Mild Cognitive Impairment (MCI) is defined as a level of decline in cognitive functioning that does not meet severity of decline of a dementia diagnosis [1] , but that has: 1) change in cognition recognised by the affected individual or observers; 2) objective impairment in one or more cognitive domains; and 3) independence in functional activities [2] . MCI can be diagnosed with a clinical interview and objective and standardised cognitive assessment, and when deficits are not attributable to another medical or psychological condition (Swan et al., 2021) [3] . The prevalence of MCI for people aged 65 years and over is up to 20% [4] [5] . In age-related cognitive decline, there is a close relationship between wellbeing and physical, mental, emotional, and cognitive health [6] . In addition, sedentary behaviour is related to cognitive decline in older individuals [7] . People who are physically active and get sufficient sleep are less likely to develop dementia, and effectively engaging in physical activities can be preventative of later disability [8] [9] . People with age-related cognitive decline who are physically active and get sufficient sleep can enhance their quality of life [8] [9] .

Age-related cognitive decline can result in reduced physical activity levels [9] . Having levels of physical activity that are lower than those recommended is detrimental to physical and mental health [10] . A lack of physical exercise can be linked to more depressive symptoms, lower wellbeing, greater hopelessness, lower quality of life, and 25 physical health diseases (for example, cardiovascular disease [CVD], stroke, hypertension, osteoarthritis, diabetes, and chronic obstructive pulmonary disease [COPD]) [11] .

Physical activity is associated with better late-life cognition, and aerobic exercise can reduce cognitive impairment [9] . The UK Chief Medical Officers “Physical Activity” report states that even minimal level of exercise generates health benefits [12] . Engaging in physical activity can reduce the risk of cognitive decline, MCI, Alzheimer’s disease, and vascular dementia; and can improve cognitive outcomes in older adults [13] [14] . Physical activity can improve cognition, functioning, and mood, reduce behavioural problems in MCI [13] [15] - [18] , and reduce risk of dementia diagnosis in people with MCI [19] [20] .

Healthy lifestyles are emphasised in NHS Long-Term Plan [21] [22] , and are known to improve wellbeing, cognition, functioning, and mood, and reduce behavioural problems in early stages of dementia [13] [15] - [18] . It is recommended that interventions to maintain healthy lifestyles are used in age-related cognitive decline to reduce risk of mood problems and further cognitive decline [23] . To be effective, exercise and physical activity-focused healthy lifestyle interventions need an individualised approach to enable people with experience of cognitive decline to derive benefits [24] .

The risk of depressive symptoms can be reduced by engaging in more physical activity and less sedentary behaviour [25] . Physical activity is beneficial in reducing the risk of depression by increasing levels of neurotransmitters, distracting from stressful stimuli, reducing anxiety, and improving self-efficacy and self-esteem [26] . Hence, physical exercise can help older adults engage in cognitive and social activities preventing depression and cognitive decline [27] .

Sleep problems are common in older adults (approximately 50% prevalence) and are associated with poor quality of life, increased suicide risk, cognitive impairment, depression, and ability to function effectively [26] [28] . Sleep loss can increase impulsive reactions to negative stimuli, resulting in increased failure to inhibit negative and faster responses that are maladaptive [29] . Quality sleep and wellbeing are positively correlated [30] , poor sleep negatively affects the quality of interpersonal relationships that are important to wellbeing [31] . Poor sleep quality is a risk factor for MCI and Alzheimer’s disease [13] . There is a lack of effective psychosocial interventions for older adults that enhance sleep quality; drug therapy for insomnia is not effective for many people and has negative side effects [32] .

Moderate to high levels of stress is a common problem experienced by people with age-related cognitive decline [33] . Neurodegeneration may lead to increased vulnerability to stressors [9] . If a person’s stress threshold is reached, they can feel overwhelmed and they may no longer be able to function effectively [34] . Stress can lead to decline in short-term memory, reduced problem-solving, poor emotional control, reduced communication, inability to fully express needs, increase in anxiety, and behavioural issues [34] . Supporting a person with age-related cognitive decline to develop coping strategies (which can include improving sleep quality and physical activity) can reduce personal stress [35] . Depression, health, wellbeing, sleep, stress, and physical activity are interlinked [36] [37] . Healthy levels of night-time sleep positively impact the secretion of cortisol, which may reduce the risk of stress and mental illness [38] [39] .

The UK Government stated that data generated by smart devices worn by individuals enable personalised health interventions allowing people to “be co-creators of their own health” [40] . A Fitbit accurately records physical activity, and sleep detection is 95% accurate [41] . Actively incorporating and applying the functions of a Fitbit can significantly increase physical activity, self-awareness, motivation, and goal setting, healthier lifestyles, sleep, and reduce body weight [42] - [45] .

To seek to improve sleep quality, physical activity, and wellbeing of community-based patients, the study team has developed a physical activity and sleep hygiene intervention which has been implemented and evaluated over a period of five years in various patient populations. In our previous work, we found that the intervention improved participants’ physical activity, sleep quality, motivation, self-awareness, functioning, wellbeing, healthy lifestyles, and quality of life, and reduced anxiety and depression levels [46] - [53] .

This present study investigates acceptability and feasibility: whether Active Feedback can be offered in a Memory Assessment Service (MAS) and whether patients of a MAS are willing to take part in the intervention. The study investigated the impact of this intervention in a population experiencing age-related cognitive decline, it addresses the question: “What is acceptability and feasibility of Active Feedback and the effect on stress, mental wellbeing, and sleep quality, and what are the links between these factors?”

This study investigated the acceptability and feasibility of Active Feedback and impact on sleep quality, stress, and wellbeing. The study team found that MAS staff can deliver, and patients will choose to undertake Active Feedback, providing evidence for the acceptability and feasibility of the intervention. Whilst there were improvements in measures of stress, wellbeing, and sleep quality compared to baseline, these were not statistically significant.

Note: ^*denotes significant correlation at p <0.001.

The results did not support our previous work where we have found that the intervention significantly improved participants’ wellbeing, mental health, and sleep quality [48] [49] [52] . The key differences in participant population were that this study’s participants were older and experiencing more than normal age-related cognitive decline. It is assumed that factors related to this meant that patients did not experience statistically significant improvements seen previously. People experiencing more than normal age-related cognitive decline might be expected to decline in terms of stress, wellbeing, and sleep quality, we did not find this over the period of the study possibly indicating potential benefits of the Active Feedback intervention.

WEMWBS has a UK general population mean score of 51; scores in this study’s population shows they were lower than this but higher than the cut-off point for a definition of experiencing low wellbeing [56] . Participants in this sample scored on average above cut off point for insomnia at the three times points [60] , but many participants indicated they are experiencing sleep problems, a need which should be assessed and addressed in this population through appropriate assessment, advice, therapy, and medication. The PSS scores indicate this sample are experiencing moderate stress on average, rather than high or low stress levels [61] , investigating and addressing needs related to stress and stressors in this population could improve coping and wellbeing, there was significant negative correlation found between stress and wellbeing.

In our most recent work [52] , the intervention was expanded to include motivational interviewing and goal setting. Motivational interviewing and goal setting are effective tools in motivating people to engage in healthy lifestyle behaviours [62] . Interventions to enhance motivation for healthier lifestyles can help elicit long-term healthy lifestyle behaviour change [63] . Grounding healthy lifestyle intervention programmes in behaviour change theory can foster self-efficacy and increase the likelihood of intervention efficacy [64] . Further research could seek to deliver and assess the impact of this expanded intervention in the population which formed the basis of this current study. The study team are also investigating the delivery of this intervention by a qualified health coach, and this could be an option for delivery in a MAS.

Study limitations include the lack of control group and relatively small sample size. People who agreed to participate were self-selected; thus, it is possible more participants with better than average levels of cognitive functioning seen by MAS agreed to participate. The participants attended a MAS service in one county in the UK reducing generalisability; however, similar services are provided by all NHS providers.

There is a lack of healthy lifestyle interventions available in MAS, and Active Feedback has been found to be feasible and acceptable. A manualised version of the expanded intervention to include motivational interview and goal setting is now available to access free of charge via: https://www.nhft.nhs.uk/research/ . This expanded intervention could be made available to MAS patients, delivered by a qualified health coach and evaluation of outcomes undertaken.

We wish to thank the participants for their involvement and the staff at the NHS Trust for their support.

Funding for Fitbits was provided by the University of Kent.