Should Dual Task Training or Action Observation Therapy be Used in Geriatric Individuals?

Aging leads to significant declines in both motor skills and cognitive functions. While walking, balance, and general mobility are particularly impaired, cognitive functions such as attention, memory, and decision-making are also observed. The physical decline and cognitive decline associated with aging make it difficult for older adults to maintain independence in their daily activities. Studies have shown that cognitive impairments are directly related to mobility loss.

For individuals over 65, it is crucial to recommend therapeutic interventions that support healthy aging, aim to increase physical and cognitive function, and prevent physical limitations. In recent years, Action Observation Therapy (EGT), a cognitive strategy, has begun to be used in rehabilitation programs for the elderly, aiming to enhance motor learning and functional recovery. Action observation is a cognitive process based on observing actions performed by others without actually performing any movements. In EGT, participants first observe a meaningful action and then imitate it themselves. This stimulates motor learning and motor memory formation, facilitating the understanding and imitation of movements. EGT is a complementary strategy used to improve motor skills, facilitate motor learning, and stimulate neuroplasticity.

Another method used in recent years to improve motor skills and cognitive functions in the elderly is dual-task training (DTT). Dual-task training is based on the simultaneous execution of two motor-motor or cognitive-motor tasks. This methodology can be defined as the ability to simultaneously complete a secondary, cognitive, or motor task while maintaining the primary task of walking or postural balance.

A review of the literature has demonstrated that motor + cognitive dual-task training provided to elderly individuals is an effective intervention for improving cognitive function, health status, and life satisfaction, and reducing depression, in community-dwelling elderly individuals. Another study suggests that a dual-task intervention incorporating cognitive and physical activities in the elderly results in greater improvements in walking speed than interventions involving only physical activities. One study in the literature has reported that EGT improves cognitive function in individuals with MS. However, it appears that further research is needed on its effects on cognitive functions. A study published in 2025 reported that EGT, administered in addition to conventional treatment in elderly individuals, was effective in improving motor skills.

In light of this information, the investigators see that dual-task training and action observation therapy can be used to improve cognitive and physical functions in the elderly. However, it is also noteworthy that studies indicating that dual-task training can cause dual-task confusion in the elderly, leading to poorer performance. A review of the available literature reveals that studies on HDI and EGT mostly focus on a single disease, and no studies comparing these two methods, which may be effective in improving cognitive and motor functions in geriatric individuals, have been found.

More evidence is needed on outcome measures such as motor skills and cognitive functions for HDI and EGT in the geriatric population. Our proposed study will provide data and contributions to fill this gap in the literature.

Research question: In terms of the method used when implementing exercise programs in geriatric individuals, is conventional exercise training, dual-task training, or action observation therapy more effective on parameters such as cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life?

Hypotheses:

H0a: Dual-task training applied to geriatric individuals does not improve cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.

H0b: Action observation therapy applied to geriatric individuals does not improve cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.

Hypothesis H0c: There is no difference between the groups in terms of the effects of conventional exercise training, dual-task training, and action observation therapy applied to geriatric individuals on cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.

Hypothesis H1a: Dual-task training applied to geriatric individuals improves cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.

Hypothesis H1b: Action observation therapy applied to geriatric individuals improves cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.

Hypothesis H1c: There is a difference between the groups in terms of the effects of conventional exercise training, dual-task training, and action observation therapy applied to geriatric individuals on cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.

Objectives: The aim of this study was to examine the effects of dual-task training and action observation therapy on parameters such as cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life in geriatric individuals and to compare them with conventional exercise training.

Originality: There are studies demonstrating the use of dual-task training and action observation therapy to improve motor skills and cognitive functions in various diagnostic groups and in geriatric individuals. However, the investigators observe that there are more limited studies on the use of EGT in the elderly compared to HDI. The investigators believe that our study, which examines the effects of HDI and EGT on parameters such as motor skills and cognitive functions in geriatric individuals and compares these effects with conventional exercise training, will have a significant place in the literature. Our study aims to contribute to the literature by comparatively examining two different approaches that simultaneously intervene not only in motor skills but also in cognitive functions. Thus, it will provide insights into the holistic effects of different therapy methods on both motor skills and cognitive functions. The findings will provide recommendations for use in geriatric rehabilitation processes and help identify strategies that can improve overall health.

Type of Study This study is designed as a prospective experimental study. Location and Time of Study Data will be collected from nursing homes, nursing home elder care and rehabilitation centers, and Bahadın Elderly Living Center affiliated with the Ministry of Family and Social Services located in Yozgat and Çorum provinces. To avoid cross-contamination between the experimental and control groups, data for the experimental and control groups will be collected from different centers.

Research Population and Sample The sample for this study was determined using power analysis. According to calculations using the G\*power 3.1.9.7 package program, with a total of 66 participants (22 in each group), an effect size of 0.40 and a significance level of 0.05, the power of the study will be 81.8%. This power is over 80%, making it sufficient. The sample will be selected from nursing homes, nursing home elder care and rehabilitation centers, and Bahadın Elderly Living Center affiliated with the Ministry of Family and Social Services located in Yozgat and Çorum provinces. These institutions will be listed, and three institutions will be selected from among the listed institutions, taking into account the high number of elderly individuals and their ability to meet the inclusion criteria. The groups to which geriatric individuals at these institutions will be assigned (HDE, EGT, and CG) will be determined using a sealed envelope method and randomized. Geriatric individuals at these institutions who meet the inclusion criteria and sign the informed consent form will be included in the study. A total of 66 participants will be selected, 22 geriatric individuals for each group.

Inclusion Criteria

* Agreeing to participate in the study * Being over 65 years of age * Scoring 24 or higher out of 30 on the Mini Mental State Examination * Being literate Exclusion Criteria * Having a musculoskeletal condition that prevents the performance of the tests and exercises * Having a visual or hearing impairment that prevents participation in the study * Having a neurological, psychiatric, or other condition that prevents participation in the study Having a medical diagnosis * Having undergone any surgical procedure within the last six months Exclusion criteria * The individual voluntarily withdraws from the study * Failure to maintain exercise continuity (Participants must complete at least 80% of the exercise sessions (20/24 sessions) for the study to be considered applicable) * Having an additional diagnosis that would prevent participation in exercise during the study period * Failure to comply with instructions Data collection tools * Sociodemographic Questionnaire * Mini Mental State Examination (MMSE) * Clock Drawing Test * Tinetti Balance and Walking Test * Timed Up and Go Test (TUG) * Hand Dynamometer Grip Strength * 5-Times Sit-to-Stand Chair Test (5KSOKT) * Sit-and-Reach Flexibility Test * CASP-19 Quality of Life Scale for Elderly People - Turkish Version (CASP-13) * Modified Borg Scale (MBS) The sociodemographic characteristics of geriatric individuals will be determined with a descriptive questionnaire.

The outcome measures listed below will be assessed using the specified scales during the initial and final evaluations.

Assessment of Cognitive Functions: Because elderly individuals must have adequate communication and cognitive status, their cognitive functions will be assessed using the "Mini Mental State Examination (MMSE)" for inclusion in the study. The highest possible total score is 30, and scores below 24 indicate cognitive impairment. Volunteers scoring 24 or higher on the MMSE will be accepted into the study. The adapted Turkish version of this scale, originally known as the "Mini-Mental State Examination (MMSE), will be used. The MMSE will be used not only as an admission requirement but also in the final assessment. In addition, the "Clock Drawing Test" will be used to test constructional praxis, comprehension, and planning abilities. The individual is asked to draw a clock, place numbers inside it, and mark the time as it is announced. A score below four is consistent with impaired cognitive function. Scoring is as follows: Writing 12 in the correct place: 3 points, Writing all twelve numbers: 1 point, Drawing the hour and minute hands: 1 point, Marking the announced time correctly: 1 point.

Balance and Gait Assessment: The "Tinetti Balance and Gait Test (TDYT)" will be used to assess the balance and gait of geriatric individuals. The TDYT was first developed by Mary Tinetti under the name Performance-Oriented Assessment of Mobility Problems in Elderly Patients (POMA) to evaluate patients at high risk of falling. It was later developed and named the "Tinetti Gait and Balance Assessment". The TDYT evaluates balance ability and gait under two main headings. The first 9 questions are about balance, and the total score is the balance score. The next 7 questions are about gait, and the total score is the gait score. Three values are assigned for each unit: 0-1-2. 2 points represent correct performance of the specified movement; 1 point represents correct performance of the specified movement; A score of 0 indicates that the specified movement is performed with adaptations, and a score of 0 indicates that the movement cannot be perform