesis (reviewed
by Kempermann, 2008). A part of the neurogenic reserve hypothesis is the
concept of enriched environment. It has been successfully introduced as
experimental paradigm into animal research and refers to the circumstances of
housing and living. Enriched environment includes somatosensory, visual and
social stimulation and has shown to promote learning and improved cogni-
tive performance (Nithianantharajah & Hannan, 2009). Enriched environment
may also promote epigenetic effects (Kaliman et al., 2011).
Brain imaging techniques allow for the study of in vivo effects of exer-
cise on a systems level. Recently, Colcombe et al. (2006) studied brain
volume in older adults assigned to either 6 months of an exercise interven-
tion (45 minutes walking for 3 days a week), or a stretching and toning,
non-aerobic, control group. The older adults who walked 3 days a week
displayed increases in gray matter volume in the frontal and temporal cor-
tex and were better on an episodic memory task. These findings are also
relevant with regard to structural imaging findings related to aging such as
cortical thinning and decline of white matter integrity (Madden et al., 2012;
Salat et al., 2004) since they indicate counteracting neuroplastic effects of
PA on a structural level. Aging-related structural changes may be modified
by cognitive interventions, as has been recently demonstrated (Engvig et al.,
2011). This lends support to the assumption of a reciprocal stimulation of
neuroplasticity as the possible mechanism linking PA with cognitive func-
tion. Figure 1 illustrates the relation between age-related neural changes and
counteracting neuroplastic mechanisms in cognitive aging.
The response of brain circuits to PA interventions has yielded intrigu-
ing findings. For instance, Voelcker-Rehage, Godde, and Staudinger (2011)
studied three groups with aerobic exercise, coordination, and stretching as
a control condition and found three patterns of activity-related responses in
an executive control task (Flanker task): increased task-related activity over
frontal and anterior cingulate gyrus for the control condition, decreased activ-
ity for superior, middle and medial frontal areas (corresponding to Brodmann
Areas 6,9) in the aerobic condition as well as increased activity in the inferior
frontal and superior parietal cortex for the coordination group. The findings
for the aerobic group would be interpreted as a more efficient activity of the
older subjects after successful aerobic training. Furthermore, a 1-year inter-
vention study performed by Voss et al. (2010) examined the impact of PA
254 EDUARD KRAFT

F IGURE 1. Key features of the neural and behavioural changes of aging and as well as modifying factors.
Adapted and modified from Park and Reuter-Lorenz (2009).

Physiological Neural
structural level changes

- Reduction of brain volume - Frontal recruitment

- Decline of white matter - Neurogenesis
integrity - Distributed processing
- Thinning of cortical - Bilaterality
thickness

Cognitive
Aging
decline

- New learning
- Engagement
- Exercise
- Cognitive training

Physical and
Behavioral sensorimotor
level deterioration

on the resting brain network activity for higher cognitive function. Results
showed that aerobic exercise improved the aging brains functional efficiency
in higher-level cognitive networks. One year of walking (three times a week
for 40 minutes per session) increased functional connectivity between aspects
of the frontal, posterior, and temporal cortices within the Default Mode
Network and a Frontal Executive Network. Effects were observed only after
12 months of training, compared to non-significant trends after 6 months
(Voss et al., 2010). The changes in connectivity were behaviourally rel-
evant, since increased functional connectivity was associated with greater
improvement in executive function, as measured with the Wisconsin Card
Sorting Test and a task-switching paradigm. Interestingly, also the control
group assigned to non-aerobic fitness training (stretching and toning) showed
increased functional connectivity. In this context, it is of particular interest,
that a recent study shows the beneficial effects of exercise on crucial brain
structures involved in memory processing such as the hippocampus (Erickson
et al., 2011). It is known that the hippocampal and medial temporal lobe
volumes are larger in physically active adults as is hippocampal perfusion.
These authors showed in a randomized controlled trial involving 120 older
adults a 2% increase of the volume in the anterior hippocampus (Erickson
et al., 2011). This increased hippocampal volume was associated with greater
 COGNITION, PHYSICAL ACTIVITY, AND AGING 255

serum levels of brain derived neurotrophic factor (BDNF), a mediator of neu-

rogenesis in the dentate gyrus of the hippocampus. Unfortunately it is very
difficult to establish what the structural and physiologic correlate for the
volume increase really is. Given the experimental data on animals and the
concomitant increase of BDNF, it is tempting to speculate, that these findings
reflect adult neuroneogenesis, though previous work using different fMRI
methodology would also suggest perfusion or synaptic density as the cause
for this volume increase (Ilg et al., 2008). Unfortunately, these authors did
not test whether these improvements in spatial memory transferred to other
cognitive domains such as improvements in executive function.
In summary, the position paper of the American College of Sports
Medicine from 2009 stating the beneficial effects of regular physical exercise
on cognitive function seems justified (Chodzko-Zajko et al., 2009). It stresses
the emerging evidence of combined cognitive and aerobic training paradigms
in conjunction. A similar conclusion is derived by the authors of the Cochrane
review on the effects of PA on cognition in elderly individuals (Angevaren
et al., 2008). The authors identified 11 randomized controlled trials fulfilling
appropriate quality standards. Eight of 11 showed beneficial effects. However,
recently, Snowden et al. (2011) also summarized intervention trials linking
exercise with cognitive performance. They concluded that there is insuffi-
cient evidence to suggest that exercise improved cognition in older adults.
Important methodological pitfalls for this apparent mismatch of conclusions
are discussed by Miller, Taler, Davidson, and Messier (2012) who argue that
the association between exercise and preserved cognition during aging is
clearly demonstrated. But the specific hypothesis that physical exercise is a
cause of healthy cognitive aging has yet to be validated (Miller et al., 2012).

POSSIBLE INTERVENTIONS TO IMPROVE COGNITION IN

AGING
Based on the previously discussed phenomena, a variety of interventions have
been discussed to foster compensation for the declining cognitive function
in aging. Concerning cognitive training, this topic has been dealt with in
detail in previous reviews such as the article by Noack, Lovden, Schmiedek,
and Lindenberger (2009). Those authors described systematically in detail
the most relevant findings of studies published before the year 2009. One
important fact they stressed in their literature review was the transfer effect of
the interventions reported on. They organized their overview of the interven-
tion studies according to training performed as strategy-based, process-based
or multifactorial approaches (Noack et al., 2009). The latter was used by
Mahncke et al. (2006) in training tasks tapping on basic sensory functions
such as identification and discrimination and cognitive functions including
256 EDUARD KRAFT

short-term memory and text comprehension. This study was performed on

182 elderly subjects who were stratified into three groups (training group,
contact control group, and no-contact control group).The intervention group
was assigned to solve and practise six tasks of adaptive difficulty in 40 one-
hour sessions. In contrast, the contact control group listened and watched
educational lectures on DVD, whereas the no-contact control group did not
receive any kind of intervention. As a result, the intervention group showed
improvements on all trained exercises. Furthermore, only people from the
intervention group improved significantly in a test of global auditory memory,
which was used as transfer task.
Basak, Boot, Voss, and Kramer (2008) also performed a study with a
multifactorial cognitive intervention. In their study, the authors trained elderly
individuals on playing strategy computer games. These games demanded cog-
nitive resources in domains such as complex-problem solving, dual-tasking,
working memory, and spatial orientation. All participants underwent a test
battery of tests assessing executive control or visuospatial attention before
and after training. Training participants in comparison to those in a no-contact
control group showed improved performance in four out the six cognitive tests
assessing executive control (Basak et al., 2008). Despite seemingly impres-
sive transfer effects in the participants of this study, Noack et al. (2009)
interpreted these findings with caution. Apparently, the cognitive abilities
examined in the cognitive test battery of the study by Basak and associates
might have been trained directly during gaming practice. Additionally, taking
into account that no active control group was included, motivational effects,
social activation or familiarization cannot be discarded (Noack et al., 2009).
Whereas most interventions studies employed mostly either exercise
or cognitive training as interventions, very few studies have to date used a
multimodal interventional approach. In this respect a conceptually impor-
tant study was conducted by Kattenstroth, Kolankowska, Kalisch, and Dinse
(2010) indicating the beneficial effects of amateur dancing in elderly sub-
jects. They compared a group of elderly subjects with a history of multi-year
amateur dancing to an age-, education-, and sex-matched control population.
Compared to the control group, individuals of the amateur-dancing group
showed a higher cognitive performance as well as better posture and balance
parameters. Individual analysis of the data revealed that the amateur-dancing
population lacked individuals showing poor performance instead of showing
subjects with better results. This implies maintaining a regular schedule of
dancing into old age can preserve cognitive, motor, and perceptual abilities.
This study points towards other important co-variables implied in success-
ful aging including diet and social interaction. Since dance is highly socially
interactive, this might be as important as the aerobic exercise component of
 COGNITION, PHYSICAL ACTIVITY, AND AGING 257

ballroom (or amateur) dancing. These studies suggest that ball room danc-
ing may be considered to be a real world enriched environment (Kattenstroth,
Kalisch, Kolankowska, & Dinse, 2011).
A further recent study stresses the importance of the type of exercise
performed and potential differential effects on separate cognitive domains.
In this study, Voelcker-Rehage et al. (2011) showed that cardiovascular
training and coordination training led to differential effects in respect to
cognition in 12 months. Whereas walking intervention improved accuracy
and speed in executive functioning (examined with a Flanker Search
task) and perceptual processing using a Visual Search Task, coordination
training led to a significant improvement in performance accuracy in the
Visual Search Task. An important ongoing intervention study is currently
conducted by the Center for Vital Longevity at the University of Texas in
Dallas (http://vitallongevity.utdallas.edu/). This major study includes six
interventions such as quilting engagement, digital photography, combined
quilting/photography, social control, placebo control, and no treatment
control (Goh & Park, 2009). Although these interventions were aimed at
keeping the subjects learning (accordingly therefore building scaffolds), the
researchers discarded activity that would also provide exercise such as danc-
ing, to avoid confusion between cognitive engagement and exercise but also
because of the potential of falling and injury (Goh & Park, 2009). However,
multimodal training such as PA with concomitant skill learning may possibly
be more effective than unimodal learning. Oswald, Gunzelmann, Rupprecht,
and Hagen (2006) conducted one of the few studies in which a combined
approach of cognitive training in conjunction with PA was applied. Those
authors studied 375 community residents aged 75–93 years. The training
effects were evaluated over 5 years with different interventions (cognitive
training, psychoeducational training, physical exercise, combined physical
exercise and cognitive training, and a control group without any intervention).
In this study, the physical and cognitive status of the participants could be
preserved on a higher level by a combined physical and cognitive training.
In contrast, physical training and cognitive training alone was not effective
in maintaining cognitive function or physical status.
Another study using combined interventions has been conducted by
Fabre, Chamari, Mucci, Masse-Biron, and Prefaut (2002). This study enrolled
participants aged 60–76 years into one or three training sessions per week
lasting for 2 months. The aerobic training session consisted of rapid walk-
ing and/or jogging and cognitive training was performed using memory
training. The combined training showed significantly improved memory
(Wechsler memory scale) compared to either memory or aerobic training
alone. However, frequency of the interventions varied between combined and
single interventions.
258 EDUARD KRAFT

Despite the advantages of the combined interventions in both studies,

these findings are difficult to interpret, because of the unequal time of expo-
sure of the different interventions. Finally, a study performed by O’Dwyer
(2009) studied 39 older adults, aged between 60 and 80 years, who were
allocated to one of three groups: combined aerobic exercise and cognitive
training, aerobic exercise only, and control group. Training sessions were per-
formed during 16 weeks. Significant within-group improvements were seen
in the exercise and combination participants. However, there were only a few
significant changes in the between-group comparison. There were no sig-
nificant improvements in functional performance. The interpretation of the
results of this study is also limited by the small sample size. Unfortunately,
none of these studies included imaging measures of brain changes into the
protocol, to determine how behavioural findings would be reflected by struc-
tural or functional brain changes. Given the uncertainties related to combined
interventions, researchers from the Gerontopsychology Research Unit of the
University of Zurich are currently conducting an intervention study with older
adults (Schaefer & Schumacher, 2011). Subjects will be randomized to one
of four groups, consisting of three intervention groups and one control group.
One group will perform treadmill training sessions first and then verbal work-
ing memory training sessions. The second group would perform the verbal
working memory training first and then the treadmill training. The third group
performs the verbal working memory training simultaneously with the tread-
mill training in all training sessions. This set-up will allow to measure the
effect of the training sequence as well as the training condition, comparing a
dual-task condition to a single task approach. The authors are using a promis-
ing approach by combining a cognitive training and exercise modality, which
are supposed to activate the cerebellum as the same brain region (Schaefer &
Schumacher, 2011). It remains to be seen whether the simultaneous perfor-
mance of the combined intervention proves to be superior to the sequential
performance, in particular because the simultaneous task is much more dif-
ficult. It may be possible that many participants fail to achieve a comparable
performance level of the single task.
Crucial for the confirmation of the main hypothesis formulated in this
review, that combined interventions would be more effective stimulators of
neuroplasticity, would be the use of neuroimaging techniques to provide phys-
iological or anatomical evidence in the design of all future intervention trial.
Over the next years, the results of this type of research investigating com-
bined interventions may have important consequences for the development
of training programs and for life-style recommendations to influence healthy
and successful aging.
 COGNITION, PHYSICAL ACTIVITY, AND AGING 259

THE ROLE OF TECHNOLOGY IN SUPPORTING COMBINED

INTERVENTIONS
A final consideration concerns the increasing use and role of technol-
ogy to provide an efficient approach to achieve healthy and successful
aging. Numerous authors have stressed the potentially beneficial impact
of technology on these topics (Lindenberger, Lovden, Schellenbach, Li, &
Kruger, 2008). Such an approach would be dependent on designing and
applying electronic aid devices that externalise many of the impaired cog-
nitive functions (as an add-on rather than as a singular application). In recent
years, several devices have been developed to assist specific cognitive func-
tions. The most common cognitive domains supported by those aids were
memory functions. In particular, prospective memory, which is a crucial skill
in activities of daily living, has been externalised in most of the devices cur-
rently in use. An example of this approach is Autominder (Pollack, Brown,
Colbry, & McCarthy, 2003). This kind of technical device could be used to
externalize memory load. In disengaging memory load, the elderly subject
could better take advantage of the compensatory potential of frontal recruit-
ment as explained above. However, Lindenberger et al. (2008) have reviewed
the requirements for the successful handling of memory aids for elder pop-
ulations and point out major problems related to those technologies. To date
these problems have not yet been resolved. Hence, the specific devices, which
are available at present to externally support memory function, are not prac-
tical tools for healthy older individuals, because of the risk of deteriorating
the supported domains. But the increasing availability of inexpensive train-
ing programs on platforms such as smartphones and iPads, technology may
be a promoter of large-scale use of such environments for cognitive train-
ing (for instance www.brainjog.org). The same tools might be also useful to
perform regular exercise in a self-monitored fashion at home. Recent tech-
nical advances such as inexpensive wireless sensors provide the opportunity
to closely monitor activity and control for the quality of exercise and pro-
vide important feedback for individuals (Dobkin & Dorsch, 2011). In the
near future it seems feasible to use this kind of technology in combined
interventions.

CONCLUSION AND PERSPECTIVES

The work presented in this review documents the various advances that have
been made in our understanding of how PA influences cognitive function and
how both may be linked to each other in the process of successful aging.
There is a need for additional research in this exciting area. At present it
can be concluded, that PA stimulates important metabolic changes that affect
cognition directly, but also improves the neurophysiological mechanisms on
260 EDUARD KRAFT

which cognitive training may act upon, namely structural and functional
plasticity. As has been discussed in this overview, the biological evidence
includes various different metabolic and physiologic mechanisms, such as
neurotrophic factors, angiogenesis, neurogenesis, synaptogenesis as well as
epigenetic processes. Only a few studies are available which have examined
combined interventions. The results are confounded by methodological limi-
tations. Additionally, none of these studies has used markers of brain changes
on a physiological or structural level. Several topics will have to be considered
in combined interventions. The optimal timing and the frequency of com-
bined interventions remains to be elucidated. It also has to be established
whether simultaneous performance in a dual-task setting proves superior to
sequential training. Furthermore, there might be an optimal age window, in
which older subjects will mostly profit from this type of interventions, since
concomitant medical conditions such as cardiovascular diseases, metabolic
and musculoskeletal conditions become more limiting in age groups beyond
80 years. It is also an important issue whether mainly older people with
a sedentary lifestyle would benefit from this type of interventions, rather
than elderly individuals who already lead an active lifestyle and could only
minimally improve further by additional combined training.
Finally, individual genetic predisposition and epigenetic profiles may
have to be taken into account. Despite all these uncertainties, we have reason
to believe that we can come up with evidence-based and effective programs
to help our older citizens to maintain functioning and participation by aging
successfully.

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