Abstract

Objective

Describing the prevalence and incidence of cognitive impairment in older adults, considering the isolated and combined presence of leisure-time physical activities, hypertension, and obesity.

Methods

An observational, analytical, cohort study was conducted based on the data records of baseline (2008-2009) and follow-up (2016-2017) from the Campinas FIBRA Study. Screening for dementia and self-report measures concerning the number of weekly hours of low and moderate levels of leisure-time physical activities, hypertension, and nutritional status based on the body mass index (BMI) were applied.

Results

There were 394 aged participants; 71.8% were female and 74.4% had less than four years of formal education. The mean age at the baseline was 72.8±5.3 years old, and at follow-up was 81.4±4.8. At baseline, the most prevalent concurrent conditions were physical inactivity and hypertension (21.5%), and the least prevalent were physical inactivity, obesity, hypertension and cognitive deficit (0.6%). Associations were observed between physical inactivity at follow-up, or for both measurement periods, and cognitive impairment at follow-up. Inactive participants at the baseline showed a higher incidence ratio of cognitive impairment at follow-up, adjusted for sex, age, education, nutritional status and hypertension (RI=2.27; 95%CI: 1.49-3.45; p<0.001).

Conclusion

Prevalence and incidence of cognitive deficit mostly reflected the influence of low levels of leisure-time physical activity at baseline and follow-up.

Keywords
Cognition; Exercise; Nutritional Status; Hypertension; Older Adults

Resumo

Objetivo

Descrever a prevalência e a incidência de deficit cognitivo em pessoas idosas, considerando a presença isolada e conjunta de atividades físicas no lazer, hipertensão arterial sistêmica e obesidade. Igualmente analisar a presença isolada e simultânea de inatividade física, obesidade, hipertensão e deficit cognitivo em dois tempos de medida.

Métodos

Foi realizado um estudo observacional, analítico e de coorte, baseado nos registros dos bancos de dados da linha de base (2008-2009) e do seguimento (2016-2017) do Estudo Fibra Campinas. Foram realizadas medidas de rastreio de demência, de autorrelato de horas semanais de atividades físicas de no lazer de diferentes intensidades, de hipertensão arterial e de status nutricional, com base no Índice de Massa Corporal (IMC).

Resultados

Participaram 394 pessoas idosas, 71,8% das quais eram mulheres; 74,4% tinham escolaridade <4 anos; M_idade =72,8±5,3 na linha de base e M_idade =81,4±4,8 no seguimento. Na linha de base, as condições conjuntas mais prevalentes foram inatividade física e hipertensão (21,5%) e as menos prevalentes, inatividade física, obesidade, hipertensão e deficit cognitivo (0,6%). Foram observadas associações entre deficit cognitivo e inatividade física no seguimento. Idosos inativos na linha de base apresentaram maior razão de incidência de deficit cognitivo no seguimento, ajustada por sexo, idade, escolaridade, estado nutricional e hipertensão (RI=2,27; IC 95%: 1,49-3,45; p<0,001).

Conclusão

A prevalência e a incidência de deficit cognitivo em idosos refletem a influência de baixo nível de atividade física no lazer na linha de base e no seguimento.

Palavras-Chave:
Cognição; Exercício físico; Estado Nutricional; Hipertensão; Pessoas Idosas

Introduction

Changes in cognitive status are more likely in those aged 70 and 80 years old, when functional capacity tends to decline, cognitive losses become more likely, the manifestation of chronic degenerative diseases are more evident, and interindividual differences more noticeable than in early old age¹1 Neumann LTV, Albert SM. Aging in Brazil. Gerontologist. 2018;58(4):611-617. doi:10.1093/geront/gny019.

Changes in cognitive status in old age result from a multifactorial process, in which non-modifiable determinants, such as age and genetics, act together with risk factors arising from the way people live their lives and the choices they make, depending on their beliefs, possibilities, social arrangements and education²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X,³3 Yuan M, Chen J, Han Y, et al. Associations between modifiable lifestyle factors and multidimensional cognitive health among community-dwelling old adults: Stratified by educational level. Int Psychogeriatrics. 2018;30(10):1465-1476. doi:10.1017/S1041610217003076. Diabetes mellitus, obesity, systemic arterial hypertension and depression; smoking and physical inactivity, and a lower education level, increase the risk of cognitive decline in old age⁴4 Oliveira FF de. Doença de Alzheimer. Novos critérios de diagnóstico. In: Pivi GAK, Scgultz RR, Bertolucci PHF, eds. Nutrição Em Demência. São Paulo/SP: Scio; 2013:30-42. https://doi.org/10.1590/S0004-282X2005000400034
https://doi.org/10.1590/S0004-282X200500... . About one third of cases of dementia can be avoided with proper management of determinants that include physical activity and diet management, among other modifiable factors, through healthy habits and self-care²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X.

The term physical activity refers to a wide class of voluntary actions performed by the skeletal muscles, generating higher caloric expenditure than that observed when the body is at rest⁵5 Strath SJ, Kaminsky LA, Ainsworth BE, et al. Guide to the assessment of physical activity: Clinical and research applications: A scientific statement from the American Heart association. Circulation. 2013;128(20):2259-2279. doi:10.1161/01.cir.0000435708.67487. Within the scope of epidemiological research in geriatrics, measures of physical activity are established through surveys of the engagement of older adults in actions that occur in different spaces and at different times, following different logics and intentions. Among them are utilitarian physical activities, subordinated to specific objectives, such as those performed in work situations, while commuting and during domestic hygiene. There are non-utilitarian physical activities, but subordinated to a purpose, which are carried out in leisure situations. Among these are physical exercises and sports, the former characterized by planning, structuring and systematization associated with the purpose of maintaining or improving physical condition. Sports respond to pre-established, common sense rules, and their main objective is participation, but they can also be aimed at physical conditioning⁶6 Ainsworth BE, Kaskell WL, Whit MC, Irwin ML, Swartz AM, Strath SJ, et al Compendium of physical actiities: Na update of activity codes and MET intensities. Medicine & Science in Sports and Exercise, 2000: 32 (Suppl): S498-504..

There is great interest in creating indicators of people’s involvement in practices that require body movement and physical effort and are carried out in free or leisure time. They are associated with different values ​​and meanings, mainly related to health, socialization and the improvement of physical conditioning⁵5 Strath SJ, Kaminsky LA, Ainsworth BE, et al. Guide to the assessment of physical activity: Clinical and research applications: A scientific statement from the American Heart association. Circulation. 2013;128(20):2259-2279. doi:10.1161/01.cir.0000435708.67487,⁶6 Ainsworth BE, Kaskell WL, Whit MC, Irwin ML, Swartz AM, Strath SJ, et al Compendium of physical actiities: Na update of activity codes and MET intensities. Medicine & Science in Sports and Exercise, 2000: 32 (Suppl): S498-504.. There is evidence of a positive association between high levels of leisure-time physical activity and a decrease in the risk of cognitive decline in old age⁷7 Engeroff T, Ingmann T, Banzer W. Physical activity throughout the adult life span and domain-specific cognitive function in old age: A systematic review of cross-sectional and longitudinal data. Sport Med. 2018;48(6):1405-1436. doi:10.1007/s40279-018-0920-6

8 Erickson K, Hillman C, Stillman C, et al. Physical activity, cognition, and brain outcomes: A review of the 2018 physical activity guidelines. Med Sci Sport Exerc. 2020;51(6):1242-1251. doi:10.1249/MSS.0000000000001936

9 Falck RS, Landry GJ, Best JR, Davis JC, Chiu BK, Liu-Ambrose T. Cross-sectional relationships of physical activity and sedentary behavior with cognitive function in older adults with probable mild cognitive impairment. Phys Ther. 2017;97(10):975-984. doi: 10.1093/ptj/pzx074-¹⁰10 Stephen R, Hongisto K, Solomon A, Lönnroos E. Physical activity and Alzheimer’s disease: A systematic review. J Gerontol A Biol Sci Med Sci. 2017;72(6):733-739. doi:10.1093/gerona/glw251, supporting the notion that the regular practice of these activities is a relevant modifiable risk factor for maintaining cognitive status.

Unfortunately, the engagement of older adults in leisure-time physical activities tends to decline⁵5 Strath SJ, Kaminsky LA, Ainsworth BE, et al. Guide to the assessment of physical activity: Clinical and research applications: A scientific statement from the American Heart association. Circulation. 2013;128(20):2259-2279. doi:10.1161/01.cir.0000435708.67487,¹¹11 Van Der Zee MD, Van Der Mee D, Bartels M, De Geus EJC. Tracking of voluntary exercise behaviour over the lifespan. Int J Behav Nutr Phys Act. 2019;16(1):1-11. doi:10.1186/s12966-019-0779-4,¹²12 Costa T, Ribeiro L, Neri A. Prevalence of and factors associated with leisure-time physical activity in older adults from seven Brazilian cities: data from the FIBRA study. Rev Bras Atividade Física Saúde. 2015;20(2):174. doi:10.12820/rbafs.v.20n2p174, together with functionality¹²12 Costa T, Ribeiro L, Neri A. Prevalence of and factors associated with leisure-time physical activity in older adults from seven Brazilian cities: data from the FIBRA study. Rev Bras Atividade Física Saúde. 2015;20(2):174. doi:10.12820/rbafs.v.20n2p174 and living space¹¹11 Van Der Zee MD, Van Der Mee D, Bartels M, De Geus EJC. Tracking of voluntary exercise behaviour over the lifespan. Int J Behav Nutr Phys Act. 2019;16(1):1-11. doi:10.1186/s12966-019-0779-4,¹²12 Costa T, Ribeiro L, Neri A. Prevalence of and factors associated with leisure-time physical activity in older adults from seven Brazilian cities: data from the FIBRA study. Rev Bras Atividade Física Saúde. 2015;20(2):174. doi:10.12820/rbafs.v.20n2p174. Likewise, systemic arterial hypertension (SAH) and obesity can act as barriers to engaging in leisure-time physical activities¹³13 Costa TB, Neri AL. Medidas de atividade física e fragilidade em idosos: dados do FIBRA Campinas, São Paulo, Brasil. Cad Saude Publica. 2011;27(8):1537-1550. doi:10.1590/S0102-311X2011000800009 and cognitive health¹⁴14 Phillips C. Lifestyle modulators of neuroplasticity: how physical activity, mental engagement, and diet promote cognitive health during aging. Neural Plast. 2017;2017. doi:10.1155/2017/3589271,¹⁵15 Espeland MA, Lipska K, Miller ME, et al. Effects of physical activity intervention on physical and cognitive function in sedentary adults with and without diabetes. J Gerontol A Biol Sci Med Sci. 2017;72(6):861-866. doi:10.1093/gerona/glw179. The impact of these changes is felt in the physical³3 Yuan M, Chen J, Han Y, et al. Associations between modifiable lifestyle factors and multidimensional cognitive health among community-dwelling old adults: Stratified by educational level. Int Psychogeriatrics. 2018;30(10):1465-1476. doi:10.1017/S1041610217003076,¹¹11 Van Der Zee MD, Van Der Mee D, Bartels M, De Geus EJC. Tracking of voluntary exercise behaviour over the lifespan. Int J Behav Nutr Phys Act. 2019;16(1):1-11. doi:10.1186/s12966-019-0779-4, cognitive¹⁴14 Phillips C. Lifestyle modulators of neuroplasticity: how physical activity, mental engagement, and diet promote cognitive health during aging. Neural Plast. 2017;2017. doi:10.1155/2017/3589271,¹⁵15 Espeland MA, Lipska K, Miller ME, et al. Effects of physical activity intervention on physical and cognitive function in sedentary adults with and without diabetes. J Gerontol A Biol Sci Med Sci. 2017;72(6):861-866. doi:10.1093/gerona/glw179 and psychosocial³3 Yuan M, Chen J, Han Y, et al. Associations between modifiable lifestyle factors and multidimensional cognitive health among community-dwelling old adults: Stratified by educational level. Int Psychogeriatrics. 2018;30(10):1465-1476. doi:10.1017/S1041610217003076 spheres, affecting the quality of life of older adults¹⁷17 Neri AL, Melo RC, Borim FSA, Assunção D, Cipolli GC, Yassuda MS. Avaliação de seguimento do Estudo Fibra: caracterização sociodemográfica, cognitiva e de fragilidade dos idosos em Campinas e Ermelino Matarazzo, SP. Rev. Bras. Geriatr. Gerontol. 2022;25(5):e210224 https://doi.org/10.1590/1981-22562022025.210224.pt
https://doi.org/10.1590/1981-22562022025... and interfering in health system costs and impacting the economy of families¹¹11 Van Der Zee MD, Van Der Mee D, Bartels M, De Geus EJC. Tracking of voluntary exercise behaviour over the lifespan. Int J Behav Nutr Phys Act. 2019;16(1):1-11. doi:10.1186/s12966-019-0779-4,¹⁴14 Phillips C. Lifestyle modulators of neuroplasticity: how physical activity, mental engagement, and diet promote cognitive health during aging. Neural Plast. 2017;2017. doi:10.1155/2017/3589271.

Brazilian literature on the effects of the isolated or combined presence of leisure-time physical activity levels, hypertension and obesity on the cognitive status of older adults is scarce. The theme is important considering that the three conditions act in determining the cognitive status in adult life and in old age and their control integrates an arsenal of resources for dementia prevention. This study aimed to describe the prevalence and incidence of cognitive impairment in older adults, considering the isolated or concurrent presence of leisure-time physical activities, SAH and obesity, while also analyzing the isolated and concurrent presence of physical inactivity, obesity, hypertension and cognitive impairment in two measurement times.

Methods

The research adopted an observational, analytical, cohort design, based on baseline and follow-up records from the electronic database of the Frailty in Brazilian Elderly Study (FIBRA Campinas). Its participants were part of the sample of a multicenter, population-based study on frailty in older adults, with baseline and follow-up measurements taken in 2008 and 2009 and 2016 and 2017, respectively.

At baseline, the sample consisted of 900 individuals aged 65 and over, recruited by trained personnel, in family households and in points of flow of older adults located in 90 census tracts drawn at random, from all census units in the urban area from the municipality of Campinas, SP, Brazil. Quotas of men and women aged 65 to 69, 70 to 74, 75 to 79 and 80 and over, to be recruited to represent the older adult population were estimated, with a 4% margin of error. The follow-up sample comprised 394 older adults aged 72 years or over, recruited from addresses collected at baseline and interviewed in 2016 and 2017. Among these, 129 (14.3%) had died and 377 (42.9%) were considered as sample losses, because they could not be located (60.2%) or because the area in which they lived offered risk to the interviewers (0.9%), refusal to participate (31.8%) or withdrawal (1.8%), and exclusion due to the research criteria (5.3%).

The eligibility criteria for the baseline sample were 65 years of age or over and permanently residing in the census tract and household. Older adults who presented the following were excluded: severe sensory and communication problems; motor and language sequelae resulting from stroke; restricted to bed or a wheelchair; advanced-stage Parkinson’s disease; cognitive impairment suggestive of dementia; cancer and undergoing chemotherapy treatment. In the follow-up, older adults who declared not knowing or not wanting to respond to items of the instruments used to measure the variables of interest were excluded.

The older adults were invited to participate in a single data collection session at previously scheduled dates and times: at baseline in community centers, clubs, churches, schools and basic health units; and during follow-up, at home. Details on the composition of the sample for the two phases, on recruitment and on data collection have been described in previous publications¹⁶16 Neri AL, Yassuda MS, Araújo LF, et al. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saúde Pública. 2013;29(4):778-792. https://doi.org/10.1590/S0102-311X2013000400015
https://doi.org/10.1590/S0102-311X201300... ,¹⁷17 Neri AL, Melo RC, Borim FSA, Assunção D, Cipolli GC, Yassuda MS. Avaliação de seguimento do Estudo Fibra: caracterização sociodemográfica, cognitiva e de fragilidade dos idosos em Campinas e Ermelino Matarazzo, SP. Rev. Bras. Geriatr. Gerontol. 2022;25(5):e210224 https://doi.org/10.1590/1981-22562022025.210224.pt
https://doi.org/10.1590/1981-22562022025... .

Verbal, clinical, and performance measurements were part of the research protocol at baseline and follow-up. Measurements of leisure-time physical activity was derived from the investigation of daily and weekly time spent practicing moderate and vigorous physical exercise, using 11 dichotomous items selected from the Minnesota Leisure Activity Questionnaire¹⁸18 Lustosa LP, Pereira DS, Dias AC, et al. Tradução e adaptação transcultural do Minnesota Leisure Time Activities Questionnaire em idosos. Geriatr Gerontol Aging. 2011;5(2):57-65., which uses the level of caloric expenditure evaluated in metabolic equivalent of task (MET, where 1 MET =1 kcal/kg/h) as a criterion⁶6 Ainsworth BE, Kaskell WL, Whit MC, Irwin ML, Swartz AM, Strath SJ, et al Compendium of physical actiities: Na update of activity codes and MET intensities. Medicine & Science in Sports and Exercise, 2000: 32 (Suppl): S498-504.. Activities considered as moderate, 3 to 6 METs, were: walking, cycling, ballroom dancing, gymnastics at home, hydrogymnastics, bodybuilding, and adapted volleyball. Activities considered as vigorous, more than 6 MET, were: gymnastics at a gym or club, light running, vigorous running, and swimming. For each activity performed in the last week, data on the frequency of practice and minutes per day were collected. Based on the WHO (2020) criteria, older adults who practiced 150 minutes of moderate activity or 75 minutes of vigorous activity at baseline and/or follow-up¹⁹19 WHO Guidelines on physical activity and sedentary behaviour. geneva: World Health Organization; 2020. PMID: 33369898 were considered active. Based on these indicators, the older adults were classified into four groups: active at baseline and at follow-up (Active/Active); inactive at baseline and follow-up (Inactive/Inactive); active at baseline and inactive at follow-up (Active/Inactive); and inactive at baseline and active at follow-up (Inactive/Active).

SAH was assessed through three consecutive blood pressure measurements performed in the sitting and standing positions²⁰20 Neri AL, Yassuda MS. Características Sociodemográficas dos participantes e procedimentos do Estudo Fibra 80+.In: Neri AL, Borim FSA, Assumpção D. Octogenários em Campinas: dados do Fibra 80+. Campinas: Alínea;2019.21-37.. Older adults with systolic pressure ≥140 mmHg and/or diastolic pressure ≥90 mmHg²¹21 Malachias MVB, Souza WKSB, Plavnik FL, Rodrigues CIS, Brandão AA, Neves MFT, Bortolotto LA, et al. 7a Diretriz Brasileira De Hipertensão arterial. Arq Bras Cardiol. 2016;107(Supl.3):1-83. https://doi.org/10.5935/abc.20160151
https://doi.org/10.5935/abc.20160151... were considered hypertensive. Obesity assessment was based on anthropometric measurements of weight and height, which were converted into body mass indexes [BMI = weight (kg)/height (m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X)] and compared with indicators of nutritional status: underweight (BMI ≤23.0 kg/m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X); normal weight (BMI >23.0 and <28.0 kg/m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X); overweight (BMI ≥28.0 and <30.0 kg/m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X) and obesity (BMI ≥30.0 kg/m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X) established by the World Health Organization²²22 Organización Panamericana de la Salud. Encuesta multicéntrica: Salud, bienestar y envejecimiento (SABE) en América Latina y el Caribe. In: XXXVI Reunión Del Comité Asesor de Investigaciones En Salud. Washington, DC.; 2001. https://iris.paho.org/handle/10665.2/45890?locale-attribute=pt.. Based on these values, the older adults were classified as obese (BMI ≥30.0 kg/m²2 Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Potential for primary prevention of Alzheimer’s disease: An analysis of population-based data. Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-X) and non-obese (other BMI values).

Cognitive status was indicated by the median scores obtained by older adults in the Mini Mental State Examination (MMSE)²³23 Bertolucci PHF, Brucki SMD, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr.1994;52(1):01-07. doi:10.1590/s0004-282x1994000100001, adjusted for years of education, minus one standard deviation (17 for those who never attended school, 22 for those with 1 to 4 years of education, 24 for those with 5 to 8 years, 26 for those with 9 or more years)²⁴24 Brucki SMD, Nitrin R, Caramelli P, Bertolucci PHF, Okamoto IH. Suggestions for utilization of the mini-mental state examination in Brazil. Arq Neuropsiquiatr. 2003;61(3 B):777-781. doi:10.1590/s0004-282x2003000500014. Thus, participants were classified with or without cognitive impairment.

At the two measurement periods, the variables submitted to statistical analysis were cognitive impairment (dependent variable) and leisure-time physical activity x inactivity, sex, age, education, SAH and nutritional status (independent variables). Comparisons were made between prevalences using the McNemar test. The observed prevalences were used to construct two Venn diagrams: one for baseline and the other for follow-up. Chi-square tests were performed to verify the variables statistically associated with physical activity x inactivity for these two periods. Poisson regression analysis was performed at follow-up to estimate the incidence ratio of cognitive impairment, with the respective 95%CI confidence intervals. All variables were incorporated into this adjusted analysis. The results were referenced at a significance level of 5% (p<0.05).

Before the interview, all participants signed a term of free, informed consent regarding the objectives and procedures of the research, and the ethical commitments of the researchers. The research projects and the pertinent documentation were previously approved by the Research Ethics Committee of the State University of Campinas by reports 907.575 (baseline), 1.332.651 (follow-up) and 3.281.728 (this study).

Results

At baseline, the participant mean age was 72.8±5.3 years old and at follow-up, it was 81.4±4.8 years old. The majority were women (71.8%) and had between 0 and 4 years of education (74.4%). Table 1 presents the baseline and follow-up percentages of older adults who were classified as: physically active or inactive; with or without SAH; eutrophic, underweight, overweight or obese; and with or without cognitive impairment suggestive of dementia. At follow-up, a significantly higher number of inactive older adults and older adults with hypertension were observed than at baseline.

In Figure 1, the Venn diagram presents the isolated and concurrent prevalence of hypertension, obesity, leisure-time physical inactivity and cognitive impairment at baseline. Among the older adults, 23.0% presented hypertension, 19.1% were inactive, 7.0% showed cognitive impairment, and 3.7% were obese; 21.5% were both inactive and hypertensive, 7.0% were hypertensive and showed cognitive impairment, 4.3% were obese and hypertensive, 3.0% were obese and inactive, 2.4% were inactive and showed cognitive impairment, and 0.6% were obese and showed cognitive impairment.

The same relationships observed at baseline were present at follow-up: 35.6% of the participants were inactive and hypertensive, 20.4% were inactive and 11.4% were hypertensive, inactive and presented cognitive impairment (Figure 2).

To calculate of the incidence of cognitive deficit in the follow-up, the active older adults were excluded from the baseline sample (n=75), since the aim was to observe which variables were associated with a change in status, considering sex, age, education, SAH, obesity and leisure-time physical activity. Associations were observed between physical inactivity at follow-up, or for both measurement periods, and cognitive impairment at follow-up (Table 2).

According to the result of the Poisson regression model test, adjusted for the variables sex, age, level of education, nutritional status and SAH, older adults who were inactive at follow-up showed a higher incidence ratio for cognitive impairment at follow-up (Table 3).

Discussion

At baseline and follow-up, low leisure-time physical activity and SAH were the most prevalent conditions, while obesity and cognitive impairment were the least prevalent. The incidence of cognitive impairment at follow-up was higher among physically inactive older adults than among those who were physically active. The prevalence of obesity did not increase during follow-up, in contrast to that observed for low weight, possibly due to the presence of older adults in the sample. However, a significant association was determined between obesity and cognitive impairment.

From baseline to follow-up, a significant increase was observed for physically inactive older adults in leisure situations. A literature review which analyzed data from several countries showed that the inactivity rate increases among adults over 70 years old, affecting between 35% and 80% of the population²⁶26 Zubala A, MacGillivray S, Frost H, Kroll T, Skelton DA Gavine A, Gray NM, Toma M, Morris J. Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews. PLoS One. 2017;12(7):e0180902. doi: 10.1371/journal.pone.0180902. In this study, the number of inactive older adults varied in a similar manner, increasing from 44.4% to 81%. The larger number of inactive people was probably motivated by the loss of functional and cognitive abilities and the emergence of limitations associated with these. Fear of falls and injuries and a lack of motivation and family support, together with the scarcity of information on exercises separate older adults from the practice and make them more vulnerable to chronic diseases, disability and inactivity³3 Yuan M, Chen J, Han Y, et al. Associations between modifiable lifestyle factors and multidimensional cognitive health among community-dwelling old adults: Stratified by educational level. Int Psychogeriatrics. 2018;30(10):1465-1476. doi:10.1017/S1041610217003076,²⁷27 Pivetta NRS, Marincolo JCS, Neri AL, Aprahamian I, Yassuda MS, Borim FSA. Multimorbidity, frailty and functional disability in octogenarians: A structural equation analysis of relationship. Arch Gerontol Geriatr. 2020; 86:103931. doi:10.1016/j.archger.2019.103931.

Data from this study indicate that SAH showed an increased prevalence at follow-up, when 64.4% of older adults were hypertensive. These data are comparable with other similar national population studies²⁸28 Massa KHC, Duarte YAO, Filho ADPC. Análise da prevalência de doenças cardiovasculares e fatores associados em idosos, 2000-2010. Ciênc & Saúde Col. 2019; 24(1):105-114. https://doi.org/10.1590/1413-81232018241.02072017
https://doi.org/10.1590/1413-81232018241... ,²⁹29 Nunes BP, SRR Batista, FB Andrade, PRB Souza Junior, MF Lima-Costa, LA Facchini. Multimorbidade em indivíduos com 50 anos ou mais de idade: ELSIBrasil. Rev Saude Publica. 2018;52(Supl.2):10s. https://doi.org/10.15446/rsap.v21n5.77775
https://doi.org/10.15446/rsap.v21n5.7777... , and in the international scenario, similar data were obtained for the population over 70 years of age²⁶26 Zubala A, MacGillivray S, Frost H, Kroll T, Skelton DA Gavine A, Gray NM, Toma M, Morris J. Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews. PLoS One. 2017;12(7):e0180902. doi: 10.1371/journal.pone.0180902,³⁰30 Saco-Ledo G, Valenzuela PL, Ruiz-Hurtado G, Ruilope LM, Lucia A. Exercise reduces ambulatory blood pressure in patients with hypertension: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2020;9(24):e018487. doi: 10.1161/JAHA.120.018487. The practice of physical exercises and the presence of SAH has a reverse causality relation, as regularly active individuals show lower rates of cardiovascular diseases, while non-practitioners are more likely to present these types of disease³⁰30 Saco-Ledo G, Valenzuela PL, Ruiz-Hurtado G, Ruilope LM, Lucia A. Exercise reduces ambulatory blood pressure in patients with hypertension: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2020;9(24):e018487. doi: 10.1161/JAHA.120.018487,³¹31 Gabrys L, Baumert J, Heidemann C, Busch M, Finger JD. Sports activity patterns and cardio-metabolic health over time among adults in Germany: Results of a nationwide 12-year follow-up study. J Sport Health Sci. 2021;10(4):439-446. doi: 10.1016/j.jshs.2020.07.007. The practice of physical activity is closely linked to good cardiovascular health and lower rates of disease. In this research, the concurrent prevalence of SAH and physical inactivity increased during follow-up. In contrast, the implementation of an active routine helps control blood pressure, improves cardiovascular function and protects cognitive function¹1 Neumann LTV, Albert SM. Aging in Brazil. Gerontologist. 2018;58(4):611-617. doi:10.1093/geront/gny019,³⁰30 Saco-Ledo G, Valenzuela PL, Ruiz-Hurtado G, Ruilope LM, Lucia A. Exercise reduces ambulatory blood pressure in patients with hypertension: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2020;9(24):e018487. doi: 10.1161/JAHA.120.018487.

The increase in the concomitant occurrence of the conditions studied at follow-up, compared with baseline, can be associated with the decrease in functional reserves resulting from aging, in combination with lifestyle¹³13 Costa TB, Neri AL. Medidas de atividade física e fragilidade em idosos: dados do FIBRA Campinas, São Paulo, Brasil. Cad Saude Publica. 2011;27(8):1537-1550. doi:10.1590/S0102-311X2011000800009. One Brazilian study that analyzed the patterns of multimorbidity in individuals aged 50 years old or over, associated the occurrence of two or more diseases with age, a risk factor for the coexistence of several chronic health conditions²⁹29 Nunes BP, SRR Batista, FB Andrade, PRB Souza Junior, MF Lima-Costa, LA Facchini. Multimorbidade em indivíduos com 50 anos ou mais de idade: ELSIBrasil. Rev Saude Publica. 2018;52(Supl.2):10s. https://doi.org/10.15446/rsap.v21n5.77775
https://doi.org/10.15446/rsap.v21n5.7777... . The same result was obtained in a clinical¹1 Neumann LTV, Albert SM. Aging in Brazil. Gerontologist. 2018;58(4):611-617. doi:10.1093/geront/gny019 and an epidemiological study²⁸28 Massa KHC, Duarte YAO, Filho ADPC. Análise da prevalência de doenças cardiovasculares e fatores associados em idosos, 2000-2010. Ciênc & Saúde Col. 2019; 24(1):105-114. https://doi.org/10.1590/1413-81232018241.02072017
https://doi.org/10.1590/1413-81232018241... , in which 80% of adults over 70 years old presented at least two chronic conditions. The coexistence of these factors can influence other systems, trigger comorbidities, increase systemic inflammation, and impair physical and cognitive health²⁶26 Zubala A, MacGillivray S, Frost H, Kroll T, Skelton DA Gavine A, Gray NM, Toma M, Morris J. Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews. PLoS One. 2017;12(7):e0180902. doi: 10.1371/journal.pone.0180902,³⁰30 Saco-Ledo G, Valenzuela PL, Ruiz-Hurtado G, Ruilope LM, Lucia A. Exercise reduces ambulatory blood pressure in patients with hypertension: A systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc. 2020;9(24):e018487. doi: 10.1161/JAHA.120.018487. Physical and cognitive losses are often associated with multimorbidities, disabilities and inactivity²⁷27 Pivetta NRS, Marincolo JCS, Neri AL, Aprahamian I, Yassuda MS, Borim FSA. Multimorbidity, frailty and functional disability in octogenarians: A structural equation analysis of relationship. Arch Gerontol Geriatr. 2020; 86:103931. doi:10.1016/j.archger.2019.103931.

Cognitive decline was mainly influenced by the condition of physical inactivity: older adults who were physically inactive at baseline and at follow-up were 2.27 times more likely to present cognitive impairment than those who exercised at some point. The literature indicates that physical inactivity is associated with worse cognitive health and a greater probability of developing dementia and Alzheimer’s disease¹⁴14 Phillips C. Lifestyle modulators of neuroplasticity: how physical activity, mental engagement, and diet promote cognitive health during aging. Neural Plast. 2017;2017. doi:10.1155/2017/3589271. Inactive older adults have a 20 to 30% greater risk of developing cognitive losses than those who exercise³²32 Cunningham C, O' Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;30(5):816-827. doi: 10.1111/sms.13616. In contrast, physical activity can help improve cognitive function and, consequently, delay the progression of cognitive impairment, even in older adults who practice activities below recommended levels³³33 Cheval B, Csajbók Z, Formánek T, Sieber S, Boisgontier MP, Cullati S, Cermakova P. Association between physical-activity trajectories and cognitive decline in adults 50 years of age or older. Epidemiol Psychiatr Sci. 2021;30:e79. doi: 10.1017/S2045796021000688.

Participants active at baseline and inactive at follow-up were more likely to score for cognitive impairment at follow-up. There is evidence that discontinuing exercise in a group of older adults for just 10 days resulted in reduced hippocampal blood flow, a predictor of cognitive impairment in the long-term³⁴34 Alfini AJ, Weiss LR, Leitner BP, Smith TJ, Hagberg JM, Smith JC. Hippocampal and cerebral blood flow after exercise cessation in master athletes. Front Aging Neurosci. 2016;8:184. doi: 10.3389/fnagi.2016.00184. From such findings, we can infer the importance of regular and uninterrupted practice of exercises to maintain good cognitive health.

A study involving 3,752 adults and older adults, using a methodology similar to that developed by this research, tracked the participants’ physical activity for 12 years and classified the individuals into four groups: active in the pre- and post-test periods; inactive in both these periods; active in the pre-test period, and inactive in the post-test period; and inactive in the pre-test period and active in the post-test period³¹31 Gabrys L, Baumert J, Heidemann C, Busch M, Finger JD. Sports activity patterns and cardio-metabolic health over time among adults in Germany: Results of a nationwide 12-year follow-up study. J Sport Health Sci. 2021;10(4):439-446. doi: 10.1016/j.jshs.2020.07.007. They observed that the groups formed by older adults who were inactive in the pre- and post-test periods, and those who were active in the pre-test and inactive in the post-test period, were more likely to present chronic diseases and had worse general health status, which were significantly associated with cognitive impairment. These results suggest that long-term physical inactivity can harm physical health, functionality and cognition.

The difficulty in implementing an exercise routine, in combination with symptoms of illness, disability and use of medication³3 Yuan M, Chen J, Han Y, et al. Associations between modifiable lifestyle factors and multidimensional cognitive health among community-dwelling old adults: Stratified by educational level. Int Psychogeriatrics. 2018;30(10):1465-1476. doi:10.1017/S1041610217003076,²⁶26 Zubala A, MacGillivray S, Frost H, Kroll T, Skelton DA Gavine A, Gray NM, Toma M, Morris J. Promotion of physical activity interventions for community dwelling older adults: A systematic review of reviews. PLoS One. 2017;12(7):e0180902. doi: 10.1371/journal.pone.0180902 increases inactivity and exposes older adults to the risks of developing cognitive impairment and comorbidities³²32 Cunningham C, O' Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020;30(5):816-827. doi: 10.1111/sms.13616. Even though they do not present a consensus regarding the ideal quality and quantity of ideal exercises for the older adult population, such studies converge in their appraisal of this practice, as a great ally in the fight against cognitive decline and physical inactivity³¹31 Gabrys L, Baumert J, Heidemann C, Busch M, Finger JD. Sports activity patterns and cardio-metabolic health over time among adults in Germany: Results of a nationwide 12-year follow-up study. J Sport Health Sci. 2021;10(4):439-446. doi: 10.1016/j.jshs.2020.07.007. The practice of physical exercises is inherent to good cognitive health, prevents chronic diseases and contributes to a process of successful aging. Despite presenting practical limitations, it is still a simple, effective, lower cost action for older adults and the health system than the use of medication. Over the years, readjusting and planning activities to maintain the ideal level of demand is important to avoid discouragement and discontinuation.

At follow-up, obesity was shown to be a protective factor for cognition among the oldest participants, a finding also observed in the systematic review by Dall and Hassing³⁵35 Dahl AK, Hassing LB. Obesity and cognitive aging. Epidemiol Rev. 2013;35:22-32. doi: 10.1093/epirev/mxs002.. Although this cannot be considered indicative of a cause and effect relationship, this data suggests the presence of greater cognitive reserve and more robust health status in the obese older adults than in those who scored for frailty, sarcopenia, low weight and associated morbidities, most of whom died earlier.

One limitation of this study is that the records obtained at two time periods separated by a relatively long interval fail to inform us about how continuous or intermittent the practice of exercises was over the years, because intermediate measures are unavailable. Another limitation stems from the fact that data on leisure-time physical activities were self-reported and were not supplemented by objective measures. The strengths of the study result from the prospective design and the fact that the follow-up sample is composed of long-lived people from a sample that was originally population and census based.

Conclusion

Physical inactivity represented a risk factor for cognitive decline in the sample studied. In contrast, the continuous practice of physical exercises is a tool for promoting successful aging, healthy cognition, and the prevention of chronic diseases and their consequences. More data are required to elucidate mechanisms that explain how physical exercises can facilitate improvements in these conditions in the long-term.

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