Age is a major factor in cognitive decline [1] . Around 15% of individuals aged 65 - 84 years develop cognitive dysfunction, including memory impairment; this increases to 40% for those aged 85 years or older [2] . Mild cognitive impairment (MCI) is a classification of cognitive impairment not reaching a diagnosis of dementia [3] . The UK prevalence of MCI for those 65+ years, is 6% to 20% [4] [5] . MCI is associated with impaired quality of life and work productivity and increases the risk of later dementia diagnosis [6] [7] , with annual progression rates of MCI to dementia estimated as ranging from 10% to 15% [8] [9] . Many other people experience age-related cognitive impairment, which while impacting on their functioning, would not meet an assessment of MCI or dementia [10] .

Guidance recommends the implementation of health promoting interventions for older people to reduce cognitive decline, risk of dementia diagnosis and promote quality of life and wellbeing [11] . Participation in meaningful physical exercise and activities promotes healthy physical functioning and mental wellbeing in the elderly [12] . Improvements in emotional, psychological, social wellbeing, and cognitive functioning are associated with regular physical activity [13] . Physical activity/exercise has a positive effect on improved cognitive function in older adults without dementia [14] , and physical activity and exercise improves cognitive and noncognitive (e.g., quality of life, disability, and physical function) outcomes in people with MCI [15] . Physical activity also attenuates the risk for dementia associated with aging in older adults with MCI [16] . A meta-analysis concluded that physical activity has a positive effect on cognition for those experiencing dementia or MCI, and that there is a need to include physical activity as part of the treatment plan for those experiencing cognitive impairments [17] . This had led to the development of several healthy lifestyle interventions e.g., Prevention of Dementia by Intensive Vascular Care (PreDiva), Finnish Geriatric Interventions Study to Prevent Cognitive Impairment and Disability (FINGER) and the Multidomain Alzheimer Preventive Trial (MAPT) [18] .

Apart from the lack of physical activity, poor sleep quality is negatively associated with subjective wellbeing in older adults [19] . Good quality and sufficient sleep contribute to primary and secondary prevention of metabolic conditions such as obesity, diabetes, hypertension and coronary heart disease [20] . Effective sleep has significant positive effects on composite mental health: reducing depression, anxiety, rumination, stress, and psychotic symptoms; there is a dose response showing that greater improvements in sleep quality leads to greater improvements in mental health [21] . Sleep promotes the consolidation of memory (declarative, procedural and emotional memories) [22] , and sleep deprivation impairs memory, verbal fluency and response inhibition [23] . Poor sleep quality is associated with increased risk of cognitive decline [24] . Neuropsychiatric symptoms including sleep problems have high prevalence in MCI and dementia [25] . Therefore, sleep problems should be identified and treated to preserve cognition [26] .

Regular physical activity and sleep are important factors to restore physical and mental health [27] . In recent years, wearable activity trackers have been found to encourage healthy physical activities and reduce barriers to engage in exercise [28] , promote behaviour changes including healthy lifestyle self-management and goal setting [29] , and increased physical activity [30] . Wearable activity trackers are associated with improved physiological outcomes (e.g., reduced BMI and blood pressure) and can improve mental health and wellbeing through increases in physical activity [31] . Furthermore, wearable trackers can improve sleep quality and effective sleep duration, as they provide access to a range of data about sleep and give insight into individuals’ sleep health enabling people to employ strategies to improve sleep quality where possible [32] . The mechanisms of wearable trackers include providing quantified feedback [33] , or what we describe as “Active Feedback”, where activity trackers provide live data relating to activity and sleep, whilst indicating whether the individual is meeting their goals or not. Wearable activity trackers as part of a health service provided healthy lifestyle intervention can improve mental health, sleep quality, quality of life, levels of physical activity and wellbeing [34] . Although wearable activity trackers have been studied widely in adult populations, this is not the case in relation to older adults, especially those with MCI.

The aim of this current study is to understand the experience and impact of a physical activity and sleep wrist-worn tracker-based healthy lifestyle intervention (Active Feedback) for older patients attending a memory assessment service (who do not receive a dementia diagnosis). Specifically, the research looks to understand how a healthy lifestyle intervention could impact and benefit this group of people, examining what works well, and what does not work well.

Participants were initially asked some questions about their practical use of the watch and the different functions that they engaged with. This information was collected using basic content analysis, see Table 1.

From the thematic analysis, a thematic map was developed that comprised two global themes, “Understanding exercise and sleep as part of my lifestyle” and “Understanding my experience of the healthy lifestyle intervention”, made up of several interlinked themes. This is presented in Figure 1.

Through the analysis of the interview data, an understanding was gained into how the participants viewed exercise and sleep as part of their lifestyles. An insight was also gained into how they experienced a healthy lifestyle intervention, the impact of this, and what worked well and what did not work as well. Overall, it was found that sleep and exercise were important for patients’ overall health (physical and mental) and wellbeing, and that the lifestyle intervention employed can encourage patients to examine and understand their physical activity and sleep related lifestyle behaviours and take steps to implement positive healthy lifestyle behaviour change.

When engaging in physical activity and exercise, patients acknowledged this can bring about a sense of wellbeing. They discussed how exercising gives them more energy, and makes them feel more positive in relation to their mood. They also perceived exercise as being beneficial to their physical and mental health, both by the action of actually doing the activity, and the social element that can come with exercise (walking with others/gym classes); this aligns with existing research findings [41] [42] . There is a wide-ranging positive impact of physical activity and exercise on self-esteem, cognitive function, mood, and quality of life, as well as in decreasing stress tendencies which is associated with aggravating mental and physical disease [43] . There is a link between exercising with others and feelings of social bonding and belonging [44] , which is associated with motivation [45] .

Sleep was acknowledged as important for the participants, in that quality sleep was associated with a positive emotional state, and poor sleep impacted negatively on physical and emotional functioning. This aligns with previous research, where it is acknowledged that sleep loss and poor-quality sleep disrupts how the brain processes emotions [46] . Reduced sleep has been associated with decreased positive affect [47] . Parsons et al. [48] found that sleep quality was associated with increased intensity and duration of positive emotion, decreased intensity of negative emotion and reported use of positive emotion regulation strategies. This highlights the need for individuals to seek ways to try and ensure they get quality sleep. This could be achieved by addressing some of the barriers to quality sleep identified in this research: thoughts (overthinking and ruminating) and physical issues (pain, physical illnesses).

The participants expressed how the Fitbit was a beneficial element of the intervention, providing them with a tool to check, monitor and validate their healthy lifestyle behaviours such as exercise, giving them a point of reference. This aligns with research suggesting that wearable fitness trackers encourage and increase physical activities and reduce barriers and promote behaviour change [28] [29] [30] . Equipment such as Fitbits have been found to be beneficial as part of an intervention for older people. Wu et al. [49] found that wearable trackers were effective for adults age 60+ in increasing daily steps, but that this was more effective when incorporated with other intervention components (such as telephone counselling, goal setting and self-monitoring). In this study, the Fitbit was found to encourage individuals to set targets and goals, motivating them to achieve these through the feedback received and the ability to monitor what they were doing. Goal setting is a widely acknowledged and accepted strategy for promoting physical activity [50] , and the National Institute for Health and Care Excellence [51] state that goal setting should be present in any type of intervention looking to change behaviours. The Fitbit’s impact went beyond exercise goals, as it was found to influence broader lifestyle behaviours. This suggests a ripple effect, where positive changes in one aspect, such as exercise, cascade into improvements in mood, sleep, and other behaviours. Understanding these interconnected effects could guide the design of comprehensive lifestyle interventions.

Participants expressed some barriers to undertaking exercise with a common theme being due to bad or unfavourable weather, which aligns with prior research [52] . Participants don’t just view poor weather as a logistical challenge but express an emotional aversion to unfavourable conditions. Exploring the emotional impact of weather-related barriers on motivation and exercise adherence could offer insights into tailoring interventions to address emotional as well as practical aspects of engagement. Investigation is required as to how the Fitbit could play a role in mitigating this barrier, and whether Fitbit features or notifications tailored to weather conditions could enhance motivation and exercise.

The Fitbit was a good way for many participants to check, monitor and validate their sleep. For some it just provided them with knowledge and understanding about their sleep and sleep patterns; for a small proportion it also facilitated the implementation of healthier lifestyle actions such as better sleep habits and routines, going to bed earlier, and refraining from using phone and computer screens in the period immediately before sleep. It is becoming recognised that there are several potential benefits of using wearable sleep trackers, including that they enable easy accessibility to information about sleep and other behaviours, in an individual’s own natural environment, for extensive periods, providing data that can be collected at any time with little active engagement from the individual (just need to wear the device), and providing data in summary form [32] .

In the current research, the Fitbit was mostly used for information gathering and checking, so perhaps participants could be directed or taught on how to utilise this information to facilitate behaviour change and implement good sleep hygiene. Liang et al. [53] , identified that there is limited support to help individuals make sense of sleep data they receive, so designed a web-based tool (SleepExplorer) to remedy this, finding that the visualisations of sleep data and contextual factors (exercise, mood, caffeine consumption) helped individuals make sense of their data, and guided them in taking actions to improve their sleep. In addition, participants did not engage with the information sheets about sleep hygiene and exercise so this also needs to be remedied; it might be that information needs to be discussed more in face-to-face interactions, reiterated over the course of using the Fitbit or could be incorporated as part of a web- based tool, like Sleep Explorer [53] and offered as part of the intervention.

The Fitbit was a tool that could promote and encourage social interactions, all of which were found to be beneficial. The information that the Fitbit provided was shared with other people to open conversations to support useability and engagement and attend to other potential health issues. Participants’ partners were found to look at the watch and help with monitoring. This unique aspect suggests that wearable technology can not only empower individuals but also actively involve their support networks. Therefore, understanding the dynamics of partner involvement through technology could be pivotal in designing effective interventions. Involving partners also promotes accountability, which has been found to increase effort, and when fitness goals are made public or shared and they require some form of accountability (i.e., in this case sharing of Fitbit data) it can increase physical activity [54] . Outdoor activities, interactions with others, and the sense of community contributed to overall wellbeing. Next steps should investigate features or functionalities within Fitbit that contribute to the sense of community, potentially enhancing its role as a holistic wellbeing tool beyond exercise tracking. Finally, in the current research, the data was used by the participants to share with health professionals to open conversations about other physical health issues (e.g., diabetes) and discuss these to address them. Patients therefore become more active users of healthcare, not passive consumers. This unique function transforms the Fitbit from a personal tracking device into an information communication tool, positively influencing patient and healthcare provider interactions and treatment plans.

Participants were recruited from memory assessment services in one NHS trust, and were a relatively small purposive sample, thereby limiting the generalisability. However, generalisability of qualitative research findings is normally not an expected attribute [55] , so instead credibility, transferability, dependability, and confirmability of the data [40] was sought. Participation was voluntary and those who agreed to participate, on a self-selective basis may introduce bias in that they are potentially more likely to have had a positive experience; the data didn’t capture those who did not engage with the service and/or dropped out and who may have offered a different perspective. This includes those who felt they could not take part in the study as they didn’t feel able to make use of the technology or were not comfortable using devices such as Fitbits. In addition, it was beyond the scope of this paper to examine the direct impact of the intervention on memory, focusing on impact on areas that could be associated with ways to help and support memory (i.e., exercise, sleep), and so this needs addressing in ongoing research.

This research has found that there is benefit in offering individuals who are experiencing age-related cognitive impairment or who have been diagnosed with MCI, a healthy lifestyle intervention to facilitate and promote engagement with exercise and better sleep hygiene and routines. Active Feedback offers a suitable structure for delivery of a healthy lifestyle intervention. Active Feedback encouraged individuals to understand the role of exercise and sleep in their lives, and to use wearable tracking technology (Fitbits) to encourage positive healthy lifestyle changes. This was found to be beneficial in relation to mental and phy- sical health and wellbeing—which could in turn have positive impact on cognitive function memory; this warrants further exploration to examine for causal relationships. Active Feedback can be integrated into memory assessment services to have positive impact on wellbeing, mental health and physical health, and enable these services to deliver healthy lifestyle interventions, something that is currently high on the agenda for national governments and health services.

Funding for the Fitbits was provided by University of Kent, but study design, analysis, interpretation, and reporting was independent of the funder.

The authors declare no conflicts of interest regarding the publication of this paper.

Walker, K., Griffiths, C., Yates, J., Birkett-Swan, L., Hina, F. and Ang, C.S. (2024) The Experience and Impact of a Fitbit-Based Physical Activity and Sleep Hygiene Intervention for Older Adults Experiencing Cognitive Decline. Ad- vances in Aging Research, 13, 41-59. https://doi.org/10.4236/aar.2024.133004