Стратегии охраны мозга у лиц среднего возраста с незначительным нейрокогнитивным расстройством: аналитическая оценка.

Background

Mild neurocognitive disorder (mNCD) is characterised by a measurable decline in one or more cognitive domains that represents a change from prior functioning but does not significantly interfere with an individual’s daily activities [ 1 , 2 ]. The terms ‘mNCD’ and ‘mild cognitive impairment’ (MCI) have often been used interchangeably [ 3 , 4 ]. However, mNCD encompasses a wider range of cognitive impairment aetiologies, making it more applicable to diverse populations [ 2 ]. This condition reflects a prodromal stage of dementia, although trajectories are heterogeneous, and some cases remain stable or revert to prior cognitive functioning [ 5 , 6 ].

Over the past decade, dementia prevention has been increasingly prioritised as a rapidly growing global public health challenge [ 7 , 8 ]. Concurrently, epidemiological works on dementia prevention estimated that approximately 40–45% of dementia cases can be reduced or delayed by addressing a set of modifiable risk factors [ 9 ]. These include behavioural (physical inactivity, smoking, excessive alcohol consumption), cardiometabolic (obesity, hypertension, diabetes, elevated LDL cholesterol), psychosocial (depression, social isolation, low educational attainment), head injury, sensory (hearing impairment, untreated vision loss), and environmental exposure (air pollution). The term ‘brain health’ is generally preferred over ‘dementia risk-reduction,’ which is often seen as stigmatising. ‘Brain health’ resonates with individuals across different age groups and fosters proactive engagement in long-term strategies, behavioural changes, and offers a more acceptable and empowering way to discuss prognosis and address risk factors [ [10] , [11] , [12] , [13] ].

Brain health is defined as a state of brain “functioning across cognitive, sensory, social-emotional, behavioural and motor domains, enabling a person to realise their full potential over the life course, irrespective of the presence or absence of disorders” [ 14 ]. Pathological processes underlying late-life dementia typically begin decades before clinical diagnosis, with accumulating evidence showing that midlife (typically 40–65 years) is a critical phase for modifying risk factors [ 15 , 16 ]. Most modifiable risk factors, such as mood changes, poor sleep, and hearing loss, emerge and are most amenable to change at midlife [ 17 , 18 ]. Vascular, metabolic and mental health also cluster during these years, alongside work and caregiving responsibilities that can both support and constrain health behaviours [ 19 , 20 ]. Brain health, however, is not merely a biological or pathological matter; it is fundamentally shaped by a complex network of real-world socio-economic and environmental factors [ 7 ]. Social determinants of health (SDoH) are the social, economic, and environmental conditions that shape health risks and access to care [ 21 ], thereby influencing who can engage with and benefit from strategies to optimise brain health. SDoH can be characterised using the PROGRESS-Plus framework to synthesise equity-relevant characteristics (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, and “Plus” factors such as age and disability) [ 22 ].

Pharmacological approaches to dementia prevention typically target pathology or symptoms with cholinesterase inhibitors, insulin, and emerging monoclonal antibodies [ 23 , 24 ]. These have shown minimal to negligible effects on MCI progression or have limited eligibility for patients [ [25] , [26] , [27] ]. Non-pharmacological strategies are therefore regarded as the cornerstone of current brain health initiatives. However, these approaches mainly focus on older adults or the general healthy population [ 28 , 29 ]. Past research has primarily investigated multimodal interventions delivered in trial settings and in high-income countries [ 30 , 31 ]. This scoping review, therefore, sought to understand how middle-aged individuals with mNCD, who face a higher risk of dementia, manage daily responsibilities while maintaining brain health in real-world environments. The main aim was to map the range and characteristics of non-pharmacological brain health strategies used by this group. The secondary aims were to map and analyse how these individuals select and engage with these strategies, considering barriers, facilitators, and equity-related issues.

Methods

This scoping review followed the Joanna Briggs Institute (JBI) methodology and drew on the framework proposed by Arksey and O’Malley [ 32 ], as refined by Levac and colleagues [ 33 ]. Reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [ 34 ]. Ethical approval was not required.

Protocol and registration

The protocol was developed a priori and registered on HRB Open Research ( https://hrbopenresearch.org/articles/8-63/v3 ). The data-charting form was refined iteratively during pilot extraction, as anticipated in the protocol, to capture additional descriptive variables that emerged as relevant. These refinements did not change the eligibility criteria, population definition, study-selection process, or review objectives. No substantive deviations from the protocol were made.

Search strategy

The search strategy was initially developed for PubMed via MEDLINE by a subject librarian (DS) working together with a member of the review team (JD). A limited search was conducted in July 2025 to identify relevant articles. Text words in the titles, abstracts and index terms used to describe these articles were analysed to refine the search strategy. Once finalised, the search strategy was adapted for Embase via Elsevier, CINAHL via EBSCOhost and PsycINFO. Search strategies combined controlled vocabulary (e.g., MeSH) with free-text terms synonymous with mild neurocognitive disorder, brain health, midlife, and non-pharmacological strategies. All searches were conducted on 14th August 2025.

The search was limited to studies published in English from January 2015 onwards to ensure the evidence reflects contemporary definitions, methodologies and technological advances in brain health research, since the earliest record pertaining to ‘brain health’ being discussed and recognised as a concept stems from the 2015 International Association of Gerontology and Geriatrics and its Global Aging Research Network consensus panel [ 35 ]. The language limiter was applied to ensure accurate screening of abstracts based on the review team's language capabilities and translation constraints, and to ensure consistent data extraction and synthesis. We also examined the reference lists of all included articles to identify additional studies. Grey literature searches targeted guidelines, reports, and evaluations from international organisations and brain health strategies. The full search strategy is provided in Supplementary Table 1.

Eligibility criteria

The Population-Concept-Context (PCC) framework [ 36 ] was used to define the eligibility criteria and to ensure alignment with our exploratory research aims within a specific population and context. The population of focus was middle-aged adults with mNCD, with midlife operationally defined as being aged 40–65 years [ 37 ]. Studies frequently recruited participants across broader age ranges. Therefore, eligibility was determined by their recruitment criteria and reported participant age characteristics, including adults aged 40–65 years and studies with mixed-age samples overlapping with the midlife period. The reported age characteristics, including the mean age, standard deviation or age range, were used to describe the extent to which each sample represented the midlife population. mNCD was treated as an aetiologically inclusive syndrome, allowing the review to capture relevant studies across different clinical populations. We excluded studies focusing exclusively on participants with younger-onset or established major neurocognitive disorders. The central concept was non-pharmacological approaches, including lifestyle modifications, cognitive and social activities, psychological and coping strategies, digital tools, and engagement with services. We focused on real-world settings, including community, occupational, or clinical environments in any country. Controlled laboratory paradigms without clear translation to everyday practice were excluded as they may not reflect the practical experiences of adopting or maintaining brain health.

Data screening

Search results from each database were imported into EndNote 21 and then uploaded to Covidence ( www.covidence.org ) [ 38 ], as detailed in Supplementary Table 2. Each title and abstract screening was conducted independently by at least two reviewers (JD, YMcC, KF, and JH) against predefined eligibility criteria. Articles deemed potentially relevant by reviewers progressed to full-text review, which was completed independently by three reviewers (JD, JH, and YMcC). Disagreements at each stage were resolved through discussion and, when necessary, mediated more conservatively by another reviewer (TK). Twelve protocols that progressed to full-text screening were separately searched to determine whether the completed studies could be included. Unfortunately, six could not be found, and the others no longer met the age criteria for this scoping review.

Data extraction and synthesis

Data were extracted by three reviewers independently using a data extraction template in Microsoft Excel. JH and YMcC extracted 24% of the included studies, and JD completed the rest. Extracted information included study characteristics (e.g., sample size, study design), participant characteristics (e.g., age, diagnostic criteria of MCI), bibliographic details (e.g., author, year), description of strategies (e.g., type, duration), modifiable factors of brain health addressed, PROGRESS-Plus equity factors, and key barriers or facilitators of engaging in interventions. We completed a descriptive and narrative synthesis approach consistent with JBI guidance for scoping reviews.

Results

Search results

The study selection process and search results are presented in a PRISMA-ScR flow diagram ( Fig. 1 ). A total of 6842 articles were retrieved from the initial search and uploaded to Covidence; after deduplication, 6349 unique studies were included in title and abstract screening. Of these, 247 articles were retained for full-text screening, and 17 studies are included in this review.

Study characteristics

Table 1 summarises the characteristics of the included studies. Predominant study designs include randomised controlled trials (RCTs) (n = 7, 41.2%), quasi-experimental studies (n = 3, 17.6%), and observational studies (n = 7, 41.2%). Geographical location of studies includes Asia (n = 7, 41.2%) [ [39] , [40] , [41] , [42] , [43] , [44] , [45] ], Europe (n = 6, 35.3%) [ [46] , [47] , [48] , [49] , [50] , [51] ], North America (n = 3, 17.6%) [ [52] , [53] , [54] ] and Africa (n = 1, 5.9%) [ 55 ]. The total number of study participants across the 17 completed studies was 14,486. The reported settings included community (n = 6, 33.3%), hospital clinics (n = 6, 33.3%), rehabilitation centres (n = 4, 22.2%), and one study was located in a workplace [ 45 ]. Most studies (n = 15, 88.2%) included mixed-sex participants, and two included only females [ 39 , 48 ]. A gender imbalance was observed across the literature, with ten studies reporting a predominantly female participant base.

Cognitive heterogeneity across studies

The aetiology and level of cognitive impairment diagnosis significantly shaped the interpretation and applicability of the findings. Participants spanned a wide range of underlying aetiologies, highlighting that mNCD is not a monolithic condition, but rather a heterogeneous diagnosis. mNCD aetiologies included neurodegeneration, such as MCI [ 41 , 43 , 51 , 52 ], secondary to systemic disease, such as Cancer-Related Cognitive Impairment (CRCI) and HIV-associated Neurocognitive Disorder (HAND) [ 48 , 55 ], specific neurodegenerative disorders, such as Multiple Sclerosis (MS) [ 46 , 47 ] and Huntington’s Disease (HD) [ 49 ], and brain injury [ 53 , 54 ]. Given this heterogeneity, findings were interpreted within each study’s clinical context and synthesised descriptively rather than treated as a clinically homogeneous group. An example is the vascular and metabolic improvements noted in miners with hypertension [ 45 ], which were regarded as highly beneficial for that population, but irrelevant to the metacognitive deficits observed in the amnestic MCI population [ 51 ]. Most studies targeted mild impairment, while O’Neil-Pirozzi & Hsu [ 54 ] specifically examined individuals with chronic moderate-to-severe brain injury-related cognitive impairment.

Brain health strategies

In this review, ‘brain health strategies’ was the umbrella term used for actions intended to support brain health among middle-aged adults with mNCD, including both formalised interventions (structured programmes delivered or evaluated by researchers), and self-directed practices adopted by individuals. All studies were mapped to modifiable risk factors [ 9 ]. Although 14 modifiable risk factors are known, only 4 were directly addressed, and another 3 were addressed as only secondary components. Hearing and visual loss were included only as basic eligibility criteria for participation, with researchers ensuring that participants had adequate sensory function to avoid confounding cognitive testing [ 39 , 51 ]. Air pollution, an emerging risk factor for cognitive decline, as well as LDL cholesterol, traumatic brain injury and low education, were not examined in the studies.

Formalised interventions

Physical inactivity, social isolation, and depression were the most targeted modifiable risk factors in this group. Structured exercise interventions included a 16-week aerobic exercise programme [ 39 ], a 12-week dual-task training programme involving dance with simultaneous cognitive tasks [ 43 ], and a 12-week moderate-intensity aerobic cycling programme [ 55 ]. Across these studies, improvements in cognitive function and related biomarker were reported, with Fitriana et al. [ 39 ] reporting significantly lower Apolipoprotein E (ApoE) levels in women with MCI and Nweke et al. [ 55 ] reporting a five-fold improvement in working memory of individuals with HAND compared with control groups. Although a limited benefit for working memory was shown in Parial et al.’s [ 43 ] study, immediate and delayed memory improved for participants with MCI post-intervention. A longer 2-year multi-component lifestyle programme targeting hypertension incorporated exercise, glucose control, smoking, and alcohol modification, and demonstrated improvements in blood pressure, working memory, and cognitive function over time [ 45 ].

Social isolation was addressed as a secondary modifiable risk factor through cognitive training and rehabilitation interventions. These included an RCT comparing computerised cognitive training and music therapy in individuals with HD [ 49 ], a virtual-reality cognitive rehabilitation programme with multisensory stimulation for individuals with MS [ 47 ], a computerised cognitive programme from BrainHQ [ 54 ], and metacognitive or reasoning-based training in individuals with brain injury [ 53 ]. These studies reported improvements in selected cognitive or executive outcomes within their respective clinical populations. In addition, increased connectivity between executive-control and sensorimotor networks, as well as abstract reasoning, a skill crucial in daily life for stimulating frontal lobe functions, was reported by Vas [ 53 ] and Moreu-Valls et al. [ 49 ]. Some interventions inherently involved group settings, providing social interaction as an added benefit, allowing participants to share experiences [ 43 , 46 , 53 ]. In addition, group-based interventions often reported that psychosocial improvements were linked to social interaction. For example, the dual-task Zumba intervention reported improved quality of life, which could partly stem from the social nature of dancing together [ 43 ].

Mindfulness-based interventions targeted depression and psychological well-being. These were added to existing programmes rather than being stand-alone interventions, such as psychoeducation with reflection for individuals with CRCI [ 48 ] or the Metacognitive Training in MS (MaTiMS) programme for individuals with MS, which is explicitly aimed at managing neuropsychiatric symptoms [ 46 ]. Although objective test scores did not improve, participants reported improved perceived cognitive function, stress, mood, and self-efficacy.

Self-directed practices

Observational studies predominantly captured self-directed practices through naturally occurring dietary patterns, compensatory memory tactics, and lifestyle behaviours. Dietary strategies were examined exclusively through naturally occurring eating habits, including longitudinal analyses of whole-egg consumption [ 40 ], aquatic foods and omega-3 fatty acids [ 44 ] and adherence to a culturally adapted Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet [ 42 ]. Beyond specific nutrients, an Italian study examined the relationship between a self-directed time-restricted eating pattern and cognition [ 50 ]. Although these studies reported that healthier dietary patterns and eating behaviours were associated with better cognitive outcomes, they did not support any modifiable risk-reduction claims, and the findings were interpreted as associations rather than effects.

Self-reported engagement in cognitively stimulating leisure activities and the use of compensatory strategies were associated with better outcomes. People living with amnestic MCI reported using compensatory strategies, such as external aids (lists, notebooks, calendars, written notes and reminders) and readily deployable tools to reduce everyday cognitive burden and preserve their independence [ 51 ]. Questionnaires were used to examine habitual activity as part of participants’ overall lifestyle engagement [ 41 , 52 ]. Longitudinally, higher engagement in physical, cognitive and social activities was associated with slower cognitive decline among individuals on a dementia trajectory, whereas no association was observed among those who remained cognitively normal [ 52 ]. Chen et al. [ 41 ] examined a multi-domain self-management profile (healthy diet, exercise, cognitively stimulating activities and social engagement) with caregiver support factors for individuals with MCI. Rather than an outcome, social support was treated as an influencing factor on patients’ self-management approach to adhering to a risk-reduction lifestyle.

Facilitators and barriers identified across strategies

Table 2 outlines the key facilitators and barriers noted by participants and researchers across all studies. Multiple patterns emerged regarding the facilitators and barriers that shaped the success, adherence, and feasibility of strategies. These factors varied according to population characteristics, strategy type, and duration.

Facilitators

A key set of facilitators across the studies concerned the accessibility, enjoyment, and contextual fit of the formalised interventions. Programmes that integrated cognitive stimulation into socially meaningful activities, such as dual-task Zumba Gold [ 43 ], semi-immersive virtual reality training [ 47 ], and customised music therapy [ 49 ], often reported high participant satisfaction, positive mood effects, and high session completion rates. These formats not only stimulated cognitive functions but also enhanced motivation through enjoyment and peer interactions, both of which are critical to strategy adherence and reframing cognitive challenges in less stigmatising terms for individuals with mNCD. Similarly, the delivery flexibility of an online intervention proved especially valuable during the COVID-19 pandemic and for participants with mobility limitations [ 46 ]. Melis et al. [ 48 ] also proactively reduced the number and length of mindfulness sessions to prevent dropout. In a different context, Nweke et al. [ 55 ] improved adherence to aerobic exercise by relocating exercise locations closer to participants' residences, thereby reducing transportation barriers. Researcher facilitation and deliberate adherence management were also critical facilitators in formalised interventions. Facilitation cues and guidance, regular messaging or calls, proactive management of non-attendance (e.g., ‘make-up appointments’ to accommodate those who could not attend), researchers following up on missed sessions, and encouraging participants to complete homework tasks contributed to higher participation and attendance rates [ 39 , 46 , 49 , 53 , 54 ].

Other studies demonstrated that integration into existing support systems can further improve the success of strategies. Caregiver involvement, defined as participants whose caregivers participated in brain-healthy behaviours, was associated with modelling and improved adherence to brain-healthy lifestyle changes among individuals with MCI [ 41 ]. Similarly, lifestyle changes implemented in a workplace setting over multiple years facilitated participation by integrating formalised interventions into a routine occupational health system, thereby reducing reliance on self-initiation alone [ 45 ]. At a broader psychological level, stronger individual health beliefs, preserved awareness, self-control, and motivation to cope with cognitive difficulties facilitated the adoption and maintenance of lifestyle or cognitive strategies. Individuals with amnestic MCI reported using memory recall strategies at rates similar to those of healthy controls [ 51 ], suggesting that, despite objective impairments, people with MCI may retain a high level of strategic engagement, particularly when strategies are familiar or socially normalised. In addition, those who believed they could still reduce their risk of dementia were more likely to use compensatory strategies such as enhanced self-monitoring, grocery planning, or dietary consistency [ 42 ].

Barriers

The most prominent barriers included health-related limitations, time burden, logistical constraints, and underlying socioeconomic factors. In studies involving populations with chronic conditions, health-related obstacles presented recurrent issues in formalised interventions, with a quarter of participants withdrawing due to disease relapse or treatment [ 46 ] and missing sessions due to scheduling conflicts with medical appointments and intercurrent illness [ 54 ]. Similarly, health issues and competing role demands saw nearly half of the eligible women with CRCI decline enrolment or show low adherence to integrating strategies into daily home life [ 48 ]. In addition, high cognitive load and increased session duration were identified as barriers to participation in intervention studies. Participants reported that their concentration waned as sessions progressed and recommended shorter sessions with more frequent breaks to prevent fatigue [ 43 , 46 , 48 ]. Despite designing interventions to leverage procedural learning by implementing a fixed routine, participants did not initiate sessions independently and required additional cueing or supervision [ 43 , 53 , 54 ]. These studies noted that relying on self-initiation, even with a consistent schedule, was unrealistic for many cognitively impaired individuals unless strong external prompting structures were in place. Conversely, another study involving participants with HD reported high adherence and satisfaction with all activities, despite randomisation that led to one intervention arm beginning with participants with more severe cognitive impairment [ 49 ].

In Baetge et al.’s [ 46 ] study, transitioning the intervention online due to COVID-related logistics created barriers, including limited internet access, device availability, and reduced personal connection in group sessions. Similarly, in Nweke et al.’s [ 55 ] study, long travel distances to exercise centres hindered participation, prompting referrals to clinics closer to participants’ homes, however, adherence remained below 75% despite these efforts. At the socioeconomic and belief level, lower income and low social support were associated with poorer adoption of healthy lifestyles in individuals with MCI, indicating real-world resource constraints within this population [ 41 , 51 ]. Barriers to self-reported practices were frequently rooted in low self-efficacy and limited understanding of effective techniques. Participants with MCI who used memory-aid strategies rated themselves as significantly less confident in their ability to apply those strategies effectively in real-world settings [ 51 ]. Some participants also reported embarrassment and social discomfort when struggling with cognitive tasks in group settings, which led to dropout and avoidance of self-guided practice [ 43 ]. Furthermore, even promising lifestyle changes encountered behavioural resistance. Most participants did not naturally follow an early-time-restricted eating window, suggesting that dietary timing changes may be difficult to implement without targeted behavioural support [ 50 ]. Similarly, Li et al. [ 44 ] acknowledged that, despite positive cognitive associations, participants’ concerns about mercury exposure from fish consumption could deter long-term dietary adherence.

Equity across studies

Across included studies, equity-relevant characteristics mapped to PROGRESS-PLUS were most often reported descriptively and less often used analytically. The ‘Plus’ factors were integral to every study because samples were defined by cognitive impairment, and this scoping review examined a specific age range. However, most PROGRESS characteristics were inconsistently measured and rarely used to test differential effects or guide analysis. A clear pattern emerged by study type, with larger studies examining self-directed practices having more comprehensive equity coverage and adjusting for core social variables (typically age, sex, and education) [ 40 , 42 , 50 ], and one study explicitly incorporating social support and caregiver characteristics into brain health lifestyle modelling [ 41 ]. In contrast, many formalised intervention studies treated equity characteristics primarily as descriptive background variables or eligibility criteria, such as excluding individuals with sensory impairment or severe depression, rather than as explanatory variables [ 39 , 43 , 51 , 52 ]. Table 3 outlines the PROGRESS-Plus characteristics of all studies.

By PROGRESS characteristics, place of residence was predominantly urban, either in clinical centres, health-engaged community settings, or assisted living facilities, and only one study was based in a rural industrial setting, explicitly anchoring risk and intervention feasibility within workplace-based conditions [ 45 ]. Equity patterns varied systematically across countries or health systems, although race and ethnicity were rarely characterised beyond the country or language-level. Cultural specificity was largely inferred and adapted through local adaptation, such as the Chinese-adapted MIND diet, which accounts for the traditional consumption of freshwater fish [ 42 ], in contrast to Western staples such as wine, dairy, and olive oil [ 50 ]. Cognitive impairment commonly intersected with systemic or occupational risks, such as HAND in Nigerian adults across diverse low- and middle-status occupations [ 55 ], or hypertension in Chinese mining communities [ 45 ], compared to High-Income Countries (HICs), where it was more often framed as a function of ageing [ 51 ], lifestyle [ 50 ] or treatment effects [ 48 ]. In East Asian and Low- and Middle-Income countries (LMICs), strategies were often framed around familial responsibility and community-based peer support. An example is the dyadic design that explicitly models caregiver characteristics and perceived social support as key determinants of a patient’s lifestyle [ 41 ].

Gender representation was frequently biased by recruitment context, with samples being heavily female-dominated, particularly from dance studies or those having breast cancer [ 42 , 44 , 48 ], and male predominance in specific mining occupational cohorts [ 45 ]. Only a few studies examined gendered differences in adherence or outcomes. Education was commonly captured but seldom used beyond adjustment despite its centrality to cognitive reserve and intervention feasibility. Many cohorts in the HICs were highly educated to university level [ 48 , 52 , 53 ], while some cohorts from East Asian communities also had substantial secondary or higher education [ 41 , 44 ], raising concerns about external validity for less educated populations. Similar to education, socioeconomic status was measured through income, insurance coverage, or occupation and reported in only four studies [ 40 – 42 , 50 ], limiting the interpretation of equity in access, adherence, and benefit from strategies. Lower educational attainment was strongly linked to lower cognitive scores, less healthy lifestyles, and reduced motivation to engage in brain health behaviours in Chinese cohorts [ 40 ]. Conversely, higher income levels or health insurance coverage correlated with better cognitive test scores and a greater inclination to adopt dementia risk-reduction lifestyles [ 41 ]. Finally, social capital was most often reported as a secondary component, either through perceived social support scales [ 41 ], lifestyle questionnaires that included social engagement [ 52 ], or through incidental social contact in formalised group-based interventions [ 39 , 43 , 46 , 53 ]. The ‘Plus’ factors of disability and disease status were typically defined by single aetiologies (MS, HD, CRCI, HAND, TBI or MCI), which were appropriate for condition-specific efficacy testing but limited cross-condition comparisons.

Discussion

The strategies used by middle-aged adults with mNCD to maintain brain health predominantly involved risk-factor modification, cognitive reserve enhancement, and compensatory supports for everyday functioning. This clustering is broadly consistent with contemporary framings of brain health as multidomain functioning shaped by continuous interaction between biology and environment across the life course [ 7 ]. Physical inactivity was the most commonly represented modifiable risk factor. Several formalised intervention studies reported improvements in selected cognitive outcomes, while observational studies identified associations between habitual activity and cognitive trajectories [ 39 , 43 , 52 , 55 ]. However, consistent with other studies [ 56 , 57 ], effects were domain-specific and sometimes delayed, highlighting the need for longitudinal measurements of physical activity and clearer activity-response optimisation for middle-aged individuals. These findings, therefore, should not be interpreted as evidence of effectiveness because the included studies differed substantially in design, population, intervention content and outcome measurement. Cardiometabolic prevention research was also identified [ 45 , 50 ] but remained scarce relative to its epidemiological importance. This scarcity is difficult to justify given that midlife cardiovascular risk factors, particularly hypertension and metabolic control, are repeatedly described as major factors in cognitive trajectories and dementia risk [ 30 , [58] , [59] , [60] ]. It also represents a missed opportunity given the ‘equity promise’ of scalable, primary-care-based vascular risk management [ 61 ]. The epidemiological salience of midlife vascular risk and its comparatively limited representation in this review suggests a translational gap rather than a knowledge gap. Diet strategies were methodologically bifurcated in observational studies [ 40 , 42 , 44 ], which aligned conceptually with cardiometabolic-related neurodegenerative risk, yet, similar to other studies [ 62 , 63 ], they remain better interpreted as a cognition risk association rather than a risk-reduction claim. This highlights a recurring interpretive slippage in brain health messaging and research translation, in which observational associations are sometimes presented as causal evidence for prevention.

Consistent with other research [ 64 , 65 ], some studies reported more favourable outcomes among individuals identified as high-risk or already experiencing cognitive decline, suggesting a cognitive reserve mechanism in those with this pathology [ 52 ]. However, this conflicts with the composition of many study participants, who were relatively able to engage with structured programmes, thereby inflating perceived feasibility and obscuring structural constraints. Thus, the populations for whom strategies may be most clinically relevant are not necessarily the ones most represented.

Equity considerations further clarify why feasibility and effectiveness cannot be separated. PROGRESS-PLUS characteristics were often identified descriptively and did not explicitly inform studies or strategies, contrary to the recommendation of applying an equity lens when designing and evaluating strategies [ 66 ]. Strategies reliant on literacy, technology, or complex multi-component approaches [ 46 , 47 , 54 ] risked exacerbating inequities and inequalities among individuals with lower socioeconomic status, lower education, and those with complex diseases, precisely the populations most likely to face constrained opportunities for sustained behavioural change [ 61 , 67 ]. In addition, formalised interventions targeted modifiable risk factors, whereas the most powerful facilitators and real-world constraints remained at the social and structural levels of the midlife life course.

Intensive multi-week training, structured exercise sessions, lengthy programmes and travel requirements were frequently indicated with adherence difficulties, including dropout, non-attendance and scheduling conflicts. In this context, these are often better interpreted as an intervention–context mismatch rather than as individual-level adherence failure, indicating that the participation burden itself functions as an equity mechanism. This is reinforced by Migeot et al. [ 68 ], who argue that, under adverse social conditions, even non-monetary costs, such as time and effort, become under-recognised and unequally distributed social determinants of brain health. Several studies often implicitly assumed time commitments from participants in their formalised interventions [ 47 , 49 ], yet temporal inequity, defined as unequal access to and control over discretionary time, functioned as a social determinant that constrained participation and engagement [ 69 ]. This can be interpreted as high-agency strategies may be least accessible to those most structurally exposed to dementia risk, making feasibility a core equity outcome rather than a secondary implementation detail.

Similarly, Daly’s conceptualisation of the ‘iceberg of dementia risk’ emphasises that addressing only lifestyle behaviours and strategies is inadequate, given the impact of structural determinants and deprivation from economy, housing, work, and education [ 70 ]. This was evident in Li et al.’s [ 45 ] study, which showed participants receiving lifestyle advice and interventions, but some were unable to afford their antihypertensive medications, thereby leaving a primary modifiable risk factor unaddressed. Public health messaging intended to promote brain health has also overwhelmingly centred on high-agency individual strategies and has inadvertently reinforced culpability for communities whose risk distribution reflects unresolved structural inequalities rather than individual fault [ 71 ]. Furthermore, a systematic review on brain health found that most samples were drawn from relatively advantaged, WEIRD (Western, Educated, Industrialised, Rich, Democratic) settings and trial cohorts [ 72 ], echoing broader concerns that populations from minority communities and LMICs are underrepresented in both observational and interventional studies [ 5 , 14 ]. Consistent with this, studies included in this scoping review found participants were mostly educated and predominantly from urban areas in seven HICs. Finally, it is notable that no included study explicitly reported participant co-design; instead, all were based on existing evidence or researcher-designed programmes.

Overall, the predominance of condition-specific samples, the frequent reliance on urban, educated, and physically active participants, and the absence of core social determinants limit the ability to identify which subgroups may experience more favourable outcomes, which remain underserved, and how to tailor multidomain brain health strategies. In particular, there is a dearth of studies exploring the lived experiences of middle-aged individuals with mNCD, and even fewer adopt an explicit equity lens despite growing recognition that equity factors shape opportunities to engage in brain health behaviours.

Implications for future works

Future research should shift from isolated efficacy studies to pragmatic, co-designed, implementation-focused works that test how brain health strategies can be embedded within schools, workplaces, primary care, and community services. It should also move beyond descriptive reporting towards intentional, equity-informed sampling and analysis, and should evaluate and tailor strategies for effectiveness, feasibility, and equity across clinically and aetiologically heterogeneous populations and settings. More importantly, future brain health research needs to extend beyond individual-level lifestyle framings to evaluate structural interventions that explicitly address deprivation, nonmonetary costs, and broader social determinants. There is also a need for studies to better capture the contextual variability of ‘midlife’. Rather than relying on a single age interval, studies should justify their operational definition and report sufficiently granular age information to allow re-aggregation across alternative definitions in subsequent evidence syntheses.

In practical terms, future work can involve tailoring programmes for those of lower socioeconomic status, adapting materials for different literacy levels, offering low-tech and culturally adapted options, and partnering with community organisations that have trusted relationships with underserved populations and those with existing mNCD to co-create solutions. Finally, at policy level, evaluation frameworks should mandate reporting of reach, adherence, and outcomes by socioeconomic and demographic indicators to ensure that benefits are distributed fairly across midlife populations.

Limitations

This scoping review provides essential insights into an understudied population, but it has limitations. Although grey literature sources were searched, no eligible grey literature records were identified; therefore, the final evidence base comprised peer-reviewed journal articles. It is thus possible that relevant research available as preprints, conference proceedings, or dissertations may have been missed. Second, this scoping review included studies published from 2015. The search was limited to ensure that the evidence reflects contemporary definitions, methodologies, and technological advances in brain health research, as the past 10 years have marked a shift toward multi-domain prevention strategies and alignment with global policy initiatives. The heterogeneity in the age reporting of the included studies should be considered when interpreting the findings of this review. We operationalised midlife by chronological age, defined as 40 to 65 years; however, studies did not apply uniform age eligibility criteria, and several recruited participants across broader adult age ranges and did not report findings separately for participants within the midlife period. One such study, which reported a mean age of 67.67 years, was retained because its recruitment criteria included participants within the prespecified midlife age range. Nevertheless, the absence of age-disaggregated findings in this study means that the proportion of middle-aged participants could not be established, limiting the extent to which the results can be attributed specifically to midlife adults. Evidence limitations also constrain how assertively recommendations can be made in clinical practice, such as for specific dietary patterns or social connectivity, for which there is insufficient data to justify major changes in guidelines, thereby making clinical messaging more cautious and less directive.

Conclusion

International programmes and frameworks advocate for brain health through prevention, early intervention, and risk reduction. This scoping review identified a diverse range of formalised interventions and self-directed strategies used by individuals with mNCD across aetiologically heterogeneous populations within the midlife age range. The findings indicate that engagement with these strategies was influenced by a complex interplay of psychological, cognitive, and logistical factors, as well as social determinants of health, while equity considerations were rarely systematically integrated into their design and implementation. The included studies reported outcomes relating to cognitive functioning, psychological well-being, and health-related behaviours, although the nature and extent of reported outcomes varied across population characteristics, intervention designs, and study methodologies. Formalised interventions were implemented primarily in a top-down manner, which may have contributed to recurring barriers related to adherence, accessibility and feasibility. Collectively, these findings provide an important foundation for understanding the breadth and characteristics of current evidence and for identifying strategies that warrant further rigorous and aetiology-specific evaluation during midlife. Future brain health strategies should also prioritise feasibility, cultural responsiveness, equity, and co-production with participants to reflect real-world needs and constraints.

Funding

Three authors (JD, JH & YMcC) are currently recipients of the SNMHS PhD scholarship from their affiliated university (University College Dublin). The funders had no role in the study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.

Declaration of generative AI and AI-assisted technologies in the writing process

None

Ethical statement

Ethical approval is not required.

Data statement

The data supporting the findings of this study are available within the article and its Supplementary Materials. The full extracted dataset is available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Joshi Dookhy: Writing – review & editing, Writing – original draft, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Yvonne McCague: Writing – review & editing, Methodology, Formal analysis. Jim Hickson: Writing – review & editing, Methodology, Formal analysis. Diarmuid Stokes: Software, Resources, Methodology. Thilo Kroll: Writing – review & editing, Supervision, Methodology, Conceptualization. Kate Frazer: Writing – review & editing, Supervision, Methodology, Conceptualization.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

None

Footnotes

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.tjpad.2026.100657 .

Contributor Information

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Yvonne McCague, Email: yvonne.mccague@ucdconnect.ie.

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Kate Frazer, Email: kathleen.frazer@ucd.ie.

Supplementary materials

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