Protocol of a Randomized, Single-Blind, Controlled Trial of an 18-Month, Home-Based, High-Intensity, Exercise Intervention in Older, Cognitively Unimpaired APOE e4 Carriers

Stephen M Rao^1*Alexandria L Chorba¹MJ Helppi¹Alina Tuladhar¹Amanda Penko¹Sarah Holley¹Brandon Nehls¹Sabrina Paulino¹Matthew C Streicher¹Audrey Zhu¹Kellie Bruening¹Sally Durgerian¹Katherine A Koenig¹Mark Lowe¹Stephen E Jones¹Rachel Galioto¹Jagan A Pillai¹Lynn M Bekris²James B Leverenz²Anson B Rosenfeldt¹Tamanna Singh¹Gerald J Beck¹J. Carson Smith³Jay Alberts¹

• ¹Cleveland Clinic, Cleveland, Ohio, United States
• ²University of Washington, Seattle, Washington, United States
• ³University of Maryland, Baltimore, Maryland, United States

The World Health Organization highlighted the potential protective role of exercise against cognitive decline, all-cause dementia, Alzheimer's disease (AD), and vascular dementia in healthy individuals. We have previously shown that exercise is particularly beneficial for older, cognitively unimpaired apolipoprotein E4 (APOE e4) carriers. A key unanswered question is whether a long-term, high-intensity aerobic exercise intervention initiated in a cohort of previously inactive older individuals at genetic risk for AD has neuroprotective properties. Design: CYCLE-AD is a randomized, single-blind, single-center, controlled trial of a home-based, high-intensity exercise intervention involving 150 older e4 carriers (ages 65-80 years) who are healthy, cognitively unimpaired, and physically inactive. Participants are randomized into two groups: Indoor Cycling (IC) or Usual and Customary Care (UCC) (target of 75 each). IC participants exercise 3x/week on an upright stationary cycle ergometer at a moderate-vigorous intensity for 18 months. Those in the UCC group are expected to maintain enrollment levels of activity.Outcomes: Comparison of IC and UCC groups on change in primary and secondary outcomes over baseline, 9-month, and 18-month evaluations. Primary outcomes are VO2peak (Fitness), 5-trial total recall on the Rey Auditory Verbal List Learning Test (Episodic Memory), and total hippocampal volume derived from structural MRI (Brain Atrophy). Secondary outcomes include comprehensive neurocognitive and physical function test batteries, MRI scans including structural and functional connectivity measures, and blood-based biomarkers. Hypotheses: Over an 18-month interval, physically inactive e4 carriers who engage in high-intensity aerobic exercise will demonstrate less cognitive decline and hippocampal atrophy than physically inactive e4 carriers who did not participate in a formal exercise program. Conclusion: Successful demonstration of a scalable, home-based, high-intensity aerobic exercise intervention in altering the trajectory of AD pathophysiology and its effects on cognitive functioning will transform AD treatment, improve patient outcomes and quality of life, and reduce health care costs. ClinicalTrials.com registration number: NCT04748861