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Z. Jiayuan1, J. Xiang-Zi2,*, M. Li-Na1, Y. Jin-Wei1, Y. Xue3


1. Psychology Nursing, Harbin Medical University, Daqing, Heilongjiang) China; 2. Business management department, Suzhou Industrial Park Institute of Service Outsourcing, Suzhou, Jiangsu, China; 3. Neurology/Daqing Longnan Hospital, Daqing, Heilongjiang, China. * co-first author

Corresponding Author: Meng Li-Na, No.39 Xinyang Street, Harbin Medical University, Daqing, Heilongjiang Province, China, Tel: 86-18604586122, Email:

J Prev Alz Dis 2021;
Published online July 5, 2021,



Background: The Objective: To assess the effectiveness of a mindfulness-based Tai Chi Chuan on physical performance and cognitive function among cognitive frailty older adults.
Design: A single-blind,three-arm randomized controlled trial.
Setting: Three communities in Daqing, China.
Participants: The study sample comprised 93 men and women aged 65 years or older who were able to walk more than 10 m without helping tools, scored 0.5 on Clinical Dementia Rating (CDR) and absence of concurrent dementia, identified pre-frailty (scored 1-2 on Fried Frailty Criteria) and frailty older adults (scored 3-5 on Fried Frailty Criteria).
Intervention: Subjects were randomly allocated to three groups: Group1, which received mindfulness intervention (formal and informal mindfulness practices); Group 2, which received Tai-Chi Chuan intervention; Group 3, which received MTCC intervention.
Measurements: The primary outcomes was cognitive frailty rate(measured by Fried Frailty Criteria and Clinical Dementia Rating-CDR) , the secondary outcome were cognitive function (measured by Min-Mental State Examination-MMES) and physical level (measured by Short physical performance battery- SPPB, Timed up and Go test-TUG and the 30-second Chair test). They were all assessed at Time 1-baseline, Time 2-after the end of 6-month intervention and the follow up (Time 3-half year after the end of 6-month intervention).
Results: The baseline characteristics did not differ among the groups.Improvements in the cognitive function (MMES), physical performance (SPPB, TUG, 30-second Chair test) were significantly difference between time-group interaction (p<.05). The rate of CF was significantly different among groups at 6-month follow-up period (χ2=6.37, p<.05). A lower prevalence of frailty and better cognitive function and physical performance were found in the Group 3 compared with other two groups at the follow-up period (p<.05).
Conclusions: MTCC seems to be effectively reverse CF, improving the cognitive and physical function among older adults, suggesting that MTCC is a preferably intervention option in community older adults with cognitive frailty.

Key words: Cognitive frailty, mindfulness, Tai Chi, physical, cognitive.




Physical and cognitive impairment frequently overlap in older adults. Recent studies have showed that an interrelationship between physical frailty and cognitive impairment existed (1). Therefore a new conceptual construct—cognitive frailty (CF)—characterized by the simultaneous existence of both cognitive impairment and frailty, was proposed in 2013 by an international consensus group (2). A recent meta-analysis which focused on CF older adults in community showed that the CF was found to be a significant predictor of the short-term and the long-term mortality and dementia, disability, and other adverse health outcomes (3). Older adults with CF are more likely to develop dementia than the two individual components, and could provide a new direction for healthy aging (4). Early diagnosis, detection and intervention of CF are of great significance for delaying the occurrence and development of dementia (5). A series of evidence suggested that physical exercise was associated with improvements in health related outcomes in older adults with frailty (6-9). However, currently no optimal interventions can be recommended for cognitive function and physical health promotion in older adults with CF as the evidence base is small and of limited quality.
In the last decade, Tai Chi Chuan (TCC) has been widely adopted in physical exercise aiming to improve physical performance in community older adults in China, which being proposed as a high efficiency exercise by the Centers for Disease Control and Prevention (CDC) (10). The pulling movement in TCC is beneficial to improve the flexibility and coordination of the body and reduce the probability of injury. Several studies proved that TCC could effectively promote physical fitness and muscle protein anabolism in frail older adults and was more effective than conventional exercise approaches for reducing the incidence of falls (11-14). The training spirit of TCC is to complete harmony of body and mind which is similar to the mindfulness skills. Mindfulness is broadly defined as present-focused, non-judgmental awareness (15). Evidence shows that mindfulness-based interventions has yielded positive effects on enhancing the ability of cognitive reserve and slowing down the aging-associated cognitive decline, promoting active aging among mild cognitive impairment (MCI) older adults in the community (9). Regarding to the consistency of core mechanism between mindfulness and TCC, some researchers have mixed systematic mindfulness training with TCC to investigate the health benefits both in physical and psychology (16-17). Mindfulness-based Tai Chi Chuan (MTCC) may be more suitable for CF older adults, however, whether MTCC can reduce cognitive frailty is currently unknown.
With the continuing growth of the CF population and the community health care policy in China, implementing a more feasible and effective intervention would widely promote healthy aging. Consequently, in this study we aim to use a rigorous randomized control trial design to investigate the effects of an MTCC intervention on cognitive function and physical performance in the CF older adults. We hypothesized that compared with mindfulness intervention and TCC exercise, MTCC would be greatly more effective in both cognitive and physical aspects among CF populations.



Study Design

This study was a single-blind, three-arm randomized controlled trial conducted in three communities in Daqing, China. All participants who met the inclusion criteria and agree to participant finished the written informed consent, and then they were allocated to group 1 (Mindfulness group) or group 2 (TCC group) or group 3 (MTCC group) by lottery method. The study was approved by the the committee on ethics in research of Harbin Medical University. Our reporting in the manuscript adheres to the CONSORT 2010 guidelines. The study was registered under Chinese Clinical Trials Registry (ChiCTR2100042851).


Participants were recruited by putting up a poster through collaboration with three communities. The inclusion criteria included: 1- aged 65 years or older; 2- had no serious mental or physical disease; 3- could walk without helping tools; 4- a score of 0.5 in CDR ; 5- pre-frail and frail older adults. These with dementia or undergoing similar or other physical and cognitive intervention were excluded. Finally 93 participants were recruited (Figure 1).

Figure 1. Study flow diagram


Randomization and Masking

Participants were randomly assigned to either a mindfulness intervention or a TCC group or a MTCC group using sequentially numbered, opaque, sealed envelopes with NCR (no carbon required) paper, conducted by a trained research assistant independent of the study design.The implement of interventions and data collection were conducted by independent teams that blinded to to group allocation.


The programs in this study were established and carried out by professional team which consisted of two psychologists (qualified in mindfulness intervention for eleven years), two physical education and sports specialists (qualified in TCC program for more than ten years) and one rehabilitation medicine specialist (major in geriatric rehabilitation). All the participants received a six-month intervention which consisted two stage: the first stage was a 1-hour group intervention (varied in size) twice weekly for three months in community facilities, such as senior or community centers and the second stage was a 1-hour individual practice twice weekly for three months. To avoid the group contamination, the interventions were separated in time and sites. The details of each group intervention were as follows,
Group 1 (mindfulness intervention): All participants received a booklet about mindfulness skills. It consisted of four basic forms of meditation practices (body scan, walking meditation, gentle yoga, sitting meditation). During group intervention, each session began with a 10-minute short-review aiming to solving the existing problems, and then a 45-minute exercises and a 5-minute summary. After participants had a good grasp of basic mindfulness practice, they were taught to integrate mindfulness into daily life such as eating, hearing, smelling, observing.During individual session, participants were required to continue mindfulness training under the supervision and guidance for 3 months.
Group 2 (TCC intervention): All participants received a picture booklet about induction of TCC. 24-Simplified TCC was conducted. During group intervention, each session began with a 10-minute warm-up (including muscle stretching and joint movement) aiming to avoid injure, and then a 45-minute exercises and a 5-minute cool-down activity (deep breathing and relaxing). Participants were taught how to carry out different TTC forms such as “Starting Posture”, “Hold the Lute”, “Cloud Hands” , “Turn and Kick with Left Heel”, etc. During individual session, participants were required to continue TCC training under the supervision and guidance for 3 months.
Group 3 (MTCC intervention): All participants received a booklet about MTCC program.The MTCC involved practice of a core of modified exercise forms mixed together mindfulness and TCC postures aimed at stimulating and integrating body, sensory, and cognitive systems, the practice focused on present, non-judgment, peaceful state involving TCC movements.
During group intervention, participants were taught how to be mindfulness and find connections between mindfulness and TCC practice. Besides, the modified MTCC forms were introduced to participants. After they grasped the basic practice skills, they began to carry out different MTTC forms including the seated formats, standing formats and stepping formats. Each session began with a 10-minute warm-up (including muscle stretching and joint movement) aiming to avoid injure, and then a 45-minute exercises and a 5-minute cool-down activity (deep breathing and relaxing). During individual session, participants were required to continue MTCC training under the supervision and guidance for 3 months.
The theme of each group were shown in Table 1. If all participants have any problems during intervention period, they could contact their tutor at any time.

Table 1. The theme of each group during group intervention


Variables and Outcomes

Demographic data was collected by self-reported questionnaires: age, sex and BMI. Assessment were conducted at baseline (Time 1-one week before commencing the program), after the intervention (Time 2-six month after commencing the program) and follow-up (Time 3-one year after commencing the program).
The primary outcome was the rate of CF at follow up period among different groups. We defined no cognitive frailty as non-frail (scored 0 on Fried Frailty Criteria) and without MCI (CDR=0). 1- Fried Frailty Criteria, which is based on the five Cardiovascular Health Study criteria defined as: slowness/unintentional weight loss/weakness/exhaustion/low physical activity (18); 2- Clinical Dementia Rating (CDR) was used to assess the cognitive function from six aspects :memory/orientation/judgment and problem solving/community affairs/home and hobbies/and personal care.The levels ranged from 0-3 (none to severe). The higher scores, the poorer cognitive performance (19).
The secondary outcomes were change of cognitive function and physical performance of participants. The assessment included: 1- Cognitive function-The Mini-Mental State Examination (MMSE) consists of 11 items was used to assess the cognitive function from five aspects :orientation/memory/attention/language ability /comprehensive/judgment. The score ranged from 0-30 that higher score indicate better cognitive function (20); 2- Physical function-Short physical performance battery (SPPB) was used to assess gait speed, chair stand, and balance tests. Total scores ranged 0-12 that higher points indicate better physical function (21); The Timed Up and Go test (TUG) was used to assess mobility and requires both static and dynamic balance, the time it took form the beginning movement until returned to the seated position was recorded in seconds (22); The 30-second Chair test was administered to assess the core strength which calculated by times (23).

Data analysis

The sample size was calculated by using the G-power 3.1 program with a power (1- β) of 0.95, a significance level of 0.05, From related data (6), we set an effect size of 0.21, finial a sample size was 75 participants, and assuming a 20% estimate loss of follow-up. Finally the sample size was 93. Statistical analyses were performed using SPSS 22.0 (IBM Corp., Armonk, NY, USA). All analyses followed the intent-to-treat principle. Categorical variables were expressed as percentages and continuous variables with mean and SD. Demographic characteristics and basic CF level were compared using a t-test and Chi-square tests. Between-group differences for the effects of intervention were assessed using the Chi-square test for CF rate.Three-way analysis of variance (ANOVA) compared outcome variables between the three groups at three assessment points (three time points × three groups). The post hoc Bonferroni test was used to assess changes within groups. Set p <0.05 as statistically significant.



There were two participants lose to follow up, one in group 1 (because of refuse to continue the study) and one in group 3 (because of be hospitalized) respectively and finally a total of 91 participants completed all the assessment.

Demographic and baseline characteristic

Baseline characteristics were not significantly different among the three groups. The mean age was 71.4±4.6 years (range = 65-81 y), and 56% (n=51) were female. The details of physical performance and cognitive function variables across groups at the baseline were illustrated in (Table 2.Characteristics of Participants). Fried’s Frailty Criteria, MMSE, SPPB, TUG, and 30-second Chair test showed no significantly different and has the comparability among groups (P > .05).

Table 2. Characteristics of Participants (N = 91)

Note. BMI- Body Mass Index;MMSE- Mini Mental State Examination ;SPPB-Short Physical Performance Battery; TUG,Time Up and Go;SD-Standard Deviation


Effects of interventions on CF rate after one year

The Group 1 (mindfulness group) showed there were 2 participants reversed to no CF state and the reversed rate was 6.7%; Group 2 (TCC group) showed there were 4 participants reversed to no CF state and the reversed rate was 12.9%; Group 3 (MTCC group) showed there were 9 participants reversed to no CF state and the reversed rate was 30%.The distribution of CF significantly differed among groups in the follow-up period (χ2=6.37, P=0.041).

Effects of interventions on physical performance and cognitive function

Table 3 revealed the changes in frailty, physical performance and cognitive function from baseline to follow-up (Time 1-Time 3) in the three groups. Group 3 showed the changes better outcomes than the Group 1 and Group 2 at the post hoc significance level in the scores for frailty(p=.039), SPPB (p=.004),TUG ( p<.000), MMSE (p=.018) in the follow up period. However, difference in score for 30-second chair test (p=.112) did not reach statistical significance difference (p>.05). The variables of physical performance (SPPB, TUG, 30-second chair test) and cognitive function (MMSE) showed significant Group×Time interaction (p<.05). The details were shown in Table 3 and Figure 2.

Table 3. Changes in all variables across time among the groups (N = 91)

Note. SPPB-Short Physical Performance Battery; TUG,Time Up and Go;MMSE- Mini Mental State Examination ;SD = standard deviation


Figure 2. Changes in all variables across time among the groups

A-C: Physical Performance. D:cognitive function. SPPB- Short Physical Performance Battery; TUG, Time Up and Go; MMSE- Mini Mental State Examination



To our best knowledge, this is the first three-arm RCT study to compare the effects of three intervention programs on cognitive function and physical performance in community older adults with CF. The main finding in this study revealed that the 6-month MTCC intervention was optimal in reversing cognitive frailty, significantly improving the cognitive function and physical performance. According to the definition of CF by the International Academy on Nutrition and Aging (IANA) (24), in our study participants were recruited based on the cognitive state (a point of 0.5 in CDR, without concurrent dementia) with pre-frailty (scored 1-2 on Fried Frailty Criteria) or frailty level (scored 3-5 on Fried Frailty Criteria). The participants in MTCC group showed a highest reverse rate of CF (30%) at 6-month follow-up. Moreover, the MTCC group also showed significant improvement from baseline in SPPB, TUG and MMSE at the end of intervention and follow-up period.
Regarding the improvement of physical performance, participants in the TCC group and MTCC group gained more benefits than mindfulness group. Both of the TCC and MTCC group received the Chinese traditional exercise program- Tai Chi Chuan. In our study, we applied the 24-simplified TCC to participants which was more suitable for older adults. After 6-month intervention, the physical function of gait speed, static and dynamic balance, range of motion, reflex control and core strength were increased. Previous studies have reported that TCC training leads to positive changes in neuromuscular functions in older adults (13, 25). The findings from our study are aligned with other RCT trails on the effect of TCC exercise on promoting physical benefits in older adults (26-27). As one of the highest-tier evidence-based health-promoting and disease prevention exercise, TCC has been widely adopted by communities in China. In our study, TCC exercise training program was adjusted to be easily implementable according to the condition and demand of older adults. Compared with TCC group, MTCC received modified Tai Chi Chuan program that was a mindfulness-based TCC consisted of training of mind-body coordination, the beneficial effects on physical function was more significant. The aim of practice was to achieve the state of «motion in quietness» and focus on the moment. In MTCC program, participants were taught to carry out gentle TCC postures under the continuous attention of consciousness to avoid brute force so as to improve the effect of exercise.
In terms of cognitive function, significant change in MMSE was found between group and time interaction in the present study. What’s more, the MMSE score in MTCC group yielded the highest among the three groups. The participants in MTCC group received the mindfulness skills which combined with TCC exercise, both of them were beneficial to cognitive recovery. The systemic review reported that mindfulness training has a positive effect on cognitive functions in a wide group of populations, including the aging adults with early cognitive degeneration (28). A recent study found that the mindfulness practice could enhance functional brain connectivity in the default mode network in older adults with cognitive impairment and reduce hippocampal volume atrophy in MCI with positive impacts on brain regions most related to dementia (29). Regarding to the receptivity of the older adults, we integrated the systemic mindfulness skills into daily life and exercise which was easily for older adults to grasp and practice everyday. After the 6-month intervention , most of CF older adults in MTCC group could practice by themselves and continue to practice in future. Training with mindfulness involved TCC, participants cultivated self-regulation of attention, allowing attention to be maintained on the immediate exercise experience allowing for increased recognition in the present that helped them to achieve a “harmony of body and mind” state to promote health.
One major strength of our study was that we adopted a multidomain program – MTCC-involving not only cognitive training (mindfulness skills) but also combined with physical activity (TCC) to facilitate training-driven brain plasticity and better performance in physical and cognitive functions. To our best knowledge, this was the first RCT design to investigate the effectiveness of MTCC program on the cognitive function and physical performance in CF older adults. The MTCC training yielded a notable result in reversing the CF. After 6-month follow up, thirty percentage of participants in MTCC group had no frailty and MCI which was very impressive. For Chinese community older adults, the MTCC program were easy to grasp and apply to their daily life. The lose of follow-up rate was very low (2.75%) which represented participants adhere with the study. Moreover, most of participants reflected the program was helpful and useful and they would like to practice after the end of intervention. Previous studies have proved that cognitive intervention or physical exercise had beneficial effects on older adults (30-32). It was recommended that the comprehensive program which led to both promotion in physical performance and cognitive function should be targeted to the older adults (33-34), however fewer feasible interventions could systematically and effectively improve the conditions of CF older adults. In this study we designed a MTCC program tailored for older adults which was easily implementable and efficient. In accordance with hypothesis, a six-month MTCC training program resulted in a long-term effect on a significant reduction in the CF rate and promotion in the cognitive and physical functions among older adults with CF. During the MTCC training, participants were required to focus on the present moment, involving self awareness and understanding of every movement process which involved posture shift and center of gravity shift. The weight of the body changed all the time to strengthen the ability of control the balance of the body (35-36). The outstanding benefits of MTCC may due to capture the similarities of mindfulness and TCC and combine them to create the overlapping effect through practice.
Although we use a rigorous and well-controlled randomized trials, the study has several limitations. Firstly, due to the limitations of funding, the validated biochemical measures for CF older adults were not used in this study, further study investigations using subjective and objective indicators are recommended to investigate the mechanism of the interventions.
Secondly, although this trial was conducted in multicenter, these communities were in one province. To generalize the findings could be enhanced by involving more states.



In conclusion, our findings proved that mindfulness practice and TCC exercise were beneficial in the domains of cognitive function and physical performance among CF older adults. Moreover, the current randomized controlled trail showed evidence that the tailored MTCC program combined mindfulness practice and TCC exercise was most effective in reversing CF state. MTCC was a efficacious and innovative program that could serve as a model to improve cognitive function and physical performance in community older adults with CF in China.


Funding: This study was supported by grants from the Ministry of education, humanities and social sciences research projects [Fund No.17YJCZH129].

Acknowledgments: All authors were grateful for all the participants and community staffs in this study for their corporation.

Conflict of interest: All authors have declared no conflicts of interest for this article.

Ethical standard: The study design was approved by the Institutional Review Board of Harbin Medical University. All participants signed written informed consent.



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