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Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety

Overview

This paper reports Phase 1 of the EXCEL (Exercise for Cognitive Health) study. It presents the development of an evidence-informed model of mechanisms of action (MoAs) for physical activity interventions targeting people in mid- to later-life experiencing cognitive concerns alongside symptoms of depression or anxiety. Using a qualitative design that triangulated data from semi-structured interviews with 21 participants, a critical review of 24 published studies, and the Capability, Opportunity and Motivation Behaviour (COM-B) framework, the study identifies the key factors influencing physical activity engagement in this at-risk population. The resulting model provides specificity, directionality and linked behaviour change approaches for intervention tailoring to optimise dementia risk reduction. Findings from this model directly informed the design of the EXCEL Phase 2 intervention (Ellis et al. 2026).

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Developed by the Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, in collaboration with NorthWestern Mental Health, Royal Melbourne Hospital. Funded by the Australian Government's Medical Research Future Fund (MRFF) and the National Health and Medical Research Council of Australia Dementia Research Team Grant (APP1095097)

Individual authors

Eleanor Curran, Victoria J Palmer, Kathryn A Ellis, Terence W H Chong, Thomas Rego, Kay L Cox, Kaarin J Anstey, Alissa Westphal, Rebecca Moorhead, Jenny Southam, Rhoda Lai, Emily You, Nicola T Lautenschlager

Key insights

This study is the first to develop a targeted, evidence-informed model of the mechanisms through which physical activity interventions can effectively support behaviour change in people aged 45 and older who live with both cognitive concerns and symptoms of depression or anxiety. By triangulating participant lived experience, published evidence and behavioural science theory, the model identifies five key areas for intervention tailoring — knowledge, attitudes, self-regulation skills, social opportunities, and access to flexible resources — with emotional regulation emerging as a uniquely critical and previously under-emphasised factor for this population.

<p>None of the 21 interview participants were aware of physical activity guidelines for dementia risk reduction, and most lacked detailed procedural knowledge about the type, amount or intensity of activity required. Many assumed incidental activity was sufficient. This gap highlights the need for interventions to provide specific, accessible knowledge &mdash; including conceptual and procedural information from trusted sources &mdash; as a foundation for behaviour change.</p>

<p>In contrast to existing published literature on physical activity behaviour change, emotional regulation emerged as a particularly prominent theme in interviews. Participants described how depression and anxiety symptoms directly undermined their capacity to act on intentions, even when motivation and knowledge were present. Negative emotions, difficulties with emotional self-regulation and low confidence in psychological self-management skills created a vicious cycle of inactivity that is specific to this population and requires deliberate targeting in intervention design.</p>

<p>While participants broadly valued avoiding dementia, their commitment to personally adopting recommended physical activity was closely tied to their individual risk appraisals and beliefs about personal benefit. Many underestimated their own dementia risk, which was associated with reduced urgency to change behaviour. Interventions need to actively support realistic personal risk appraisal and help participants understand how physical activity can benefit them specifically, including for mood and anxiety symptoms.</p>

<p>Participants who were already active attributed their success to specific self-regulation skills: making activity habitual, monitoring their own behaviour, noticing immediate emotional and physical benefits, and adapting when health problems or life disruptions arose. Those who were inactive described low confidence in these same skills as a key barrier. Interventions should explicitly build behavioural regulation skills, particularly strategies to manage the cognitive and emotional difficulties common in this population.</p>

<p>Access to social opportunities &mdash; particularly a sense of accountability to a health professional, coach or peer &mdash; was consistently identified as a powerful facilitator of physical activity engagement. Professional support was additionally linked to overcoming fears of injury or health deterioration. Many participants also valued technology-based tools for self-monitoring and accountability. Interventions should provide structured opportunities for social connection, professional guidance and accessible accountability tools.</p>

<p>The final model, organised by the COM-B framework&#39;s three domains of Capability, Motivation and Opportunity, identifies five key mechanisms of action: being informed to enable change; individual attitudes and urgency for change; skills and confidence to make and enact intentions; access to social opportunities; and access to reliable and flexible resources. Importantly, these mechanisms interact and reinforce each other, meaning interventions that address multiple areas simultaneously are likely to be more effective than single-focus approaches.</p>

Did this resource draw on transformative evidence?

<p>Yes &mdash; Semi-structured interviews with 21 people aged 45&ndash;80 experiencing cognitive concerns and mild to moderate depression or anxiety formed a primary data source. Participants shared detailed perspectives on their experiences of physical activity, dementia risk reduction, self-regulation, barriers and preferences for intervention support. This lived experience data was a foundational input into the model and produced insights &mdash; particularly around emotional regulation &mdash; that were not identified in the existing published literature.</p>
<p>Yes &mdash; Interview domains were developed by the study team based on their established expertise in dementia risk reduction and mental health research. Behaviour change techniques (BCTs) identified from the literature were mapped to mechanisms of action using an expert consensus tool. The final model was refined through group discussion and consensus among the multidisciplinary research team, which included psychiatrists, psychologists, exercise physiologists and other allied health researchers with direct clinical experience in this population.</p>
<p>Yes &mdash; A critical review of 24 published studies examining physical activity interventions for people with cognitive concerns, depression or anxiety was conducted. Studies were searched systematically through Ovid MEDLINE and PubMed and assessed using an established BCT taxonomy. Findings from this review were triangulated with interview themes and the COM-B behavioural science framework to develop the integrated model. Thematic analysis followed Braun and Clarke&#39;s established approach, with independent coding and consensus processes to ensure rigour.</p>

How can this resource help me as a...?

Toggle audience types below to explore.

This qualitative study and model development paper is directly relevant to researchers working in dementia prevention, physical activity behaviour change, mental health, and complex intervention design. It provides a replicable methodological approach and a theoretically grounded model that can inform future research in this and related populations.

Relevant to psychologists, psychiatrists, exercise physiologists, occupational therapists, social workers and other health professionals working with older adults experiencing cognitive and mental health concerns. The model identifies specific behaviour change targets and example intervention strategies that can be applied in clinical and community settings.

Relevant to those developing dementia prevention policy and mental health promotion frameworks. The study provides an evidence base for the unique needs of people with co-occurring cognitive and mental health concerns, and identifies priorities for intervention investment.

Relevant to leaders designing or commissioning physical activity programs for this population. The model provides a framework for ensuring interventions address the full range of mechanisms influencing engagement, particularly emotional regulation and social accountability.

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Categories

Resource type

Model of Care

Evidence Summary

Target audiences

Researchers

Practitioners

Policymakers

Service Leaders

Translational research priority theme

Community-based models of care

Workforce capability

Promoting prevention, early intervention and help-seeking

Embedding evidence-informed continuous improvement

Supporting system navigation, partnerships and collaborative care

Delivering compassionate care, support and treatment

Enabling reflective and supportive ways of working

Delivering holistic and collaborative assessment and care planning

Population cohort

Older Adults

Adults

Collaborative Centre core function

Service delivery

Lived Experience Participation

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