Effects of resistance training exercise on cognitive performance in elderly individuals with memory impairment: Results of a controlled trial

Abstract

Objective: To detect the effects of a resistance training programon cognitive performance and muscle strength in sedentaryelderly individuals with memory impairment. Methods: Thirty-onesedentary elderly persons with no dementia or depression wererandomly distributed into two groups: Physical Activity Group andControl Group. The resistance training exercise program lastednine months and consisted of three series of six exercises persession, carried out on lever-type equipment for approximatelyone hour, twice a week. Every three months, both groups weresubmitted to the following cognitive tests: Rivermead BehavioralMemory Test (RBMT), Wechsler Adult Intelligence Scale (WAIS)Direct and Indirect Digit Span, Memory Complaints Scale, andCambridge Cognitive Test (CAMCOG). Results: After nine months,the group that did resistance exercises showed a significantincrease in the standardized RBMT score (p = 0.021) and in musclestrength (p < 0.001), with no significant difference in the otherparameters evaluated. Conclusions: These results indicate thatsupervised resistance exercises can improve memory performancein sedentary elderly individuals with prior memory compromise,besides increasing muscle strength.

Full text

ORIGINAL ARTICLE
einstein. 2008; 6(4):402-7
Effects of resistance training exercise on cognitive
performance in elderly individuals with memory impairment:
results of a controlled trial
Efeitos dos exercícios resistidos no desempenho cognitivo de idosos com comprometimento
da memória: resultados de um estudo controlado
Alexandre Leopold Busse1, Wilson Jacob Filho2, Regina Miskian Magaldi3, Venceslau Antônio Coelho4,
Antônio César Melo5, Rosana Aparecida Betoni6, José Maria Santarém7
ABSTRACT
Objective: To detect the effects of a resistance training program
on cognitive performance and muscle strength in sedentary
elderly individuals with memory impairment. Methods: Thirty-one
sedentary elderly persons with no dementia or depression were
randomly distributed into two groups: Physical Activity Group and
Control Group. The resistance training exercise program lasted
nine months and consisted of three series of six exercises per
session, carried out on lever-type equipment for approximately
one hour, twice a week. Every three months, both groups were
submitted to the following cognitive tests: Rivermead Behavioral
Memory Test (RBMT), Wechsler Adult Intelligence Scale (WAIS)
Direct and Indirect Digit Span, Memory Complaints Scale, and
Cambridge Cognitive Test (CAMCOG). Results: After nine months,
the group that did resistance exercises showed a significant
increase in the standardized RBMT score (p = 0.021) and in muscle
strength (p < 0.001), with no significant difference in the other
parameters evaluated. Conclusions: These results indicate that
supervised resistance exercises can improve memory performance
in sedentary elderly individuals with prior memory compromise,
besides increasing muscle strength.
Keywords: Aging; Health of the elderly; Dementia; Cognition
disorders; Motor activity
RESUMO
Objetivo: Detectar os efeitos de um programa de exercícios
resistidos no desempenho cognitivo e na força muscular de idosos
sedentários com comprometimento da memória. Métodos: Trinta e
um idosos sedentários sem demência ou depressão foram distribuídos
aleatoriamente em dois grupos: Grupo Atividade Física e Grupo Controle.
O programa de exercícios resistidos durou nove meses e consistiu de
três séries de seis exercícios por sessão, realizados em aparelhos com
sistema de alavancas, por aproximadamente uma hora, duas vezes
por semana. Ambos os grupos foram submetidos aos seguintes testes
cognitivos a cada três meses: Teste Comportamental de Memória
de Rivermead (RBMT), Amplitude de Dígitos Diretos e Indiretos
do Wechsler Adult Intelligence Scale (WAIS), Escala de Queixas de
Memória e Teste Cognitivo de Cambridge (CAMCOG). Resultados:
Após nove meses, o grupo que realizou os exercícios resistidos teve um
aumento significativo do escore padronizado do RBMT (p = 0,021) e
da força muscular (p < 0,001), sem diferença significativa dos demais
parâmetros avaliados. Conclusões: Estes resultados indicam que os
exercícios resistidos supervisionados podem melhorar o desempenho
da memória em idosos sedentários com prévio comprometimento,
além de determinar o aumento da força muscular.
Descritores: Envelhecimento; Saúde do idoso; Demência; Transtornos
cognitivos; Atividade motora
Study carried out at the Geriatric Service of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP – São Paulo (SP), Brazil.
1 PhD; Assistant Physician at Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
2 Full Professor of Geriatrics at Faculdade de Medicina of Universidade de São Paulo – FMUSP, São Paulo (SP), Brazil.
3 Assistant physician of the Department of Geriatrics at Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
4 Assistant physician of the Department of Geriatrics at Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
5 Physical education professional of Centro de Estudos em Ciências da Atividade Física (CECAFI) of Geriatrics at Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
6 Physical education professional of Centro de Estudos em Ciências da Atividade Física (CECAFI) of Geriatrics at Faculdade de Medicina of Universidade of São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
7 PhD; Coordinator of Centro de Estudos em Ciências da Atividade Física da Disciplina (CECAFI) of Geriatrics at Faculdade de Medicina of Universidade de São Paulo – HC-FMUSP, São Paulo (SP), Brazil.
Corresponding author: Alexandre Leopold Busse – Avenida Angélica, 1.761 – conj. 114 – Higienópolis – CEP 01239-020 – São Paulo (SP), Brasil – Tel.: 11 3214-2953 – e-mail: alebusse@gmail.com
Received on: May 28, 2008 – Accepted on: Oct 30, 2008

einstein. 2008; 6(4):402-7
Effects of resistance training exercise on cognitive performance in elderly individuals with memory impairment: results of a controlled trial 403
INTRODUCTION
Aging of the population is a worldwide phenomenon
that has been increasing due to a marked decrease in
fecundity and increase in life expectancy(1-2). One of the
consequences of this is the increase in prevalence of
dementia that is clinically characterized by a compromise
in fixation or evocation memory and impairment of at
least one other cognitive dominion (language, praxis,
and executive functions)(3).
However, the complaint of memory difficulty is one of
the most frequent in the elderly. One study performed in a
metropolitan Brazilian region demonstrated that 54% of
elderly individuals interviewed had memory complaints(4).
There are medications that can be beneficial in cases of
dementia, but there was no benefit in elderly subjects
who presented only with memory impairment(5-6).
Therefore, memory rehabilitation by non-
pharmacological means has been intensely sought.
Recently, a correlation between the preservation or
even improvement of cognitive performance and
physical exercises, especially aerobic exercises, has
been particularly researched. A systematic review
which included 18 longitudinal studies (1966 to
2001) concluded that aerobic exercises may provide
a consistent advantage in cognitive performance of
sedentary elderly individuals(7). Another systematic
review including 30 studies (1970 to 2003) demonstrated
a decrease in occurrence of dementia(8).
One particular type of physical exercise has shown
great benefit in the elderly: strength training, also called
resistance exercises(9). Nevertheless, the effects of these
on cognition have not been studied very often.
OBJETIVE
Therefore, the objectives of this study were to
evaluate the effects of a supervised resistance exercise
program on cognition in sedentary elderly subjects with
memory impairment; to compare the performance of
the subjects in cognition tests and the progression of
muscle strength as to gender.
METHODS
The study was conducted at the Memory of the Elderly
Outpatient´s Clinic (AMI) of the Geriatric Service
of Hospital das Clínicas of Faculdade de Medicina da
Universidade de São Paulo (HC-FMUSP), site for patient
selection, clinical follow-up and cognitive assessments.
Inclusion criteria were: elderly of both genders
aged 60 years or more who had not performed
programmed physical exercises in the six-month
period prior to the selection process; subjective
memory complaints reported by the patient or by
an informant; geriatric depression scale (GDS)(10)
within normal limits; mini-mental state examination
(MMSE)(11) within limits of normal corrected by
schooling(12); changes in the objective memory test: a
screening Rivermead test score equal to or less than
nine(13); preserved function in instrumental and basic
activities of daily life(14-15).
Exclusion criteria were: dementia, depression and
anxiety disorders as per Diagnostic and Statistical
Manual of Mental Disorders of the American
Psychiatric Association (DSM – IV) criteria(3);
head trauma or stroke in the previous year; recent
use of substances that contribute to memory loss
(alcohol, antidepressants, anxiolytics, neuroleptics,
anticonvulsants, hypnotics, opioid analgesics);
alterations in laboratory tests (glucose, hepatic
transaminases, thyroid hormones, creatinine, urea,
sodium, potassium, calcium, erythrocyte sedimentation
rate, serology for syphilis, levels of vitamin B12 and
folic acid), and unstable cardiovascular disease.
Once the selection criteria were met, patients
signed an informed consent form approved by the
Commission for Research Project Analysis (CAPPesq)
of HC-FMUSP and names were drawn by a person
independent of the research using papers taken from
an opaque envelope, with two possibilities: Intervention
Group or Control Group. Both groups were evaluated
as per a cognitive assessment protocol at baseline, and
after three, six, and nine months(13).
Cognitive assessment
• Cambridge cognitive test (CAMCOG) is a cognitive
test (with 67 items) that evaluates orientation,
language, memory, praxis, attention, abstract
thinking, perception, and calculation. The score
varies from 0 to 107(16-17).
• Rivermead Behavioral Memory Test (RBMT) is a
memory test consisting of a battery of practical tasks
which seeks to simulate daily situations, in order to
decrease the interference of cultural factors. The
standardized score varies from 0 to 24 and screening
scores vary from 0 to 12(13).
• Direct and Indirect Digit Span of the Wechsler Adult
Intelligence Scale (WAIS) measures the capacity for
concentration and working memory, respectively. It
consists of a repetition of a sequence of numbers
and both scores vary from 0 to 14(18).
• Memory Complaints Scale (MCS) is a questionnaire
derived from “The Cambridge examination for
mental disorders of the elderly” (CAMDEX) and
was designed so that the greater the number of
complaints, and the greater their interference in the

einstein. 2008; 6(4):402-7
404 Busse AL, Filho WJ, Magaldi RM, Coelho VA, Melo ac, Betoni RA, Santarém JM
subject’s life, the greater the score that varies from 0
to 21 is(19).
Statistical analysis
In order to compare the means of the groups, the
t-Student test was used for continuous variables. In
categorical variables, χ2 test or proportion analysis of
two samples was used, and, in reduced samples, the
Fischer’s exact test was applied. To analyze the effect
of group and time and the effect of group and gender
regarding the results of the cognitive tests, the analysis of
variance (ANOVA) was used for repeat measurements.
A value of α < 0.05 was adopted, and the analysis was
carried out using the MINITAB 14 statistics program.
Intervention
The resistance exercises were performed at the
Experimental Therapeutic Gymnasium as per the
training protocol used by Centro de Estudos em Ciências
da Atividade Física (CECAFI) of the Department of
Geriatrics of FMUSP. The protocol carried out at the
CECAFI was based on scientific evidence on the use of
resistance exercises with safety and efficacy to increase
muscle strength in the elderly(9).
The program consisted of six exercises per training
session, lasting for approximately one hour each time,
twice a week. In each exercise, loads were progressively
increased in series of 12, 10, and 8 repetitions. Each
repetition was made slowly, with approximately three
seconds during the concentric contraction phase and six
seconds in the eccentric contraction phase. The series
of eight repetitions was performed with the highest
load, which was increased in subsequent sessions by
the supervising physical therapist or physical education
professional, always attentive to not allowing a tendency
towards isometry in apnea.
As cardiovascular safety measures, arterial blood
pressure was measured before and after the sessions,
with a resting period of one to two minutes between
the series, avoiding maximal muscle contraction in
apnea during the repetitions. The protocol was directed
towards training of the large muscle groups (chest press,
rowing, leg press, calves, abdominal, and lumbar). The
exercises were carried out on six equipment pieces with
system of levers and weights (Biodelta Maxiflex line)
RESULTS
Subject characteristics
Thirty-one elderly individuals were selected (8 men and
23 women) and distributed by drawing of names: 17 to
the Resistance Training Group and 14 to the Control
Group. The mean age among the participants was 72.2
± 5.4 years (varying from 62 to 86 years). There was
no statistical difference in the means of age, level of
schooling, and chronic diseases between the groups.
A statistical difference was identified (p = 0.049) as to
gender between the groups. Four participants, two from
the Resistance Exercise Group and two from the Control
Group abandoned the study before its conclusion, but
all data obtained during follow-up of these individuals
were included in the statistical analysis. The subject
characteristics in the initial phase are presented in
Table 1.
Variables
Control
Group
(n = 17)
Physical
Activity Group
(n = 14)
p value
Age: mean ± sd (years) 73.3 (± 6.4) 70.4 (± 3.6) 0.13*
Women/men 15 / 2 8 / 6 0.049**
Schooling: mean ± sd (years) 4. 3 (± 4.6) 6. 3 (± 3.8) 0.24*
CAMCOG: mean ± sd 81.3 (± 8.1) 82.9 (± 8.9) 0.62*
Rivermead test: mean ± sd 16.1 (± 3.2) 15.5 (± 3.2) 0.61*
Arterial hypertension 10 (58.8%) 7 (50%) 0.78***
Diabetes mellitus 3 (17.6%) 4 (28.6%) 0.66**
Coronary artery disease 1 (5.9%) 1 (7.1%) 1.0**
Arterial fibrillation 1 (5.9%) 1 (7.1%) 1.0**
Dyslipidemia 5 (29.4%) 7 (50%) 0.16***
Stroke 1 (5.9%) 0 (0%) 1.0**
Hypoacusis 1 (5.9%) 1 (7.1%) 1.0**
Osteoporosis 4 (23.5%) 2 (14.3%) 0.67**
Table 1. Baseline sample characteristics
* t-Student test; ** Fisher’s exact test; *** proportion analysis of two samples
Cognition results
The results of the cognitive assessment may be evaluated
by data in Table 2. The physical activity group showed
an increase with statistical significance in the RBMT
mean detected during the fourth assessment, after nine
months of resistance training (Figure 1). An effect of
interaction between the group and time was detected
(p = 0.021). The initial means in both genders are
not the same (p = 0.003), since the mean in males is
greater than that in females, regardless of the group. In
the Physical Activity Group (PA), men showed a mean
variation (final minus initial values) of 0.8 (95%CI=
-2.1-3.7), and for women it was 4.7 (95%CI = 2.3-7.1).
In the Control Group, men showed a mean variation
of -4 (95%CI = -8.6-0.6) and women of -0.2 (95%CI
= -2.0-1.6). Thus, the mean variation in RBMT also
depends on the gender (p = 0.045), since the variation
in the women of AF was greater than in the men.

einstein. 2008; 6(4):402-7
Effects of resistance training exercise on cognitive performance in elderly individuals with memory impairment: results of a controlled trial 405
The CAMCOG means increased significantly in
both groups over the course of the study (p < 0.001),
but there was no difference with statistical significance
between the groups. No group effect was identified at
any of the timepoints (p= 0.322). In other words, the
means coincided, but at the end they were greater than
in the beginning, both in group physical activity and
in Control Group. No interaction effect was detected
between time and gender in the CAMCOG mean
(p = 0.71).
Muscle strength results
With the objective of estimating the variation in muscle
strength of the resistance training participants, the
means of the loads used in the series of eight repetitions
were compared, as of the end of the first month for
adaptation. There was an increase with statistical
significance in the means of the loads (Table 3). No
interaction effect was detected between gender and
progression of muscle strength by the Kruskal-Wallis
test: rowing (p = 0.16); leg press (p = 0.45); lumbar
extension (p = 0.80); abdominal (p = 0.25); pectoral
(p = 0.06), and calves (p = 0.74).
Figure 1. Mean variation (± sd) in the Physical Activity Group (PA) and in the
Control group (C) in the Rivermead test during the nine-month period of study
(p= 0.021)
Group
9630
CPACPACPACPA
20
19
18
17
16
15
14
PA
C
Group
Month
Rivermead test
Cognitive assessment Baseline 3rd
month
6th
month
9th
month p value*
CAMCOG (C) 81.3 82.1 83.4 84.5 0.32
CAMCOG (PA) 82.9 84.4 88.1 89.2
Rivermead test (C) 16.1 16.7 14.9 15.33 0.021
Rivermead test (PA) 15 17.1 17.6 18.9
MCS (C) 7.6 7.5 8.1 8.2 0.36
MCS (PA) 8.9 8.9 8.7 8.2
Direct digit span (C) 4.6 4.6 4.5 4.9 0.66
Direct digit span (PA) 4.9 4.5 4.6 4.6
Indirect digit span (C) 4.2 3.8 4.3 4.2 0.13
Indirect digit span (PA) 3.7 4 4.2 4.5
Table 2. Results of cognitive assessment in both groups
C = Control Group; PA = Physical Activity Group; *analysis of variance (group/time); MCS = memory complaint scale
Exercises 1st month 3rd month 6th month 9th month p*
Lumbar
extension
13.2 ± 7.94 27.5 ± 21.1 37.1 ± 22.8 47.1 ± 24.1 p < 0.001
Leg press 16.1 ± 8.94 25.4 ± 19.56 37.3 ± 24.39 45 ± 23.4 p < 0.001
Calves 10.3 ± 5.4 17.8 ± 15.6 22 ± 17.6 28.13 ± 20.9 p = 0.004
Rowing 10.1 ± 7.9 16.9 ± 7.6 20.4 ± 6.8 26.59 ± 11.7 p = 0.001
Abdominal 9.7 ± 5.2 15.3 ± 12.1 19 ± 13.1 22.7 ± 10.2 p = 0.001
Pectoral 5 ± 4 10.4 ± 9.1 11.7 ± 2.7 13.3 ± 2.8 p = 0.001
Table 3. Progression of mean (± sd) resistance training load (kg)
*Analysis of variance (ANOVA)
DISCUSSION
Even though the evidence that aerobic exercise benefits
cognition in the elderly is consistent, few studies have
been conducted to assess the effect of resistance
exercises on the cognition of elderly individuals. The
study by Perrig-Chiello et al.(20) was the first with this
purpose, but it only demonstrated an improvement in
general well-being.
In the present study, the RBMT mean increased
significantly in the Intervention Group in comparison
with the Control Group. We point out that RBMT was
developed to measure memory loss and monitor the
effects of rehabilitation. It is not affected by level of
schooling, age, or gender, and since it is a behavioral
test, it shows a good correlation with memory
difficulties in situations of daily life. However, there
was no statistically significant difference between the
means of the Memory Complaints Scale (MCS) of
both groups.
In the study performed by Lachman et al.(21), with
210 elderly subjects, there was an improvement in
working memory only in the subgroup with the greatest
progression of loads during training. In the study by
Cassilhas et al.(22), with 62 elderly individuals, there was
a significant improvement, both in working memory
and episodic memory. However, in these two studies,
with six-month duration, there was no selection of the
elderly according to memory complaints or by prior
performance on cognitive tests.
In this study, in the PA, there was improved
performance on the RBMT in both genders, but the
improvement in females was significantly superior. In
some prior studies it had been observed that the female
gender showed superior benefits than the male gender,
especially with aerobic exercises. Nevertheless, it still
is not clear by which mechanisms gender influences
the modulation of the effects of physical exercises on
cognition(23).

einstein. 2008; 6(4):402-7
406 Busse AL, Filho WJ, Magaldi RM, Coelho VA, Melo ac, Betoni RA, Santarém JM
The significant increase in CAMCOG, both in
the Control Group and the Intervention roup can be
explained by the test learning effect, since there is only
one version applied every three months. The learning
effect did not occur with the RBMT, possibly because
there are four versions of it and a different version was
used at each assessment. Performance on CAMCOG
was statistically the same for both genders.
There was no statistically significant difference
between the means of the direct and indirect digit span
in both groups. Therefore, this is different from the
study performed by Lachman et al.(21) and the study by
Cassilhas et al.(22), in which a significant improvement
was noted in these tests.
Muscle strength was measured indirectly, i.e., by
progression of loads in the resistance training program.
There was a significant increase in loads in the six-piece
equipment used, between the end of the first month and
the end of the ninth month of training, which was similar
in both genders. The mean increase estimated in muscle
strength was 178%, similar to the results obtained in
studies carried out in our region with a similar exercise
protocol(24-25).
Increased sociability is, no doubt, one of the
objectives of the prescription of physical exercises
to promote health for any age bracket. It is possible,
then, that the greater social interaction afforded by the
practice of resistance exercises contributed towards an
improved performance in memory in the Intervention
Group. However, it has been noted in various studies
that the greater the intensity of the exercise, the
better the progression of cognitive performance,
demonstrating that increased sociability, in itself, is
not sufficient(26).
This study presents relevant contributions to
scientific knowledge, but there are some limitations
that may be adjusted in future research projects.
The number of participants was small, which led
to a significant difference in distribution of the
genders between the groups during the random
distribution. A more expressive sample size would
certainly lend greater reliability to the results found,
and would eventually show other benefits that were
not significant in this study. The results of cognitive
assessment could also be more reliable if the raters
had no prior knowledge of which group the subjects
belonged to.
CONCLUSIONS
The results indicate that nine months of supervised
resistance exercises may be effective in improving the
memory performance of sedentary individuals with
memory impairment. In the Intervention Group, there
was a significant improvement in performance of the
RBMT in both genders, but the improvement in the
female gender was more expressive. The CAMCOG
may be affected by learning the test if it is applied
repeatedly, with intervals of three months. The increase
in muscle strength in the Intervention Group was very
significant in all muscle groups covered in the resistance
exercise protocol. There was no difference in proportion
of muscle gain between genders.
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