Dual-Task vs. Multicomponent Exercise in Institutionalized Seniors

Official title

Effects of Dual-Task Versus Multicomponent Exercise Programs on Fear of Falling and Fall Risk in Institutionalized Older Adults: A Randomized Controlled Trial

Overview

The aging global population faces a major public health challenge regarding the growing number of older adults in long-term care facilities. Institutionalized older adults exhibit high rates of sedentary behavior, accelerating physiological decline (such as sarcopenia, diminished muscle strength, and impaired balance) and increasing fall risk. Beyond biomechanical risks, the fear of falling acts as a psychological barrier, creating a negative spiral of frailty where a lack of confidence leads to activity restriction. This further reduces functional capacity and paradoxically increases the actual fall risk. Addressing fall risk requires interventions targeting both the physical mechanisms of balance and the psychological mechanisms of self-efficacy. Current WHO guidelines emphasize multicomponent physical activity (combining balance, strength, and aerobic training) to prevent falls. However, traditional programs may not fully address the cognitive-motor interference of real-world falls, which often occur during complex, divided-attention tasks. Institutionalized older adults often struggle to allocate attentional resources efficiently. This study posits that breaking the spiral of inactivity requires stimulating the complex demands of daily living. The investigators hypothesize that a Dual-Task Exercise Program, integrating cognitive challenges (e.g., executive function tasks, memory recall) into a multicomponent routine, will provide superior benefits compared to a Multicomponent Exercise Program alone. By training cognitive functions to process mental stimuli while maintaining motor control, the goal is to improve physical and cognitive capabilities and enhance participants' confidence. This randomized controlled trial aims to compare the effects of these two modalities on physical fall risk and psychological fear of falling. Conducted in a nursing home for over 12 weeks, participants will be randomly assigned to either the Control Group (Multicomponent Training: physical strength and balance) or the Experimental Group (Dual-Task Training: physical protocol with simultaneous cognitive stimulation).

Detailed description

Ageing is a universal biological process. However, the trajectory of physical and cognitive decline varies significantly across individuals based on their lifestyle and environment. Literature consistently demonstrates that older adults residing in long-term care institutions (nursing homes) represent a particularly vulnerable demographic compared to those living in the community. While community-dwelling older adults often maintain a baseline level of physical activity through household chores, social interactions, and recreational tasks, institutionalized older adults frequently face an environment characterized by sedentarism and a lack of autonomy. This environmental physical deprivation in institutional settings leads not only to physical deconditioning (loss of strength, loss of balance, and reduced mobility) but also to a lack of cognitive stimulation. The absence of complex daily challenges means that these individuals rarely engage the neuro-motor pathways required to manage simultaneous tasks. Consequently, institutionalized older adults are at a disproportionately high risk of adverse health outcomes, most notably falls.

Falls are not merely biomechanical events caused by muscle weakness; they are deeply intertwined with psychological factors. Recent systematic reviews highlight fear of falling as a critical health concern that affects a vast majority of institutionalized older adults, regardless of whether they have a history of falling. Fear of falling acts as a psychological barrier that triggers a negative spiral of frailty, specifically, the fear leads to self-imposed activity restriction, which further degrades physical fitness (i.e., strength and balance), thereby paradoxically increasing the actual risk of future falls. Breaking this cycle is imperative. The literature suggests that interventions must address not only the physical capacity to move but also the confidence to move safely. While physical activity is widely recognized as a protective factor, reducing fall risk and promoting independence, the specific type of physical activity that best addresses the psychological aspect of fear of falling remains a subject of investigation.

International guidelines, such as those from the World Health Organization and Cochrane reviews, advocate for multicomponent exercise programs by combining resistance, balance, and aerobic training, as the most effective strategy for fall prevention. These programs, typically prescribed at moderate intensities, have proven effective in improving pure physical parameters like muscle strength and static balance. However, a critical gap exists between clinical improvements and real-world applicability. Standard multicomponent exercise is often performed in controlled environments where the individual focuses exclusively on the motor task (i.e., single tasking). Yet, in daily life, falls rarely occur when an individual is solely focused on walking. Instead, falls predominantly happen during complex, multi-task scenarios, such as walking while talking or carrying objects, navigating obstacles, or processing environmental cues. This discrepancy suggests that traditional multicomponent training may lack ecological validity. It strengthens the muscles but may not sufficiently train the brain to allocate attentional resources efficiently during movement, leaving the older adult vulnerable when distracted.

The Cognitive-Motor Interference theory posits that when older adults with cognitive deficits attempt to perform a motor task and a cognitive task simultaneously, performance in one or both domains deteriorates. This dual-task cost is a strong predictor of falls. Therefore, to effectively reduce fall risk and, crucially, the fear of falling, an intervention must simulate these complex demands. This leads to the hypothesis that dual-task training, the integration of simultaneous cognitive challenges (e.g., verbal fluency, arithmetic calculations, memory recall) into physical exercise, may offer superior benefits to multicomponent training alone. By forcing the central nervous system to manage competing attentional demands, dual-task training aims to improve neuroplasticity and executive function alongside physical conditioning.

The primary aim of this investigation is to determine whether increasing the complexity of the training stimulus (Dual-Task) yields greater benefits than the standard physical stimulus (Multicomponent) in institutionalized older adults. Specifically, this study seeks to understand if adding a cognitive load to a standard exercise protocol is a key ingredient required to significantly reduce fear of falling and improve functional mobility in this specific population. Rather than focusing solely on the volume or intensity of exercise, as emphasized in general guidelines, this research focuses on the specificity of the training type. If dual-task training proves more effective, it suggests that fall prevention strategies in nursing homes should move beyond simple repetitive movements and embrace physical and cognitive training. The findings will support healthcare professionals in tailoring interventions that are not only physically strengthening but also cognitively engaging, ultimately promoting a more robust and confident functional independence among the oldest old.

Interventions

• Behavioral Multicomponent Exercise Program
  The program consists of 45-60 minute sessions, twice a week for 12 weeks. It includes resistance training (using free weights, elastic bands, and body weight), static and dynamic balance training, and aerobic walking exercises. Intensity is moderate, adjusted to individual tolerance using the Borg Scale.
• Behavioral Dual-Task Exercise Program
  Participants perform the exact same physical exercises as the control group (same duration, frequency, and intensity), but with simultaneous cognitive tasks designed to induce cognitive-motor interference. Tasks include verbal fluency (naming animals/colors), arithmetic calculations (subtraction), and memory recall while performing motor movements.

Primary outcome measures

• Change in Fear of Falling [Time frame: Baseline (Week 0) and Post-Intervention (Week 13).]

Secondary outcome measures (3)

• Change in Functional Mobility and Fall Risk [Time frame: Baseline (Week 0) and Post-Intervention (Week 13).]
• Change in Physical Performance [Time frame: Baseline (Week 0) and Post-Intervention (Week 13).]
• Exercise Adherence (Attendance Rate) [Time frame: Through study completion (up to Week 12).]

Eligibility criteria

Inclusion criteria

• Aged 65 years or older.
• Resident in the institution (nursing home) for at least 6 months.
• Autonomous ambulation capacity (independent walking ability, with or without walking aids like canes or walkers).
• Medical clearance/approval to participate in physical exercise.
• Ability to understand verbal instructions and communicate.
• Absence of severe cognitive impairment that prevents understanding of the tasks.

Exclusion criteria

• Uncontrolled cardiovascular or metabolic conditions (e.g., severe heart failure, unstable angina, recent myocardial infarction in the last month).
• Severe musculoskeletal, visual, or auditory impairments that preclude participation in the exercise program.
• Diagnosis of severe dementia or other neurological conditions that prevent following the protocol instructions.
• Absence from more than 5 consecutive sessions or attendance of less than 75% of the total sessions.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Prevention

Study locations

Portugal · 1 center

• Santa Casa da Misericórdia de Alcobaça — Alcobaça

Publications

• Sherrington C, Fairhall NJ, Wallbank GK, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb SE. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31;1(1):CD012424. doi: 10.1002/14651858.CD012424.pub2. PMID 30703272
• Schumann M, Feuerbacher JF, Sunkeler M, Freitag N, Ronnestad BR, Doma K, Lundberg TR. Compatibility of Concurrent Aerobic and Strength Training for Skeletal Muscle Size and Function: An Updated Systematic Review and Meta-Analysis. Sports Med. 2022 Mar;52(3):601-612. doi: 10.1007/s40279-021-01587-7. Epub 2021 Nov 10. PMID 34757594
• Savvakis I, Adamakidou T, Kleisiaris C. Physical-activity interventions to reduce fear of falling in frail and pre-frail older adults: a systematic review of randomized controlled trials. Eur Geriatr Med. 2024 Apr;15(2):333-344. doi: 10.1007/s41999-024-00944-9. Epub 2024 Feb 27. PMID 38411771
• Oliveira ARC, Magueja CMP, Goncalves de Almeida AM. Actions to control the fear of falling in older people: An umbrella review. Arch Gerontol Geriatr. 2026 Feb;141:106087. doi: 10.1016/j.archger.2025.106087. Epub 2025 Nov 20. PMID 41289647
• Feng C, Adebero T, DePaul VG, Vafaei A, Norman KE, Auais M. A Systematic Review and Meta-Analysis of Exercise Interventions and Use of Exercise Principles to Reduce Fear of Falling in Community-Dwelling Older Adults. Phys Ther. 2022 Jan 1;102(1):pzab236. doi: 10.1093/ptj/pzab236. PMID 34636923

Identifiers

NCT: NCT07427225 · CE/IPLEIRIA/88/2025

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗