A Cross-sectional Survey of an Ongoing Public Multimodal Intervention for Cognitive Health for Older Adults in Times of Covid-19

Background In recent decades, the proportion of older adults in the population has continued to rise and with it the need for intervention programs to maintain cognitive functions into old age. Multiple lifestyle factors, rst and foremost physical, cognitive, and social activities, have been shown to be crucial to forestalling decline in cognitive functions. However, since Covid-19 has curtailed opportunities for such activities, strategies must be designed to support older adults to remain cognitively healthy. This study describes a newly developed ongoing publicly available preventive intervention, called brain coach, to support and stimulate cognitive activity in older adults. The intervention consists of weekly recommendations for evidence-based physical, cognitive, social, mindful, and creative activation exercises that can be integrated in daily life. 660 participants participated in an online cross-sectional survey examining experienced benets and changes in relation to the program. Participants reported benets in memory, well-being, attitudes towards the brain, and lifestyle habits. Importantly, time invested in the intervention as well as some characteristics of participants, such as personality and positive attitude toward brain health, show positive relationships with these experienced benets. Further research will explore the effects of such a multimodal intervention in a longitudinal randomized controlled trial study. cognitive decline. This pilot study aims to evaluate an ongoing multimodal online intervention with a cross-sectional survey. The intervention raises older adults’ awareness of the impact of their lifestyle on their cognitive health and sends them weekly exercise suggestions to support them in making cognitively stimulating activities part of their routine.

indirect effect on cognition through improved physiological mechanisms related to stress and immune function, a direct effect has been proposed through the repeated activation of attentional functions (Malinowski & Shalamanova, 2017)). Indeed, evidence has shown that mindfulness-based interventions improve cognition in older adults both with and without mild cognitive impairment (Wells et al., 2019;Zhang et al., 2018).
Another factor is creativity, which is linked not only to mental and physiological health indicators but also to cognition in older age (e.g., Sharma & Babu, 2017). Individuals that frequently engage in highly creative activities demonstrate higher cognitive reserve than individuals with more routine activities (Colombo et al., 2018). Intervention studies with older adults both with and without mild cognitive impairment or dementia found greater positive effects on cognitive functions and daily living ability after creative therapy (e.g. drawing, dance, music, story-telling) than after standard cognitive training (Martinec & Lera, 2018;Zhao et al., 2018). In addition to interventions traditionally identi ed as creative, other creative activities include idea generation and improvising (cf. Flood & Phillips, 2007).
Finally, humor leads to the release of endorphins in the brain and a reduction of cortisol, which produces psychological and physiological effects that are similar to the bene ts of aerobic exercise (cf. Berk et al., 2001). Also, humor is a form of cognitive reappraisal, allowing individuals to reappraise daily stressors. Therefore, humor is suggested as an approach to decrease stress and protect cognitive abilities in older adults (cf. Mallya et al., 2018). Humor interventions have been shown to relieve chronic pain, and enhance happiness and life satisfaction (e.g. Tse et al., 2010).
In sum, research into cognitive health suggests that the effect of these activities on cognitive tness may be additive. Consequently, a generally active lifestyle seems to be more effectual than speci c short-term interventions (Kuster et al., 2016). The present cross-sectional study evaluates an ongoing public multimodal intervention that combines all of the evidence-based factors mentioned above to support older adults in their cognitive tness and health. The intervention consists of weekly exercise recommendations for physical, cognitive, social, mindful, and creative activities for daily life combined with psychoeducational information about the impact of their lifestyle on their cognitive health. The purpose of the intervention was to encourage and instruct participants to make particular activities and speci c exercises part of their daily activities. The aim of this cross-sectional study survey was to determine what kind of individuals participate in such a public intervention, how much time they spend on the exercises, and whether they experience any bene ts from the intervention. Furthermore, we aimed to investigate how the characteristics of the participants and the time they invested in uenced self-rated changes and lifestyle adaptations.

Participants
The intervention began in the German-speaking part of Switzerland in March, and the cross-section survey was conducted from August to October 2020. A total of 660 individuals participated in the study. Inclusion criteria were met when a participant used the intervention for personal reasons and exhibited an age minimum of 60 years, resulting in a total of 542 participants who were included in statistical analyses. Demographic data comprised age (M = 71.47, SD = 6.34, range: 60-92), years of education (M = 13.80, SD = 1.82, range: 6-16), sex (76.2% female), civil status (3.0% unmarried, 45.0% married, 9.0% divorced, 9.0% widowed, and 1.5% civil union), and health condition (47.5% very good, 48.6% rather good, 3.7% rather bad, and 0.3% bad).

Procedure
The free offer of a "brain coach" intervention was advertised in the online media. Individuals who registered for the intervention received a task sheet by email every week or every second week (length: approx. 2-5 pages). Participants were encouraged to implement the exercises and activities in their daily lives. They were free to choose which of the exercises they performed, when, and how intensely.
After 5 months, the online survey was sent by email to participants who had been part of the intervention for at least 3 months at the date of the evaluation.
Participants completed the online survey anonymously.

Intervention
Every week or every second week, participants received a task sheet (3-6 pages) containing descriptions and links to short video demonstrations of various cognitive activation exercises for everyday life. The evidence-based exercises are designed to support cognitive health and addressed ve areas: memory through cognitive training tasks and memory strategies such as N-back exercises and the loci method, coordination through physical coordination tasks such as balance and juggling exercises, mindfulness through exercises for increased self-awareness such as a breathing task, creativity through enhancement of creative processes such as connecting unrelated things, community through ideas for social activities without physical contact due to Covid-19, and humor through funny jokes and cartoons. In addition, the task sheets included psychoeducational information about brain functions and neuroplasticity as well as explanations about the effects of the exercises and strategies on neural processes and cognitive health.

Self-reported measures
Characteristics of participants Personality. The Big Five Inventory, a 10 item questionnaire that records responses on 5-point Likert scales (Rammstedt & John, 2007) was used as a measure of personality traits.
Attitude towards the aging brain. Participants' attitudes toward their aging brains were assessed with a questionnaire designed by the authors and including ve questions. One question assessed general belief in neuroplasticity, and the other four questions assessed the strength of positive and negative attitudes towards the aging brain on Likert scales ranging from 1 (no, not at all) to 4 (yes, a lot): Belief in neuroplasticity. Participants' belief in their aging brains' plasticity was assessed with the question "What do you think about your aging brain?" Responses were recorded on an open scale ranging from 0 (age-dependent cognitive decline) to 10 (brain stays adaptive and capable).
Positive attitude. The strength of positive attitude (con dence in conserved learning ability) was calculated from the mean value for the general conviction about the plasticity of the brain and personal con dence in being able to positively in uence cognitive tness.
Negative attitude. The strength of negative attitude (worry about cognitive decline) was de ned by calculating the mean value of general worries about biological, age-dependent cognitive decline and individual concerns about experienced decline in learning and memory.

Intervention commitment
The frequency with which exercises were performed was assessed with the question "How regularly do you perform exercises from the Hirncoach-program on average?" Five answer options were available, ranging from "less than every other week" to "daily." The weekly time invested in the exercises was assessed with the question "How much time do you spend weekly on average doing exercises from the Hirncoach program?" The ve answer options ranged from "less than 15 min a week" to "more than 2 hours a week." The overall time invested for the intervention was calculated by multiplying the time invested in the intervention per week by the number of weeks since the individual date of registration.

Perceived intervention-induced bene t
Bene t in cognitive tness: Participants were asked about the perceived effect of the intervention on their memory performance ("Have you experienced any bene t from the Hirncoach exercises for your cognitive tness, such as memory?").
Bene t in well-being: Participants were asked about the perceived effect of the intervention on their well-being ("Have you experienced any bene t from the Hirncoach exercises for your well-being, such as mindfulness, so far?").
Bene t in brain health-related attitude. Participants were asked whether the intervention changed their attitude toward their brain health ("Have the Hirncoach exercises changed your attitude towards your brain health?").
Bene t in activities: Participants were asked whether the intervention changed their behavior ("Have you changed any activities that bene t the brain or body in everyday life because of the intervention?').
All answers were given on a Likert scale ranging from 1 (no) to 4 (yes, a lot).

Data Analysis
Descriptive statistical analyses were performed as mean and standard deviation and as frequency distribution for the sample characteristics, intervention commitment, and self-reported bene t of intervention. Correlation analyses were performed to analyze the relationship between participants' characteristics (belief in neuroplasticity, attitude towards brain health, personality), intervention commitment (total time investment), and self-reported bene ts through the intervention (change in memory, mindfulness, attitude, activities). Kendall-Tau-b and Spearman coe cients of correlation were used, but for clarity only results from the former are reported. Finally, analysis of multiple linear regressions was performed with the dependent variable generalized experienced bene t, de ned by the average of experienced effects on cognitive tness and well-being and on brain-health-related attitude and behavior, and the two independent variables time investment and belief in neuroplasticity to analyze the variance and the strength of their relationships.

Results
Descriptive results and frequency distributions of sample characteristics, intervention commitment, and self-reported bene t are shown in Table 1 and Figs. 1-3. Correlations between these variables are shown in Table 1.

Sample characteristics
On average, participants used the intervention twice per week (see Figure 1). The average days of participation was 135.04 (SD = 36.75). The average of hours invested related to the intervention was 22.31 (SD = 28.13) and the mean of weekly invested hours related to the intervention was 0.65 (SD = 0.72; see Figure  2). Participants described the experienced bene t of intervention as "pretty much" on the four-point Likert Scale (M = 3.04, SD = 0.56; see Figure 3), with the highest bene t on the attitude towards brain health (M = 3.14, SD = 0.78).
Personality is related to attitude towards aging brain and time investment Of the Big Five dimensions of personality, conscientiousness and agreeableness (r = .14, r = .12, respectively, both p < .01) as well as extraversion and openness (both r = .09, p < .05) were positively related with time invested in the intervention, whereas neuroticism was negatively related, r = -.10, p < .01. The same pattern was found for the association with belief in neuroplasticity. By contrast, neuroticism showed a positive association with worries about cognitive decline, r = .12, p < .01, whereas conscientiousness, extraversion, and openness showed a negative association (r = -.16, r = -.12, r = -.08, respectively).

Time invested in the intervention is related to self-reported bene t
There was a signi cant relationship between time invested and bene t experienced in cognitive tness, r = .26, p < .01; well-being, r = .26, p < .01; attitude, r = .20, p < .01; and activity, r = .29, p < .01.
Concerning the regression analyses with general experienced bene t as dependent variable and both time invested and belief in neuroplasticity as independent variables, a signi cant regression equation was found (F (2,357) = 34.737, p < .000), with an R 2 of .093. Participants' general experienced bene t increased by 0.01 rating points for each hour of investment and by 0.136 for each rating point of belief in neuroplasticity. Both time investment and belief in neuroplasticity were signi cant predictors of generalized bene t experienced.

Discussion
There is increasing scholarly support for the view that cognitive health is positively related to an active lifestyle that integrates physical, cognitive, and social activities. Restrictions imposed in response to Covid-19 have dramatically reduced older adults' opportunities for such stimulating activities in their daily lives.
To forestall cognitive decline, a multimodal intervention is offered publicly. It informs participants about the impact of their lifestyle on their cognitive health and sends them weekly suggestions for evidence-based exercises that strengthen cognitive health. It also encourages them to make cognitively stimulating activities part of their daily routine with recommendations related to lifestyle factors shown to be crucial for cognitive health. This cross-sectional study aimed to assess commitment to this intervention and bene t experienced from it. We were interested in what kind of individuals participate in such a public intervention, how much time they spend on the exercises, and whether they experience any effects from the intervention. Furthermore, we aimed to investigate how the participants' characteristics and time invested relate to self-rated changes and lifestyle adaptations.

Characteristics of participants
The mean age of participants was 71 years. This is in line with the nding that older people's worries about their memory and dementia is highest around the Three quarters of the participants were female. This is comparable with memory and health intervention studies, where 79% or even 82% of at-risk older participants were female (McDougall et al., 2010; Settersten & Lauver, 2004). Other ndings con rm that women are more concerned about their health and about developing dementia, engage in more health-promoting behaviors, and seek preventive healthcare measures more often (see Pinkhasov et al., 2010, for a review). Some explanations that could account for such gender differences are women's greater willingness and ability to take care of themselves when they are sick, several stereotypical masculine behaviors, and men's inclination to self-reliance, physical toughness, and emotional control (cf. Pinkhasov et al., 2010). However, there is as yet no consensus regarding whether men or women bene t more from interventions (see Barha et al., 2017;Stern et al., 2007, for reviews). Our sample showed no difference between males and females in intervention-related bene ts (t(367) = 0.70, p > .05.).
More than 90% of the participants were in rather good or good health. This is not surprising because the intervention was noncommittal and online. Consequently, only individuals with access to internet and su cient mental and self-regulation resources to implement the exercises independently were able to participate. Other research has demonstrated that perceived health status in uences participation in health promotion behaviors (Settersten & Lauver, 2004).

Intervention commitment
The average weekly time invested in exercises was around 50 minutes, performed on average twice per week. This suggests that intervention commitment was quite high and con rms the animating effect of the intervention. It is also in line with other interventions in older adults, which elicited between one and three home exercise sessions per week on average (cf. Picorelli et al., 2014), and it corresponds to the suggested intensity of lifestyle intervention activities (Klimova et al., 2017).

Self-reported perceived bene ts and time investment
Around 60 % of the participants estimated that they bene tted substantially from the intervention and more than 25% reported very high bene t. Because this survey was cross-sectional, retrospective bias cannot be excluded, and no causal interpretation can be made. Nevertheless, the result suggests that participants experienced positive effects from the exercises introduced in the intervention. Importantly, this assumption is supported by the nding that selfreported bene ts were closely related to the time invested in intervention-related exercises. This con rms that the higher the investment in active lifestyle, the higher the bene ts experienced over time (cf. Kuster et al., 2016).
Participants experienced comparable positive effects on their memory performance, well-being, attitude towards their brain health, and activities in daily life. This con rms that interventions integrating recommendations and instructions of evidence-based exercises and lifestyle activities for cognitive health can exert a positive effect not only on cognition but also on well-being, attitude, and lifestyle activities (e.g. Hudes et al., 2019;Klimova et al., 2017;Ng et al., 2017).
Relationship between personality, attitude towards brain health, and time investment Except neuroticism, all of the big ve personality factors were positively related to participants' belief in neuroplasticity. In contrast, neuroticism was related to higher worries about cognitive decline. This is in line with ndings of a positive correlation between neuroticism and dementia worry (e.g. Furr, 2018).
Furthermore, neuroticism was negatively related to time invested in intervention-related activities, whereas the other personality traits were positively related to this factor. The associations of both positive attitude and intervention commitment with conscientiousness were the strongest among the personality traits, which is in line with the nding that higher conscientiousness is associated with lower dementia risk (Kaup et al., 2019). Our ndings suggest that personality may in uence attitudes towards both the aging brain and the importance of lifestyle interventions to older adults. In particular, individuals with high neuroticism can be encouraged by providing them with information about the brain's capacity for plasticity and the impact of active lifestyles on cognitive health.
Individuals with stronger belief in neuroplasticity indicated greater time investment in the intervention-related exercises and reported higher bene t experienced in cognitive tness, well-being, attitude, and activity. This is in line with studies demonstrating that individuals with positive age stereotypes show less and slower cognitive decline than individuals with negative stereotypes (Levy et al., 2016;2012). Positive attitude to brain health seems to promote the willingness and motivation to invest in healthy behaviour and to protect cognitive health.

Limitations and outlook
The main limitation of this study is the cross-sectional method, which precludes any conclusions about causalities and intervention effects. Also, all measures were self-reported and therefore prone to bias and social desirability.

Conclusions And Implications
This ongoing public intervention, which is offered to older adults to support them in maintaining their cognitive health, follows Williams and Camper`s (2010) appeal that "older adults may be advised to add new cognitive, physical, and social activities, and improved nutrition to support successful cognitive aging and to improve neuroplasticity." The present multimodal lifestyle intervention includes recommendations for such evidence-based activities, lifestyle advice, and background information about the aging brain. It is of considerable length and tailored to life circumstances that have changed in the Covid-19 pandemic. This cross-sectional survey suggests the bene ts of the intervention on memory, well-being, positive attitude toward the aging brain, and the lifestyles of older adults. Importantly, booth time investment and participants belief in neuroplasticity were positively related to experienced intervention bene t.
The present analyses highlight the potential of public multimodal health intervention and psychoeducation to motivate older adults to change their health behavior. Speci cally, the data reveal the importance of participants' attitudes toward brain health to their investment in behavior that protects cognitive health. Moreover, it seems important at a societal level to nd ways to promote positive age stereotypes and attitudes towards the aging brain. Neuropsychoeducative information, such as about the neuroplasticity of the aging brain, should always be part of cognitive intervention and health programs.
Being aware of the brain's capacity for plasticity and the resulting importance of everyday activities may motivate people to adopt and maintain healthier lifestyles and thus reduce or even prevent cognitive decline and dementia. To maximize the utility of such lifestyle interventions, recommendations could be personalized to participants' lifestyles and attitudes towards brain health (cf. Barha et al., 2017). Furthermore, public lifestyle interventions should be implemented as early as possible to support the protection of older adults' health and brains before impairment occurs.
In sum, the results of this cross-sectional survey indicate that this public multimodal intervention animated participating older adults to invest in their cognitive health and that resulting bene ts were experienced in daily lives. All participants agreed at the beginning of the questionnaire to give their answers anonymously.

Consent for publication
Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
There is no commercial interest in the described intervention, therefore no con ict of interest to declare.  Note. n = sample size; M = mean; SD = standard deviation. a Variables 1-4 represent experienced change in the equivalent value. c Variables 9-13 represent B personality traits.