Reach
Screening was performed by a study coordinator in 23 SCs, where 437 out of 672 older adults were eligible to participate. A total of 199 older adults (167 of them were females) were enrolled into the program study, with a mean age of 76.82 ± 8.97 years. Hence, the intervention reached 45.5% of the eligible population. Most of the participants (93.6%, n = 177) only had primary or no education, and 7.4% (n = 12) had at least secondary education. Mean cognitive impairment risk score of participants was 7.97 ± 1.13.
Five participants withdrew from the study before baseline assessments (reasons - family objection, inability to commit to the schedule or inability to complete the baseline assessments due to language barrier). During the assessments, RBANS was conducted in either Mandarin or English. Most participants could communicate in Mandarin, even though they may prefer Hokkien or Cantonese dialects. However, few individuals were unable to understand the assessors during parts of the test that required recall-repetition of Mandarin words. This lack of understanding was not identified in the recruitment phase; and these individuals were excluded and considered as dropouts as the rest of the program would have require this basic understanding of English or Mandarin. The remaining 194 participants were randomized into the intervention (IG, N = 96) and control groups (CG, N = 98). During the study, a further 61 participants dropped out due to medical problems, loss of interest, personal commitments such as caring for grandchildren or death (unrelated to program participation) (Fig. 1).
Effectiveness
There were no between-group differences in age, risk score, gender, education, total RBANS t-score, RBANS domains t-scores, EQ-5D index, EQ VAS, and blood lipid panel measures at baseline (Table 1).
Table 1
Baseline Characteristics of the Participants
Variable | IG | CG | p |
Mean ± SD | N | Mean ± SD | N |
Characteristic | | | | | |
Age | 75.61 ± 9.01 | 95 | 77.90 ± 8.84 | 96 | .100 |
Gender | | 96 | | 97 | .705 |
Males | 13.5% | | 15.5% | | |
Females | 86.5 | | 94.5% | | |
Education | | 97 | | 92 | .767 |
Below primary Above primary | 92.8% 7.2% | | 94.6% 5.4% | | |
Risk score | 7.92 ± 1.18 | 96 | 8.06 ± 1.06 | 97 | .370 |
Assessment | | | | | |
Total RBANS (T-scores) | 51.38 ± 9.66 | 89 | 49.22 ± 10.12 | 94 | .143 |
Immediate memory | 51.43 ± 9.46 | 92 | 49.13 ± 9.94 | 96 | .106 |
Visuospatial/constructional | 50.84 ± 9.7 | 91 | 49.38 ± 10.33 | 95 | .391 |
Language | 51.34 ± 9.62 | 92 | 49.08 ± 10.04 | 96 | .117 |
Attention | 50.58 ± 10.08 | 92 | 49.62 ± 10.04 | 96 | .498 |
Delayed memory | | | | | |
Total cholesterol | 174.7 ± 43.96 | 74 | 182.03 ± 39.42 | 80 | .186 |
HDL | 53.24 ± 14.18 | 74 | 56.70 ± 16.86 | 83 | .114 |
LDL | 99.14 ± 36.77 | 72 | 102.05 ± 35.01 | 79 | .577 |
Triglycerides | 118.36 ± 52.55 | 73 | 119.11 ± 57.33 | 81 | .674 |
Glucose | 110.15 ± 24.45 | 74 | 115.93 ± 47.34 | 82 | .352 |
QoL VAS | 79.39 ± 17.26 | 92 | 81.01 ± 17.47 | 97 | .429 |
QoL Index | 0.82 ± 0.21 | 93 | 0.83 ± 0.24 | 97 | .319 |
P value indicates statistical difference between Intervention Group (IG) and Control Group (CG). Blood test unit of measure are in mg/dL. |
Between-group effects. There were no between-group differences in total RBANS score and in immediate memory, visuospatial/constructional, language, attention, and delayed memory scores after six months. There were also no between-group differences in quality of life measures and all blood parameters (See Additional File 5).
Within-group effects. There were no significant changes in total RBANS scores and immediate memory, visuospatial/constructional, language, and delayed memory scores in both the IG and CG from baseline to follow-up. The CG had significantly lower attention scores at follow-up (Median = 46.44) than at baseline (Median = 47.59), Z = 2.63, p = .0085. The CG also had significantly lower QoL VAS at follow-up (Median = 80) than at baseline (Median = 85), Z = 3.49, p = .0005, and significantly lower QoL index scores at follow-up (M = 0.78, SD = 0.29) than at baseline (M = 0.85, SD = 0.22), t = 2.54, p = .0133. LDL increased significantly in the intervention group following the intervention, Z = -2.97, p = .003, with baseline median LDL at 93 mg/dL and follow-up median LDL at 100.5 mg/dL (See Additional File 5).
Physical assessments were conducted only on the first and last session of the intervention, hence results were based on the within-group effects only for the IG. The IG improved significantly in the 2-minute steps test and both left and right handgrip strength following the intervention (Table 2).
Table 2
Physical Performance Test: Effect of the Multi-Domain Intervention Programme within the Intervention Group
Variable | N | Baseline | 24 weeks | p |
Steps test | 57 | 54.47 ± 23.65 | 62.77 ± 27.07 | .0018* |
Chair stand | 69 | 14.09 ± 5.68 | 16.75 ± 6.54 | < .0001* |
Handgrip strength (R) | 74 | 16.36 ± 5.61 | 18.15 ± 5.53 | < .0001* |
Handgrip strength (L) | 74 | 15.63 ± 5.31 | 17.02 ± 5.05 | .0002* |
Data presented in mean ± SD. P value indicates statistical difference within Intervention Group (IG). |
From the participant questionnaire, subthemes that emerged from free-text responses included physical, cognitive, and psychosocial benefits through participation in the program. Participants felt “more toned”, had “more strength”, and “walked faster,” and did not need to take certain chronic illness medications anymore. Effectiveness of the exercises in improving physical fitness achieved a mean score of 4.21 ± 0.63. Participants felt that the cognitive games improved their alertness, allowed them to make new friends, and boosted their self-confidence. Small group activities and CCT games achieved a mean effectiveness score of 3.93 ± 0.46 and 3.97 ± 0.45, respectively (Table 3).
Table 3
Responses from IG participant questionnaire (n = 70) [maximum score of 5]
Questionnaire Items | Score |
Dual-task exercise | |
How often did you attend the group exercises in a month? | 4.56 ± 0.82 |
Do you find the exercises easy to follow? | 3.96 ± 0.71 |
Do you feel that the exercise sessions were useful in improving your physical fitness? | 4.21 ± 0.63 |
Small group activities | |
How often did you attend the games/activity session in a month? | 4.60 ± 0.87 |
Do you find the games/activities easy to follow? | 3.53 ± 0.89 |
Do you feel that the games/activities were useful in improving your cognition? | 3.94 ± 0.46 |
Computerised cognitive training | |
How often did you attend the cognitive classes in a month? | 4.44 ± 1.00 |
Do you think the cognitive classes were easy to follow? | 2.79 ± 0.93 |
Do you think the cognitive classes were useful in improving your cognition? | 3.97 ± 0.46 |
Nutritional guidance | |
How often did you use the Glycoleap handphone application in a month? | 1.28 ± 0.76 |
Do you think the Glycoleap handphone application was user-friendly? | 2.32 ± 1.28 |
Do you think that having a dietician was helpful in making healthier food choices? | 3.27 ± 1.23 |
Have your eating habits changed after the programme? | 3.58 ± 0.62 |
Data presented in mean ± SD. Questions were based on 5-point Likert scale where lower scores indicate negative responses and higher scores indicate positive responses. |
Adoption
At the centre level, during the recruitment phase which spanned over a year, recruiters contacted 103 SCs via email, of which 39 centres (38%) responded and 23 SCs were screened. Upon successful screening and consent from the SCs, the program was adopted by 9 centres (8.7%), 2 of which were formed through combining themselves with smaller affiliated centres in the vicinity. The remaining 14 SCs who had also participated in screening could not take up the program despite interest as they were unable to accommodate the study within their schedule or the lack of eligible participants to form a sizeable group – an estimate of 30 participants per centre was deemed as most sustainable and practical for training and doing group activities.
At the participant level, 77 from IG completed the intervention and both assessments and 74 from CG completed both assessments. On average, IG attendance for the dual-task physical exercises, small group activities and CCT sessions was 75.78 ± 19.13%, 78.90 ± 20.25% and 70.99 ± 23.77% respectively. Only 15% in IG used the nutritional application consistently even though participants were taught usage one-on-one. Smart phones were loaned to 4 participants who did not own one, but they were returned unused. Others who did not own phones refused to take up the loan.
SCs reported space constraint and difficulties in encouraging participation as challenges faced. Space to accommodate an average of 10 participants was required to conduct group physical exercises. Tables and chairs were also needed to conduct the cognitive exercises. However, SCs are located in the void decks of public housing flats and some (especially those in older estates) have limited indoor floor area for group physical exercises. The group exercises for larger groups are conducted outside the SAC premises. The lack of space is compounded by multiple simultaneous activities at the centres, such as board games and handicraft sessions. Most centers made phone calls to remind participants to attend classes and one made house visits to persuade participants to attend.
Implementation
All intervention components were conducted consistently by respective implementers for the study duration. Before program implementation, each SCs, implementers, and researchers agreed on schedule dates of program activities. The program comprised 48 sessions − 31% physical-cognitive dual-task exercises and 61% cognitive sessions, of which 18% were based on small group activities and 48% were CCT. Nutritional guidance was intended to be on-going via the application throughout the length of the intervention. The application also contained access to online nutritional education modules, quizzes and games that participants were free to use at their convenience.
When approval and support from management of each centre was obtained, the program was implemented within 2–3 months. The first session for all centres started within two weeks after baseline assessment. Researchers made random visits to observe the sessions and ensure that the program was conducted according to schedule and protocol.
There were no major deviations from the protocol other than the nutritional component. Due to participants’ unfamiliarity with the nutritional application and IT in general, and the lack of WiFi connection at home, participation rate was very low − 86% reported that they did not use the application. Participants’ free-text responses showed they had difficulties in all stages of using the application - logging in, staying logged in, taking and sending photos and conversing with the dietician via the application, or remembering the task of doing photo logs of their food.
To mitigate the low usage rate, dieticians made phone monthly calls (15–20 min) to participants to provide nutritional intervention and address participants’ concerns on diet/food choice. To further engage participants, monthly nutritional health talks were conducted and extended to CG participants too. Despite the monthly calls, some participants remained uncontactable. Only 16 (20%) participants responded to all six consultation phone calls, 42 (52%) responded to at least three calls and 61 (76%) responded to at least one call. The low answer rate can be attributed to a subtheme that emerged from participants’ responses, which are difficulties due to hearing problems, phone switched off or fear of calls from strangers. The dietician also suggested that on some occasions, there was no one at home.
Other minor deviations were reported by exercise trainers who had to conduct physical assessments at the program’s first session initially, resulting in the reduction of exercise time from 1 hour to less than 15 minutes, as some participants were late. However, this was not deemed to have any impact on the outcome of the data. To mitigate this, subsequent physical assessments were performed separately by GERI staff.
Implementers suggested that the lack of SCs and their own manpower introduced additional challenges to program facilitation as program was attended by many participants with mobility limitations (e.g. slow gait or could not stand for long). Implementers found that if they had to assist participants with mobility limitations (going to toilet, retrieving items needed for small group activities), other participants would be sometimes neglected, and sessions hampered. Other constraints were related to health issues. As some of the physical exercises was considered strenuous to participants with health conditions, implementers felt that the medical conditions of participants may not have been adequately screened by the SCs using PAR-Q assessment. The implementer for physical-cognitive exercise training had to make additional assessments to identify the participants with some mobility limitations that require additional attention during training.
The CCT implementer reported that tiredness and restlessness from exercise sessions prior to the CCT sessions and insufficient training time were reasons for less than optimal engagement sometimes. The lack of space in some SCs had also been cited as a constraint.
Overall, both participants and centre managers had positive feedback for trainers and for the overall program, suggesting that the program was well delivered. Participants’ overall satisfaction with the program was 3.90 ± 0.80 (out of 5) and 94.2% of participants would recommend the program to their relatives and friends. Participants had positive comments for the program and trainers for all components of the program. The program was “fun” and “novel’, and trainers were described as “helpful”, “accommodating”, “lively”, “funny”, and “patient”. Similarly, centre managers’ overall satisfaction with the program was 4.67 ± 0.47 (out of 5), and 100% of them would recommend the program to other centre managers.
The cost of the program was estimated by the implementers to be SG$620 per participant, not including the cost of manpower and a tablet needed for cognitive training. But since this was a funded RCT, the program was delivered to participants at no cost. When participants were asked how much they were willing to pay for the whole program, out of 70 who answered, 17.4% were willing to pay less than $10, 21.7% less than $50 and 7.2% less than $100. More than 50% were not willing to pay or were unsure. Reasons included being on low income support or not being able to valuate the program. As the program was conducted in SCs, there was no cost for renting of spaces and most participants were not required to travel, other than to the centres they were already visiting almost daily.
Maintenance
At the centre level, all the centres who completed the questionnaire expressed interest to continue with the program. To date, 2 centres have approached one of the implementation partners to discuss the possibility of holding health talks for their members. There were no other enquiries or enrolment for the other components. This could be due to cost - most SCs rely on government support and private donations for operations and will have limited funds for additional activities. Five centres have yet to complete the full program due to COVID-19 related mandatory suspension of centre activities.
At the participant level, 48 out of 70 IG participants (68.5%) reported that they intended to continue doing the exercises they had learnt. Nine participants did not want to continue the program beyond the study, five only wanted to continue the exercise component of the program, and 54 wanted to continue the entire program beyond the study.
Impact of COVID-19 pandemic
The first case of COVID-19 in Singapore was confirmed on 23 Jan 2020 and the Health Ministry issued suspension of all senior centres activities on 8 Feb 2020. This resulted in the suspension of the study. The IG groups at 2 last centres had already completed 79% and 87.5% of the intervention respectively. We were able to complete these “post” intervention (considered as 24 weeks) assessments for participants of these centres within two weeks of study suspension. The suspension affected the wait-list CG participants at two centres that were into the 2nd to 4th week of the program, while the remaining 3 had not started. Decision was made to stop the study in May 2020 when the centres closure was still in force.