INTRODUCTION

Hypertension is a major risk caused of the death, accounted for 26.9% of deaths in 2015.¹ Previous study have found that hypertension is associated with poor cognitive performance ², about 46% of patients with hypertension experienced cognitive decline ³. Patients with hypertension have shown an impairment in some cognitive domain such as memory, executive function, and speed of information processing ^2,3,4. A study conducted over 20 years showed a U-shaped relationship between cognitive impairment and diastolic blood pressure (DBP). ⁵ Patients with hypertension have a double risk of cognitive decline compared to the general population. ³ Furthermore, the study found uncontrolled hypertension and treatment of antihypertensive-affected lesions in white matter. ⁶ In addition, age, gender differences, years of hypertension, body mass index (BMI) is the risk of cognitive deficits. ^7,8

Exercise is very important intervention for prevention and management of hypertension. The World Health Organization (WHO) defines exercise as a subcategory of planned, structured, repetitive and directed physical activity with the aim of increasing or maintaining one or more components of physical fitness. ¹ Many studies have reported that exercise for patients with hypertension has significant health benefits, one of which is reducing blood pressure ⁹, increasing oxygen uptake^9,10, decrease in body mass index, improve quality of life ⁹, and reduce depression ¹⁰. Exercise has a positive effect on cognitive function, specifically improving memory ¹². Based on the results of previous studies, it was found that exercise can slow the rate of cognitive decline ¹².

In the digit era, many innovations have been designed to help people physically active. Smartphone technology and cellular applications have shown promising results in physical activity and health promotion. ¹³ Evidence shows that pedometers, iStepLog, web-based, and text messages are effective for promoting exercise. ¹⁴ The results of previous studies reported that there were nearly 97,000 mobile health (mHealth) and fitness applications in 2012 and among the 300 most downloaded applications, 102 were related to exercise and physical fitness. ¹⁵ Indonesia is a country with the sixth largest internet user in the world. ¹⁶ However, the majority of internet used for social media and only a little is used for other positive things such as monitoring health and fitness conditions. Therefore, the purpose of this study was to determine the effect of mobile app-exercise to improve cognitive functions in patients with hypertension.

MATERIAL AND METHODS

RESULTS

Overall, 120 participant were enrolled in this study. We conducted a test of normal distribution and the results showed that data of cognitve function was normally distributed based on the nonsignificant Kolmogorov-Smirnov test. The mean age of the sample was 56.42 ± 10.6 years old. The majority of respondent were male 70 (58.3%), had lower education level 61 (50.8%), and unempoyed 77 (64.2%). The mean of body mass index was in the normal range (23.34 ± 4,4), systolic blood pressure 127.5 ± 11.9), and diastolic blood pressure was 81.92 ± 8.63. About one third of respondent were smoking and none of them drink alcohol (Table 1).

Table 1.  Demographic characteristics and clinical variables of patients with hypertension (n=120) 

One hundred patients with hypertension completed all baseline data collection and were assigned to mobile-base walking intervention. Findings from pair t test showed that in walking intervention using mobile-base application, the mean score of MoCA showed improved after intervention, from 23.3 ± 3.42 to 26.7 ± 2.78 (p=0.010). In more detail, there were improvement after intervention in domain of naming (2.930.34 vs. 3.141.06, p=0.003), attention (2.39 ± 0.68 vs. 3.12 ± 1.04, p=0.001), and abstraction (1.56 ± 0.49 vs. 2.01 ± 0.89, p=0.043).

We did not found significant result for other cognitive domain such as executive function, verbal memory, registration and learning, deay recall memory, and orientation as measured by MoCA (Table 2).

Table 2.  Cognitive function before and after mobile-based exercise in patients with hypertension (n=120) 

Note: * pair t test

DISCUSSION

Our study found that by using home based-exercise using mobile application can improve congnitive function in patients with hypertension. Previous evidence reported that the use of a pedometer was associated with a significant increase in physical activity (around 2,000 steps per day) and a reduction in body mass and blood pressure¹⁴. Pedometer is a low-cost application, allowing people to track their level of physical activity every day without the enhancements needed to be used like a commercial pedometer. In a pedometer, people must have a predetermined step target (10,000 steps) and a step diary as the main motivating factor for increasing physical activity. It also comes with daily feedback and a percentage of archived goals that can be additional motivational factors to change a person's lifestyle from sedentary to active health. Although the majority of participant were graduated from elemntary school, they had succefull installed the exercise App in their mobile phone. Therefore, utilize technology in the primary care for prevention of cognitive function among patients with hypertension is usefull and workable to enhance their exercise activity.

The mechanism for improving cognitive function through actual exercise is not yet known clearly. Postulates that have existed are neurobiological mechanisms including angiogensis, neurogenesis, and synaptogenesis ⁴. Exercise increases brain-derived neurotrophic factor (BDNF) levels, which play an important role in neuroplasticity and neuroprotection. Evidence in human studies shows that exercise can increase serum BDNF levels in the brain, hippocampal, prefrontal, and cingulate volumes, and improve memory ²¹. Future studies included a biomarker to understand the effect of execrcise to the cognitive function is warranted to conduct in Indonesia.

Several studies have been conducted to see the greater benefits of exercise on improving cognitive function. Studies conducted on healthy elderly report that exercise programs carried out for 12 months routinely show more memory improvement. ²² In a systematic review of the effectiveness of exercise in healthy elderly people on improving cognitive function, the exercise program (partly running) with moderate intensity, 30% - <70% VO2 reserve, 3 times per week, for 8 to 42 weeks has an effect positive on cognition ¹⁷. Therefore, promoting exercise to all patients with hypertention is very important not only to control their blood pressure but also to prevent from cognitive decline.

This study has some limitation. First, we did not have a control group thus another covariate that may affected the cognitive change were not measured. Second, although all participant had successful installed exercise App in their mobile phone, majority of our respondent were graduated from elementary school thus sometime had difficulty to used mobile App. However, this study has several strengths, first, this is first study conducted in low income country to utilized the digital application to help people organized their exercise and this study conducted in one of the biggest cities in Indonesia that may be can represent condition of hypertensive patients in Indonesia in general. Therefore, future studies conducted using more rigorous methods is warranted to see the true effect of this technology. Second, we used MoCA instead of MMSE that considered as more validated questionnaire to measure cognitive function.

CONCLUSIONS

In conclusion, our study highligth that the used of mobile-App for exercise is promosing approch to enhance physical activity, thus improve their cognitive function. Future study using rigors method exploring effect of mobile-App for exercise is very important to provide stronger evidence. Health care professional may try to utilize technology in providing care, particularly in promoting exercise.