applied

sciences
Article
Associations of Balance, Strength, and Gait Speed with
Cognitive Function in Older Individuals over 60 Years:
A Cross-Sectional Study
José Daniel Jiménez-García 1 , Sonia Ortega-Gómez 2, * , Antonio Martínez-Amat 1
and Francisco Álvarez-Salvago 3

1 Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23071 Jaén, Spain;
[email protected] (J.D.J.-G.); [email protected] (A.M.-A.)
2 MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences, University of
Cadiz, and Biomedical Research Innovation Institute of Cádiz (INiBICA), 11001 Cadiz, Spain
3 Department of Physiotherapy, Faculty of Health Sciences, European University of Valencia,
46010 Valencia, Spain; [email protected]
* Correspondence: [email protected]; Tel.: +34-956-016-200

Abstract: This research examined the association between the risk of falls and cognitive function in
older individuals at risk of mild cognitive impairment. One hundred seventy-five older adults were
included in 2021. Balance confidence was scored using the Activities-Specific Balance Confidence
Scale (ABC), gait speed was assessed by the 4 m test, handgrip strength by a digital dynamometer,
and balance by the Timed Up-and-Go Test (TUG). The Mini-Mental State Examination (MMSE), The
Controlled Oral Word Association Test, and The Boston Naming Test short-version questionnaires
assessed global cognitive function, verbal fluency, and language, respectively. A bivariate correlation
analysis and multivariate linear regressions were applied, adjusting for confounders (BMI, sex, age,
and educational level). Shorter time in the TUG and greater educational status were independently
Citation: Jiménez-García, J.D.; associated with improved scores on the MMSE. Lower age and greater educational status were
Ortega-Gómez, S.; Martínez-Amat, A.; independently associated with increased phonological fluency. Better ABC and performance on the
Álvarez-Salvago, F. Associations of TUG and higher educational attainment were independently associated with enhanced semantic
Balance, Strength, and Gait Speed fluency. Higher education level and gait speed were independently associated with increased
with Cognitive Function in Older language (all p < 0.05). Improved physical factors, such as gait speed, grip strength, balance, and
Individuals over 60 Years: A
balance confidence enhanced cognitive function, particularly global cognitive function, verbal fluency,
Cross-Sectional Study. Appl. Sci. 2024,
and language, in individuals over 60, with education as a potential confounder.
14, 1500. https://doi.org/
10.3390/app14041500
Keywords: older adults; aging; accidental falls; cognitive impairment; physical fitness
Academic Editors: Marios
Hadjicharalambous and
Nikolaos Zaras

Received: 22 January 2024

1. Introduction
Revised: 8 February 2024 Falls constitute a major health issue and are the number two cause of unintentional
Accepted: 10 February 2024 injuries leading to fatalities globally [1]. Due to changes in various physiological systems
Published: 12 February 2024 associated with aging, older individuals face the greatest susceptibility to falling, affecting
between 30–40% of this population [2,3]. In particular, the highest number of fatal falls
occurs after the age of 60 [1]. Falls are multifactorial and their consequences are not only
physical, such as injury and disability, but also psychological, especially the apprehension
Copyright: © 2024 by the authors.
about falling, and social, such as social seclusion and institutionalization [2]. These con-
Licensee MDPI, Basel, Switzerland.
ditions have an impact on the well-being of older individuals and may be costly for our
This article is an open access article
public health system [2,3].
distributed under the terms and
In older individuals, diminished physical capabilities stand out as a primary contrib-
conditions of the Creative Commons
utor to falls [4]. Therefore, enhancing functional capacity, which is defined as the ability
Attribution (CC BY) license (https://
of the person to independently perform activities of daily living (ADLs), was shown to
creativecommons.org/licenses/by/
4.0/).

Appl. Sci. 2024, 14, 1500. https://doi.org/10.3390/app14041500 https://www.mdpi.com/journal/applsci

Appl. Sci. 2024, 14, 1500 2 of 13

be efficacious in preventing falls among seniors [5]. Recent research showed that pre-
scribing physical exercise with a focus on mitigating strength and muscle mass loss while
maintaining balance and gait is effective in this population [5].
Slow gait is a well-established factor indicating the risk of falls among elderly individu-
als [6]. Walking involves coordinated functioning of the nervous, sensory, cardiorespiratory,
and musculoskeletal systems, which are influenced by age [6]. During aging, gait abnor-
malities due to poor joint range of motion and decreased muscle strength, among other
disorders, become more prevalent [7]. Approximately 10% of older adults aged 60–70 years
suffer from gait abnormalities, rising to more than 60% in those over 80 years of age [6].
Consequently, gait speed is considered a valuable tool for the early detection of vulnera-
bility to falls, and recent studies established potential gait speed cut-off points for older
adults [8,9].
Similarly, balance disorders also contribute to an increase in falls [10]. Balance skills
enable individuals to control their posture and react to disturbances; dynamic balance
refers to maintaining equilibrium during movement [11]. Postural imbalance, limitation of
the functional peripheral visual field, proprioceptive impairment, and further complaints
that greatly compromise balance are most often manifested in senescence [10].
Another element linked to a heightened risk of falls is the gradual decrease in skeletal
muscle mass and strength that accompanies the aging process, which is a condition known
as sarcopenia [12]. This geriatric syndrome is influenced by aging, hormonal changes,
chronic diseases, inflammation, and malnutrition, among other factors [13]. A substantial
body of scientific evidence [14] underscores the significance of grip strength as a biomarker
for successful aging. However, it is not directly associated with ADLs like walks, which
serve as an index of mobility in older individuals.
It is evident that cognitive function, which progressively declines with advancing
age, is inversely related to fall risk [2]. However, a recent systematic review and meta-
analysis [15] regarding the risk of falls in seniors with cognitive impairment found no
relationship between the level of cognitive functioning and falls in this population, whereas
functional performance was linked.
Given the strong relationship between cognitive function and fall risk, knowing
whether physical status factors that influence falls are also related to cognitive function level
will allow for a better understanding of the relationship between physical and cognitive
functioning on fall risk in older adults. This information could provide a more complete
insight into the mechanisms underlying falls and cognitive dysfunction and help to identify
more effective interventions to prevent them. Therefore, this research work aimed to
explore the associations between fall risk based on predictors of functional capacity and
cognitive function in older individuals at risk of mild cognitive impairment (MCI). Our
hypothesis was that individuals with a higher risk of falls, specifically those with lower
gait speed, handgrip strength, and poorer dynamic balance, would exhibit lower cognitive
performance, specifically in language and semantic and phonological fluency, in older
people over the age of 60 years.

2. Materials and Methods

2.1. Participants
The current study was a cross-sectional descriptive and analytical study that was
carried out between February and March 2021. A total of 175 people were randomly chosen
by means of the Social Affairs departments of Malaga City Council and Pizarra City Council
(Malaga) (Figure 1). Participants were included if they were at least 60 years of age, resided
in Malaga or Pizarra (Malaga), able to communicate without problems, and could read
and understand the informed consent form and the object of the study. In addition, they
were excluded if they had central or peripheral neurological disorders, rheumatological
diseases; severe somatic or psychiatric diseases; severe cognitive impairment; pacemakers
or prostheses; auditory or vestibular pathologies; or any other conditions that could affect
balance, functional activity, and hinder an accurate functional assessment. Additionally,
 the dynamometry measurement, participants were required to preserve a standard bi-
pedal position with the arm fully extended throughout the entire test. Individuals were
instructed to perform three attempts of maximum grip strength using their dominant
Appl. Sci. 2024, 14,hand,
1500 with a 30-second pause between each trial. To ensure accuracy, the dynamometer 3 of 13
was calibrated to size 5.5 for males, whereas for females, the ideal grip size was custom-
ized according to hand dimensions [18]. A standard of 16 kg for females and 27 kg for
males was applied to determine
individuals low muscle
involved strengthresearch
in concurrent [19]. Thisstudies
test demonstrated validity
that could potentially impact this
and reliability, with an ICC exceeding 0.80
project were also excluded. [20].

Elderly who were initially

contacted to participate in

this study (n=302)

Declined to participate

(n=67)

Elderly who agreed to be

examined (n=235)

Did not show up (n=28)

Elderly screened (n=207)

Being younger than 60 Suffering vestibular Suffering rheumato- Having prosthesis

years (n=9) problems (n=8) logic problems (n=8) (n=7)

Elderly who were examined after the eligibility criteria and finished all the

functional and psychological tests of the study (n=175)

Figure
Figure 1. Flowchart Flowchart
1. study
of the of the study participants.
participants.

2.3.4. Dynamic Balance In cases where a selected individual was not eligible for inclusion in the sample due to
lack of access, unwillingness, or failure to meet the inclusion criteria, the following person
The Timed Up-and-Go Test (TUG) is designed to evaluate dynamic balance and func-
from the list replaced them to maintain the sample size. The sample size determination
tional mobility in older adults [21]. The test involves a patient transitioning from a seated
was carried out with version 3.1.9.2 of G*Power.
to a bipedal position,Based
walkingon three meters, turning
an estimated incidencearound,
of 30% returning, and
of falls (at sitting
least back
once in in the target
a year)
the chair. The length of time the individual spent completing this sequence was recorded.
group, the study sample size was obtained using the formula for estimating the proportion,
Each participantwhere
underwent the testrate
the assumed twice,
wasand
0.3,the top αtime
with achieved
= 0.05 and a was recorded
precision of ±[22].
0.06. A 25% safety
This test has demonstrated reliability, with an ICC ranging between 0.95
margin was added to account for registration failures, drop-outs, orand 0.99 [23].
individuals who did
not want to participate; therefore, a required sample size of 175 subjects was calculated.
Initially, we provided an overview of the primary objectives and motivations behind
the study. Subsequently, we briefly outlined the potential risks associated with the study. All
procedures were conducted in an anonymous manner. Prior to enrolment, each participant
provided informed written consent. Approval for this study was granted by the Ethics
Committee of the University of Jaén (DIC.17/5.TES 19 February 2018) and adhered to
Appl. Sci. 2024, 14, 1500 4 of 13

the principles of the Declaration of Helsinki, good clinical practices, and relevant laws
and regulations.

2.2. Sociodemographic and Anthropometric Information

Sociodemographic details, i.e., date of birth, marital status, level of education, and
place of residence, were documented. Anthropometric parameters, including weight,
height, waist-hip ratio, and BMI, were recorded. For these assessments, individuals were
without shoes and dressed in undergarments. Additionally, behavioral patterns pertaining
to physical activity, including type and frequency, as well as information on smoking and
any falls encountered in the previous year, were gathered.
For the measurement of waist circumference, a 1.5-m flexible measuring tape (Lufkin,
W606PM, Sparks, MD, USA) was utilized, with the midpoint between the last rib and
the iliac crest serving as the reference point. Two measurements were taken while the
participant stood upright.

2.3. Fall Risk Outcomes

2.3.1. Balance Confidence
The Activities-Specific Balance Confidence Scale (ABC) is a structured survey designed
to assess an individual’s confidence in performing activities without experiencing balance
issues. Comprised of 16 items, with each one assessed on a scale from 0% to 100% (where
0% denotes no confidence and 100% signifies full confidence), the questionnaire generates
an aggregate score calculated by summing the scores of all items and dividing the total
by 16. This resultant aggregate score also spans from 0% to 100%. The Spanish version
demonstrated outstanding internal consistency (Cronbach’s α = 0.92) and significant test-
retest reliability, as indicated by an intraclass correlation coefficient (ICC) of 0.86 [16].

2.3.2. Gait Speed

The 4 m walking test of the Short Physical Performance Battery (SPPB) [17] was aimed
at assessing the gait speed at a normal walking pace. It has been employed as a predictive
instrument for potential disability and can assist in the assessment of function in later life.
The duration, measured in seconds, required to complete the specified route was reported.
The SPPB was shown to be reliable with an ICC of 0.87 [17].

2.3.3. Handgrip Strength

The evaluation of upper body muscular strength, specifically handgrip strength, was
conducted using a digital dynamometer (TKK 5101 Grip-D; Takei, Tokyo, Japan). During
the dynamometry measurement, participants were required to preserve a standard bipedal
position with the arm fully extended throughout the entire test. Individuals were instructed
to perform three attempts of maximum grip strength using their dominant hand, with a
30-s pause between each trial. To ensure accuracy, the dynamometer was calibrated to
size 5.5 for males, whereas for females, the ideal grip size was customized according to
hand dimensions [18]. A standard of 16 kg for females and 27 kg for males was applied to
determine low muscle strength [19]. This test demonstrated validity and reliability, with an
ICC exceeding 0.80 [20].

2.3.4. Dynamic Balance

The Timed Up-and-Go Test (TUG) is designed to evaluate dynamic balance and
functional mobility in older adults [21]. The test involves a patient transitioning from a
seated to a bipedal position, walking three meters, turning around, returning, and sitting
back in the chair. The length of time the individual spent completing this sequence was
recorded. Each participant underwent the test twice, and the top time achieved was
recorded [22]. This test has demonstrated reliability, with an ICC ranging between 0.95 and
0.99 [23].
Appl. Sci. 2024, 14, 1500 5 of 13

2.4. Cognitive Function Outcomes

2.4.1. Global Cognitive Function and Screener for Mild Cognitive Impairment
The Folstein Mini-Mental State Examination (MMSE) is a cognitive function assess-
ment comprising 30 questions. It evaluates various cognitive domains, including attention
and orientation, memory, registration, recall, calculation, language, and the ability to draw
a complex polygon [24]. The combined score derived from the evaluation acts as a measure
of overall cognitive function. It is also a recognized screener for MCI [25], where the most
sensitive cut-off points for this condition are [26] 30–28 points, which shows the individual
is healthy with cognitive function intact; 27–24 points, which indicates possible MCI; and
23 points or less, which can indicate moderate-to-severe cognitive impairment.

2.4.2. Verbal Fluency

The Controlled Oral Word Association Test (COWAT) is a frequently employed neu-
ropsychological measure aimed at assessing phonologic and semantic fluency [27,28]. This
verbal fluency test gauges the capacity to generate words either starting with a desig-
nated letter (phonological) or falling within the same classification (semantic). Within a
1-min timeframe, participants are tasked with articulating the maximum number of words
they can that either commence with a specific alphabet letter (F, A, or S) or fall within
a designated category (kitchen, animals, or countries). Proper names and word-derived
variations are excluded. The COWAT is widely utilized for evaluating verbal fluency and
is recognized as a sensitive indicator of brain dysfunction. It is acknowledged that the
administration of verbal fluency tests is a crucial component in conducting a comprehensive
assessment of neuropsychological functioning [27,28].

2.4.3. Language
Language was measured with The Boston Naming Test short version (BNT-30). Sum-
mation scores span from 0 to 30. Lower scores point toward heightened obstacles in lexical
retrieval. The cumulative score for this test comprises the addition of the correct responses
provided spontaneously plus those produced with semantic stimulus cues [29]. Its validity
and reliability are well established and reviewed elsewhere [28].

2.5. Statistical Analysis

Continuous variables are displayed as means and deviations from the mean, while
categorical variables are depicted as proportions and occurrence frequencies. The normal
distribution of all variables was evaluated using the Kolmogorov–Smirnov examination.
Bivariate correlation analysis was utilized to explore potential individual associations
between a range of factors (independent variables, such as balance confidence, gait speed,
handgrip strength, and dynamic balance, alongside other covariates, such as BMI, sex,
age, and educational level) and global cognitive function, language, and semantic and
phonologic fluency. To investigate the independent associations between the present
variables, both a multivariate linear regression model and a step-by-step method were
implemented to incorporate variables into the model. Cognitive status was documented
as the dependent variable in separate models, considering the significance in bivariate
correlation (p < 0.05), and was integrated into the multivariate linear regression. The
adjusted R2 was used to calculate the effect size coefficient of multiple determinations
in linear models. An R2 less than 0.02 was considered insignificant, moderate if ranging
between 0.02 and 0.15, and substantial if it surpassed 0.35. A confidence level of 95%
was adopted (p < 0.05). The analysis of data was carried out utilizing the SPSS statistical
package for Windows (SPSS Inc., Chicago, IL, USA).

3. Results
Descriptive characteristics of the participants are shown in Table 1 for all participants
together (n = 175) and separately by sex (n = 137 women, 78%). The majority of the partic-
ipants were either married or cohabiting (69.14%), had completed primary education or
Appl. Sci. 2024, 14, 1500 6 of 13

had lower educational attainment (80.56%), and the average BMI was 29.80 ± 4.78 kg/m2 .
Descriptive statistics for the variables examined in the current research work indicated that
the TUG duration was 7.09 ± 1.53 s. The handgrip strength was 25.59 ± 8.12 kg. The bal-
ance confidence measured with ABC showed 76.27 ± 21.61 points as the score total. Finally,
as an independent variable, the gait speed showed 2.283 ± 0.50 s in the 4 m walking test.
Regarding the dependent variables, the score total of the MMSE, which served as a global
indicator of cognitive function, averaged 25.95 ± 3.01, falling within the range indicative of
possible MCI. The total numbers of words given for the phonologic and semantic fluency
from the COWAT were 32.07 ± 12.69 and 31.75 ± 10.25, respectively. Regarding language
measured with BNT, the total correct score was 10.45 ± 2.86.

Table 1. Descriptive data of the study sample.

Characteristics Total (n = 175) Men (n = 38) Women (n = 137)

Mean SD Mean SD Mean SD
Age (years) 66.64 5.58 64.98 4.84 67.11 5.70
BMI (kg/m2 ) 29.80 4.78 30.14 3.93 29.71 5.01
N Percentage N Percentage N Percentage
Retired 150 85.71 26 69.42 124 94.51
Occupational status Working 6 3.42 4 10.52 2 1.46
Unemployed 19 10.87 8 10.06 11 4.03
Single 5 2.85 4 10.52 1 0.73
Marital Status Married/cohabiting 121 69.14 7 18.42 114 83.21
Separated/divorced/widowed 49 28.01 27 71.06 22 16.06
No formal education 60 34.28 12 31.58 48 35.03
Primary education 81 46.28 17 44.75 64 46.71
Educational level Secondary education 24 17.51 6 15.78 18 13.13
University 10 5.71 3 7.89 7 5.13
Mean SD Mean SD Mean SD
MMSE (score) 25.93 3.01 26.47 2.44 25.78 3.15
Phonologic fluency (w) 32.07 12.69 37.05 12.19 30.70 12.51
Semantic fluency (w) 31.75 10.25 34.79 13.65 30.90 8.98
Language (score) 10.45 2.86 11.79 2.50 10.08 2.85
TUG (s) 7.09 1.53 6.77 1.47 7.17 1.55
Handgrip strength (kg) 25.59 8.12 37.77 7.28 22.21 4.14
ABC (score) 76.27 21.61 83.77 17.45 74.20 22.25
Gait speed (s) 2.283 0.50 2.09 0.46 2.33 0.51
ABC: Activities-Specific Balance Confidence Scale. BMI: body mass index. MMSE: Mini-Mental State Examination.
TUG: Timed Up-and-Go Test.

Table 2 displays the bivariate analysis, which demonstrated that the dependent vari-
ables in this study (namely, the MMSE as a screener for MCI, phonologic and semantic
fluency, and language) significantly positively correlated with educational level. When
analyzing the MMSE score, significant negative associations with the TUG and gait speed
were also found. When more words were given in the phonologic fluency test, a correlation
between an increase in the handgrip strength and a higher score in confidence balance
was observed. When analyzing the semantic phonologic and language results, significant
negative correlations were also found with the TUG and gait speed. Furthermore, handgrip
strength and ABC showed a positive correlation with semantic fluency and language.
Regarding the covariates incorporated in the analysis, sex showed correlations with phono-
logic and semantic fluency and language. Furthermore, age was observed in correlations
with the MMSE score, semantic fluency, and language.
Appl. Sci. 2024, 14, 1500 7 of 13

Table 2. Pearson’s correlations among variables analyzed in this study.

Phonologic Semantic
MMSE Language
Fluency Fluency
TUG −0.236 ** −0.122 −0.303 ** −0.219 **
Handgrip strength 0.140 0.201 ** 0.190 * 0.264 **
ABC 0.135 0.161 * 0.277 ** 0.205 **
Gait speed −0.150 * −0.139 −0.352 ** −0.297 **
Age (years) −0.149 * -0.144 −0.385 ** −0.353 **
Sex −0.095 −0.207 ** −0.157 * −0.246 **
Educational level 0.330 ** 0.509 ** 0.318 ** 0.542 **
BMI (kg/m2 ) −0.068 0.046 −0.110 −0.066
ABC: Activities-Specific Balance Confidence Scale. BMI: body mass index. MMSE: Mini-Mental State Examination.
TUG: Timed Up-and-Go Test. * p < 0.05. ** p < 0.01.

The multivariate linear regression analysis, as indicated in Table 3, unveiled various

independent associations with distinct cognitive domains in this investigation. A shorter
time in the TUG was associated with an elevated MMSE total score, and an increase in the
educational level was associated with a total score in the MMSE (R2 = 0.149). A higher
education level was associated with an increase in the number of words answered in the
phonologic fluency test and age was linked to a decline in the word count answered in
the phonologic fluency test (R2 = 0.320). Lower times in the TUG and gait speed were
associated with an increase in the total number of words answered in the semantic fluency
test and lower educational level and total score in the ABC were associated with a decrease
in the total number of words answered in the semantic fluency test (R2 = 0.133). Lastly,
a higher level of education correlated with an elevation in the comprehensive language
score, whereas gait speed exhibited an association with a decrease in the total language
score (R2 = 0.372).

Table 3. Multivariate linear regression analyses for variables related to cognitive function factors.

Variable B β t 95% CI p-Value

MMSE TUG −0.538 −0.275 −2.254 −1.09 −0.67 0.025
Educational level 1.268 0.319 3.838 0.616 1.920 <0.001
Phonologic fluency Educational level 7.360 0.041 5.965 4.921 9.797 <0.001
Age −0.554 −0.244 −3.551 −0.862 −0.246 <0.001
Semantic fluency Educational level 3.678 0.273 3.364 1.520 5.873 0.001
Gait speed −4.931 −0.241 −1.970 −9.873 0.011 0.049
TUG −1.378 −0.207 −2.572 −2.437 −0.320 0.011
ABC 0.077 0.163 2.045 0.003 0.152 0.042
Language Educational level 1.796 0.476 6.613 1.260 0.233 <0.001
Gait speed −1.654 −0.290 −2.661 −2.882 −0.427 0.009
B: unstandardized coefficient. β: standardized coefficient. CI: confidence interval. ABC: Activities-Specific Balance
Confidence Scale. MMSE: Mini-Mental State Examination. TUG: Timed Up-and-Go Test.

4. Discussion
The aim of the current study was to investigate whether the risk of falls, as determined
by predictors of functional ability, may be related to cognitive function in older individuals
at risk of MCI. Our findings suggest that older individuals with higher dynamic balance,
handgrip strength, or gait speed, as well as increased confidence in their balance or higher
levels of education, demonstrated better cognitive function across most of the dimensions
we assessed. Additionally, diminished dynamic balance emerged as a significant predictor
of lower MMSE scores and decreased semantic fluency, while reduced gait speed was a
strong predictor of reduced semantic fluency and language skills, even when controlling
for educational level. Notably, the population showed a mean MMSE score that reflected
Appl. Sci. 2024, 14, 1500 8 of 13

that a proportion of the sample may have MCI, although these data should be treated
with caution.

4.1. Dynamic balance

Poorer dynamic balance performance was connected to cognitive impairment and
could be a risk factor for MCI in our sample. Along this line, the study by Greene and
Kenny [30], which examined the relationship between quantitative parameters of the TUG
and global cognitive function assessed to the MMSE, along with our present work, reported
similar associations. However, in their case, participants with a low level indicative of
dementia according to the test were excluded. In contrast, Katsumata et al. [31] concluded
that the TUG was not related to MMSE scores in their healthy 80-year-old population, as
did another study [32] with a population and methodology more similar to our study. The
latter two studies [31,32] further categorized the sample into groups based on dynamic
balance performance, as opposed to our use of continuous test values. There appears to be
no definitive consensus on this relationship. However, if we expand our examination with
more tests on functional decline that inform about the risk of MCI, more evidence points
toward an identifying and useful role for the TUG [33,34].
The relationship between dynamic balance and phonetic fluency, semantic fluency,
and language was also investigated. Our results indicated that older individuals with
better balance performance achieved better on these cognitive dimensions but there was no
evidence for phonetic fluency. It is worth noting that previous research studies showed a
relationship between TUG achievement and verbal fluency in aged individuals with and
without MCI, with more studies on phonologic [31,35,36] than semantic fluency [35]. The
lack of significance in the relationship with phonetic fluency in this study may have been
because, although both types of verbal fluency are important components of language
and communication, they focus on different aspects of language processing [37]. In the
semantic fluency test, category premises, and thus, access to the semantic lexicon, have an
influence [37]. This may result in a greater variety of responses and a better ability to detect
cognitive function than phonological fluency in a population that does not exhibit word
production problems, such as aphasia. Furthermore, there is no evidence of a relationship
between lexical retrieval difficulties as a measure of language using the BNT and balance,
as is the case for other physical aptitudes [38]. Therefore, this article provides a novel
finding for further exploration.
In brief, dynamic balance tests may be effective in the clinical setting to detect cognitive
decline in the aging stage. Moreover, future research should verify the association in older
people between dynamic balance and semantic fluency and language, with the latter mainly
assessed by the BNT.

4.2. Gait Speed

The link between gait performance and cognitive ability in aging has received in-
creased attention due to studies that demonstrated that gait is not solely a motor activity
but also involves cognitive processes [39]. In line with the aforementioned findings on
dynamic balance, our results also indicate that higher gait performance was associated
with better cognitive function, except for phonological fluency. On one hand, lower gait
speed is strongly linked to more significant overall cognitive decline, as assessed by MMSE
performance [40]. However, a recent study [34] that compared gait to other physical skills
demonstrated a stronger association with dynamic balance in healthy older individuals and
those with MCI. On the other hand, the relationship between gait speed and verbal fluency
appears more complex. Semantic fluency was found to be correlated in one study [41] but
not in another [42], while for phonological fluency [42], no significant relationship was
observed, aligning with our findings. A possible explanation for the lack of connection
between gait and phonological fluency might be similar to the relationship with dynamic
balance. Indeed, dynamic balance and gait are closely interconnected, as gait involves
effective dynamic balance. Moreover, both have an indirect link with cognitive flexibility,
Appl. Sci. 2024, 14, 1500 9 of 13

as the latter may influence a person’s ability to adapt to changing situations where gait and
dynamic balance become more crucial.
Furthermore, the specific relationship between gait and the BNT is not consistently sup-
ported. Although gait speed is the gait parameter most strongly studied with cognitive function,
regarding its association with language performance according to the BNT, Valkanova et al. [38]
observed that longer stride length was related to better language proficiency.
In short, gait speed testing, like dynamic balance, could be a practical tool for detecting
cognitive impairment in the aging. On the other side, more studies should clarify the
relationship between gait speed and verbal fluency and specifically study the gait speed
variable in relation to language.

4.3. Handgrip Strength

A previous study [40] documented a positive relationship between handgrip strength
and global cognitive function, as evaluated by the MMSE, in healthy older individuals
or those with MCI. Moreover, this relationship may carry more weight in women [43,44].
In contrast, our study found no such association, which aligns with the results of several
recent investigations [45–47]. In a cross-sectional study conducted by Jin et al. [45], there
was no evidence to suggest that increased handgrip strength led to higher global cognitive
function. It is worth noting that our study, like Jin et al.’s [45], dealt with a relatively
younger sample, around 60 years old, compared with octogenarian samples. This age
difference may have reduced the sensitivity of the measurement tests in detecting cognitive
and physical decline at these ages.
On the other hand, our findings regarding handgrip strength showed a positive rela-
tionship with improved phonological and semantic fluency, as well as language outcomes.
These associations are quite novel, as they were scarcely studied previously, especially in
the case of the association with semantic fluency, which has limited supporting evidence in
certain cross-sectional and longitudinal studies [12,48].
Therefore, it is imperative to conduct additional investigations to solidify our under-
standing of the correlation between handgrip strength and cognitive function. Similarly,
studies that investigate handgrip strength and its relationship with verbal fluency and
language are needed to support our novel findings.

4.4. Balance Confidence

The findings of this research also demonstrated that stronger balance confidence in
everyday tasks was associated with better verbal fluency and language skills but not with
overall cognitive function. As far as we are aware, no prior studies explored the association
between balance confidence and global cognition, and the dimensions of verbal fluency
and language in healthy older individuals. Notably, a recent study [49] investigated such
associations in aged individuals with MCI attributed to Alzheimer’s and Parkinson’s
diseases. Several cognitive tests were administered to a sample of individuals aged over
60 years, with some of these tests overlapping with the assessments used in the present
research. In contrast, the research paper by Chen et al. [49] reported a significant positive
correlation only within the Alzheimer’s group between performance on the MMSE test
and balance confidence. The differences in characteristics between our study sample and
that of Chen et al. [49] may have contributed to the divergent findings, as older individuals
with Alzheimer’s disease often have impaired perception of danger or incapacity [49].
In this context, current literature in healthy older adults [50] primarily investigates
balance confidence in relation to physical function and does not explicitly focus on its
relationship with cognitive function. Exploring this connection in future research may
provide valuable insights into these outcomes and help elucidate the link between the
perception of subjective balance and cognition.
Appl. Sci. 2024, 14, 1500 10 of 13

4.5. Covariates
All controlled covariates, except BMI, partnered with cognitive function, and educa-
tional level influenced the relationships between cognitive function and risk factors for
falls. It is widely acknowledged that educational level has a significant impact on cognitive
function [51], and even on areas of physical function, including walking speed and strength
in old age [38,48]. Formal education fosters the development of cognitive skills that can
help individuals maintain better cognitive performance as they age [51]. Similarly, age,
reflecting the aging process, and gender, which implies physiological differences in aging
and even cultural disparities in access to education [51], also play roles.
BMI appears to have some connection with the progression of MCI in individuals [51].
However, in the present research, the sample was primarily composed of individuals who
were overweight or obese, and this data distribution has not facilitated a precise study of
the impact of BMI.

4.6. Limitations and Strengths

Admittedly, these findings should be cautiously interpreted, as the current research
is limited in certain respects. Perhaps the most important limitation is the cross-sectional
design, which prevents the establishment of causal associations. Notably, the limited
number of male individuals in the sample did not allow for a balanced distribution of the
sexes. Additionally, the majority of the sample was overweight or obese, which complicated
the understanding of the impact of BMI on associations in older individuals.
However, despite the aforementioned limitations, this research possesses several
strengths. Cognitive function was assessed across multiple dimensions using validated
questionnaires. The physical tests employed to evaluate physical function are validated
and suitable for the target population. Furthermore, cognitively relevant covariates were
included, and the age of the sample is crucial for the early detection of MCI.

4.7. Implications and Future Research

The evidence presented in this paper implies that the strategies targeted at achieving
a high level of physical functioning may be successful in mitigating the risk of MCI and
preserving cognitive function in older individuals. Furthermore, our results also suggest
that the assessment of dynamic balance and gait speed could be useful tools at the clinician
level for the screening of cognitive impairment in aging people. Subsequent investigations
should validate the associations observed within this particular age group and explore
their long-term implications.

5. Conclusions
Increased gait speed, handgrip strength, balance, and balance confidence, which
lead to a reduced risk of falls, contribute to improved cognitive performance overall,
including the dimensions of verbal fluency and language, in individuals over the age of 60.
Furthermore, the level of education seems to play a role as a confounding factor in these
relationships. At the clinical implementation level, the assessment of dynamic balance and
gait speed could be useful tools for the screening of cognitive impairment in aging people.
Forthcoming studies ought to confirm the relationships identified within this specific age
range and delve into their potential long-term consequences.

Author Contributions: Conceptualization, J.D.J.-G., S.O.-G. and F.Á.-S.; methodology, J.D.J.-G.

and A.M.-A.; validation, J.D.J.-G. and S.O.-G.; formal analysis, J.D.J.-G.; investigation, J.D.J.-G.;
resources, J.D.J.-G. and A.M.-A.; data curation, J.D.J.-G.; writing—original draft preparation, S.O.-G.;
writing—review and editing, J.D.J.-G. and F.Á.-S.; visualization, S.O.-G.; supervision, A.M.-A.; project
administration, A.M.-A.; funding acquisition, A.M.-A. All authors have read and agreed to the
published version of the manuscript.
Funding: This research was funded by the 2014–2020 Operational Program FEDER in Andalusia,
grant number 1260735.
Appl. Sci. 2024, 14, 1500 11 of 13

Institutional Review Board Statement: The study was conducted in accordance with the Decla-
ration of Helsinki and approved by the Ethics Committee of the University of Jaén (DIC.17/5.TES
19 February 2018).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are available on request from the authors.
Acknowledgments: The authors extend their appreciation to the senior citizen volunteers who
graciously contributed their time to take part in the study. We also express our gratitude to the
professionals who were engaged in the process.
Conflicts of Interest: The authors declare no conflicts of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.

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