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Article

The Effects of Six Months of Exercise on Single- and Dual-Task Posture, Gait, and Functional Mobility Relative to Usual Care Alone Among People Living with Dementia: The ENABLED Pilot Randomized Controlled Trial

by
Deborah A. Jehu
1,*,
Ryan Langston
1,
Charmi Patel
1,
Andre Soares
1,2,
Jennifer L. Waller
3,
Ryan M. Carrick
4,
Colleen Hergott
5,
Lufei Young
6,
William Hall
7,
Dawnchelle Robinson-Johnson
7,
Crystal Allen
8,
Richard Sams
8,
Mark Hamrick
9,
Ying Huang
2,
Haidong Zhu
2 and
Yanbin Dong
2
1
Department of Community & Behavioral Health Sciences, School of Public Health, Augusta University, Augusta, GA 30912, USA
2
Georgia Prevention Institute, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
3
Department of Family and Community Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
4
Department of Occupational Therapy, College of Allied Health Sciences, Augusta University, Augusta, GA 30912, USA
5
Department of Physical Therapy, College of Allied Health Sciences, Augusta University, Augusta, GA 29841, USA
6
School of Nursing, University of North Carolina, Charlotte, NC 27599, USA
7
Claiborne Assisted Living Facility, Augusta, GA 39648, USA
8
Georgia War Veterans Nursing Home, Department of Family and Community Medicine, Augusta University, Augusta, GA 30912, USA
9
Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(12), 6624; https://doi.org/10.3390/app15126624
Submission received: 5 April 2025 / Revised: 5 June 2025 / Accepted: 7 June 2025 / Published: 12 June 2025
(This article belongs to the Special Issue Advances in Sports Science and Movement Analysis)
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Versions Notes

Abstract

:
Cognitive–motor integration is the coordination of cognitive and motor processes; it is commonly impaired among people living with dementia (PWD) and may be improved through exercise. This pilot randomized controlled trial (1:1) aimed to determine the effect of 6 months of exercise on cognitive–motor integration compared to usual care in n = 42 PWD at two residential care facilities. Participants completed single- and dual-task standing (30 s of standing while counting backward by 1 s), walking (4 m walk while naming words), and timed-up-and-go (TUG) tests (TUG with a category task), measured using APDM inertial sensors at baseline and 6 months (age = 82 years, 35% female, Montreal Cognitive Assessment = 10.2 ± 5.9, NCT05488951). The adapted Otago Exercise Program involved 60 min of lower-body strength and balance exercises and walking 3x/week for 6 months. Usual care involved regular social activities and healthcare appointments. Exercise provoked increased single-task stride length and increased dual-task TUG turn velocity compared to usual care (p < 0.05). Usual care may reduce the ability to appropriately select cautious gait, as the usual care group exhibited faster dual-task gait speed at 6 months compared to the OEP plus usual care (p < 0.05), which was faster than their single-task gait speed. Our results support implementing the OEP to improve cognitive–motor integration in PWD.

1. Introduction

Dementia is defined as cognitive decline significant enough to impair activities of daily living [1]. There are over 55 million people living with dementia (PWD) worldwide [2]. PWD have twice the risk of falling [3], which could be partly due to simultaneous impairments in dual-task cognition and mobility [4]. Cognitive–motor interference occurs when concurrently performing a cognitive and a motor task (dual-task) that results in a decline in performance on one or both tasks, relative to the performance of each task separately (single-task performance) [5]. Theoretical models postulate that cognitive–motor impairments could stem from a competition for attentional resources (e.g., central capacity sharing model, bottleneck theory) and/or a competition for shared information-processing neural pathways [6]. Typically, PWD observe greater cognitive–motor interference compared to those without dementia, with dual-tasks often performed serially rather than simultaneously [7], thereby impacting functional independence and fall risk [4]. This cognitive–motor impairment is likely a function of deteriorated neural network mapping and white matter integrity in PWD [8]. Cognitive–motor interference has been linked to falls in those with cognitive impairment [9]. Promising interventions targeting cognitive–motor integration have been shown to strengthen vulnerable brain networks in individuals at risk for developing dementia [10]. However, advancements in care-targeted improvements in cognitive–motor integration are needed for those with a diagnosis of dementia.
Exercise has been shown to improve dual-task mobility in those without dementia [11,12,13]. However, therapeutic intervention advancements in PWD have been limited because PWD have been historically excluded from research due to researchers’ eligibility criteria [14]. Exercising may be a viable strategy to improve cognitive–motor integration and functional mobility, but the evidence is mixed. Exercise seems to have a small but meaningful improvement in global cognition [15]; however, the effects of exercise on executive function appear to be unclear, with one meta-analysis showing no effect [15] and another revealing a small, meaningful effect among PWD [16]. One meta-analysis found that the type of exercise did not moderate the effect on cognition [15], while another meta-analysis found that resistance exercise drove improvements in cognition [16]. While multimodal exercise appears to improve activities of daily living, it does not affect muscular strength, posture, or mobility in PWD; however, the strength of the evidence was low to moderate [17]. More recent randomized controlled trials (RCTs) and quasi-experimental research have shown promising improvements in strength, functional mobility, and balance following strength and balance exercise [18,19] as well as dance [19,20]. These mixed results demonstrate the need for further research to clarify the role of exercise in improving cognitive–motor integration in PWD.
PWD are often inactive and sedentary [21]. Therefore, further research is needed to determine if exercise is a viable strategy to improve dual-task mobility impairments due to the lack of research examining the effect of exercise on cognitive–motor integration in PWD and the need for tailored intervention [12]. There are no evidence-based guidelines regarding adapted exercise programs, frequency, duration, and type of exercise in PWD [22,23]; only general exercise recommendations for PWD from the American College of Sports Medicine [22] and the National Institute on Aging [24]. There have been several other recommendations for physical activity for PWD, including dance, mirroring exercises, and escorting PWD to exercise, which helps foster adherence [23,25]. The Otago Exercise Program (OEP), which was developed in New Zealand as a 6-month home-based exercise program consisting of muscle strength and balancing exercises as well as walking to prevent falls in frail community-dwelling older adults without dementia, may be a solution [26]. The OEP has been shown to reduce falls by 33% in older adults without dementia, which reduces expenditures for healthcare and rehabilitation [27,28]. The OEP can likely be modified to meet the needs of PWD, but further research is needed. Promising pilot RCTs have examined the effectiveness of the OEP on health outcomes among PWD. Specifically, it has improved upper limb muscle strength and range of motion as well as functional ability in people living with early-stage dementia [29]. The OEP has also elicited improvements in balance and functional mobility in people living with mild cognitive impairment and PWD [30]. Other work has shown that the OEP improved lower body strength, balance, and aerobic ability in PWD [31]. While preliminary evidence suggests that the OEP decreases fall risk in PWD, these pilot trials have included small sample sizes, and the OEP was unsustainable after the intervention period due to the number of staff members required to monitor and aid the participants [25]. To our knowledge, no studies have examined the effect of the OEP on dual-tasking in PWD.
The aim of the strENgth And BaLance exercise on Executive function in people living with Dementia (ENABLED) study was to conduct a pilot 6-month assessor-blinded RCT to determine if the adapted physical therapist-led OEP, combined with usual care, improved single- and dual-task mobility when compared to usual care alone among PWD who reside in residential care facilities. We hypothesized that exercise combined with usual care would improve single- and dual-task mobility relative to usual care alone among PWD.

2. Materials and Methods

2.1. Study Design

This was a pilot parallel, 6-month assessor-blinded randomized (1:1) controlled trial. The ENABLED trial included n = 21 PWD in the usual care group and n = 21 PWD in the exercise plus usual care group. All participants resided in a residential care facility. This trial was registered on clincialtrials.gov (NCT05488951). The protocol was published [32] and presented at a conference [33]. A community advisory board, administrative leadership, and healthcare providers at local residential care facilities provided feedback to assist our trial design and delivery. The Consolidated Standards of Reporting Trials were followed for adequate reporting [34].

2.2. Ethics Approval and Consent/Assent to Participate

Handwritten informed consent was obtained from the legally authorized representatives of eligible participants. After acquiring informed consent, handwritten assent was obtained from the PWD. The Augusta University Institutional Review Board approved all protocols (Study #1836020).

2.3. Recruitment

Participants living with dementia from all causes were recruited from the Georgia War Veterans Nursing Home and the Claiborne Assisted Living Facility’s memory care unit. Participants were recruited between July 2022 and January 2023. These local sites also allotted space for assessments and exercise training.

2.4. Eligibility Criteria

The inclusion criteria for participants were (1) age equal to or greater than 55 years; (2) inhabited a residential care facility; (3) had any variant of dementia confirmed by medical history and/or a physician; (4) could read, write, and speak English with acceptable visual and auditory acuity; (5) could walk 4 m without the assistance from another person; (6) had a legally authorized representative who could provide informed consent; (7) could provide assent; (8) understood and followed instructions; (9) had a life expectancy of ≥12 months estimated by a healthcare provider; and (10) were able to stand for 30 s unassisted. The exclusion criteria included (1) inability to comprehend or follow instructions; (2) severe psychiatric condition; (3) delirium; (4) an acute medical condition; (5) any recent surgeries impairing mobility; (6) enrolled in any other research studies; (7) severe vision loss; (8) severe aphasia that impaired communication; (9) receiving hospice care; and (10) any medical condition contraindicating exercise (e.g., unstable cardiac disease).

2.5. Sample Size Calculation

The sample size estimation, including 21 PWD/group (n = 42 participants in total), was determined using SAS 9.4 for the primary outcome (the Color-Word Stroop Test), as outlined in the ENABLED protocol [32].

2.6. Randomization and Blinding

After the baseline assessment, we randomized participants (1:1) to the exercise (n = 21) or usual care group (n = 21). Sequence randomization was generated in SAS 9.4 by a statistician and uploaded to OnCore. The assessors were blinded from treatment allocation in OnCore. Randomization was stratified by biological sex (female/male) and study site, and then blocked randomization was performed using random block sizes of 2 and 4 within each sex and site group. Permutations of exercise or usual care were performed in each block.

2.7. Procedures

The study procedure is displayed in Figure 1. Participant testing was completed at baseline and 6 months for primary and secondary outcomes. The follow-up testing occurred between January 2023 and July 2023. All outcome measures were valid, and physical functioning was measured with APDM inertial sensors in two trials of single- and dual-tasks. APDM inertial sensors measured spatiotemporal gait parameters, stability, and joint kinematics [35]. APDM sensors have been shown to be reliable in measuring balance and gait parameters and their changes over time [36]. To address inter-rater reliability, assessors—which included an occupational therapist and experienced researchers—met to demonstrate consistency and accurate use of inertial sensors.

2.8. Measures of Physical Functioning

We assessed single-task posture, which involved standing with feet apart while completing no cognitive task, and dual-task posture, which involved standing with feet apart while counting backward by 1’s from a random two-digit number between 80–99. We examined sway area (°/s2), frequency of sway (Hz), jerk (m2/s5), and sway velocity (m/s). Single-task gait involved walking 4 m with no cognitive task, and dual-task gait involved walking 4 m while naming as many words as possible that start with the letters F, A, or S [37]. Outcome measures included gait speed (m/s), double support (%), stride length (m), and upper body range of motion (°). Functional mobility was assessed using the TUG, which involved getting up from a chair, walking 3 m, turning around, walking back, and sitting down [38,39]. Participants completed the TUG with no cognitive task, as well as while completing a category task of as many words in the animal or fruit category [40]. Outcome measures included task duration (s), turn duration (s), turn velocity (°/s), and lean angle (°). Turning was assessed with a 360°turn with APDM inertial sensors. Outcome measures included task duration (s), turn angle (°), and turn velocity (°/s). Lower extremity strength was assessed with the five-time sit-to-stand using APDM inertial sensors. Outcome measures included task duration (s) and lean angle (°).

2.9. Descriptive Measures at Baseline

The demographic information from participants’ charts included age, sex, dementia diagnosis, the date of diagnosis, fall history in the last 6 months, and the Functional Comorbidity Index. The Functional Comorbidity Index consists of 18 evenly weighted comorbidities stratifying physical functional status. We recorded the total number of comorbidities using the Functional Comorbidity Index (0–18) [41]. We also measured body fat composition (%), skeletal muscle composition (%), and weight (kg) via the Omron Body Composition Monitor.
The Montreal Cognitive Assessment (MoCA) was used for global cognition assessment [42,43]. The MoCA additionally measures executive function, short-term memory recall, visuospatial abilities, attention, concentration and working memory, language, and time and place orientation.
The 6-item Morse Fall Scale was used for fall risk assessment. This scale consisted of a history of falling, secondary diagnosis, ambulatory aids, intravenous therapy, gait, and mental status. A Morse Fall Scale score of 0–24 indicates no risk, 25–50 indicates low risk, and ≥51 indicates high risk.

2.10. Intervention: Adapted Otago Exercise Program

OEP is an evidence-based physical therapist-led home-based strength and balance training program designed for frail, community-dwelling older adults [44,45,46,47,48]. The exercise intervention must be adapted for PWD because of their unique needs and limitations to physical activity, such as forgetfulness [49], planning problems [49], and apathy [50]. We adapted the OEP by adopting a person-centered approach for PWD, delivered in a group setting of 5–7 participants per session in residential care facilities. A physical therapist led 30 min of tailored lower body strength and balance exercises from the OEP manual, followed by 30 min of walking. The physical therapist ensured that the program remained adequately challenging, such as adding ankle weights when participants became stronger, or reducing weights following an acute decline in performance, such as following an illness. This program was 3 times per week for 6 months. Volunteers aided the physical therapist with tasks such as guiding participants to and from the activity room and spotting during exercises. All staff and volunteers received training in dementia communication techniques.

2.11. Usual Care (Control)

All 42 participants were provided with usual care from healthcare providers (e.g., primary care providers, specialists, community nurse visits, paid care provider visits, hospitalizations as required, and any necessary treatment for any illness and/or comorbidities). All participants were provided with the opportunity to partake in social activities at the nursing home or assisted living facility (e.g., bingo, outings, arts and crafts).

2.12. Data Analysis

All statistical analyses were performed using SAS 9.4. Statistical significance was assessed using a two-sided alpha level of 0.05 unless otherwise noted. Descriptive statistics within the group (exercise and usual care) and measurement time (baseline and 6 months), where appropriate, were determined. Before testing, assumptions for different inferential statistical methods were assessed, including expected values greater than 5 for chi-square tests, tests of normality of residuals, and equality of variance for analysis of variance. Mixed model methods as missing data were not imputed.
Two different sets of analyses were performed: an intent-to-treat analysis (ITT) and a Per Protocol analysis. All participants were included in the ITT analysis. All usual care participants and only OEP plus usual care participants who attended at least 2 exercise sessions per week for 6 months were included in the Per Protocol analysis. The Per Protocol analysis was performed due to the hypothesis that improvements in outcomes are likely related to the dose of exercise received [51,52].
Chi-square tests or two-sample t-tests were used to examine differences between groups for those variables measured only at baseline or only at 6 months. Mixed models unadjusted for potential covariates were used to examine changes over time between groups. Fixed effects in each model included the group and time effects and the two-factor interaction between these effects. The participants nested within groups were treated as a random effect. A compound symmetric correlation structure was used to estimate the correlation between time points. A Kenward-Roger adjustment to the denominator degrees of freedom was used to determine the F-tests for all effects. The F-test for the group by time interaction was the statistical test of interest. Statistically significant results of this test indicate that the changes over time were different between the exercise and usual care groups. Since not all pairwise comparisons were of interest, we applied a Bonferroni adjustment to the overall alpha level for the number of pairwise comparisons. After examining the unadjusted models, all analyses were then performed controlling for age and the MoCA.

3. Results

3.1. Demographic Characteristics

There were 228 residents living in the residential care facilities who were assessed for eligibility. During the preliminary chart review, 128 residents did not meet the eligibility criteria, such as not having dementia. Nineteen (n = 19) of the residents’ power of attorneys were not interested in the PWD under their legal authority participating in the study, and three PWD were not interested in participating. Of the remaining eligible residents, 42 were randomized into the OEP plus usual care (n = 21) or the usual care group (n = 21). The enrollment rate was 18.4% (i.e., n = 42/228; 228 represents the total number of residents with and without dementia at the residential care facilities). Eight (n = 8) participants were lost to the 6-month follow-up, leaving n = 34 included in the final analysis with n = 17 per group (Figure 1). Participant demographics were 35.7% female, 16.7% African Americans, 82.1 ± 8.1 years of age, and a MoCA score of 10.0 ± 5.9 points (Table 1). Participants were in clinical stages 4–5 of dementia [53].

3.2. Physical Function Outcomes

3.2.1. Adjusted Intent to Treat Analysis

Figure 2, Figure 3, Figure 4 and Figure 5 display the posture, gait, and TUG, as well as the 360° turn and 5x sit-to-stand, respectively. Two measures improved in the OEP plus usual care group. Firstly, single-task gait stride length increased from baseline to 6 months in the OEP plus usual care group (0.59 m to 0.75 m, +0.16 m; p = 0.03). Secondly, TUG dual-task turn velocity increased from baseline to 6 months in the exercise (71.19°/s to 90.15°/s; +18.96 °/s; p = 0.0003) group. Several variables showed similar results in both groups. Single-task gait lower leg double support average showed a significant decrease from baseline to 6 months in both the exercise (35.51% to 11.94%; −23.57%; p < 0.0001) and usual care (34.04% to 15.07%; −18.97%; p < 0.0001) groups. Both the exercise (38.69% to 32.37%; −6.32%; p = 0.02) and usual care groups (39.78% to 33.88%; −5.90%; p = 0.0495) showed a significant decrease from baseline to 6 months in dual-task gait lower leg double support average. Single-task gait speed showed a statistically significant increase from baseline to 6 months in both the exercise (0.41 m/s to 0.63 m/s; +0.22 m/s; p = 0.01) and usual care (0.44 m/s to 0.68 m/s; +0.24 m/s; p = 0.047) groups. TUG single-task turn velocity increased from baseline to 6 months in the exercise (81.23°/s to 105.24°/s; +24.01 °/s; p = 0.001) and usual care (87.88°/s to 100.24°/s; +12.26 m/s; p = 0.03) groups. TUG dual-task duration decreased from baseline to 6 months in the exercise (40.86 s to 29.32 s; −11.54 s; p = 0.01) and usual care (41.13 s to 31.69 s; −9.45 s; p = 0.03) groups. Interestingly, in the adjusted ITT analysis, post hoc pairwise comparisons after 6 months revealed faster gait speed during dual-tasking in the usual care compared to the OEP plus usual care group (0.35 m/s to 0.77 m/s; +0.42 m/s; p = 0.01). Mid-swing leg elevation during dual-tasking increased from baseline to 6 months (0.53 cm to 1.56 cm; +1.03 cm; p = 0.04) in the usual care group. The unadjusted and adjusted ITT are in Appendix A Table A1 and Table A2.

3.2.2. Adjusted per Protocol Analysis

In the adjusted Per Protocol analysis, one variable showed statistically significant interactions between group and time: single-task TUG turn velocity. Both the exercise and usual care groups increased the single-task TUG turn velocity from baseline to 6 months, but the OEP plus usual care group had a greater increase than the usual care group. The OEP plus usual care group showed improved performance from baseline to 6 months, with no change in the usual care group. Only the OEP plus usual care group exhibited a statistically significant increase in stride length during dual-task walking from baseline to 6 months (0.49 m to 0.73 m; +0.24 m, p = 0.01). The OEP plus usual care group exhibited faster turn velocity during the single- (81.36°/s to 109.63°/s; +28.27°/s, p = 0.002) and dual-task TUG (70.59°/s to 88.34°/s; +17.75°/s, p = 0.002) from baseline to 6 months. Single-task gait lower leg gait speed increased from baseline to 6 months in the OEP plus usual care group (0.41 m/s to 0.60 m/s; +0.19 m/s; p = 0.045). Dual-task gait lower leg double support average was greater at baseline than at 6 months in the OEP plus usual care group (37.39% to 31.60%; −5.79%; p = 0.047). Dual-task gait lower leg gait speed was faster at 6 months than at baseline in the OEP plus usual care group (0.37 m/s to 0.53 m/s; +0.16 m/s; p = 0.047). Lastly, the TUG single-task sit-to-stand lean angle was greater at baseline than at 6 months in the OEP plus usual care group (40.82° to 29.24°; −11.58°; p = 0.043). Two variables showed similar results in both groups. First, both the exercise (35.72% to 13.68%; −22.04%, p = 0.01 n = 9) and usual care groups (33.80% to 14.90%; −18.90%, p < 0.0001, n = 21) exhibited a statistically significant decrease in the double-limb support percentage during the 4 m single-task walk from baseline to 6 months. Second, TUG dual-task duration was greater at baseline than at 6 months in the exercise (40.63 s to 28.44 s; −12.19 s; p = 0.04) and usual care (39.73 s to 30.64 s; −9.09 s; p = 0.03) groups. Two variables showed an improvement in the usual care group; specifically, TUG single-task turn velocity increased from baseline to 6 months in the usual care (89.05°/s to 101.23°/s; +12.18°/s; p = 0.03) group and the single-task gait lower leg elevation mid-swing average was lower at baseline than at 6 months in the usual care group (0.95 cm to 1.37 cm; +0.42 cm; p = 0.046). The unadjusted and adjusted Per Protocol results are in Appendix A Table A3 and Table A4.

4. Discussion

4.1. Main Findings

Our novel adapted training program with usual care elicited greater improvements in several single- and dual-task physical function measures than usual care alone among PWD. Similar findings between the ITT and Per Protocol analyses suggest that exercise with usual care in any amount may be a viable therapeutic intervention approach among PWD in residential care facilities.
Our findings extend previous RCTs in healthy older adults [48,49,50], as well as community-dwelling PWD [12,13,20,25,29,30,31,54], such that 6 months of adapted OEP training improved spatial (stride length) and temporal (velocity) measures of single- and dual-task mobility in PWD in residential care facilities compared to usual care alone. While both groups showed improvements in gait speed and dual-task performance, the OEP plus usual care group had notably greater gains in stride length, turn velocity, and lower leg double support during dual-tasking. Our results are in line with a pilot RCT that also found improved spatial (stride length) and temporal (gait speed, cadence, single support percentage) dual-task gait improvements but only during difficult dual-tasks in community-dwelling PWD following 12 weeks of exercise, relative to the control group who received low-intensity exercise [55]. A quasi-experimental study showed that a 10-week dance intervention and dual-task exercise intervention improved both spatial (stride length) and temporal (cadence) dual-task walking in community-dwelling females living with mild dementia; however, there was no control group [20]. Furthermore, the OEP plus usual care group experienced significant improvements in single-task gait and TUG performance, particularly in turn velocity and sit-to-stand lean angle. The improvements in single- and dual-task physical function reflect improved balance control, lower extremity strength, and functional performance [13]. Increased stride length may also correlate with fewer falls, as reduced stride length is predictive of fall risk in older adults due to a lack of lateral stability [56]. Impairments in cognitive–motor integration are common among PWD and affect the visuomotor processing needed for several daily activities, such as reaching movements, fine motor movements, and coordination during cognitive tasks [8]. The improvements observed by the OEP plus usual care group in cognitive–motor integration in dual-tasking are important to daily life for PWD because cognitive and physical function independently predict recurrent falls [57].
Interestingly, the usual care group exhibited significantly faster dual-task gait speed at 6 months compared to the OEP plus usual care group, which was also notably faster than the 6-month single-task gait speed. Previous work suggests that those with more severe dementia may be at a greater risk for falls during dual-tasking due to a reduced decision-making ability to select an appropriate gait strategy during dual-tasks, thereby inadvertently hurrying and increasing their risk for falls [4]. Our findings extend this work to suggest that 6 months of usual care may negatively impact appropriate attention prioritization during dual-tasking compared to 6 months of exercise. More specifically, the usual care group may have exhibited cognitive overload during dual-tasking and increased their gait speed as a risky compensatory strategy, which increased their likelihood of falls. In contrast, participants in the OEP plus usual care correctly employed a cautious gait pattern in response to greater attention demand in an effort to allocate attention resources to both tasks [58,59]. Our results highlight the potential benefits of exercise in preserving both cognitive and motor functions in PWD in residential care facilities and inform therapeutic interventions.
We examined whether there was a dose effect of exercise on outcomes, specifically if twice-per-week exercise improved outcomes more than any amount of exercise. Our results were similar between the ITT and Per Protocol analyses, suggesting that exercise in any amount improves dual-tasking. Previous work has shown that exercising at low- and high-intensity heart rates improves gait in PWD, with high-intensity training showing greater benefits [54]. Further studies are needed to determine the full extent of the dose and frequency effect of exercise on PWD. Therefore, the adapted OEP plus usual care may be a viable intervention strategy to improve these outcome measures relative to usual care alone among PWD residing in residential care facilities, but further investigation is warranted.

4.2. Limitations

Several limitations must be considered when interpreting these findings. These findings are only generalizable to PWD in residential care facilities with the ability to stand and walk with minimal assistance. We only recruited from two residential care facilities, and there was limited population heterogeneity among participants. The participants varied in functional impairments and dementia severity. Dementia severity also impacts mobility [4]. Polypharmacy was observed in most participants. Furthermore, our participant sample included only 35.7% females, even though females are more likely to acquire dementia, and it is unclear whether this affected the results [60]. While all participants had a confirmed diagnosis of dementia, the dementia subtype was often not available. This missing data may limit and/or confound our findings, as different causes of dementia and dementia subtypes manifest differently and have varying disease progression. Specifically, some subtypes of dementia, such as progressive supranuclear palsy, dementia with Lewy body dementia, hydrocephalus, and vascular dementia, alter gait and fall risk more than other subtypes, such as Alzheimer’s dementia or frontotemporal dementia [61]. Our small sample size limited our statistical comparisons. Larger and more longitudinal trials are needed to ascertain the effect of exercise on functional mobility among PWD. There may have been attrition bias, as only n = 9 participants adhered to at least 2x/week exercise for our Per Protocol analysis; however, similar results were observed in the ITT analysis and Per Protocol analysis. While the inertial sensor placement may have varied across assessors, all assessors were trained to ensure standardization. The scalability, implementation, and cost-effectiveness of tailored exercise interventions for PWD require further research.

4.3. Implications

Approximately 45% of dementia cases can be avoided through lifestyle interventions [62]. Our study extends previous work to suggest that gait and functional mobility may improve following the adapted OEP plus usual care relative to usual care alone among PWD. Our results also suggest that wearable inertial sensors may serve as a potential biomarker for improved gait and functional mobility following exercise [63]. Clinicians can implement the adapted OEP with usual care to improve balance and functional mobility in PWD. These improvements in cognitive–motor integration can be tracked with single- and dual-task assessments. The optimal exercise prescription in PWD is unclear [16,64]. Thus, our study may have implications for exercise prescription in terms of the type, intensity, duration, and frequency of exercise needed to improve single- and dual-task physical function. Future research may consider determining whether exercise improves gait pattern recognition through machine learning techniques among PWD [65].

5. Conclusions

The OEP plus usual care had clinically relevant improvements in single- and dual-task physical function, including stride length and velocity, relative to usual care alone in PWD in residential care facilities. In general, exercise adherence did not seem to impact the influence of the OEP plus usual care on outcomes, indicating that any amount of exercise may improve cognitive–motor integration. This pilot RCT may have implications for using an adapted exercise program in clinical care management and lifestyle interventions for PWD to improve cognitive–motor integration.

Author Contributions

Conceptualization, D.A.J.; methodology, D.A.J.; intervention, A.S., statistical analysis, J.L.W.; data collection, D.A.J., Y.H., C.P. and R.M.C.; data management, D.R.-J., W.H., R.S., C.A., C.P. and D.A.J.; writing—original draft preparation, R.L. and D.A.J.; writing—review and editing, R.S., L.Y., M.H., H.Z., A.S., C.H. and Y.D.; visualization, D.A.J.; funding acquisition, D.A.J., M.H., C.H. and Y.D. All authors have read and agreed to the published version of the manuscript.

Funding

This study is funded by the Intramural Grants Program at Augusta University to D.A.J. and M.H. (IGPCT00028), NIA P01 AG036675 (Core C) to M.H., and Intramural Grants Program at Augusta University to Y.D. (IGPP00033). These funding agencies did not play a role in the study design. We would like to acknowledge the contribution of the residential care facility staff, who worked closely with our team to facilitate the intervention and testing.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Augusta University (1836020, 29 May 2022).

Informed Consent Statement

Informed consent was obtained from all subjects’ legally authorized representative. Assent was obtained from all subjects involved in the study.

Data Availability Statement

The original contributions presented in this study are included in the article. Further inquiries can be directed to the corresponding author.

Acknowledgments

We would also like to thank the numerous student volunteers who assisted our physical therapist in delivering the intervention.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
PWDPeople living with dementia
RCTRandomized controlled trial
OEPOtago Exercise Program
MoCAMontreal Cognitive Assessment
TUGTimed-up-and-go
APDMAmbulatory Parkinson’s Disease Monitoring
ITTIntent-to-treat

Appendix A

Table A1. ITT unadjusted mixed model results on inertial sensor measures.
Table A1. ITT unadjusted mixed model results on inertial sensor measures.
VariableLeast Squares Mean (SE) for Group x Time InteractionFp-Value
OEP Plus Usual Care Usual Care
Baseline6 MonthsBaseline6 Months
Single-Task Postural Sway
 Sway Area (m2/s4) ˅0.40 (0.20)0.16 (0.23)0.16 (0.07)0.18 (0.07)0.780.39
 Centroidal Frequency (Hz) ˄0.93 (0.08)1.02 (0.09)0.94 (0.06)1.03 (0.06)0.010.91
 Jerk (m2/s5) ˅23.55 (12.09)12.79 (13.41)5.66 (4.58)12.17 (4.58)1.670.21
 Sway Velocity (m/s) ˅0.45 (0.10)0.30 (0.12)0.25 (0.03)0.22 (0.03)0.480.50
Dual-Task Postural Sway
 Sway Area (m2/s4) ˅0.35 (0.11)0.25 (0.14)0.26 (0.07)0.18 (0.07)0.010.91
 Centroidal Frequency (Hz) ˄0.95 (0.08)1.01 (0.09)1.11 (0.06)1.13 (0.06)0.230.64
 Jerk (m2/s5) ˅26.94 (10.95)8.45 (13.25)8.90 (2.32)9.75 (2.32)1.390.28
 Sway Velocity (m/s) ˅0.40 (0.07)0.43 (0.08)0.25 (0.05)0.28 (0.05)0.000.99
360 Turn
 Turn Angle (°) ˄231.80 (27.21)217.80 (34.71)293.42 (21.61)280.55 (23.19)0.000.98
 Duration (s) ˅4.62 (0.34)4.50 (0.47)5.42 (0.48)4.93 (0.51)0.210.65
 Turn Velocity (°/s) ˄105.04 (10.92)90.35 (13.68)104.82 (9.37)110.83 (9.90)1.640.22
4 m Walk Single-Task
 Double-Limb Support (%) ˅33.90 (2.15)11.24 (2.53)33.01 (1.76)13.83 (1.83)0.580.46
 Mid-Swing Elevation (cm) ˄1.17 (0.21)1.66 (0.25)1.18 (0.19)1.64 (0.19)0.010.92
 Gait Speed (m/s) ˄0.48 (0.06)0.66 (0.07)0.50 (0.07)0.74 (0.07)0.220.64
 Stride Length (m) ˄0.63 (0.06)0.75 (0.06)0.68 (0.06)0.81 (0.06)0.010.92
 Medial–Lateral Trunk Range of Motion (°) ˄3.79 (0.42)4.25 (0.45)4.30 (0.55)3.84 (0.55)3.170.09
4 m Walk Dual-Task
 Double-Limb Support (%) ˅38.74 (1.72)32.06 (1.89)38.85 (1.84)32.80 (1.91)0.030.86
 Mid-Swing Elevation (cm) ˄0.98 (0.20)1.45 (0.21)0.76 (0.40)1.71 (0.41)0.550.47
 Gait Speed (m/s) ˄0.35 (0.05)0.49 (0.05)0.34 (0.18)0.75 (0.18)0.970.34
 Stride Length (m) ˄0.50 (0.06)0.67 (0.06)0.54 (0.11)0.78 (0.11)0.130.73
 Medial–Lateral Trunk Range of Motion (°) ˄3.35 (0.33)3.71 (0.36)4.17 (0.52)4.37 (0.52)0.110.74
TUG Single-Task
 Duration (s) ˅30.88 (5.02)27.66 (5.14)23.10 (2.31)20.90 (2.31)0.160.70
 Sit-to-Stand Lean Angle (°) ˄36.37 (3.17)30.99 (3.72)35.94 (3.74)32.91 (3.75)0.210.65
 Turn Angle (°) ˅129.43 (9.62)149.28 (9.90)143.74 (7.68)149.53 (7.68)1.990.18
 Turn Duration (s) ˅3.06 (0.25)3.51 (0.26)3.38 (0.16)3.19 (0.16)3.370.09
 Turn Velocity (°/s) ˄84.96 (9.84)105.33 (9.92)88.67 (6.46)101.13 (6.46)1.690.21
TUG Dual-Task
 Duration (s) ˅37.35 (4.54)26.49 (4.80)37.10 (4.39)28.17 (4.33)0.190.67
 Sit-to-Stand Lean Angle (°) ˄36.26 (4.19)30.03 (4.93)34.83 (3.48)34.50 (3.43)0.990.34
 Turn Angle (°) ˅119.34 (12.21)148.61 (13.21)117.31 (8.65)135.04 (8.65)0.550.47
 Turn Duration (s) ˅3.20 (0.22)3.86 (0.25)3.13 (0.23)3.23 (0.23)1.880.19
 Turn Velocity (°/s) ˄76.33 (7.64)90.45 (7.76)76.60 (5.92)89.21 (5.98)0.050.82
5x Sit-to-Stand
 Duration (s) ˅27.43 (5.52)32.26 (5.72)20.12 (2.23)19.36 (2.23)3.090.11
 Sit-to-Stand Lean Angle (°) ˄33.61 (3.26)29.44 (3.81)35.51 (4.09)32.48 (4.09)0.040.84
˄ higher scores indicate better performance. ˅ lower scores indicate better performance.
Table A2. ITT adjusted mixed model results on inertial sensor measures, with age, sex, and the time-dependent MOCA as covariates.
Table A2. ITT adjusted mixed model results on inertial sensor measures, with age, sex, and the time-dependent MOCA as covariates.
VariableLeast Squares Mean (SE) for Group x Time InteractionEffect
Size
ηp2		Fp-Value
OEP Plus Usual Care Usual Care
Baseline6 MonthsBaseline6 Months
Single-Task Postural Sway
 Sway Area (m2/s4) ˅0.43 (0.21)0.14 (0.24)0.15 (0.10)0.19 (0.10)0.00191.240.28
 Centroidal Frequency (Hz) ˄0.97 (0.10)1.04 (0.10)0.96 (0.07)1.06 (0.07)0.00120.060.81
 Jerk (m2/s5) ˅28.86 (12.42)14.35 (13.58)7.01 (5.72)15.12 (5.87)0.00352.610.12
 Sway Velocity (m/s) ˅0.47 (0.11)0.30 (0.12)0.26 (0.05)0.24 (0.05)0.00350.740.40
Dual-Task Postural Sway
 Sway Area (m2/s4) ˅0.29 (0.14)0.19 (0.16)0.20 (0.09)0.12 (0.09)0.00350.020.90
 Centroidal Frequency (Hz) ˄0.96 (0.10)1.03 (0.11)1.13 (0.08)1.15 (0.08)0.00280.260.62
 Jerk (m2/s5) ˅27.14 (11.25)7.99 (13.43)8.53 (3.22)9.48 (3.23)0.00521.390.26
 Sway Velocity (m/s) ˅0.42 (0.09)0.46 (0.10)0.25 (0.07)0.28 (0.07)0.00000.000.96
360 Turn
 Turn Angle (°) ˄234.95 (33.91)212.50 (39.72)291.68 (27.25)283.15 (28.85)0.00130.090.77
 Duration (s) ˅4.67 (0.48)4.24 (0.61)5.46 (0.49)5.22 (0.53)0.00140.040.84
 Turn Velocity (°/s) ˄98.03 (13.58)93.28 (15.58)100.01 (10.43)102.80 (10.97)0.00420.200.66
4 m Walk Single-Task
 Double-Limb Support (%) ˅35.51 (2.41)11.94 (2.65)34.04 (2.05)15.07 (2.13)0.00420.970.33
 Mid-Swing Elevation (cm) ˄0.88 (0.24)1.42 (0.26)0.93 (0.22)1.36 (0.23)0.00140.100.75
 Gait Speed (m/s) ˄0.41 (0.06)0.63 (0.07)0.44 (0.08)0.68 (0.08)0.00140.020.88
 Stride Length (m) ˄0.59 (0.06)0.75 (0.07)0.66 (0.07)0.78 (0.07)000090.110.75
 Medial–Lateral Trunk Range of Motion (°) ˄3.43 (0.51)3.94 (0.54)3.86 (0.61)3.45 (0.62)0.04042.600.12
4 m Walk Dual-Task
 Double-Limb Support (%) ˅38.69 (2.34)32.37 (2.32)39.78 (1.86)33.88 (1.92)0.04040.010.91
 Mid-Swing Elevation (cm) ˄0.86 (0.28)1.17 (0.29)0.53 (0.42)1.56 (0.44)0.04041.120.30
 Gait Speed (m/s) ˄0.34 (0.07)0.37 (0.08)0.33 (0.18)0.77 (0.20)0.04041.240.28
 Stride Length (m) ˄0.49 (0.08)0.67 (0.08)0.53 (0.12)0.78 (0.13)0.04040.140.72
 Medial–Lateral Trunk Range of Motion (°) ˄3.07 (0.44)3.72 (0.46)4.11 (0.52)4.23 (0.53)0.01510.790.38
TUG Single-Task
 Duration (s) ˅31.60 (5.58)27.93 (5.65)23.56 (3.14)21.73 (3.14)0.00680.470.51
 Sit-to-Stand Lean Angle (°) ˄39.39 (4.21)34.34 (4.61)37.70 (3.87)34.40 (3.89)0.00200.100.76
 Turn Angle (°) ˅124.23 (12.37)141.19 (12.10)136.51 (10.80)143.38 (10.81)0.01740.980.34
 Turn Duration (s) ˅3.15 (0.29)3.42 (0.28)3.35 (0.16)3.23 (0.16)0.02561.620.23
 Turn Velocity (°/s) ˄81.23 (11.96)105.24 (11.80)87.88 (7.97)100.14 (7.99)0.02593.100.10
TUG Dual-Task
 Duration (s) ˅40.86 (5.80)29.32 (5.88)41.13 (5.18)31.68 (5.03)0.00270.150.70
 Sit-to-Stand Lean Angle (°) ˄40.40 (5.66)34.57 (6.02)37.40 (3.82)35.31 (3.67)0.00690.350.56
 Turn Angle (°) ˅127.99 (15.38)153.26 (15.38)119.12 (10.79)135.27 (10.85)0.00250.250.62
 Turn Duration (s) ˅3.53 (0.28)3.98 (0.28)3.23 (0.24)3.35 (0.24)0.00760.590.45
 Turn Velocity (°/s) ˄71.19 (9.21)90.15 (9.14)75.97 (6.60)86.46 (6.63)0.00711.780.20
5x Sit-to-Stand
 Duration (s) ˅28.82 (6.07)32.57 (6.16)20.40 (2.82)19.96 (2.83)0.02271.660.22
 Sit-to-Stand Lean Angle (°) ˄29.74 (4.39)26.16 (4.82)33.12 (4.52)29.13 (4.54)0.00020.000.95
˄ higher scores indicate better performance. ˅ lower scores indicate better performance.
Table A3. Per Protocol unadjusted mixed model results on inertial sensor measures.
Table A3. Per Protocol unadjusted mixed model results on inertial sensor measures.
VariableLeast Squares Mean (SE) for Group x Time InteractionFp-Value
OEP Plus Usual CareUsual Care
Baseline6 MonthsBaseline6 Months
Single-Task Postural Sway
 Sway Area (m2/s4) ˅0.67 (0.37)0.20 (0.37)0.16 (0.07)0.18 (0.07)1.050.34
 Centroidal Frequency (Hz) ˄0.87 (0.09)1.01 (0.09)0.94 (0.06)1.03 (0.06)0.240.63
 Jerk (m2/s5) ˅34.77 (22.97)19.20 (22.97)5.66 (4.58)12.17 (4.58)1.190.31
 Sway Velocity (m/s) ˅0.56 (0.19)0.32 (0.19)0.25 (0.03)0.22 (0.03)0.550.48
Dual-Task Postural Sway
 Sway Area (m2/s4) ˅0.26 (0.09)0.24 (0.09)0.26 (0.07)0.18 (0.07)0.340.57
 Centroidal Frequency (Hz) ˄0.89 (0.07)1.01 (0.07)1.11 (0.06)1.13 (0.06)0.860.37
 Jerk (m2/s5) ˅12.32 (3.48)8.66 (3.48)8.90 (2.32)9.75 (2.32)1.250.30
 Sway Velocity (m/s) ˅0.45 (0.11)0.42 (0.11)0.25 (0.05)0.28 (0.05)0.140.71
360 Turn
 Turn Angle (°) ˄209.72 (39.15)229.94 (43.79)293.42 (21.61)280.55 (23.19)0.480.50
 Duration (s) ˅4.57 (0.52)4.89 (0.63)5.43 (0.48)4.93 (0.51)0.680.42
 Turn Velocity (°/s) ˄96.25 (15.99)84.90 (17.93)104.82 (9.37)110.83 (9.90)0.840.38
4 m Walk Single-Task
 Double-Limb Support (%) ˅34.92 (2.77)13.16 (2.91)33.01 (1.76)13.83 (1.83)0.190.67
 Mid-Swing Elevation (cm) ˄1.00 (0.26)1.47 (0.29)1.18 (0.19)1.63 (0.19)0.000.98
 Gait Speed (m/s) ˄0.46 (0.07)0.63 (0.08)0.50 (0.07)0.74 (0.07)0.260.62
 Stride Length (m) ˄0.60 (0.07)0.74 (0.08)0.68 (0.06)0.81 (0.06)0.000.95
 Medial–Lateral Trunk Range of Motion (°) ˄4.14 (0.61)4.26 (0.63)4.30 (0.55)3.84 (0.55)1.250.28
4 m Walk Dual-Task
 Double-Limb Support (%) ˅37.02 (2.29)31.48 (2.29)38.85 (1.85)32.8 (1.91)0.020.88
 Mid-Swing Elevation (cm) ˄1.00 (0.24)1.32 (0.24)0.77 (0.40)1.71 (0.41)0.940.34
 Gait Speed (m/s) ˄0.38 (0.07)0.51 (0.07)0.34 (0.18)0.75 (0.18)1.070.31
 Stride Length (m) ˄0.50 (0.08)0.68 (0.08)0.54 (0.11)0.78 (0.11)0.080.77
 Medial–Lateral Trunk Range of Motion (°) ˄3.32 (0.46)4.14 (0.46)4.17 (0.52)4.37 (0.52)1.170.30
TUG Single-Task
 Duration (s) ˅33.01 (8.12)31.36 (8.16)23.10 (2.31)20.90 (2.31)0.050.84
 Sit-to-Stand Lean Angle (°) ˄38.19 (4.64)25.98 (4.92)35.94 (3.75)32.91 (3.75)3.380.10
 Turn Angle (°) ˅133.03 (11.57)149.25 (11.10)143.74 (7.68)149.53 (7.68)1.090.32
 Turn Duration (s) ˅3.32 (0.34)3.46 (0.31)3.38 (0.16)3.19 (0.16)0.720.43
 Turn Velocity (°/s) ˄80.16 (13.88)105.76 (13.78)88.67 (6.46)101.13 (6.46)4.630.051
TUG Dual-Task
 Duration (s) ˅40.29 (6.82)28.79 (6.82)37.10 (4.39)28.17 (4.33)0.240.63
 Sit-to-Stand Lean Angle (°) ˄40.52 (5.26)28.16 (5.26)34.83 (3.48)34.50 (3.43)4.260.08
 Turn Angle (°) ˅129.07 (16.57)153.77 (14.59)117.31 (8.65)135.04 (8.65)0.120.74
 Turn Duration (s) ˅3.56 (0.24)4.06 (0.23)3.13 (0.23)3.23 (0.23)0.650.44
 Turn Velocity (°/s) ˄73.10 (10.32)85.99 (10.19)76.60 (5.92)89.21 (5.92)0.000.97
5x Sit-to-Stand
 Duration (s) ˅23.96 (5.45)30.46 (5.59)20.12 (2.23)19.36 (2.23)3.690.09
 Sit-to-Stand Lean Angle (°) ˄29.95 (3.98)25.06 (4.41)35.51 (4.09)32.48 (4.09)0.070.80
˄ higher scores indicate better performance. ˅ lower scores indicate better performance.
Table A4. Per Protocol adjusted mixed model results on inertial sensor measures, with age, sex, and the time-dependent MOCA as covariates.
Table A4. Per Protocol adjusted mixed model results on inertial sensor measures, with age, sex, and the time-dependent MOCA as covariates.
VariableLeast Squares Mean (SE) for Group x Time InteractionEffect
Size
ηp2		Fp-Value
OEP Plus Usual Care Usual Care
Baseline6 MonthsBaseline6 Months
Single-Task Postural Sway
 Sway Area (m2/s4) ˅0.69 (0.36)0.16 (0.36)0.15 (0.10)0.19 (0.10)0.01321.320.29
 Centroidal Frequency (Hz) ˄0.89 (0.11)1.01 (0.11)0.96 (0.07)1.06 (0.07)0.00070.020.89
 Jerk (m2/s5) ˅38.15 (21.65)18.85 (21.60)7.23 (5.84)15.70 (6.03)0.00031.670.23
 Sway Velocity (m/s) ˅0.58 (0.18)0.32 (0.18)0.26 (0.05)0.24 (0.05)0.00030.690.43
Dual-Task Postural Sway
 Sway Area (m2/s4) ˅0.24 (0.10)0.19 (0.10)0.21 (0.08)0.13 (0.08)0.00090.050.83
 Centroidal Frequency (Hz) ˄0.87 (0.09)1.01 (0.09)1.13 (0.07)1.15 (0.08)0.02450.880.37
 Jerk (m2/s5) ˅12.45 (4.01)8.10 (4.00)8.93 (2.99)9.93 (3.000)0.01502.020.20
 Sway Velocity (m/s) ˅0.47 (0.13)0.44 (0.13)0.24 (0.07)0.27 (0.07)0.00730.130.72
360 Turn
 Turn Angle (°) ˄217.12 (46.60)224.36 (51.05)298.38 (28.10)289.02 (29.68)0.00480.100.75
 Duration (s) ˅4.52 (0.62)4.44 (0.74)5.43 (0.51)5.23 (0.55)0.00060.010.91
 Turn Velocity (°/s) ˄94.02 (18.59)90.40 (20.20)101.42 (10.70)103.49 (11.26)0.00160.090.77
4 m Walk Single-Task
 Double-Limb Support (%) ˅35.72 (2.74)13.68 (2.97)33.80 (2.03)14.90 (2.12)0.00160.300.60
 Mid-Swing Elevation (cm) ˄0.83 (0.26)1.29 (0.29)0.95 (0.22)1.37 (0.22)0.00000.010.91
 Gait Speed (m/s) ˄0.41 (0.06)0.60 (0.07)0.46 (0.08)0.68 (0.08)0.00000.070.80
 Stride Length (m) ˄0.57 (0.07)0.74 (0.07)0.67 (0.07)0.78 (0.07)0.00370.260.62
 Medial–Lateral Trunk Range of Motion (°) ˄3.78 (0.56)3.86 (0.59)3.72 (0.65)3.29 (0.66)0.01800.800.38
4 m Walk Dual-Task
 Double-Limb Support (%) ˅37.39 (3.06)31.60 (2.99)39.83 (1.90)34.28 (1.97)0.00010.000.95
 Mid-Swing Elevation (cm) ˄0.98 (0.31)1.26 (0.32)0.65 (0.44)1.61 (0.45)0.00010.950.34
 Gait Speed (m/s) ˄0.37 (0.10)0.53 (0.11)0.35 (0.19)0.77 (0.20)0.00010.810.38
 Stride Length (m) ˄0.49 (0.09)0.73 (0.09)0.57 (0.13)0.79 (0.14)0.00010.010.94
 Medial–Lateral Trunk Range of Motion (°) ˄3.06 (0.55)4.00 (0.56)3.99 (0.56)4.12 (0.57)0.03501.630.22
TUG Single-Task
 Duration (s) ˅32.71 (8.47)30.54 (8.50)22.88 (3.13)21.16 (3.14)0.00200.030.86
 Sit-to-Stand Lean Angle (°) ˄40.82 (5.55)29.24 (5.72)37.42 (4.12)34.18 (4.14)0.05132.420.15
 Turn Angle (°) ˅129.39 (11.71)145.80 (11.18)136.42 (10.37)142.96 (10.38)0.01990.850.39
 Turn Duration (s) ˅3.37 (0.39)3.41 (0.37)3.34 (0.16)3.24 (0.16)0.00960.240.64
 Turn Velocity (°/s) ˄81.36 (15.23)109.63 (15.04)89.05 (8.04)101.23 (8.07)0.07105.920.03
TUG Dual-Task
 Duration (s) ˅40.63 (7.55)28.44 (7.43)39.73 (5.39)30.64 (5.23)0.00580.260.62
 Sit-to-Stand Lean Angle (°) ˄43.45 (6.26)31.91 (6.14)37.50 (3.89)35.49 (3.76)0.06873.070.11
 Turn Angle (°) ˅133.69 (18.76)158.23 (16.62)119.97 (11.19)135.48 (11.30)0.00420.170.69
 Turn Duration (s) ˅3.56 (0.31)4.05 (0.27)3.15 (0.25)3.29 (0.25)0.01660.490.51
 Turn Velocity (°/s) ˄70.59 (11.41)88.34 (11.36)76.07 (6.78)86.56 (6.79)0.00451.390.26
5x Sit-to-Stand
 Duration (s) ˅25.02 (5.59)30.42 (5.69)21.12 (2.85)20.57 (2.86)0.05802.840.13
 Sit-to-Stand Lean Angle (°) ˄27.81 (4.64)23.85 (5.31)33.84 (4.48)29.91 (4.48)0.00000.000.99
˄ higher scores indicate better performance. ˅ lower scores indicate better performance.

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Figure 1. Study flow diagram and procedure for the strENgth And BaLance exercise on Executive function in people living with Dementia (ENABLED) trial.
Figure 1. Study flow diagram and procedure for the strENgth And BaLance exercise on Executive function in people living with Dementia (ENABLED) trial.
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Figure 2. Single-task and dual-task posture in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) sway area, (B) frequency, (C) jerk, and (D) sway velocity.
Figure 2. Single-task and dual-task posture in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) sway area, (B) frequency, (C) jerk, and (D) sway velocity.
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Figure 3. Single- and dual-task gait in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) double limb support, (B) mid-swing elevation, (C) gait speed, (D) stride length, and (E) medial–lateral trunk range of motion; * p < 0.05.
Figure 3. Single- and dual-task gait in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) double limb support, (B) mid-swing elevation, (C) gait speed, (D) stride length, and (E) medial–lateral trunk range of motion; * p < 0.05.
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Figure 4. Single-task and dual-task timed-up-and-go (TUG) in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) double limb support, (B) mid-swing elevation, (C) gait speed, (D) stride length, and (E) medial–lateral trunk range of motion; * p < 0.05.
Figure 4. Single-task and dual-task timed-up-and-go (TUG) in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) double limb support, (B) mid-swing elevation, (C) gait speed, (D) stride length, and (E) medial–lateral trunk range of motion; * p < 0.05.
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Figure 5. Functional mobility measures in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) 360° turn angle, (B) 360° turn duration, (C) 360° turn velocity, (D) 5x sit-to-stand duration, and (E) 5x sit-to-stand angle.
Figure 5. Functional mobility measures in the Otago Exercise Program (OEP) plus usual care compared to usual care alone groups at baseline and 6 months for (A) 360° turn angle, (B) 360° turn duration, (C) 360° turn velocity, (D) 5x sit-to-stand duration, and (E) 5x sit-to-stand angle.
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Table 1. Participant characteristics for PWD; mean ± standard deviation (range of values).
Table 1. Participant characteristics for PWD; mean ± standard deviation (range of values).
VariableAll Participants (n = 42)OEP (ITT n = 21)OEP (Per Protocol n = 9)Usual Care (n = 21)
Age, years82.1 ± 8.1 (60–98)80.7 ± 7.5 (68.0–94.0)81.9 ± 8.3 (68.0–93.0)83.5 ± 8.6 (60.0–98.0)
Male; Female Sex, n (%)27 (64.3); 15 (35.7)14 (66.7); 7 (33.3)5 (55.6); 4 (44.4)13 (61.9); 8 (38.1)
Race: Black, White, Other n (%)7 (16.7), 35 (83.3), 0 (0)4 (9.5), 17 (40.5), 0 (0)2 (22.2), 7 (77.8), 0 (0) 3 (7.1), 18 (42.9), 0 (0)
Ethnicity: Hispanic, Non-Hispanic, n (%)1 (2.4), 41 (97.6)1 (4.8), 20 (95.2)0 (0), 9 (100)0 (0), 21 (100)
BMI, kg/m226.6 ± 5.5 (17.6–41.8)27.0 ± 5.7 (17.6–36.2)28.0 ± 6.5 (19.2–36.2)26.2 ± 5.5 (19.1–41.8)
FCI, total number3.7 ± 2.0 (1–9)4.0 ± 2.1 (1–8)3.6 ± 2.5 (1–8)3.4 ± 2.0 (1–9)
Medications, total number12.5 ± 5.6 (0–26)13.6 ± 6.3 (6–26)14.7 ± 6.7 (6–26)11.4 ± 4.8 (0–24)
Fall History in the Last 6 Months2.8 ± 12.2 (0–78)4.3 ± 16.9 (0–78)0.4 ± 0.7 (0–2)1.3 ± 2.3 (0–9)
Morse Fall Scale, points45.6 ± 23.9 (15–90)47.6 ± 24.9 (15–90)46.1 ± 22.6 (15–80)43.6 ± 23.4 (15–80)
MoCA, points10.0 ± 5.9 (0–19)10.6 ± 6.3 (0–19)9.3 ± 7.4 (0–18)9.5 ± 5.5 (1–19)
Dementia Onset, years3.5 ± 5.2 (0.2 to 26.6)2.1 ± 1.5 (0.4 to 5.2)1.4 ± 1.2 (0.4 to 3.0)5.0 ± 7.2 (0.2 to 26.6)
Dementia Type, n (%)    
 Alzheimer’s Disease16 (38.1)7 (33.3)3 (33.3)9 (42.9)
 Vascular Dementia3 (7.1)1 (4.8)0 (0.0)2 (9.5)
 PD Dementia1 (2.4)1 (4.8)1 (11.1)0 (0.0)
 Alcohol-Induced Dementia1 (2.4)0 (0.0)0 (0.0)1 (4.8)
 Unspecified, Without BD21 (50.0)12 (57.1)5 (55.6)9 (42.9)
Site    
 Nursing Home, n (%)24 (57.1)13 (31.0)5 (55.6)11 (26.2)
 Memory Care, n (%)7 (16.7)5 (11.9)3 (33.3)2 (4.8)
 Assisted Living, n (%)11 (26.2)3 (7.1)1 (11.1)8 (19.0)
Mobility Device, n (%)    
 Wheelchair5 (11.9)4 (9.5)0 (0)1 (2.4)
 Walker10 (23.8)6 (14.3)3 (33.3)4 (9.5)
 Cane11 (26.2)5 (11.9)3 (33.3)6 (14.3)
 None16 (38.1)6 (14.3)3 (33.3)10 (23.8)
BMI—Body Mass Index; FCI—Functional Comorbidity Index; MoCA—Montreal Cognitive Assessment; PD—Parkinson’s Disease; BD—Behavioral Disturbance.
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Jehu, D.A.; Langston, R.; Patel, C.; Soares, A.; Waller, J.L.; Carrick, R.M.; Hergott, C.; Young, L.; Hall, W.; Robinson-Johnson, D.; et al. The Effects of Six Months of Exercise on Single- and Dual-Task Posture, Gait, and Functional Mobility Relative to Usual Care Alone Among People Living with Dementia: The ENABLED Pilot Randomized Controlled Trial. Appl. Sci. 2025, 15, 6624. https://doi.org/10.3390/app15126624

AMA Style

Jehu DA, Langston R, Patel C, Soares A, Waller JL, Carrick RM, Hergott C, Young L, Hall W, Robinson-Johnson D, et al. The Effects of Six Months of Exercise on Single- and Dual-Task Posture, Gait, and Functional Mobility Relative to Usual Care Alone Among People Living with Dementia: The ENABLED Pilot Randomized Controlled Trial. Applied Sciences. 2025; 15(12):6624. https://doi.org/10.3390/app15126624

Chicago/Turabian Style

Jehu, Deborah A., Ryan Langston, Charmi Patel, Andre Soares, Jennifer L. Waller, Ryan M. Carrick, Colleen Hergott, Lufei Young, William Hall, Dawnchelle Robinson-Johnson, and et al. 2025. "The Effects of Six Months of Exercise on Single- and Dual-Task Posture, Gait, and Functional Mobility Relative to Usual Care Alone Among People Living with Dementia: The ENABLED Pilot Randomized Controlled Trial" Applied Sciences 15, no. 12: 6624. https://doi.org/10.3390/app15126624

APA Style

Jehu, D. A., Langston, R., Patel, C., Soares, A., Waller, J. L., Carrick, R. M., Hergott, C., Young, L., Hall, W., Robinson-Johnson, D., Allen, C., Sams, R., Hamrick, M., Huang, Y., Zhu, H., & Dong, Y. (2025). The Effects of Six Months of Exercise on Single- and Dual-Task Posture, Gait, and Functional Mobility Relative to Usual Care Alone Among People Living with Dementia: The ENABLED Pilot Randomized Controlled Trial. Applied Sciences, 15(12), 6624. https://doi.org/10.3390/app15126624

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