Original Research

Open Access

Effectiveness of neurobic exercise program on Belitung Nursing Journal

Volume 9(2), 100-109
© The Author(s) 2023

memory performance in community-dwelling https://doi.org/10.33546/bnj.2476

older adults with mild cognitive impairment: A

randomized controlled crossover trial
Wiyakarn Sanghuachang1 , Pornpat Hengudomsub1* , Nujjaree Chaimongkol1 ,
Naiphinich Kotchabhakdi2
1 Faculty of Nursing, Burapha University, Chon Buri, Thailand
2 Research Center for Neuroscience, Institute of Molecular Biosciences, Mahidol University, Salaya, Nakhon Pathom, Thailand

Abstract
Background: Mild cognitive impairment (MCI) is an early stage of cognitive decline in
individuals who are still able to perform their activities of daily living. They are at increased risk
of developing dementia. Improving and maintaining cognitive functions are essential goals for
older people with MCI to delay or prevent the transition to dementia.
Objective: This study investigated the effect of the neurobic exercise program on memory
performance among community-dwelling older adults with MCI.
Methods: A single-blind, randomized, controlled, two-period crossover design was used.
Thirty-two older adults who met the study criteria were randomly assigned to one of two
sequence groups, A (n =16) and B (n = 16). Group A received three weeks of neurobic
exercise, followed by a three-week washout period, and then three weeks of the traditional
brain exercise program. Group B received the treatments in the reverse order but otherwise in
a similar manner. Two aspects of memory performance were evaluated: subjective memory
and objective memory. Blinded evaluators measured the outcomes four times at baseline,
post-intervention (week 3), follow-up stage (week 7), and the end of the study (week 9).
Descriptive statistics, independent t-tests, and repeated measures ANOVA were employed for
data analyses.
Results: For subjective memory, rmANOVA revealed a significant difference of within-subject
(F1.437, 43.113 = 9.324, p <0.05) and interaction effect (time*group) (F1.437, 43.113 = 12.313, p <0.05)
and also showed significant differences of within-subject (F1.794,53.811 = 28.931, p < .05) and
interaction effect (time*group) (F1.794, 53.811 = 31.190, p <0.05) for objective memory. The study
results revealed that the participants in both groups had significantly lower mean scores on
the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), indicating better
or improved subjective memory. They also had significantly higher mean scores on the
*Corresponding author: Common Objects Memory Test (COMT) after receiving the neurobic exercise program,
Pornpat Hengudomsub, PhD indicating improvement in cognitive performance.
Department of Mental Health and Psychiatric
Nursing, Faculty of Nursing, Burapha Conclusion: The neurobic exercise intervention could improve subjective and objective
University, 169 Long-Hard Bangsaen Road,
Amphur Muang, Chon Buri, 20131, Thailand
memory among community-dwelling older adults with MCI more than those who received the
Email: pornpath@buu.ac.th traditional brain exercise program. Therefore, the neurobic exercise program can be used by
Article info: nurses and multidisciplinary teams to enhance memory performance among older adults with
Received: 8 December 2022 MCI.
Revised: 7 January 2023
Accepted: 23 February 2023
Trial registration: Thai Clinical Trials Registry (TCTR) 20210326003.
This is an Open Access article distributed
under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International License,
which allows others to remix, tweak, and build upon the
work non-commercially as long as the original work is Keywords
properly cited. The new creations are not necessarily
licensed under the identical terms. crossover trial; mild cognitive impairment; neurobic exercise; older adults; single-blind method;
E-ISSN: 2477-4073 | P-ISSN: 2528-181X brain

Background function and is considered a symptomatic stage before

dementia (Zhang et al., 2016). Among older adults, MCI
The term “Mild Cognitive Impairment: MCI” is used to describe increases the risk of dementia, especially Alzheimer’s disease.
older people with demonstrable cognitive impairment who In the US, it is an estimated 12% to 18% of people age 60 or
have not crossed the threshold for dementia (Lopez, 2013). It older have MCI (Alzheimer's Association, 2022). In Thailand,
is characterized by a minor but observable decline in cognitive approximately 71.4% of older people have been diagnosed

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with MCI (Griffiths et al., 2020). Also, dementia in older people group. Kansri et al. (2018) investigated the effects of neurobic
will rise from 1.1 million in 2030 to 2.0 million by 2050 exercise on depressive symptoms in 60 older persons with
(Leethong-In et al., 2019). Dementia significantly impacts MCI. The finding shows that neurobic exercise programs
older adults, their families, and carers. It also challenges significantly reduced depression among community-dwelling
health professionals throughout the pathway of care. The older persons with MCI. Kriengkaisakda and Chadcham
alternative strategy for reducing the prevalence of dementia is (2012) developed a brain training program based on the
to slow down its onset in older adults at risk for progression to neurobic exercise theory to target the short-term memory of
dementia. patients with mild dementia (N = 34). The result indicated that
While there is no exact cure for MCI and dementia the brain training program could improve short-term memory
nowadays, it is possible to slow down or prevent the among these patients. Wongkhamchai and Pantong (2017)
progression from MCI to dementia. Evidence shows the examined the efficiency of the neurobic exercise program in
potential benefit of cognitive intervention in older adults. The 120 patients with type 2 diabetes mellitus using a non-
neurobic exercise concept was postulated by Katz and Rubin randomized two-group posttest methodology. The result
(1999). It is a form of brain exercise designed to help keep the showed that the experimental groups’ scores on short-term
brain healthy and active. This exercise is distinct from other memory were significantly higher after training than the control
types of brain exercises. It involves non-routine or unexpected groups at three months follow-ups.
experiences using various combinations of the five physical The results of all studies showed that memory
and emotional senses. Neurobic exercise help improves nerve performance in the elderly with MCI could be improved by
impulses and the linkage between various brain data. neurobic exercise. However, rather than older adults with MCI,
Moreover, this exercise help stimulates neurons to produce most previous research focused on healthy aging, the elderly
neurotrophins that have chemical effects on nerve cell growth, with dementia, and older adults with chronic illnesses
improve nerve fiber branch and reduce nerve cell (Kanthamalee & Sripankaew, 2014; Kriengkaisakda &
degeneration. As a result, neurobic exercise can stimulate Chadcham, 2012; Wongkhamchai & Pantong, 2017). In
other parts of the brain, help prevent the decline in memory addition, the activities focused on health education and only
performance, and maintain a continuing level of memory used each physical sense to stimulate the brain (Kansri et al.,
performance (Katz & Rubin, 1999). 2018; Kanthamalee & Sripankaew, 2014). Therefore, it could
Previous studies have explored the potential benefit of be illustrated that the literature on nursing interventions aimed
neurobic exercise. Patani (2020) conducted a randomized at improving health outcomes in older adults, especially those
clinical trial (RCT) among patients with stroke (N = 40). with MCI, is limited and has methodological limitations.
Participants in the neurobic exercise group had significantly Another type of brain training, such as traditional brain
improved cognitive function and quality of life four weeks after exercise performed in the senior club affiliated with Saraburi
completing the intervention than the control group. In another Hospital in Thailand, was used to prevent or slow the
randomized controlled trial with older adults undergoing major, progression of dementia among these members. The
noncardiac, non-neurological surgery (N = 268), after traditional brain exercise was a practice-based program
receiving the neurobic exercise intervention, patients showed derived from expert panels as a part of health promotion to
a decreased incidence of delirium than the controls at seven prevent or slow the progression of dementia among older
days post-operation (Humeidan et al., 2021). In addition, in a adults. Traditional brain exercise focuses on simple brain
non-randomized two-group posttest design among older exercise and social activities. However, traditional brain
adults with comorbidities (N = 60), the result showed that one exercise has certain limitations because the program has not
month after the intervention, participants in the neurobic been empirically verified to be effective and enhance the
exercise group had lower depression scores than the control health outcomes of older adults with MCI. Therefore, the
group (Raj et al., 2020). The evidence showed that nurses play randomized, controlled, two-period crossover design was
a significant role in delivering such programs or activities for employed to examine the effectiveness of the neurobic
seniors with a wide range of cognitive declines, such as MCI exercise intervention among older adults living in the
and dementia (Tanglakmankhong, 2021). community. Memory performance, both objective and
In Thailand, a few studies have been conducted on subjective memory, served as this study’s outcomes.
neurobic exercise with older persons during hospital The study was conducted concerning the COVID
admission and in the community. Kanthamalee and restriction. In addition, the risk of confounding effects was
Sripankaew (2014) performed a single-group posttest design minimized because all interventions were delivered and
testing the effects of neurobic exercise with 22 female measured on the same participants, and every participant
dementia patients. The results demonstrated memory received both treatments. The participants serve as their
improvement one month after the neurobic exercise control. This study’s results would benefit not only older adults
intervention was completed. Nevertheless, this study did not with MCI but also those who care for them, such as their
include a control group and was limited to female participants families, nurses, and other relevant healthcare providers.
and one cognitive function domain. The effects of a neurobic The purpose of this study was to determine the effect of a
exercise program were examined by Napatpittayatorn et al. neurobic exercise program on memory performance among
(2019) in 55 older persons with normal to MCI. The findings older adults with MCI residing in the community. The specific
demonstrated that, at six months after the intervention’s aims of this study were: 1) To compare the mean differences
completion, participants in the neurobic exercise group had of subjective and objective memory between the experimental
better cognitive performance and serum Brain-Derived and control groups and 2) To compare the mean differences
Neurotrophic Factor (BDNF) levels than those in the control

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of subjective and objective memory within the experimental research assistants (RAs), including two research assistants
and the control group. who conducted the screenings and collected the outcome data
(RA1-2), and another RA3 was running the traditional brain
Methods exercise program. Two Ras (RA1-2) who are registered nurses
with at least two years of experience in geriatric care were
Study Design selected from Saraburi Hospital. The researcher trained two
This study employed a randomized controlled trial with a two- Ras (RA1-2) to collect accurate and consistent data from both
period crossover design (two 3-week intervention phases groups blindly by not knowing which group was the neurobic
separated by a 3-week washout period). The study was exercise program or the traditional brain exercise program.
conducted from June 2021 to November 2021. Group A (n = Another RA3, a registered nurse who works in the senior club,
16) received the neurobic exercise program for three weeks, was trained to run the traditional brain exercise program. This
followed by a three-week washout period, and then the study was reported in accordance with the Consolidated
traditional brain exercise program for three weeks. Group B (n Standards of Reporting Trials (CONSORT) checklist (Moher et
= 16) received the treatments in the reverse order but al., 2010) (Figure 2).
otherwise in a similar manner (Figure 1). This study had three

Figure 1 Research design

Samples/Participants were randomly assigned into groups A or B, n = 16 for each

Older people were recruited from the senior club of Saraburi group, through drawing lots (Figure 2).
Hospital in Tambon Pak Phriao, Amphoe Muang of Saraburi
province. Among 78 older adults were eligible to participate in Instruments
this study. Among them, 13 participants did not meet the study Three instruments were used in this study. First, the
inclusion criteria. Of these 78 older adults, 32 were randomly demographic variables include age, gender, marital and living
selected and consented to participate in this study. The status, education level, occupation, and underlying diseases.
inclusion criteria consisted of (1) males and females aged 60 Second, the short form of the Informant Questionnaire on
years or older, (2) scored <24 on the Montreal Cognitive Cognitive Decline in the Elderly (IQCODE), translated into Thai
Assessment (MoCA), (3) scored >12 on the Modified Barthel by Senanarong et al. (2001), was used to measure subjective
ADL index (BAI), (4) have a Body Mass Index (BMI) score in memory. This test measures the informant’s perception of the
the range 18.49-34.9 kg/m2, (5) no history of psychiatric older person’s cognitive decline. Older adults are required to
disorders or neurological conditions; no hearing or visual compare their performance today with their performance ten
impairment as diagnosed by a physician, (6) ability to write and years ago. Informants were asked to indicate the change on a
read as well as communicate well, (7) willingness to participate 16 items scale from 1 (much improved) to 5 (much worse). The
in the study throughout the program. The exclusion criteria cut-off scores were based on the total score divided by the
consisted of (1) severe complications or serious neurological number of questions (average item score range 1- 5). Lower
or musculoskeletal conditions, (2) serious conditions from scores indicated better subjective memory performance (1) A
comorbidity that made the participant unable to participate in score below 3.00 indicates improvement, (2) 3.00 indicates no
the intervention, and (3) older adults with a history of allergies change, (3) 3.01 – 3.50 indicates a slight decline; (4) 3.51-
to the food or flowers used in the activities. 4.00 indicates moderate decline; and (5) 4.01 – 5.00 indicates
In this study, the G* Power analysis was used to calculate severe decline. The Cronbach’s alpha reliability score of
the sample size, with a power of 0.08, α = 0.05, and an effect IQCODE for this sample was 0.94. Third, a standardized
size of 0.50, according to Napatpittayatorn et al. (2019). The Common Objects Memory Test (COMT) was used to measure
results indicated that the study needed 24 participants. In objective memory. The COMT was designed to assess age-
order to adjust for any participants dropping out or data related memory impairments in individuals with various
attrition, an additional 30 percent was added to the sample educational, language, and cultural backgrounds. The author
size for a total of 32 subjects in total. These 32 older adults and a bi-lingual researcher translated the COMT manual

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instructions into Thai using a translation and back-translation summed across these three steps, and the possible range was
method (Brislin et al., 1973). The translation achieved 100% 0-90. Higher scores indicated better objective memory
inter-rater agreement. The COMT (Thai version) was tested performance. The Cronbach’s alpha of the instrument was
with five older adults to ensure familiarity with the common 0.80.
objects and the distracters. The total COMT scores were

Figure 2 Consort flow diagram showing the flow of participants through each stage of the randomized crossover trial

Interventions intervention with 20 older adults for its feasibility and

Neurobic exercise program acceptability. The pilot study results showed the neurobic
The researcher developed the neurobic exercise intervention exercise intervention was feasible and acceptable among
by integrating the neurobic exercise concept (Katz & Rubin, these older adults. The neurobic exercise program utilized
1999) and previous evidence-based research (Kanthamalee & diverse combinations of physical and emotional senses. The
Sripankaew, 2014; Napatpittayatorn et al., 2019). The content, neurobic exercise program consisted of six sessions 1)
process, and arrangement of the neurobic exercise program Stimulation of visual sense through a tray game, 2) Stimulation
were validated by five experts in neurological and geriatric of smell sense through the use of natural aroma, 3) Stimulation
care. Further, the researcher tested the neurobic exercise of hearing sense through listening and identifying nature

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sounds, 4) Stimulation of the sense of touch through the date of approval Jan 26, 2021. Each participant willingly
writing and guessing game and a puzzle box game, 5) signed a consent form after learning about the goal of the
Stimulation of taste sense by tasting fruit, food, and desserts, study, the processes involved, and their rights to confidentiality
and 6) Integration of multi-senses stimulation; Application in and withdrawal autonomy. Permission to use the instruments
daily usage. The researcher conducted the intervention twice was granted by the original authors before data collection.
a week for three consecutive weeks. Each session lasted
approximately 60 minutes. The activities were done in a group Results
to stimulate the participants’ brains and help them enjoy
spending time with others. Characteristics of the Participants
Additionally, five homework assignments were given that The baseline demographic characteristics of the sample are
involved simple brain stimulation activities to activate the presented in Table 1. There was no statistical significance
participant’s brains when they were on their own. Specifically, between groups A and B in demographics at baseline. The
participants were trained to practice various activities beyond mean MoCA score was 21.13 (SD = 2.01, range 16-23), the
the daily routine. For example, changing the directions in going mean ADL score was 19.91 (SD = 0.29, range 19-20), and the
out and back home, or going to specific places such as mean BMI was 24.56 (SD= 3.61, range 16.01-34.52). The
temples, markets, etc., touching the differently shaped objects mean age of the participants was 67.53 years (SD = 4.43,
in their houses while closing their eyes and creating new range 60-78), 93.8% (n = 30) were female, 46.9 % (n = 15)
cooking menus by listing all ingredients and calculating the were married, and 87.5% (n = 28) lived with family members
cost. at home. Of the 32 participants, 87.5% (n = 28) had primary
education. 81.3% (n = 26) reported having other chronic illness
Traditional brain exercise program conditions, including hypertension 68.8% (n = 22),
The traditional brain exercise program was a practice-based dyslipidemia 46.9% (n = 15), diabetes 21.9% (n = 7), and heart
program derived from expert panels as a part of health disease 3.1% (n = 1) whereas 43.75% (n = 14) reported more
promotion activities in preventing or slowing the progression of than one condition.
dementia among older people. It was implemented in the
senior clubs affiliated with Saraburi Hospital in Thailand. Crossover Analysis
Activities based on scientific evidence were employed to Identifying carryover effects between the two study periods
improve the cognitive function of older adults. The activities was the primary objective of the analysis. The statistical
were conducted in small groups, approximately 3-4 persons analysis found no carryover effects for either outcome
per group, and focused on brain stimulation. This program (IQCODE, p = 0.219 and COMT, p = 0.139). It demonstrated
consisted of six 60-minute sessions conducted twice weekly that there were no carryover effects and that the washout
for three weeks. The activity schedule was the same period as phase of three weeks was sufficient. After that, significant
the neurobic exercise program. The activities consisted of 1) differences between the intervention effects of neurobic
Psychoeducation, “brain exercise to prevent dementia for the exercise and traditional brain exercise programs were
elderly”, 2) Drawing and coloring, 3) Paper folding, 4) Singing evaluated.
a song, 5) Photo hunting, and 6) Calculation games.
Subjective memory
Data Collection We performed repeated measures ANOVA to demonstrate
Two research assistants (RA1-2) collected data from all older differences between both groups. For subjective memory
adults with MCI in both groups four times at baseline, post- (IQCODE), rmANOVA revealed a significant difference of
intervention (week 3), follow-up stage (week 7), and the end of within-subject (F1.437, 43.113 = 9.324, p <0.05) and interaction
the study (week 9). During the intervention and data collection effect (time*group) (F1.437, 43.113 = 12.313, p <0.05). The
process, no unintentional harm or program-related negative comparisons of mean scores measured at different time points
effects were found among the participants. found non-significant differences between subjects (F1,30 =
0.023, p >0.05). Then, a post hoc t-test was conducted. For
Data Analysis this test, the significance level was adjusted by dividing it by
All statistical analyses were conducted using IBM SPSS the number of comparisons (0.05/4 (times of comparisons) =
version 26.0. Descriptive statistics were used to describe the 0.0125; Bonferroni correction). Results showed a significant
characteristics of the participants. Chi-square, Fisher’s exact difference in week 9 between the two groups (p <0.0125).
test, and independent t-test were used to examine the Details are presented in Figure 3.
differences in demographic characteristics between these two For within the group, when comparing each pair of times
groups. Repeated measures ANOVA was used to compare for Group A, pairwise comparisons of the mean differences of
the differences in mean scores of the outcomes between the IQCODE revealed significant differences at baseline and week
two groups and within the group across the four measured 3 (p <0.05). After a washout period, there were no significant
periods. differences in week 7 and week 9 (p >0.05). In group B, the
mean differences of IQCODE revealed significant differences
Ethical Considerations at baseline and week 3 (p <0.05). After a washout period, there
Ethical approval was obtained from the Research Ethics were significant differences at week 7 and week 9 (p <0.05).
Committee of Burapha University (IRB3-011/2564) and the Details are presented in Figure 4.
Ethical Committee of Saraburi Hospital (EC002/2564), the

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Table 1 Baseline demographic data of older adults with MCI

Characteristics Group A (n = 16) Group B (n = 16) t/ X2/F p-value

n % n %
Age
Range 60-74 60-78 -0.671a 0.507
Mean (SD) 67(3.46) 68.06 (5.29)
Sex
Male 1 6.3 1 6.3 0.000b 0.999
Female 15 93.8 15 93.8
Marriage status
Single 3 18.8 4 25.0 0.210c 0.901
Married 8 50.0 7 43.8
Divorced/widowed 5 31.3 5 31.3
Living status
Living alone 2 12.5 2 12.5 0.000b 0.999
Living with other 14 87.5 14 87.5
Education level
Less than high school 14 87.5 14 87.5 0.000b 0.999
Completed high school 2 12.5 2 12.5
Occupation
Not working 10 62.5 12 75.0 2.186b 0.624
Working 6 37.5 4 25.0
Income (Thai Baht/month)
Range 600-10,000 600-10,000 -0.417a 0.679
Mean (SD) 1393.75 (2320.47) 1737.50 (2338.91)
Chronic illness
No 3 18.8 3 18.8 0.000b 0.999
Yes 13 81.3 13 81.3
a = t-test, b = Fisher’s exact test, c = Chi-square

COMPARISONS OF IQCODE BETWEEN GROUPS At EACH TIME

3.5 ns ns
3.43 ± 0.36
3.41 ± 0.29 ns Group A

3.4 3.37 ± 0.25

Group B
3.30 ± 0.40 s
3.3 3.26 ± 0.21
3.25 ± 0.17

3.18 ± 0.26
3.2

3.1 3.07 ± 0.20

3
baseline week 3 week 7 week 9

--------Period 1-----------Washout----------Period 2----------

s = (p <0.0125) significantly different between groups;

ns = (p >0.0125) non-significantly different between groups

Figure 3 Comparisons of subjective memory (IQCODE) between groups at each time

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P AIRWISE COM P ARISONS OF M EAN DIF F ERENCES

OF IQCODE IN EACH G ROUP

3.5
TE 3.434
Group A
3.415
NB
NB s
3.4 3.371 Group B
ns
TE
3.3 TE ns
3.301 3.254

s 3.266 ns
3.2 TE
3.188
NB
3.1 s

3.070 NB

3
1
baseline week2 3 3 7
week week4 9
--------Period 1-----------Washout--------Period 2----------
NB= Neurobic exercise program; TE= Traditional brain exercise program;
s = (p <0.05) significantly different; ns = (p >0.05) non significantly different

Figure 4 Pairwise comparisons of mean differences of IQCODE in each group

Objective memory different time points found no significant difference between

For objective memory (COMT), rmANOVA revealed significant subjects (F1,30 = .518, p >0.05). Post hoc t-test showed a
differences of within-subject (F1.794,53.811 = 28.931, p <0.05) significant difference in week 3 between the two groups (p
and interaction effect (time*group) (F1.794, 53.811 = 31.190, p <0.0125). Details are presented in Figure 5.
<0.05). The comparisons of mean scores measured at

COMPARISONS OF COMT BETWEEN GROUPS AT EACH TIME

85 s
83.18±4.29 ns Group A
81.56±4.54
Group B
ns
80 ns
78.18±4.08 78.50±3.75
77.25±6.99 77.31±6.71
76.93±6.47

75.31±6.37
75

70
baseline week 3 week 7 week 9

--------Period 1-----------Washout--------Period 2----------

s = (p <0.0125) significantly different between groups;

ns = (p >0.0125) non-significantly different between groups

Figure 5 Comparisons of objective memory (COMT) between groups at each time

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In group A, when comparing each pair of times, pairwise differences of COMT showed no significant difference at
comparisons of the mean differences of COMT revealed baseline and week 3 (p >0.05). However, there were
significant differences at baseline and week 3 (p <0.05). significant differences in COMT scores at 7 and week 9 (p
However, there were no significant differences in week 7 and <0.05). Details are presented in Figure 6.
week 9 (p >0.05) after a washout period. In group B, the mean

P AIRWISE COM P ARISONS OF M EAN DIF F ERENCE

OF COM T IN EACH G ROUP
85 NB
83.188 Group A
NB
ESTIMATED MARGINAL MEANS

81.563
s Group B
s
80 TE
TE 78.188
77.250 ns ns
s TE
NB TE s 78.500
75 76.938 77.313
NB
75.313

70
0
baseline week3 3 week7 7 9 9
week
--------Period 1-----------Washout--------Period 2----------

NB= Neurobic exercise program; TE= Traditional brain exercise program;

s = (p <0.05) significantly different; ns = (p >0.05) non significantly different

Figure 6 Pairwise comparisons of mean differences of IQCODE in each group

Discussion brain function. BDNF helps enhance memory storage and the
number, size, and intricacy of dendritic spines (Miranda et al.,
This study aimed to evaluate the effects of a neurobic exercise 2019). BDNF levels are increased by physical activity,
program on memory performance in older individuals with maintaining a healthy weight, and leading a mentally and
MCI. We found that participants who received the neurobic socially engaged, but not unduly stressful, lifestyle. Evidence
exercise program had lower mean scores of the IQCODE and also demonstrated that neurobic exercise is an alternative
higher mean scores of the COMT than those in the traditional method for increasing BDNF levels (Gao et al., 2022).
brain exercise program at post-intervention (week 3) and at Moreover, the current study shows that the neurobic
the end of the study (week 9). Based on the neurobic exercise exercise intervention can increase BDNF levels in older adults,
concepts proposed by Katz and Rubin (1999) and relevant indicating improved brain function (Napatpittayatorn et al.,
research, these results could be explained by the fact that the 2019). According to neurobic exercise, trying to do new things
neurobic exercise program was designed to enhance memory and breaking a routine activity would help strengthen nerve
performance, both subjective and objective memory, in older cell stimulation, whereas routine activities use the same brain
adults with MCI. The researcher developed the neurobic pathways that could be brain deadening (Napatpittayatorn et
exercise program by applying the fundamental components of al., 2019; Raj et al., 2020). Doing new things or having
neurobic exercise to strengthen and enhance the memory unexpected experiences help stimulate the production of
performance of the participants. In each session, the neurotrophins, which chemically affect the growth of nerve
fundamental components and techniques of neurobic exercise cells and nerve fiber branches, reduce the degeneration of
were utilized to stimulate the brain. If the brain is stimulated by nerve cells, and increase blood flow to the brain. Moreover,
using a variety of physical sense combinations and deviates emotional sensation stimulates the diencephalon, particularly
from a usual activity, the nerve impulses and connections the hypothalamus, which regulates emotion and encodes
between different neurons in the brain assist the brain in memory by laying down memory attention. Emotional
having a steady level of mental fitness, strength, and flexibility sensation also stimulates the limbic system, contributing to
(Katz & Rubin, 1999; Scotts, 2013). memory formation by linking emotional states with memories
Neurobic exercise stimulates neurons to secrete of physical sensations (Kanthamalee & Sripankaew, 2014;
neurotrophins, which have a pharmacological effect on nerve Katz & Rubin, 1999).
cell proliferation, nerve fiber branching growth, and inhibition These results were consistent with previous research
of nerve cell degeneration (Napatpittayatorn et al., 2019). In studies that showed neurobic exercise effectively enhanced
addition, Brain-derived neurotrophic factor (BDNF) is a part of memory function in the elders. In a study conducted by
neurotrophic factors. BDNF is found all over the brain, Kriengkaisakda and Chadcham (2012), patients with mild
predominantly in the brain areas of the hippocampus, basal dementia who completed a neurobic exercise program
forebrain, and prefrontal cortex. These areas are essential for significantly improved their short-term memory three months
human learning, memory, and other cognitive functions. The after completing the program. One month after completing the
BDNF is advantageous for both long-term memory and overall neurobic exercise intervention, Kanthamalee and Sripankaew

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(2014) found an improvement in memory among 22 females to their needs. Moreover, participants appreciated the
with dementia, as measured by the Mini-Mental State neurobic exercise program because it is simple to practice
Examination (MMSE) score. At a 3-month follow-up, independently and does not require any specialized
(Wongkhamchai & Pantong, 2017) found that patients with equipment to activate the brain.
type 2 diabetes mellitus in the neurobic exercise intervention
group had significantly enhanced short-term memory scores Limitations of the Study
compared to the control group. According to Napatpittayatorn This study was was only conducted at one senior club under
et al. (2019), the participants in the neurobic exercise the Saraburi Regional Hospital. These older adults at the
intervention group showed significant improvement regarding senior club were more likely to be active and learn new things.
cognitive function and serum brain-derived neurotrophic factor In addition, this study was conducted from June 2021 to
(BDNF) six months after completing the intervention November 2021 due to the COVID restrictions. Thus, only
completion than those in the control group. participants with complete vaccinations were enrolled.
Moreover, Patani (2020) discovered that four weeks after
completion of the neurobic exercise intervention, patients had Implications to Practice and Recommendations
significantly better cognitive function and quality of life than the The results obtained from this study showed promising
controls. Therefore, previous research supports our findings positive outcomes and benefits of neurobic exercise for
that a neurobic exercise program can improve both subjective community-dwelling older adults with MCI. For further
and objective memory in older adults with MCI. However, the research, it is recommended to examine the sustainable
results showed that objective memory (COMT) score slightly effects of the neurobic exercise intervention among older
decreased in the washout period when the participants did not adults with MCI. Testing the long-term effects of increased
continue the activities to stimulate their brains. Therefore, memory function on life satisfaction, quality of life, healthy
promoting continuous activities by the older adults themselves living, fall incidents, and hospitalization or emergency
to stimulate the brain should be conducted. The evidence department visits are also recommended. In addition, future
showed that if the brain is being used continuously and studies should investigate the neurobic exercise program in
appropriately stimulated, the brain will improve even with other settings and the impact of neurobic exercise on other
advanced age (Patani, 2020). cognitions apart from memory. Testing improvement in brain
This study differs from previous neurobic exercise studies, function, such as brain waves and images, is recommended if
including activities that stimulate the brain through several possible. Also, this neurobic exercise program provides
senses. The activities presented the brain with non-routine or recommendations and practices for older adults residing in the
changed daily activities. These activities can enhance the community. Early brain stimulation, such as neurobic exercise,
memory retention of older people and delay the deterioration may benefit older persons with early signs of MCI. In addition,
of the brain. This intervention utilized the five senses and involving family members or other members of the community
added the emotional sense to each activity. The participants in the game-based brain exercise could also help older adults
were also encouraged to perform non-routine daily activities. keep enjoying and doing such activities.
This help promotes continuous growth and strength of the
nerve cells. The activities were conducted in small groups and Conclusion
the form of games. Some activities include competitions to
encourage teamwork and physical activity among participants. The neurobic exercise program is a new alternative nursing
Combining the emotional sense with the five senses will intervention approach, which was found to be effective in
stimulate the hypothalamus, which regulates emotion and enhancing significant memory performance among older
encodes memory. It also helps stimulate the limbic system, adults with MCI who are living in the community. Applying
which contributes to memory formation by integrating the available Thai herbs, aromas, and foods to stimulate the brain
emotional states with stored memories of physical sensations was useful. Moreover, the neurobic exercise program is easy
(Kanthamalee & Sripankaew, 2014). Moreover, combining two for older adults to use to stimulate their brains. It can also help
or more senses could promote the operation of the memory- older people make small changes in daily life, transforming
related regions of the brain, such as the frontal, parietal, routines into mind-building exercises. The neurobic exercise
temporal, occipital, diencephalon, and limbic systems. As a program was found to be effective in reducing or delaying
result, the function of the neural network, which is responsible subjective memory decline and improving objective memory in
for both short-term and long-term memory, is enhanced. community-dwelling older people with MCI. In addition,
At the end of the program, participants in both groups were neurobic exercise requires no need to find a special time or
asked to complete a seven-item Likert-type questionnaire to place to do it because everyday life is a neurobic exercise. The
measure their level of satisfaction with the neurobic exercise development of the care system for promoting cognitive
and traditional brain training programs. The mean satisfaction functions among community-dwelling older persons with MCI
scores for the neurobic and traditional brain exercise programs should be conducted. Nurses and multidisciplinary teams are
were 34.63 (SD = 0.50) and 33.94 (SD = 1.61), respectively. recommended to employ the neurobic exercise program
There were no statistically significant differences in alongside other activities to enhance cognitive function among
satisfaction between the neurobic and traditional brain older adults with MCI.
exercise programs (p >0.05). In response to open-ended
questions, participants reported that all neurobic exercise Declaration of Conflicting Interest
program activities were appropriate for their age and health The authors declared no potential conflicts of interest concerning the
conditions. The program activities were beneficial and suited research, authorship, publication, and publication of this article.

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 Sanghuachang, W., Hengudomsub, P., Chaimongkol, N., & Kotchabhakdi, N. (2023)

Funding among older adults with mild cognitive impairment. Journal of

Boromarajonani College of Nursing, Bangkok, 34(3), 65-76.
National Research Council of Thailand [NRCT grant D002/2564].
Kanthamalee, S., & Sripankaew, K. (2014). Effect of neurobic exercise on
memory enhancement in the elderly with dementia. Journal of Nursing
Acknowledgment Education and Practice, 4(3), 69-78. https://doi.org/10.5430/jnep.v4n
This research and innovation activity were funded by the National 3p69
Research Council of Thailand (NRCT). We appreciated the older adults Katz, L., & Rubin, M. (1999). Keep your brain alive: 83 neurobic exercises
who participated in this study. to help prevent memory loss and increase mental fitness. New York:
Workman Publishing.
Authors’ Contributions Kriengkaisakda, W., & Chadcham, S. (2012). Development of a brain-
WS and PH conceived the outline, wrote the introduction, literature review, training rehabilitation program based on neurobics exercise theory for
patients with mild dementia. Research Methodology & Cognitive
method, procedure, data analysis, and conclusion, and reviewed the whole
paper for cohesiveness. All other authors (NC and NK) contributed to the Science, 10(1), 11-25.
critical analysis of the content. Finally, all authors approved the final version Leethong-In, M., Piyawattanapong, S., Sommongkol, S., Thiengtham, S.,
to be published. & Kumniyom, N. (2019). Effects of a physical activity and brain
exercise program on cognitive ability of healthy Thai elders. Walailak
Journal of Science and Technology (WJST), 16(1), 1-8.
Authors’ Biographies Lopez, O. L. (2013). Mild cognitive impairment. CONTINUUM: Lifelong
Wiyakarn Sanghuachang has a master’s degree in gerontology nursing Learning in Neurology, 19(2), 411-424. https://doi.org/10.1212/01.
from Chulalongkorn University, Thailand. She is currently a PhD Candidate Con.0000429175.29601.97
in Nursing Science (International Program) at Burapha University, Miranda, M., Morici, J. F., Zanoni, M. B., & Bekinschtein, P. (2019). Brain-
Thailand. Her research focuses on improving the quality of life of older derived neurotrophic factor: A key molecule for memory in the healthy
adults with dementia and their families in rural communities. and the pathological brain. Frontiers in Cellular Neuroscience, 13, 363.
Pornpat Hengudomsub is an Associate Professor at the Department of https://doi.org/10.3389/fncel.2019.00363
Mental Health and Psychiatric Nursing at Burapha University, Thailand. Moher, D., Hopewell, S., Schulz, K. F., Montori, V., Gøtzsche, P. C.,
She specializes in health psychology and aging. Devereaux, P. J., Elbourne, D., Egger, M., & Altman, D. G. (2010).
Nujjaree Chaimongkol is an Associate Professor at the Department of CONSORT 2010 Explanation and Elaboration: Updated guidelines for
Pediatric Nursing at Burapha University. She is currently a Dean of the reporting parallel group randomised trials. BMJ, 340, c869.
Graduate School of Burapha University, Thailand. Her research fields https://doi.org/10.1136/bmj.c869
include health promotion, prevention, and Thailand’s health care system. Napatpittayatorn, P., Kritpet, T., Muangpaisan, W., Srisawat, C., & Junnu,
Naiphinich Kotchabhakdi is an Associate Professor at Research Center S. (2019). Effects of neurobic exercise on cognitive function and serum
for Neuroscience, the Institute of Molecular Biosciences, Mahidol brain-derived neurotrophic factor in the normal to mild cognitive
University, Thailand. He is an expert in Neuroscience. impaired older people: A randomized control trial. Songklanakarin
Journal of Science & Technology, 41(3), 551-558.
Data Availability Patani, K. A. (2020). Effect of neurobic exercises on cognitive function
The datasets generated during or analyzed during the current study are not related to post–stroke. Journal of Applied Dental and Medical
publicly available due to the subject confidential information but are Sciences, 6, 3.
available from the corresponding author on reasonable request. Raj, D., Santhi, S., & Sapharina, G. J. S. (2020). Effectiveness of neurobic
exercise program on memory and depression among elderly residing
at old age home. Journal of Complementary and Integrative Medicine,
Declaration of use of AI in Scientific Writing 17(4), 1-6. https://doi.org/10.1515/jcim-2019-0221
Nothing to declare. Scotts, J. (2013). Exercise for the brain: 70 neurobic exercises to increase
mental fitness & prevent memory loss: how non-routine actions and
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