Water-based Activity to Enhance Recall in Veterans

The primary research question of the proposed study is this: Is a combination water-based
physical exercise + cognitive training program for older Veterans with amnestic Mild
Cognitive Impairment (MCI) feasible? The primary aims of the proposed research are: 1)
demonstrate adequate recruitment and retention rates; 2) refinement of inclusion/exclusion
criteria; and 3) further refine the combination waterbased physical exercise + cognitive
training (WATER+CT) intervention.

These aims will be tested in a two-phase clinical trial with a single group design: 1)
exercise training phase and 2) a cognitive training phase. The exercise training phase
consists of a water-based physical exercise program that emphasizes cardiovascular fitness
and strength training through a combination of non-weight bearing exercises that include
land-based stretching and water-based activities. This 2-year pilot project will include 50
Veterans diagnosed with amnestic MCI age 50-90. The exercise component consists of a
six-month water-based exercise program followed by a four-week cognitive training program.
For the first two months of the water-based exercise program, Veterans will come to
thrice-weekly group sessions at Aquatic Therapy Center at the VA Palo Alto Health Care
System. This will transition to a self-paced exercise program for the remaining four months.
After completion of the exercise program, Veterans will begin classroom-based cognitive
training at the VA Palo Alto Health Care System (VAPAHCS). The cognitive training is based on
an efficacious cognitive program that is structured around two components, pre-training and
mnemonic training, both of which have been used successfully in persons with aMCI.
Assessments of adherence will be administered throughout treatment and measures of
feasibility will be completed post-treatment.

Participants will complete a variety of neuropsychological measures taping into areas of
cognition such as attention, executive functioning, and memory. To study possible predictors
of treatment response, the investigators will also collect biological (cardiovascular
functioning and brain derived neurotrophic factor [BDNF] plasma levels) and genetic data
(APOE and BDNF genotypes) from these participants. The investigators hope to provide initial
evidence of the feasibility of a waterbased exercise training augmentation for cognitive
training thus laying the groundwork for full-scale clinical trials targeting the lessening of
cognitive impairment in persons with amnestic MCI by non-pharmacological means.

Inclusion Criteria:

- Veterans aged 50 - 90

- diagnosis of aMCI

- available informant

- at least one musculoskeletal problem

- sufficient visual and auditory acuity to allow neuropsychological testing

- willingness to participate in exercise training +cognitive training program for eight
months

- approval of primary provider to participate in an exercise trial

Exclusion Criteria:

- current untreated severe psychiatric disorder, such as:

- Bipolar I

- Schizophrenia

- or Major Depressive Disorder, determined by the Mini International
Neuropsychiatric Interview (MINI)

- diagnosis of dementia, Clinical Dementia Rating (CDR) > 0.5; modified Hachinski score
4; or delirium

- history of neurological disorder, e.g.:

- multiple sclerosis

- seizure disorder

- stroke

- history of transient ischemic attacks, or systemic illness affecting central nervous
system (CNS) function, e.g.:

- liver failure

- kidney failure

- congestive heart failure

- systemic cancer

- acute illness or unstable chronic illness e.g., history of severe liver disease

- cirrhosis

- esophageal

- varices

- ascites

- portal hypertension

- hepatic encephalopathy

- current severe cardiac disease, e.g.:

- uncontrolled atrial fibrillation, defined as mean 24 hour heart rate >85
beats/min, or 24 hour maximal ventricular rate >150 beats/min

- uncontrolled ventricular arrhythmias, defined as recurrent ventricular
tachycardia > 3 beats in succession, or 24 hour packed cell volume (PVC) count >
20%; active

- pericarditis or myocarditis

- Class III/IV heart failure and / or ejection fraction < 20%

- thrombophlebitis

- pulmonary disease with a drop in O2 Sat with exercise to 90% without oxygen

- embolism within past six months

- inability to participate in an exercise stress test or inability to exercise
consistently because of orthopedic or musculoskeletal problems

- morbid obesity (BMI > 39)

- inability to read, verbalize understanding and voluntarily sign the Informed Consent