Our study findings showed that WE-RISE™ multidomain intervention is feasible to conduct in community settings and thereafter continued as a home-based program among older persons with CF. Furthermore, as far as our knowledge extends, the WE-RISE™ multidomain intervention has exhibited noteworthy achievements in capitalizing on the transitional characteristics of CF and its potential reversibility. This marks the first instance where such an intervention has effectively addressed the transitional nature of frailty, leading to positive outcomes.
Within the experimental group, 74.1% and 63% of the participants were no longer cognitively frail at the 12th and 24th weeks, respectively, compared to the control group, whereby only 10.7% and 3.6% of the participants exhibited reversal of CF. These findings highlight the fact that physical frailty and MCI (CF) are dynamic states that share common biological pathways (28–30) to have the potential for positive transitional capabilities through multidomain intervention. Our findings are also consistent with evidence showing that combined multicomponent interventions comprising nutritional, physical and cognitive interventions are more effective in reversing frailty and improving cognition than single-component interventions(31). In addition, previous studies have shown that nonpharmacological interventions targeting physical frailty and cognitive impairment require a minimum duration of 10 weeks, with sessions conducted at least twice a week, to observe significant improvements in physical and cognitive function among older individuals living in the community (32, 33). Nonetheless, it is important to acknowledge that changes in physical frailty and cognitive status can occur spontaneously over time (34), which could potentially explain the observed change in CF status among the control group in our study. Furthermore, our study findings add to the literature about the cyclic association between physical, cognitive, nutrition, and psychosocial functions in addressing multifaceted issues among older adults, suggesting that improving one aspect may positively impact the others (8, 35).
WE-RISE™ was developed as a versatile intervention so that it can be carried out in-group dynamics and individually as a home-based intervention without the requirement of expensive or specific facilities or equipment. Nevertheless, it must be pointed out that the reversal of CF to non-CF status as well as intervention effects were more prominent following the supervised, instructed, group- and center-based WE-RISE™ intervention. Supervised, group-based exercise programs have been found to be more effective than home-based interventions, especially with respect to physical and mental health among older persons (36, 37). Moreover, older persons tend to prefer group-based, face-to-face interaction, as it is more encouraging and provides better psychosocial support (38). Nonetheless, home-based programs are good alternatives because they are convenient, accessible, and inexpensive for older persons (37). This is further supported by a substudy we conducted after the completion of the 24-week follow-up during the COVID-19 pandemic, which imposed a nationwide lockdown among the participants in this study. We found that the experimental group was more physically active and functionally independent and had better psychosocial well-being throughout social and physical isolation than the control group (39). With this, WE-RISE™@Home performed after group- and center-based WE-RISE™ intervention may have empowered as well as enabled older persons to be more self-efficient and independent in carrying out the intervention.
The high retention and adherence rates indicate WE-RISE™ multidomain intervention’s success in engaging older persons on a routine basis. This is higher than several multicomponent interventions incorporating exercise, cognitive, nutritional, psychological, and medical interventions targeted at frailty, which reported loss to follow-up ranging between 8% and 24% (31, 40–42). Moreover, no serious adverse events were reported throughout the intervention. Several factors could have influenced these positive results. First, the location of the intervention, which was within the participants’ residential area, hence resolved the need for transportation and the cost it may incur. This implies that older persons are more likely to partake in regular health promotion programs should the circumstances be in their favor. Next, the intervention may have been perceived as more acceptable and approachable, as a codesign principle was undertaken in the development of WE-RISE™, taking the input from the need assessment conducted with the target population into account. Furthermore, the activities were simple to follow and administered in an inclusive, fun, motivating, and positive environment provided by the physiotherapist while also facilitating peer-group support. Intervention instructors have been recognized as a key social determinant in ensuring social cohesion, goal-setting, enjoyment, retention, and adherence to a program that shapes the experience of the participants (43). Subsequently, WE-RISE™ is versatile, as it can be carried out in-group dynamics and can be carried out individually as a home-based intervention without the requirement of expensive or specific facilities or equipment. To share a challenge faced in this study, there was a hesitancy in participation among males, whereas females were more forthcoming. It has been established that older males are less likely to participate in health promotion programs regardless of the benefits (44). Another challenge was the participants’ poor access to technology and internet access due to techno-phobia and financial constraints. This limited supervision and communication during the WE- RISE@Home™ program to only phone calls. Digital literacy and financial restriction are obstacles to technology acceptance among older persons that require cost-effective interventions to overcome (45).
In line with the evidence, WE-RISE™ multidomain intervention has shown encouraging results in addressing the multifaceted nature of CF within 24 weeks of engagement with improvements in cognitive and physical function, positive changes in body composition, improvement in self-perceived disability, HRQoL and exercise self-efficacy. The cognitive improvements in the experimental group, specifically global cognition, immediate recall of verbal memory, attention and working memory, and complex attention, can be attributed to the malleable state of brain function. According to the scaffolding theory of aging and cognition (STAC), interventions involving learning new tasks, social engagement, physical exercise, and cognitive training lead to improvements in cognition levels (46). Moreover, multicomponent exercise conducted for 12 to 24 weeks has shown cognitive improvements in attention, verbal fluency and global cognition (47), which aligns with our present study findings. However, the positive effects of physical exercise on global cognition, attention and delayed recall were observed only among older persons with MCI, emphasizing the importance of early intervention for cognitive improvement (48).
Next, the WE-RISE™ cognitive stimulation program focused on a tactile and hands-on approach to improve cognitive function and promote social engagement. The intervention also incorporated psychosocial components, creating a nurturing and friendly environment to encourage socialization and task completion within the group. Interactive and social group-based interventions that combine cognitive and physical activities while enhancing friendships may reduce the risk of cognitive decline and Alzheimer's disease and potentially preserve or improve cognitive function in older individuals with cognitive deficits. (49, 50). Psychological compensation induced by cognitive stimulation in a social setting has been associated with improvements in communication, social interaction skills and cognitive function (51). Positive cognitive gains observed in the WE-RISE™ experimental group support the hypothesis that interventions targeting cognitive function can delay the progression of cognitive impairment to dementia if implemented early (51). These improvements are attributed to neuroplasticity, which increases neural volume and activity as well as psychological changes that lead to adaptive beliefs and behaviors compensating for cognitive deficits (46, 52).
Regarding physical function, significant improvement was observed for aerobic endurance, lower body strength, and dynamic balance and mobility. The evidence supporting the improvement of physical function through adequate exercise in older adults with frailty is well established (33). Furthermore, the efficacy of multicomponent exercises, as employed in the WE-RISE™ intervention, has been emphasized in enhancing physical function, mitigating the risk of falls, and promoting overall health (53). In fact, the positive effects of exercise on brain health, including improvements in cognitive function and brain plasticity, are undeniable (54). It is noteworthy that exercise in the WE-RISE™ intervention was progressive with increased challenge and was delivered in multiple forms, for example, dance aerobics, strengthening of the cores, upper and lower limbs, multitasking, and dynamic balance. The exercises were also conducted with music and game-like delivery to make exciting rather than routine and to encourage continuous participation.
With regard to nutritional status, there were several significant interaction effects observed for body composition in terms of fat percentage (%), muscle mass (kg), total body water percentage (TBW%), bone mass (kg), basal metabolic rate (BMR) (kJ) and metabolic age (years). The experimental group was observed to have lower fat %, increased muscle mass, increased TBW %, increased BMR and decreased metabolic age following participation in the WE-RISE™ intervention compared to the control group. At present, there is a lack of studies correlating the effects of CF interventions on anthropometric and body composition outcomes. Weight loss that occurs with changes in body composition (decrease in muscle mass and increase in fat mass) has been associated with malnutrition, higher risk of disability, higher mortality rates and higher frailty risk in older persons (55). With this knowledge, the significant change in body composition over time observed in the experimental group could be interpreted as a positive outcome, as there was a significant reduction in fat % and increase in muscle mass. Furthermore, the findings of the present study imply that the progressive resistance training of the multicomponent exercise intervention may have brought upon osteogenic effects (56) contributing to the significant increase in bone mass in the experimental group. A refreshing finding from our study was that the experimental group participants in our study demonstrated a significant decrease in metabolic age. This indicates a positive impact on biological aging and suggests potential benefits for overall health and the risk of age-related conditions (57, 58).
In the present study, we found a reduction in nutrient intake for both the experimental and control groups at the 12th and 24th week follow-ups compared to baseline, as assessed using the DHQ. The experimental group showed a more significant decrease in pyridoxine intake over the 24-week intervention. At baseline, the nutrient intake of all participants did not meet the recommended nutrient intake for older persons in Malaysia, which was similar to findings observed in the study by Rivan et al. (5). The decline in nutrient intake raises concerns about possible underreporting or inaccurate reporting, potentially influenced by social desirability bias and a mindset of "less is better" (59). More critically, the participants are of lower SES in an urban area and may face financial constraints that contribute to insufficient dietary intake patterns. A one-off, group-based dietary counseling may not be sufficient, and additional supplementation or more intensive interventions may be necessary, keeping in mind the affordability and sustainability for older adults of lower SES. However, the multidomain nature of the intervention, combining exercise, cognitive stimulation, and psychosocial support, likely contributed to positive changes in body composition and improved nutritional profiles.
Favorable significant improvement in disability status, several domains of HRQoL and exercise self-efficacy of the participants of the experimental group compared to the control group following engagement in WE- RISE™ imply that they perceived to have experienced positive changes in their health and state of being. The physical activity and psychosocial components in the WE-RISE™ intervention are the most likely explanation for the significant improvement in self-perceived reduction in disability and improved social functioning. Considering that the WE- RISE™ intervention was designed to foster social interaction and engagement within the participants themselves and with the instructor, the improvements in social and societal domains of the disability assessments are justified. In addition, multidisciplinary exercise-based interventions have improved HRQoL domains, including mental health, perceived physical health, social relationships and leisure activities, among older persons with frailty (60). Moreover, regular participation in the center-based intervention followed by a guided home-based intervention may have boosted their confidence and reduced apprehension in carrying out the exercises independently due to familiarity with the regime. This corroborates the observed association between increased physical activity, increased self-esteem and improved exercise self-efficacy (61). The center-based WE-RISE™ intervention may have provided a sense of belonging, companionship and feeling important when facilitating or assisting members of their peer group during sessions, as the activities were conducted in a safe space with no competitive elements (62). Our findings support the observation that socially stimulating interventions improve psychological well-being among older persons and empower them to be active participants within the community (63).
Frailty and cognitive impairment impose significant economic burdens due to their high healthcare costs. However, the cost of the community-based, multidomain WE-RISE™ intervention was found to be relatively low. With an estimated cost of RM4.06 (≈ USD 0.90) per session comprising exercise, cognitive stimulation, dietary counseling, and psychosocial support, the WE-RISE™ intervention is affordable for older persons from low SES households. Furthermore, the intervention was conducted in PAWEs located within walking distance of participants’ homes, making it easily accessible for the community. Moreover, since the PAWEs are funded by the Malaysian Department of Social Welfare, there were no additional costs for space rentals, administration, or utilities. In comparison, a multidomain intervention for older individuals at risk of cognitive impairment in Singapore was reported to cost SGD 620 (≈ MYR1929; USD 458) per participant for 48 sessions conducted over 24 weeks. This cost did not include the expenses associated with manpower and equipment required for computerized cognitive training programs, suggesting that the total cost would be even higher (64). Although the cost of intervention was not specified in other studies, nonpharmacological interventions associated with improvements in frailty and cognitive decline have been considered cost-effective, as they result in reduced healthcare expenditure for older individuals (65, 66).
While WE-RISE™ was observed to be feasible, effective, and low in cost, the findings of this feasibility study must be considered as a preliminary stepping stone for future interventional studies. One of the main limitations of this feasibility study is that the participants were urban community-dwelling older persons of lower SES. Hence, the findings may not have generality toward rural, community dwelling, noncommunity dwelling or institutionalized populations. Moreover, the sustained effects of the intervention were not assessed after the completion of the 24-week intervention due to the unexpected COVID-19 pandemic. As a recommendation for future research, the effectiveness of WE-RISE™ in addressing the potential reversibility of CF could be benchmarked for longitudinal interventional studies with similar aims over extended follow-up periods and larger sample sizes.