A mix of exercise, a healthy diet, social engagement and brain games could improve cognitive capabilities in older adults at risk of cognitive decline or dementia, a clinical trial has found. The study, known as U.S. POINTER, is the largest trial to examine how healthy lifestyle behaviors can improve brain health. Its results were published in JAMA and presented at the Alzheimer’s Association International Conference on Monday in Toronto.

About 45 percent of dementia cases may be preventable by addressing modifiable risk factors, according to the 2024 Lancet Commission report on dementia prevention.

“If you can modify these and improve them, then it makes sense that you will improve your brain health and you might prevent dementia,” said Kristine Yaffe, a professor and the vice chair of the department of psychiatry at the University of California at San Francisco.

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The study, which was modeled on a 2015 randomized control trial in Finland, was designed to see how cognitive benefits of structured lifestyle changes could generalize to a larger, more diverse population of Americans.

The trial provides “a new recipe” to improve cognitive function and shows healthy behaviors matter for brain health, said Laura Baker, a professor of internal medicine at Wake Forest University School of Medicine and the principal investigator of the study.

Helping those most at risk

The POINTER trial involved 2,111 adults, ages 60 to 79, across five locations, who were healthy but at risk for cognitive decline and dementia, because of lifestyle factors, including a poor diet, lack of regular exercise or cardiovascular risk.

Crucially, the researchers recruited underrepresented groups that are known to be at high risk for dementia; 31 percent of participants were from ethnic or minority groups, and 78 percent had a family history of memory impairment.

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“We really wanted to make sure we had representation from many different microcultures across the U.S.,” which is not something clinical trials for Alzheimer’s disease has done a good job at, Baker said.

The participants were randomly assigned to one of two lifestyle intervention groups: one with a structured program and another with a self-guided program.

Both groups focused on physical activity, diet, cognitive training, social engagement and vascular health over the course of the two-year study.

Participants in the self-guided group received general education on health, diet and exercise and were encouraged to make the lifestyle changes that they thought best suited their needs. They also met six times with facilitators and other group participants in their communities for discussions on what they are learning.

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In contrast, the structured group had a far more intensive and demanding regime.

Physical health: Each week, participants had four days of aerobic exercise, two days of resistance training and two days of stretching and balance exercises.

Diet: They were encouraged to adhere to the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet , which is designed to promote healthy brain aging.

Cognitive training: Participants engaged with a web-based cognitive training program three times a week.

In addition, the structured group met 38 times with facilitators and fellow participants, received biannual health coaching from a medical adviser, as well as phone calls and clinic visits to assess diet and cardiometabolic health.

Having participants meet their peers offers a social component for support that is “a key ingredient in the intervention,” Baker said.

With the structured intervention, “we’re going to tell you what to do, but we’re going to help you get there. And we’re going to work with you as a partner to meet you where you are,” Baker said at a news briefing.

Both groups showed cognitive improvements throughout the two years of the trial.

But participants in the structured lifestyle group did better than people in the self-guided group.

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“It was surprising to see such significant cognitive improvement within the self-guided group compared to their initial cognitive scores,” said Klodian Dhana, an associate professor of internal medicine at Rush University Medical Center in an email. “However, this suggests that lifestyle interventions, even when based solely on educational information, can be beneficial,” said Dhana, who was not involved in the study.

For many study participants — over 90 percent stuck through the two-year trial — the experience was motivating and life-changing.

Phyllis Jones, 66, of Aurora, Illinois, said she is “forever changed” by the experience as a participant in the structured group. Her mother and grandmother had dementia, but she had been neglecting her health amid a layoff from her 28-year-long software engineering job.

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“I was circling the drain, and I felt it,” she said at a news briefing.

The researchers started Jones and her fellow participants off slow, with just 10 minutes of exercise a day. But “after all those years of being sedentary, 10 minutes was a good start and that got me going,” Jones said. “Since they took it slow, it made it so that we didn’t get discouraged. We didn’t hurt ourselves.”

Since then, she has lost 30 pounds, Jones said. Now, she wakes up to do virtual reality workouts in her pajamas each morning before work and feeding her two dogs and two cats.

Peter Gijsbers van Wijk, 72, of Houston, a participant in the self-guided group, said meeting with other participants and facilitators helped keep him motivated to work toward his health goals of getting more physical activity. His mother and two aunts had dementia.

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After the trial, van Wijk is continuing his exercise with yoga and walking five miles a day, at least five days a week. He has also started volunteering in his community to get more social contact and to give back.

“The most important thing is try out a little bit and see what you enjoy, because if you enjoy it, then you will be able to sustain,” van Wijk said.

Open questions and future

While the study findings are “very important” the longer-term effects on cognition remain unknown, Dhana said.

However, because there was no group that did not receive a lifestyle intervention, it is difficult to interpret why both self-guided and structured groups had cognitive improvements.

On the one hand, it could be a sign that even just education about healthy behaviors could improve cognition. But it could also be the result of a “practice effect” where participants improve on assessments simply because they are doing them more, said Yaffe, who was not involved in the study.

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(The study researchers said they felt an ethical responsibility to provide something beneficial for all participants.)

The difference in cognitive improvement between the two groups was also “pretty modest,” Yaffe said.

Participants in the structured group performed better in executive function than those in the self-guided group, but there were no major differences in memory or mental processing speed. This suggests “more of a vascular pathway and less of Alzheimer’s,” the hallmark of which is memory impairment, Yaffe said.

Because the study incorporated multiple types of lifestyle changes, it’s not possible to pinpoint what is most effective for different people.

Any disease that causes cognitive impairment and dementia will probably require “a multitude of solutions,” including behavioral interventions combined with medications, said Heather Snyder, a study author and the senior vice president of medical and scientific relations at the Alzheimer’s Association, which provided $50 million to fund the study.

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The researchers are now analyzing biomarkers and neuroimaging data from the participants, who are being followed for an additional four years to see how these interventions impact their cognitive health in the longer run.

At the same time, the researchers are working with partners to roll out the structured lifestyle interventions into the community “not later, but now,” Baker said.

How to improve your cognitive health

“To improve brain health, it’s important to adopt multiple lifestyle changes,” Dhana said.

There are many different ways to reduce your risk for dementia.

Move more, sit less. Sitting all day increases dementia risk, while exercising regularly can keep your brain sharp

Eat a healthier diet. You can try the MIND diet, which calls for more vegetables, berries and nuts, and limits on red and processed meats and sweets. You can try the MIND diet, which calls for more vegetables, berries and nuts, and limits on red and processed meats and sweets. Processed meats are linked to higher rates of dementia and worse cognition, while replacing them with nuts and legumes is associated with lower dementia risk, research shows.

Stay connected. Feelings of loneliness can increase the risk for dementia, while having strong social connections are a key to cognitive health.

Challenge yourself intellectually. Find ways of “stretching and using your brain, your memory, your cognition in different ways that’s different for you and that’s pushing the envelope for you,” Snyder said.