Attentional Focus Training in Older Adults

Effects of Different Attentional Focus Training Strategies on Physical Performance and Cognitive Function in Older Adults: a Randomized Controlled Trial

The ability to walk safely and efficiently is crucial for older adults to maintain their independence and minimize the risk of falls. In healthy geriatric individuals, walking typically occurs as an automatic process involving motor skills, meaning the movement is generally performed with minimal conscious thought. However, attention can influence motor performance; a lack of focus or distraction can lead to loss of balance and increase the risk of falling during walking. The effects of attention focus on geriatric individuals remain uncertain. Therefore, this study aims to investigate the effects of different attention-focused training on physical performance and cognitive function in geriatric individuals. In this randomized controlled trial, 60 participants will be randomly assigned to four groups: the internal focus exercise group (n = 15), the external focus exercise group (n = 15), the no attention focus group (n = 15), and the control group (n = 15). The control group will consist of participants from a different institution to prevent contamination. Participants in the non-control groups will attend training sessions twice a week (approximately 40 minutes each) for 12 weeks. The experimental groups will complete a total of 24 exercise sessions. All training sessions will be conducted by an experienced physiotherapist. Pre- and post-assessments will be conducted. The sociodemographic characteristics of all participants will be assessed using a descriptive form. Participants' physical performance will be evaluated using the Short Physical Performance Battery (SPPB), the Stair Climbing Test, the Timed Up and Go Test (TUG), a static balance test (single-leg stance test), and a dynamic balance test (Berg Balance Scale). Cognitive function will be assessed using the Central Nervous System Vital Signs (CNSVS) Cognitive Performance and Attention Tests. Additionally, participants' walking will be analyzed using Kinect V2 camera-based software. The data collected from the study will be analyzed using SPSS (Statistical Program for the Social Sciences). Descriptive statistics will include frequencies, percentages, means, and standard deviations. For comparisons, the significance level (p) will be set at 0.05.

Study Overview

• Status: Completed
• Conditions: Cognitive Function; Physical Performance; Geriatric Individuals
• Intervention / Treatment: Other: Internal focus training; Other: External focus training; Other: No attentional focus training

Detailed Description

Aging is an inevitable phase characterized by physiological and mental changes, including a decline in perception and awareness, as well as progressive deterioration of memory functions. According to the United Nations World Social Report (2023), the population aged 65 and older is expected to reach 1.6 billion by 2050.

With aging, motor performance, including balance, walking stability, postural stability, and movement speed, gradually declines. The literature indicates that one-third of individuals aged 65 and older experience a fall once or more per year, with the rate rising to 40% among those aged 85 and above. The risk of falling in older adults may be related to a decrease in the integration of physiological systems (cardiac, respiratory, and neuromuscular) that influence physical performance.

Physical performance is the objective measurement of an individual's ability to integrate various physiological systems (cardiac, respiratory, neuromuscular) to perform coordinated and effective movements. Due to its importance in evaluating mobility and overall physical well-being, it is considered a critical health indicator in older adults. The decline in physical performance can result from the complex interaction of physiological factors (e.g., declines in cardiovascular, musculoskeletal, and neuromuscular systems, leading to progressive loss of muscle mass and strength, reduced testosterone levels), clinical factors (e.g., depressive symptoms, multimorbidity, polypharmacy), lifestyle factors (e.g., physical activity levels), and sociodemographic factors (e.g., age, gender). This decline is evident not only in physical performance but also in cognitive function. With normal aging, the brain typically experiences shrinkage, a widely observed phenomenon, affecting both gray and white matter. This reduction in brain size is attributed to a decline in the development of dendrites, dendritic spines, axons, and synapses. As a result, cognitive abilities such as attention, memory, executive functions, language, and visuospatial skills decline with aging.

The decline in physical performance and cognitive function due to aging significantly impacts the ability to perform activities of daily living. The ability to walk safely and efficiently, which is essential for daily life, is necessary for older adults to maintain their independence and minimize the risk of falls. In healthy older adults, walking typically occurs with minimal conscious thought about the movement process. It is known that the focus of attention affects the performance of motor skills. The term "focus of attention" refers to the location of an individual's attention relative to the performance environment or task. This focus can be internal or external. An internal focus directs attention to the components of body movement during an action, whereas an external focus directs attention to the effect of the movement on the environment or the final goal. For example, during a ball throw, the individual may focus internally on the movement of the wrist, elbow, and shoulder, or externally on the ball and the target.

In recent years, various attention-focused approaches have been implemented to enhance functional and cognitive capacity in geriatric individualsProvidi. ng different attention-focus instructions to geriatric individuals has been shown to be an effective strategy for improving motor performance. A study examining the effects of internal focus, external focus, and no focus walking training during rehabilitation on conscious motor processing, balance, walking ability, and fear of falling in older adults at risk of falling found that focus reduced conscious motor processing while improving functional balance and walking (8). Furthermore, substantial evidence shows that using attention-focus methods results in improvements in physical performance. However, the effects of focus instructions on physical performance and cognitive function in geriatric individuals remain uncertain.

To address this gap in the literature, this study will investigate the effects of different attention-focus training on physical performance and cognitive function in geriatric individuals. We hypothesize that individuals who undergo attention-focused walking training during rehabilitation will demonstrate better physical performance and cognitive function compared to those who do not receive attention-focused walking training. Our study will provide data and contribute to filling this gap in the existing literature.

• Study Type: Interventional
• Enrollment (Actual): 50
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Trabzon, Turkey (Türkiye)
    • Retirement home

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Aged 65 years or older
• Willingness to participate in the study
• Ability to read and write
• Mini-Mental State Examination (MMSE) score > 24
• Ability to independently perform the tests administered as part of the study
• Ability to walk independently in the community (without a walking aid and able to walk at least 40 meters)

Exclusion Criteria:

• Presence of orthopedic, neurological, vestibular, cognitive, or other medical conditions that may affect the applicability of the assessment methods or training interventions used in the study
• History of myocardial infarction and/or coronary bypass surgery within the past year
• Severe visual or auditory impairments causing communication difficulties
• Polypharmacy (use of five or more medications per day)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Internal focus group; After obtaining informed consent to participate in the study, all participants, regardless of group, will undergo an assessment by an experienced physiotherapist prior to group allocation. They will participate in exercise sessions lasting approximately 40 minutes, twice a week for 12 weeks in the internal focus group. A total of 24 sessions will be completed by each participant. Exercise sessions will be carried out by an experienced physiotherapist. Each training session will consist of warm-up (5 minutes), balance, transfer and reaching activities (10 minutes), internal focused walking (20 minutes) and cool-down (5 minutes) exercises. The first assessment will be made before the sessions start and the final assessment will be made after the 12-week exercise program.	Other: Internal focus training; internal focus training
Experimental: External focus group; After obtaining informed consent to participate in the study, all participants, regardless of group, will undergo an assessment by an experienced physiotherapist prior to group allocation. They will participate in exercise sessions lasting approximately 40 minutes, twice a week for 12 weeks in the external focus group. A total of 24 sessions will be completed by each participant. Exercise sessions will be carried out by an experienced physiotherapist. Each training session will consist of warm-up (5 minutes), balance, transfer and reaching activities (10 minutes), external focused walking (20 minutes) and cool-down (5 minutes) exercises. The first assessment will be made before the sessions start and the final assessment will be made after the 12-week exercise program.	Other: External focus training; External focus training
Experimental: No attention focus group; After obtaining informed consent to participate in the study, all participants, regardless of group, will undergo an assessment by an experienced physiotherapist prior to group allocation. They will participate in exercise sessions lasting approximately 40 minutes, twice a week for 12 weeks in the no attention focus group. A total of 24 sessions will be completed by each participant. Exercise sessions will be carried out by an experienced physiotherapist. Each training session will consist of warm-up (5 minutes), balance, transfer and reaching activities (10 minutes), no attentional focus walking (20 minutes) and cool-down (5 minutes) exercises. The first assessment will be made before the sessions start and the final assessment will be made after the 12-week exercise program.	Other: No attentional focus training; no attentional focus training
No Intervention: Control group; no-intervention

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Short Physical Performance Battery (SPPB), stair climbing test, Timed Up and Go (TUG) test, Berg balance test, and single leg stance test	The Short Physical Performance Battery (SPPB), stair climbing test, Timed Up and Go (TUG) test, Berg balance test, and single leg stance test will be used to assess physical performance.	12 weeks
Central Nervous System Vital Signs (CNSVS)	The "Central Nervous System Vital Signs (CNSVS) Cognitive Performance and Attention Tests" will be administered to assess cognitive functions. CNSVS is an evaluation tool designed to examine the neurocognitive status of individuals aged 7 to 90. It consists of several subtests, including the Verbal Memory Test, Visual Memory Test, Finger Tapping Test, Symbol-Digit Coding Test, Stroop Test, Continuous Performance Test, and Attention Switching Test. In our study, scores obtained from these subtests will be utilized. To determine the extent of neurocognitive impairment, classification is made based on standard score points. According to this classification: >110 indicates high capacity, 90-110 indicates normal capacity, 80-89 indicates mild cognitive impairment, 70-79 indicates moderate cognitive impairment, and <70 indicates severe cognitive impairment.	12 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Gait analysis using Kinect V2	The gait analysis of participants will be conducted using Kinect V2 camera-based software. This software is developed in the MATLAB environment and processes depth images to identify joint positions. It determines the corresponding joint position for each pixel in the depth image and calculates the accuracy of this position. This enables the detection and accuracy assessment of joint positions. Parameters such as gait symmetry, step length, step width, cadence, and speed will be evaluated.	12 weeks

Collaborators and Investigators

• Sponsor: Müşerref Ebru YALÇIN

Study record dates

Study Major Dates

• Study Start (Actual): May 1, 2025
• Primary Completion (Actual): November 1, 2025
• Study Completion (Actual): November 1, 2025

Study Registration Dates

• First Submitted: November 14, 2024
• First Submitted That Met QC Criteria: November 21, 2024
• First Posted (Actual): November 22, 2024

Study Record Updates

• Last Update Posted (Actual): April 7, 2026
• Last Update Submitted That Met QC Criteria: April 5, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Cognitive function; Geriatric individuals; Physical performance; External focus; Internal focus; Attention focus
• Other Study ID Numbers: 2024/6463

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: I think the data should be kept confidential.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No