
==== Front
BMC Geriatr
BMC Geriatr
BMC Geriatrics
1471-2318
BioMed Central London

5352
10.1186/s12877-024-05352-z
Systematic Review
Meta-analysis of the effect of exercise intervention on cognitive function in elderly patients with type 2 diabetes mellitus
Lu Huan-Huan 1
Zhou Yuan 1
Chen Chen 1
Gu Ze-Juan jassicagu@163.com

12
1 https://ror.org/059gcgy73 grid.89957.3a 0000 0000 9255 8984 School of Nursing, Nanjing Medical University, Nanjing, China
2 https://ror.org/04py1g812 grid.412676.0 0000 0004 1799 0784 The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province 210000 China
19 9 2024
19 9 2024
2024
24 77017 4 2024
3 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Objective

Cognitive dysfunction is a common complication of diabetes after central nervous system involvement. The impact of exercise, as an important non-pharmacological intervention strategy, on cognitive function remains controversial. Thus, we conducted a meta-analysis to assess the impact of exercise on cognitive function of elderly patients with type2 diabetes mellitus (T2DM).

Methods

We computer searched PubMed, Web of Science, Embase, CINAHL, Cochrane Library, CNKI, Wanfang date, and VIP, and traced back the references included in the literature from 1974 to July 2024. We used RevMan5.4 software for data analysis, and also conducted sensitivity, subgroup, and publication bias analyses.

Results

Eight eligible studies with a combined total of 747 elderly patients with T2DM were included. Meta-analysis showed that the combined effect size of exercise intervention on cognitive improvement in elderly patients with T2DM was significant [SMD = 0.65, 95% CI (0.48, 0.82), P < 0.01]. The following three factors had significant effects on the overall cognitive function of participants: subgroups (MoCA group [MD = 2.22 95% CI (1.26, 3.18), P < 0.01] and MMSE group [MD = 1.81, 95% CI (0.71,2.90), P = 0.001]); intervention times (3-month intervention [MD = 3.14, 95% CI (2.50, 3.78), P < 0.01], 6-month intervention [SMD = 0.32, 95% CI (0.12. 0.52), P = 0.002], and > 6 month intervention [SMD = 0.21, 95% CI (0.45, 0.81), P < 0.01]); intervention forms (single exercise [SMD = 0.21, 95% CI (0.45, 0.81), P < 0.01] and multiple exercise [SMD = 0.86, 95% CI ( 0.39,1.33), P < 0.0001]).

Conclusion

Exercise intervention may improve cognitive function in elderly patients with T2DM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-024-05352-z.

Keywords

Elderly
Type 2 diabetes
Exercise intervention
Cognitive function
Meta-analysis
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

Diabetes mellitus (DM) is a metabolic disease caused by a combination of genetic and environmental factors [1]. In 2021, According to data released by the International Diabetes Federation (IDF) [2], an estimated 540 million individuals aged 20–79 years were reported to have diabetes globally, and this number is expected to grow to 640 million by 2030. With the aging of the global population and lifestyle changes, the prevalence rate of diabetes is increasing, and the mortality rates are rising each year [3]. The huge expenditure associated with diabetes results in a heavy burden on patients, families, and public health management. It is estimated that by 2030, the global economic burden of diabetes and its complications will exceed 2.1 trillion US dollars [4].

Patients with type 2 DM (T2DM) often have vascular, neural, brain, and other tissue and organ damage, which leads to cognitive decline [5], that is, mild cognitive impairment (MCI) [6]. In recent years, the risk of cognitive impairment in patients with T2DM has gradually increased [7]. Previous studies have confirmed that T2DM is an independent risk factor for cognitive dysfunction [8], that it accelerates brain atrophy and cognitive impairment in the elderly, and that it increases the risk of developing dementia in the future [9]. Compared to patients without diabetes, patients with T2DM have a 21% increased risk of MCI [10]. MCI is a clinical condition characterized by a decline in memory and executive abilities, and is the transitional stage between normal cognition and dementia [11]. Its high prevalence and high dementia conversion rate make it a golden intervention period for preventing dementia [12].

Among non-pharmacological treatments, exercise intervention is considered one of the important ways to improve cognitive function in elderly patients with T2DM [13]. Although some trials have shown that exercise can improve the cognitive function of patients with T2DM, the results are not consistent. A study by Yang et al. [14] and Zheng et al. [15] showed that exercise intervention can improve the cognitive function of elderly patients with T2DM and reduce cognitive barriers. However, another study found that cognitive function in patients with T2DM was negatively affected after 6 months of aerobic and resistance exercise. A meta-analysis [16] on the impact of exercise on the cognitive ability of elderly diabetes patients published in 2020 found that exercise improved the cognitive function of patients. However, the intervention measures included in the study were exercise, cognition, and dual task diet and exercise, and not just exercise intervention. To further determine whether exercise can improve the cognitive function of elderly patients with T2DM, this study aims to systematically analyze the existing evidence in randomized controlled trials concerning the impact of exercise on cognitive function among elderly patients with T2DM, and provide scientific guidance for exercise intervention in these patients. Our study differs from others in that the included literature are all randomized controlled trials and the intervention measure is only exercise intervention to avoid the influence of other intervention methods. We have also included several recently published studies [17–19], which may be more targeted toward exercise guidance in elderly patients with T2DM.

Methods

This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [20] guidelines and is registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the record number CRD42024482547.

Search strategy

The PubMed, Web of Science, Embase, CINAHL, Cochrane Library, CNKI, Wanfang date, and VIP databases were searched from 1974 to July 2024. To ensure the comprehensiveness of the search, the following Mesh terms and synonyms were used. The search strategy for PubMed was as follows: (“Diabetes Mellutis” [MeSH] OR “diabetes Mellitus” [tiab] OR “diabetes” [tiab] OR “diabetic” [tiab] OR “type 2 diabetes” [tiab] OR “DM” [tiab] OR “T2DM” [tiab]) AND (“Cognition” [MeSH] OR “cognition” [tiab] OR “cognitive function” [tiab] OR “cognitive dysfunction” [tiab] OR “cognitive disorder” [tiab] OR “cognitive impairment” [tiab] OR “mild cognitive impairment” [tiab] OR “cognitive decline” [tiab] OR “older” [tiab] mental deterioration) AND (“aged” [tiab] OR “older” [tiab] OR “elderly” [tiab] ) AND (“exercise” [tiab] OR “exercise therapy” [tiab] OR “physical activity” [tiab] OR “aerobic exercise” [tiab] OR “resistance training” [tiab]). Other English databases also adopted similar strategies. For Chinese databases, search terms are translated into Chinese. In addition, a manual search of the reference lists of the included articles was conducted. Appendix 1 provides detailed retrieval strategy.

Eligibility criteria and study selection

Studies that met the PICOS criteria were included: (1) P (Population): patients with T2DM who met WHO diagnostic criteria, with normal or mild cognitive impairment cognitive function, and age ≥ 60 years; (2) I (Intervention): any form of exercise intervention, including aerobic exercise, resistance exercise, and balance training.; (3) C (Comparison): the control group received routine care or did not change their original lifestyle; O (Outcome): Montreal Cognitive Assessment (MoCA) scores and the mini-mental state examination scale (MMSE), which are the most widely used cognitive assessment scales both domestically and internationally, and mirror the fundamental cognitive functionality of the subject were used. The exclusion criteria were as follows: (1) literature with no access to full text or incomplete data; (2) repeated publications of the same content; (3) literature published in languages other than English or Chinese; (4) other study types apart from randomized controlled trials (RCTs); (5) studies with subjects having dementia; (6) interventions that were not purely exercise-related interventions and were combined with other interventions. It should be noted that dementia is an acquired disease characterized by cognitive decline, which leads to a decrease in functional levels compared with the past and is severe enough to interfere with daily functioning and independence [21]. Mild cognitive impairment (MCI) is an intermediate state between normal cognition and dementia, wherein patients have objective cognitive impairment but overall functional levels have not decreased [11]. Therefore, dementia patients were excluded.

Literature screening and data extraction

Two researchers who had received evidence-based nursing training independently conducted literature screening and data extraction. Duplicate literature were removed through EndnoteX9 software. Preliminary literature screening was conducted by reading titles and abstracts; this was followed by further reading the full text, and finally, the inclusion of literature was determined based on inclusion and exclusion criteria. Two researchers independently read the full texts to extract and cross check the included literature, including author names, publication year, sample size, exercise intervention form, intervention intensity, intervention frequency, and outcome indicators. In case of disagreements during the process, discussion and analysis was conducted, and if necessary, opinions were sought from a third researcher to reach a consensus.

Quality assessment of the study

Articles were assessed using the Cochrane Risk of Bias tool version 2 (RoB2), and the risk of bias was used independently by two researchers. The domains of this assessment were random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), and other biases. For each criterion, a judgment was made and each criterion was classified as one of the following categories: “low risk,” “high risk,” or “unclear.” Disagreements were resolved through discussion with a third reviewer. In addition, two researchers independently assessed the quality of evidence for each outcome following the Suggested Grading, Assessment, Development, and Evaluation methodology. Discrepancies were resolved through discussion with a third researcher.

Statistical analysis

Meta-analysis was performed using RevMan 5.4 provided by the Cochrane Collaboration. The standardized mean difference (SMD) or mean difference (MD) was used as the statistical measure for effect analysis of continuous variables. The χ2 test was used to determine whether there was heterogeneity among the studies; if P > 0.1 and I2 < 50%, then the heterogeneity between studies is relatively small, and a fixed-effects model was chosen for analysis; if P < 0.1 and I2 ≥ 50%, then the heterogeneity between studies is relatively high, and a random-effects model was chosen for analysis. Obvious clinical heterogeneity can be treated with methods such as subgroup analysis or sensitivity analysis; alternatively, only descriptive analysis can be performed.

Results

Search process

Initial examination of related literature revealed 1829 studies. Of these, 1794 studies did not meet the inclusion criteria and were excluded. Thus, 35 studies were included after preliminary testing. After reading the full texts, and excluding studies wherein the research object, interventions, and outcome indicators did not match, 27 studies were further excluded, and finally, 8 studies were included in the analysis [17–19, 22–26]. The flow chart is shown in Fig. 1.

Fig. 1 Flsowchart of literature screening

Characteristics of the included studies

Eight studies including a total of 747 patients were included in the study. Out of these eight studies, six were conducted in China [17, 19, 22–24, 26], and one each in Japan [25] and Thailand [18]. There were 375 participants in the exercise group and 372 participants in the control group. All intervention groups in the study received exercise intervention, whereas participants in the control group of six studies [17, 22–26] received routine care, and participants in the control group of two studies [18, 19] maintained their original lifestyle. The basic characteristics of the included literature are shown in Table 1.

Table 1 Basic characteristics of the literature

Author	Country	Year	Sample size	Age(Mean ± SD)	Intervention	Minutes per session	Follow-up time	Outcome indicator	
			(Test/Control group)	(Test/Control group)	Test group/Control group				
Zhu et al. [23]	China	2015	37/41	69.92 ± 6.41	Baduanjin (4 times/week)	routine care	40 min each time	3/6/12 months	①	
Zhang et al. [26]	China	2017	36/38	69.53 ± 8.02	69.79 ± 6.04	Aerobic training, fitness walking (≥ 3 times/week)	routine care	40 ~ 50 min each time	3 months	①	
Wang

et al. [22]

	China	2015	43/46	62.37 ± 12.38	64.51 ± 12.07	Baduanjin, Relaxation Gong (3 times/week)	routine care	60 min each time	6/12 months	①②	
Wei et al. [24]	China	2021	60/60	72.24 ± 6.25	71.83 ± 6.67	Aerobic training: warm-up exercises such as low-intensity slow walking and gymnastics, and restorative exercises such as freehand exercises (5 times/week)	routine care	40 ~ 60 min each time	3 months	①	
Wang et al. [17]	China	2023	40/42	65.73 ± 3.99	68.07 ± 5.47	5 min warm-up, 50 min aerobic dance, 5 min relaxation training: moderate intensity (3 times/week)	routine care	60 min each time	12 months	①②	
Yamamoto

et al. [25]

	Japan	2021	36/17	73.2 ± 2.6	73.3 ± 2.5	Resistance training: elastic band exercises for upper and lower limbs (7 times/week)	routine care	15 min each time	48 weeks	②	
Chen et al.[19]	China	2023	107/111	67.56 ± 4.99	67.62 ± 5.35	Tai chi (3 times/week)	Maintaining the original lifestyle	60 min each time	24/36 weeks	①②	
Ploydang

et al.[18]

	Thailand	2023	16/17	68.9 ± 3.7	69.2 ± 5.3	Nordic Water Walking Training (3 times/week)	Maintaining the original lifestyle	60 min each time	12 weeks	①②	
Note ①Montreal Cognitive Assessment (MoCA); ②mini-mental state examination (MMSE)

Quality assessment of included studies

All eight studies [17–19, 22–26] reported random sequence allocation procedures. For the allocation concealment assessment, the risk of bias of 7 studies [17–19, 22, 23, 25, 26] remained unclear, and the risk of one study [24] was relatively low. There is no clear mention regarding the implementation of blinding by researchers and participants in the studies [17–19, 22–26]. For the blinding of outcomes assessment, only one study [19] results were measured by evaluators who were blinded to the study. For incomplete outcome data assessment, five studies [17–19, 24, 25] did not report participants lost to follow-up or reported reasons for participant withdrawal from the study, and corresponding measures were taken. With regard to selective reporting assessment, the risk of bias in two studies [19, 26] was unclear, whereas the risk in six studies [17, 18, 22–25] was relatively low. Among other risk of bias items, four studies [17–19, 25] had lower risk of bias and four studies [22–24, 26] reported unclear risk of bias. The inclusion of the results with regard to quality evaluation of the literature is shown in detail in Fig. 2.

Fig. 2 Evaluation of the quality of the included literature: (a) ROB summary. (b) ROB graph

Outcome analysis

Combined effect sizes

After merging the eight included studies [17–19, 22–26], a meta-analysis was conducted. If there were multiple intervention times in the study, the longest one was selected. If there were different measurement tools for outcome indicators, the study with MoCA score was selected. Because of the high heterogeneity (I2 = 69%, P = 0.002), a random effects model was used for analysis, and the results showed that exercise could significantly improve the cognitive function of elderly patients with diabetes, with a statistically significant difference [SMD = 0.79, 95% CI (0.64, 0.94), P < 0.01], forest plots are shown in Fig. 3. Sensitivity analysis showed that after excluding the studies by Wei et al. [24] and Tawatchai et al. [18], the heterogeneity decreased (I2 = 19%, P = 0.29), and the combined effect size did not significantly change. Meta analysis showed that exercise intervention could improve the cognitive function of elderly patients with diabetes, with a statistically significant difference [SMD = 0.65, 95% CI (0.48, 0.82), P < 0.00001]; forest plots are shown in Fig. 4. Through an in-depth analysis of the literature, it was found that the study by Wei et al. [24] had a lower intensity of exercise intervention, a shorter intervention time (3 months), and one week of adaptive training. In the study by Ploydang et al. [18], participants were first stratified by gender, age, and MoCA score, and then grouped using simple random sampling, which may be the reason for the high heterogeneity between groups.

Fig. 3 Effect of exercise intervention on cognitive function in elderly patients with type 2 diabetes mellitus

Fig. 4 Effect of exercise intervention on cognitive function in elderly patients with type 2 diabetes mellitus after culling the literature

Subgroup analysis based on different measurement tools

According to different measurement tools for outcome measures, the included studies were divided into two subgroups: MoCA and MMSE. Seven studies [17–19, 22–24, 26] were included in the MoCA group, with 694 patients, and the random effects model was used in this group (I2 = 88%, P < 0.1). The results showed that exercise intervention could improve the cognitive function of elderly patients with T2DM, with a statistically significant difference [MD = 2.22, 95% CI (1.26, 3.18), P < 0.01]; Five studies [17–19, 22, 25] were included in the MMSE group, with 335 patients in total, and this group was also analyzed using the random effects model (I2 = 84%, P < 0.1). The results showed that exercise intervention could improve the cognitive function of elderly patients with T2DM, with a statistically significant difference [I2 = 84%, MD = 1.81, 95% CI (0.71, 2.90), P = 0.001]. The reason for the high heterogeneity in the analysis may be the diversity of exercise intervention methods included in the literature, as well as differences in intervention time and exercise frequency.

Subgroup analysis based on different intervention times

According to different intervention times, subgroup analysis was conducted and the studies divided into three subgroups: 3 months, 6 months, and more than 6 months after intervention. As per the fixed effect model analysis, the results showed that all the studies with intervention durations of 3 months [18, 23, 24, 26] [I2 = 50%, MD = 3.14, 95% CI (2.50, 3.78), P < 0.01], 6 months [19, 22, 23] [I2 = 14%, SMD = 0.32, 95% CI (0.12, 0.52), P = 0.002], and more than 6 months [17, 19, 22, 23, 25] [I2 = 32%, SMD = 0.21, 95% CI (0.45, 0.81), P < 0.01] reported improvement in cognitive function with exercise among elderly patients with T2DM. The difference was statistically significant (Table 2).

Table 2 Summary of subgroup meta-analyses

Subgroup	Number of studies included	Effect model	Mata analysis	I2	P	
MD/SMD	95% CI	P	
outcome indicator	MoCA	7[17–19,22–24,26]	stochastic	2.22	1.26, 3.18	< 0.01	88%	< 0.1	
	MMSE	5[17–19,25]	stochastic	1.81	0.71, 2.90	0.001	84%	< 0.1	
intervention time	3 months	4[18,23,24,26]	fixation	3.14	2.50, 3.78	< 0.01	50%	0.11	
	6 months	3[19,22,23]	stochastic	0.32	0.12, 0.52	0.002	14%	0.31	
	> 6 months	5[17,19,22,23,25]	stochastic	0.21	0.45, 0.81	< 0.01	32%	0.21	
sports format	single campaign	4[18,19,23,25]	stochastic	0.81	0.42, 1.19	0.06	59%	< 0.0001	
	multisport	4[17,22,24,26]	stochastic	0.86	0.39, 1.33	0.003	78%	0.0003	

Subgroup analysis based on different forms of exercise

Subgroup analysis was performed based on the form of movement (single form or multiple forms). The single exercise group included 382 patients from four studies [18, 19, 23, 25]. The results using a random effects model analysis (I2 = 59%, P < 0.0001) showed that single exercise intervention could improve cognitive function among elderly patients with T2DM [SMD = 0.81, 95% CI (0.42, 1.19), P = 0.06]. The heterogeneity of our analysis was relatively high, which may be related to the different types of exercises in the study (aerobic exercise, resistance training, etc.). The exercise frequencies in the four studies also differed, with the highest and lowest frequencies differing by nearly two times, and the longest and shortest intervention times differing by nearly three times. These factors may also have contributed to the high heterogeneity. A total of 365 patients were included in four studies [17, 22, 24, 26] and analyzed as per the random effects model (I2 = 78%, P = 0.0003). The results showed that diversified exercise intervention could improve cognitive function in elderly patients with T2DM [SMD = 0.86, 95% CI (0.39, 1.33), P < 0.0001]. The heterogeneity of our analysis was relatively high, which may be related to the different numbers of movements in diverse sports. In addition, there was a significant difference in intervention duration among the four articles, with the longest being 12 months and the shortest being 3 months, which may also be a source of heterogeneity.

Sensitivity analysis and publication bias

After excluding the included studies one by one depending on different measurement tool groups, different follow-up time groups, and different exercise mode groups, no significant change was observed in the combined effect size, and the results were relatively robust. Further, on observing the funnel plot included in the meta-analysis study, the results showed that there was no significant asymmetry in the funnel plot, and the possibility of publication bias was relatively small, as shown in Fig. 5.

Fig. 5 Funnel plot of the effect of exercise intervention on cognitive function in elderly patients with type 2 diabetes mellitus

Discussion

Effect of exercise intervention on cognitive function

In this study, we conducted a meta analysis of eight randomized controlled trials to verify the impact of exercise on cognitive function of elderly patients with diabetes. Our research results show that exercise can effectively improve the cognitive function of elderly patients with diabetes. In a prospective longitudinal study [27]of elderly patients with T2DM in Israel, the researchers found that physical exercise had a positive impact on reducing the risk of cognitive decline among elderly patients, and continued participation in planned physical activities was the most beneficial. A systematic evaluation and meta-analysis by Cai et al. [28] on the impact of exercise on the cognitive function of elderly patients with T2DM found that exercise improved the cognitive function of these patients. This is consistent with our research findings. When MCI memory executive function declines, it weakens the patient’s self-management ability, leading to poor blood sugar control and further damaging the patient’s cognitive function [29]. Therefore, diabetes patients with MCI should undertake early exercise and other interventions to prevent further deterioration of cognitive function and reduce the risk of dementia.

However, the mechanism through which exercise improves cognitive function in patients with DM is currently unclear. The study by Wang et al. [30] showed that exercise intervention can activate the insulin signaling pathway and inhibit the expression of inflammatory factors. There are also studies [31–33] suggesting that exercise can enhance the levels of brain-derived neurotrophic factors, thereby improving the cognitive function of the brain. In addition, studies have found that the beneficial effects of exercise on the cognitive function of patients with T2DM may be most significant in the field of executive function [16]. The research results of Huang et al. [34] also support this conclusion. Because of the lack of relevant research on the impact of exercise intervention on different areas of cognitive function in elderly patients with T2DM, this study only explored the effect of exercise on the overall cognitive function of these patients. Future research still needs to continuously explore the impact of exercise on different areas of cognitive function.

The randomized controlled trials included in this study included various forms of exercise such as walking, slow walking, gymnastics, and eight dan brocade, which can be divided into aerobic exercise, strength training, and balance exercise. Exercise frequency in these studies was ≥ 3 times a week, with a duration of 105 to 300 min/week, with the exercise intensity mainly being moderate. This is consistent with the recommendations made by WHO in 2020 regarding physical activity in older adults [35]. We found that both aerobic exercise and resistance training contribute to the improvement of cognitive function in patients with T2DM [36, 37]. Unlike previous studies that explored exercise patterns (aerobic exercise, resistance training, and balance exercise combinations), we added subgroup analysis based on exercise forms, analyzing the number of exercises included in the same type of exercise. Subgroup analysis showed that both single exercise and multiple exercise interventions have a positive impact on cognitive function among elderly patients with T2DM. This indicates that when providing exercise guidance to patients, we can develop exercise plans for different forms of exercise based on their preferences and needs, providing a variety of choices for different patients, thereby improving exercise compliance and maximizing exercise benefits [38]. However, the heterogeneity of this subgroup analysis was high. Although we have explained the source of heterogeneity, more high-quality randomized controlled trials need to be performed in the future to verify the impact of different exercise forms on the cognitive function of elderly patients with diabetes.

The subgroup analysis results of this study show that exercise intervention for 3 months [18, 23, 24, 26], 6 month [19, 22, 23] and more than 6 months [17, 19, 22, 23, 25] can improve the cognitive function of elderly patients with T2DM. Research suggests that, considering the early signs of neurodegeneration in older adults affected by aging, 6–12 months of exercise may not be sufficient to produce detectable cognitive effects [39]. However, Ten et al. [40] implemented aerobic exercise intervention in elderly patients with mild cognitive impairment. After 6 months of intervention, it was found that the volume of the left and right hippocampus had increased, reducing the probability of dementia progression. The diversity of different backgrounds and intervention measures may be the reason for contradictory findings. In addition, this study found that the effect was more significant 3 months after intervention compared with 6 months or more after intervention. The reason for this may be that long-term regular exercise can effectively maintain the benefits of cognitive function improvement. Accordingly, as the exercise cycle prolongs, the health benefits are maintained, and the effect of further improvement in cognitive function is not significant. This is similar to the findings of a Cochrane systematic review [41], which found that the improvement effect of exercise on cognitive health in elderly individuals is not significant.

Among the “five carriages” of DM management, physical exercise is an economical, convenient, and safe one [42], and is particularly important for the early management of elderly T2DM patients with MCI. We should not only focus on exercise intervention time but also pay attention to exercise intensity and frequency. Research has shown that exercise lasting between 45 and 60 min, with moderate or vigorous intensity, with any frequency or length, is beneficial for cognitive function in adults over 50 years of age [43]. However, there is still no consensus on the impact of high-intensity training and low-intensity continuous training on cognitive function of elderly, and further research is needed to prove it.

Proper exercise intervention can be used to improve the cognitive function of elderly patients with T2DM, and should be regarded as a useful strategy in the clinical practice of the elderly. Although there is heterogeneity in the comprehensive impact of different results, these results provide guidance for the medical staff and researchers to implement exercise for elderly patients with diabetes. Owing to the patient’s cognitive decline, it is necessary to strengthen the integration of hospital and community resources and conduct regular home visits and telephone follow-ups to ensure the quality of exercise intervention [44]. In addition, medical departments may consider developing information platforms and wearable assessment tools to dynamically monitor patients’ physical activity [45], heart rate, effectiveness, and other functions and to set up automatic reminders to further improve the role of remote guidance and monitoring in hospitals. At the same time, it is recommended that caregivers use exercise diaries to record the patient’s exercise behavior to improve their motivation for physical activity [46].

Limitations

Our study has some limitations. First the number of included studies was low and the quality of these studies was average. The study subgroups were analyzed without controlling for the effects of confounding factors (gender, age) and form of exercise. Whether blinding was used in some of the literature, information on the trainers of the exercise intervention, and information on the occurrence of adverse events were unclear. Although we performed combined effect sizes and subgroup analyses, subgroup analyses based on intensity and frequency factors were lacking. Such analyses should be added to future research to supply more high-quality evidence for the time to come.

Conclusion

In summary, exercise is an important strategy for improving cognitive function in elderly patients with T2DM. In the future, more high-quality, large sample, randomized controlled trials are needed to explore the impact of different exercise parameters on the cognitive function of elderly patients with diabetes.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Acknowledgements

We would like to thank MogoEdit (https://www.mogoedit.com) for its English editing during the preparation of this manuscript.

Author contributions

Huanhuan Lu contributed to the study concept and design. Huanhuan Lu and Yuan Zhou jointly screened the literature and extracted the relevant content of the literature. Huanhuan Lu, Yuan Zhou, and Chen Chen reviewed and analyzed the results. Huanhuan Lu wrote the first draft of the manuscript, and Yuan Zhou and Zejuan Gu revised it. All authors contributed to revising and approving the final version of the manuscript.

Funding

No have.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Abbreviations

CNKI China national knowledge infrastructure

DM Diabetes mellitus

IDF International Diabetes Federation

T2DM Type 2 diabetes mellitus

MCI Mild cognitive impairment

RCT Randomized controlled trial

MoCA Montreal cognitive assessment

MMSE Mini-mental state examination

WMD Weighted mean difference

RoB Risk of bias

CI Confidence intervals

SD Standard deviation

SEM Standard error of the mean

SMD Standardised mean difference

WHO World health organization

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Huan-Huan Lu and Yuan Zhou contributed equally to this work.
==== Refs
References

1. Wu Y Ding Y Tanaka Y Zhang W Risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention Int J Med Sci 2014 11 1185 200 10.7150/ijms.10001 25249787
Wu Y, Ding Y, Tanaka Y, Zhang W. Risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. Int J Med Sci. 2014;11:1185–200.25249787
2. IDF Diabetes. Atlas 2021 | IDF Diabetes Atlas. Vol. 2024.
3. Huang ES Laiteerapong N Liu JY John PM Moffet HH Karter AJ Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study JAMA Intern Med 2014 174 251 8 10.1001/jamainternmed.2013.12956 24322595
Huang ES, Laiteerapong N, Liu JY, John PM, Moffet HH, Karter AJ. Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study. JAMA Intern Med. 2014;174:251–8.24322595
4. Bommer C Sagalova V Heesemann E Manne-Goehler J Atun R Bärnighausen T Global Economic Burden of Diabetes in adults: projections from 2015 to 2030 Diabetes Care 2018 41 963 70 10.2337/dc17-1962 29475843
Bommer C, Sagalova V, Heesemann E, Manne-Goehler J, Atun R, Bärnighausen T, et al. Global Economic Burden of Diabetes in adults: projections from 2015 to 2030. Diabetes Care. 2018;41:963–70.29475843
5. Garfield V Farmaki AE Eastwood SV Mathur R Rentsch CT Bhaskaran K HbA1c and brain health across the entire glycaemic spectrum Diabetes Obes Metab 2021 23 1140 9 10.1111/dom.14321 33464682
Garfield V, Farmaki AE, Eastwood SV, Mathur R, Rentsch CT, Bhaskaran K, et al. HbA1c and brain health across the entire glycaemic spectrum. Diabetes Obes Metab. 2021;23:1140–9.33464682
6. Van Sloten TT Sedaghat S Carnethon MR Launer LJ Stehouwer C Cerebral microvascular complications of type 2 diabetes: stroke, cognitive dysfunction, and depression Lancet Diabetes Endocrinol 2020 8 325 36 10.1016/S2213-8587(19)30405-X 32135131
Van Sloten TT, Sedaghat S, Carnethon MR, Launer LJ, Stehouwer C. Cerebral microvascular complications of type 2 diabetes: stroke, cognitive dysfunction, and depression. Lancet Diabetes Endocrinol. 2020;8:325–36.32135131
7. You Y Liu Z Chen Y Xu Y Qin J Guo S The prevalence of mild cognitive impairment in type 2 diabetes mellitus patients: a systematic review and meta-analysis Acta Diabetol 2021 58 671 85 10.1007/s00592-020-01648-9 33417039
You Y, Liu Z, Chen Y, Xu Y, Qin J, Guo S, et al. The prevalence of mild cognitive impairment in type 2 diabetes mellitus patients: a systematic review and meta-analysis. Acta Diabetol. 2021;58:671–85.33417039
8. Feng QP Li XJ Su Y Yan ZL Gao LJ Qin WB Association of rs7903146T/C and rs7901695T/C single nucleotide polymorphisms of TCF7L2 gene with susceptibility to type 2 diabetes in Han population in Inner Mongolia Chin J Diabetes 2012 20 721 4
Feng QP, Li XJ, Su Y, Yan ZL, Gao LJ, Qin WB, et al. Association of rs7903146T/C and rs7901695T/C single nucleotide polymorphisms of TCF7L2 gene with susceptibility to type 2 diabetes in Han population in Inner Mongolia. Chin J Diabetes. 2012;20:721–4.
9. Pal K Mukadam N Petersen I Cooper C Mild cognitive impairment and progression to dementia in people with diabetes, prediabetes and metabolic syndrome: a systematic review and meta-analysis Soc Psychiatry Psychiatr Epidemiol 2018 53 1149 60 10.1007/s00127-018-1581-3 30182156
Pal K, Mukadam N, Petersen I, Cooper C. Mild cognitive impairment and progression to dementia in people with diabetes, prediabetes and metabolic syndrome: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2018;53:1149–60.30182156
10. Expert consensus on Cognitive dysfunction in patients with diabetes Chin J Diabetes 2021 13 678 94
Expert consensus on. Cognitive dysfunction in patients with diabetes. Chin J Diabetes. 2021;13:678–94.
11. Jia L Du Y Chu L Zhang Z Li F Lyu D Prevalence, risk factors, and management of dementia and mild cognitive impairment in adults aged 60 years or older in China: a cross-sectional study Lancet Public Health 2020 5 e661 71 10.1016/S2468-2667(20)30185-7 33271079
Jia L, Du Y, Chu L, Zhang Z, Li F, Lyu D, et al. Prevalence, risk factors, and management of dementia and mild cognitive impairment in adults aged 60 years or older in China: a cross-sectional study. Lancet Public Health. 2020;5:e661–71.33271079
12. Dove A Shang Y Xu W Grande G Laukka EJ Fratiglioni L The impact of diabetes on cognitive impairment and its progression to dementia Alzheimers Dement 2021 17 1769 78 10.1002/alz.12482 34636485
Dove A, Shang Y, Xu W, Grande G, Laukka EJ, Fratiglioni L, et al. The impact of diabetes on cognitive impairment and its progression to dementia. Alzheimers Dement. 2021;17:1769–78.34636485
13. Luo H Sun B Ren JG Effects of exercise behavior on brain-derived neurotrophic factor, methylglyoxal and cognitive function in elderly patients with type 2 diabetes Chin J Diabetes 2022 30 593 6
Luo H, Sun B, Ren JG. Effects of exercise behavior on brain-derived neurotrophic factor, methylglyoxal and cognitive function in elderly patients with type 2 diabetes. Chin J Diabetes. 2022;30:593–6.
14. Yang L Wang XY Yan HL Clinical study of Baduanjin combined with cognitive training on cognitive weakness of Elderly Diabetes patients Chin Gen Pract Med 2023 26 2848 53
Yang L, Wang XY, Yan HL. Clinical study of Baduanjin combined with cognitive training on cognitive weakness of Elderly Diabetes patients. Chin Gen Pract Med. 2023;26:2848–53.
15. Zheng HP Yang RP Qiao AN Zhang Q Li QC Yin N Anti resistance exercise can improve cognitive function of elderly Chinese patients with type 2 diabetes Chin J Clin Med 2019 26 686 91
Zheng HP, Yang RP, Qiao AN, Zhang Q, Li QC, Yin N, et al. Anti resistance exercise can improve cognitive function of elderly Chinese patients with type 2 diabetes. Chin J Clin Med. 2019;26:686–91.
16. Cooke S Pennington K Jones A Bridle C Smith MF Curtis F Effects of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus: a systematic review and meta-analysis PLoS ONE 2020 15 e232958 10.1371/journal.pone.0232958
Cooke S, Pennington K, Jones A, Bridle C, Smith MF, Curtis F. Effects of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus: a systematic review and meta-analysis. PLoS ONE. 2020;15:e232958.
17. Wang Y Wang L Yan J Yuan X Lou QQ Aerobic training increases hippocampal volume and protects cognitive function for type 2 diabetes patients with normal cognition Exp Clin Endocrinol Diabetes 2023 131 605 14 10.1055/a-2105-0799 37268011
Wang Y, Wang L, Yan J, Yuan X, Lou QQ. Aerobic training increases hippocampal volume and protects cognitive function for type 2 diabetes patients with normal cognition. Exp Clin Endocrinol Diabetes. 2023;131:605–14.37268011
18. Ploydang T Khovidhunkit W Tanaka H Suksom D Nordic walking in Water on Cerebrovascular reactivity and cognitive function in Elderly patients with type 2 diabetes Med Sci Sports Exerc 2023 55 1803 11 10.1249/MSS.0000000000003216 37204017
Ploydang T, Khovidhunkit W, Tanaka H, Suksom D. Nordic walking in Water on Cerebrovascular reactivity and cognitive function in Elderly patients with type 2 diabetes. Med Sci Sports Exerc. 2023;55:1803–11.37204017
19. Chen Y Qin J Tao L Liu Z Huang J Liu W Effects of Tai Chi Chuan on cognitive function in adults 60 years or older with type 2 diabetes and mild cognitive impairment in China: a Randomized Clinical Trial JAMA Netw Open 2023 6 e237004 10.1001/jamanetworkopen.2023.7004 37022680
Chen Y, Qin J, Tao L, Liu Z, Huang J, Liu W, et al. Effects of Tai Chi Chuan on cognitive function in adults 60 years or older with type 2 diabetes and mild cognitive impairment in China: a Randomized Clinical Trial. JAMA Netw Open. 2023;6:e237004.37022680
20. Moher D Shamseer L Clarke M Ghersi D Liberati A Petticrew M Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement Syst Rev 2015 4 1 10.1186/2046-4053-4-1 25554246
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1.25554246
21. McKhann GM Knopman DS Chertkow H Hyman BT Jack CJ Kawas CH The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease Alzheimers Dement 2011 7 263 9 10.1016/j.jalz.2011.03.005 21514250
McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CJ, Kawas CH, et al. The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7:263–9.21514250
22. Wang J, Zhang Y, Chen SW, Chen W, Xu T, Wang H. Effect of Health preserving Exercise on cognitive function and inflammatory factors of Elderly Type 2 diabetes patients in community. J Clin Res 2015:439–42.
23. Zhu HM Zhang N Ji C Study on the effect of Baduanjin on mild cognitive impairment in elderly patients with diabetes Chin J Practical Nurs 2015 31 1202 4
Zhu HM, Zhang N, Ji C. Study on the effect of Baduanjin on mild cognitive impairment in elderly patients with diabetes. Chin J Practical Nurs. 2015;31:1202–4.
24. Wei Zp, Hua L Zhang H Zhang ZY Qin SP Intervention effect of aerobic exercise on elderly diabetes patients with mild cognitive impairment Chin J Health Med 2021 23 510 2
Wei Zp, Hua L, Zhang H, Zhang ZY, Qin SP. Intervention effect of aerobic exercise on elderly diabetes patients with mild cognitive impairment. Chin J Health Med. 2021;23:510–2.
25. Yamamoto Y Nagai Y Kawanabe S Hishida Y Hiraki K Sone M Effects of resistance training using elastic bands on muscle strength with or without a leucine supplement for 48 weeks in elderly patients with type 2 diabetes Endocr J 2021 68 291 8 10.1507/endocrj.EJ20-0550 33071273
Yamamoto Y, Nagai Y, Kawanabe S, Hishida Y, Hiraki K, Sone M, et al. Effects of resistance training using elastic bands on muscle strength with or without a leucine supplement for 48 weeks in elderly patients with type 2 diabetes. Endocr J. 2021;68:291–8.33071273
26. Zhang JP Wang JY Chen J She YW Chen L Cheng J Effect of rehabilitation intervention on cognitive function of elderly type 2 diabetes patients with mild cognitive impairment Chin J Geriatric Multiple Organ Dis 2017 16 23 7
Zhang JP, Wang JY, Chen J, She YW, Chen L, Cheng J. Effect of rehabilitation intervention on cognitive function of elderly type 2 diabetes patients with mild cognitive impairment. Chin J Geriatric Multiple Organ Dis. 2017;16:23–7.
27. Rabinowitz Y Ravona-Springer R Heymann A Moshier E Berman Y Schwartz J Physical activity is Associated with slower Cognitive decline in older adults with type 2 diabetes J Prev Alzheimers Dis 2023 10 497 502 37357290
Rabinowitz Y, Ravona-Springer R, Heymann A, Moshier E, Berman Y, Schwartz J, et al. Physical activity is Associated with slower Cognitive decline in older adults with type 2 diabetes. J Prev Alzheimers Dis. 2023;10:497–502.37357290
28. Cai YH Wang Z Feng LY Ni GX Effect of Exercise on the cognitive function of older patients with type 2 diabetes Mellitus: a systematic review and Meta-analysis Front Hum Neurosci 2022 16 876935 10.3389/fnhum.2022.876935 35572003
Cai YH, Wang Z, Feng LY, Ni GX. Effect of Exercise on the cognitive function of older patients with type 2 diabetes Mellitus: a systematic review and Meta-analysis. Front Hum Neurosci. 2022;16:876935.35572003
29. Świątoniowska-Lonc N Polański J Tański W Jankowska-Polańska B Impact of cognitive impairment on adherence to treatment and self-care in patients with type 2 diabetes Mellitus Diabetes Metab Syndr Obes 2021 14 193 203 10.2147/DMSO.S284468 33488107
Świątoniowska-Lonc N, Polański J, Tański W, Jankowska-Polańska B. Impact of cognitive impairment on adherence to treatment and self-care in patients with type 2 diabetes Mellitus. Diabetes Metab Syndr Obes. 2021;14:193–203.33488107
30. Wang M Xie K Zhao S Jia N Zong Y Gu W Aerobic exercise improves cognitive impairment in mice with type 2 diabetes by regulating the MALAT1/miR-382-3p/BDNF signaling pathway in serum-exosomes Mol Med 2023 29 130 10.1186/s10020-023-00727-1 37740187
Wang M, Xie K, Zhao S, Jia N, Zong Y, Gu W, et al. Aerobic exercise improves cognitive impairment in mice with type 2 diabetes by regulating the MALAT1/miR-382-3p/BDNF signaling pathway in serum-exosomes. Mol Med. 2023;29:130.37740187
31. Tao J Liu J Chen X Xia R Li M Huang M Mind-body exercise improves cognitive function and modulates the function and structure of the hippocampus and anterior cingulate cortex in patients with mild cognitive impairment Neuroimage Clin 2019 23 101834 10.1016/j.nicl.2019.101834 31128522
Tao J, Liu J, Chen X, Xia R, Li M, Huang M, et al. Mind-body exercise improves cognitive function and modulates the function and structure of the hippocampus and anterior cingulate cortex in patients with mild cognitive impairment. Neuroimage Clin. 2019;23:101834.31128522
32. Broadhouse KM Singh MF Suo C Gates N Wen W Brodaty H Hippocampal plasticity underpins long-term cognitive gains from resistance exercise in MCI Neuroimage Clin 2020 25 102182 10.1016/j.nicl.2020.102182 31978826
Broadhouse KM, Singh MF, Suo C, Gates N, Wen W, Brodaty H, et al. Hippocampal plasticity underpins long-term cognitive gains from resistance exercise in MCI. Neuroimage Clin. 2020;25:102182.31978826
33. Gu N Li H Cao X Li T Jiang L Zhang H Different Modulatory effects of Cognitive Training and Aerobic Exercise on resting state functional connectivity of Entorhinal Cortex in Community-Dwelling older adults Front Aging Neurosci 2021 13 655245 10.3389/fnagi.2021.655245 34135749
Gu N, Li H, Cao X, Li T, Jiang L, Zhang H, et al. Different Modulatory effects of Cognitive Training and Aerobic Exercise on resting state functional connectivity of Entorhinal Cortex in Community-Dwelling older adults. Front Aging Neurosci. 2021;13:655245.34135749
34. Huang X Zhao X Li B Cai Y Zhang S Wan Q Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: a systematic review and network meta-analysis J Sport Health Sci 2022 11 212 23 10.1016/j.jshs.2021.05.003 34004389
Huang X, Zhao X, Li B, Cai Y, Zhang S, Wan Q, et al. Comparative efficacy of various exercise interventions on cognitive function in patients with mild cognitive impairment or dementia: a systematic review and network meta-analysis. J Sport Health Sci. 2022;11:212–23.34004389
35. Bull FC Al-Ansari SS Biddle S Borodulin K Buman MP Cardon G World Health Organization 2020 guidelines on physical activity and sedentary behaviour Br J Sports Med 2020 54 1451 62 10.1136/bjsports-2020-102955 33239350
Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54:1451–62.33239350
36. Wang R Yan W Du M Tao L Liu J The effect of physical activity interventions on cognition function in patients with diabetes: a systematic review and meta-analysis Diabetes Metab Res Rev 2021 37 e3443 10.1002/dmrr.3443 33616310
Wang R, Yan W, Du M, Tao L, Liu J. The effect of physical activity interventions on cognition function in patients with diabetes: a systematic review and meta-analysis. Diabetes Metab Res Rev. 2021;37:e3443.33616310
37. Furlano JA Horst BR Petrella RJ Shoemaker JK Nagamatsu LS Changes in cognition and brain function after 26 weeks of Progressive ResistanceTraining in older adults at risk for diabetes: a pilot randomized controlled trial Can J Diabetes 2023 47 250 6 10.1016/j.jcjd.2023.01.004 36858923
Furlano JA, Horst BR, Petrella RJ, Shoemaker JK, Nagamatsu LS. Changes in cognition and brain function after 26 weeks of Progressive ResistanceTraining in older adults at risk for diabetes: a pilot randomized controlled trial. Can J Diabetes. 2023;47:250–6.36858923
38. HuMJ, Wang HF Cao LL Evaluation of intervention effect of personalized self-management prescription on type 2 diabetes patients Contemp Nurses (Next Issue) 2021 28 51 3
HuMJ, Wang HF, Cao LL. Evaluation of intervention effect of personalized self-management prescription on type 2 diabetes patients. Contemp Nurses (Next Issue). 2021;28:51–3.
39. Wyss-Coray T Ageing, neurodegeneration and brain rejuvenation Nature 2016 539 180 6 10.1038/nature20411 27830812
Wyss-Coray T. Ageing, neurodegeneration and brain rejuvenation. Nature. 2016;539:180–6.27830812
40. Ten BL Bolandzadeh N Nagamatsu LS Hsu CL Davis JC Miran-Khan K Aerobic exercise increases hippocampal volume in older women with probable mild cognitive impairment: a 6-month randomised controlled trial Br J Sports Med 2015 49 248 54 10.1136/bjsports-2013-093184 24711660
Ten BL, Bolandzadeh N, Nagamatsu LS, Hsu CL, Davis JC, Miran-Khan K, et al. Aerobic exercise increases hippocampal volume in older women with probable mild cognitive impairment: a 6-month randomised controlled trial. Br J Sports Med. 2015;49:248–54.24711660
41. Young J Angevaren M Rusted J Tabet N Aerobic exercise to improve cognitive function in older people without known cognitive impairment Cochrane Database Syst Rev 2015 2015 CD5381
Young J, Angevaren M, Rusted J, Tabet N. Aerobic exercise to improve cognitive function in older people without known cognitive impairment. Cochrane Database Syst Rev. 2015;2015:CD5381.
42. Jia SG Cao JC Qiao YC Why and how: two basic problems of Precision Exercise intervention for type 2 diabetes J Tianjin Inst Phys Educ 2024 39 115 24
Jia SG, Cao JC, Qiao YC. Why and how: two basic problems of Precision Exercise intervention for type 2 diabetes. J Tianjin Inst Phys Educ. 2024;39:115–24.
43. Northey JM Cherbuin N Pumpa KL Smee DJ Rattray B Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis Br J Sports Med 2018 52 154 60 10.1136/bjsports-2016-096587 28438770
Northey JM, Cherbuin N, Pumpa KL, Smee DJ, Rattray B. Exercise interventions for cognitive function in adults older than 50: a systematic review with meta-analysis. Br J Sports Med. 2018;52:154–60.28438770
44. Hu MJ The value of hospital community family integrated extended care in the health management of elderly diabetes patients.Practical Clinical Nurs Electron J 2019 4 173 80
Hu MJ. The value of hospital community family integrated extended care in the health management of elderly diabetes patients.Practical Clinical. Nurs Electron J. 2019;4:173–80.
45. Luo F Yang YY Progress in the application of wearable technology in the management of chronic diseases in the elderly Med Theory Pract 2024 37 2013 5
Luo F, Yang YY. Progress in the application of wearable technology in the management of chronic diseases in the elderly. Med Theory Pract. 2024;37:2013–5.
46. Tuvemo JS Anens E Johansson AC Hellström K The Otago Exercise Program with or without motivational interviewing for Community-Dwelling older adults: a 12-Month Follow-Up of a Randomized, Controlled Trial J Appl Gerontol 2021 40 289 99 10.1177/0733464820902652 32114877
Tuvemo JS, Anens E, Johansson AC, Hellström K. The Otago Exercise Program with or without motivational interviewing for Community-Dwelling older adults: a 12-Month Follow-Up of a Randomized, Controlled Trial. J Appl Gerontol. 2021;40:289–99.32114877
