Strategies Used by Middle-Aged Persons with Mild Neurocognitive Disorder to Maintain Brain Health: A Scoping Review Protocol

Brain health

The concept of ‘brain health’ has gained increasing recognition as a lifespan approach to cognitive well-being (Baumgart et al., 2015; Brain Health Scotland, 2022). Unlike ‘dementia risk-reduction’, which is often perceived as relevant only in later life, brain health resonates with individuals across different age groups and fosters engagement in long-term preventive strategies and resilience (Alzheimer’s Research UK, 2021; Arenaza-Urquijo & Vemuri, 2020). A concept analysis by Chen et al. (2022) framed brain health as an ongoing state encompassing both typical ageing processes and pathological conditions. This definition was further enhanced by the World Health Organisation (WHO), who described brain health as “functioning across cognitive, sensory, social-emotional, behavioural and motor domains, allowing a person to realize their full potential over the life course, irrespective of the presence or absence of disorders” (WHO, 2022, P. 17). Midlife offers a critical window for preventive interventions to optimise brain health, such as addressing modifiable risk factors, which begin to exert a significant influence on brain health trajectories (Livingston et al., 2020). Some of these modifiable risk factors include physical activity, mental stimulation, sleep quality and stress management, while non-modifiable factors include genetics and biological aging (Alzheimer’s Research UK, 2021; Won et al., 2025).

Brain health research gaps in midlife

Despite recent global efforts to integrate brain health into healthcare frameworks, disparities persist, particularly for individuals at midlife with mNCD who encounter unique challenges in maintaining cognitive function while managing occupational and social responsibilities (Irwin et al., 2018). Research on non-pharmacological strategies to improve and maintain brain health, including cognitive training, physical exercise, dietary modifications, and social engagement, has predominantly focused on older adults (Rosenberg et al., 2018; Treacy et al., 2023; Yaffe et al., 2024). In addition, while research in other health domains, such as cardiovascular disease and diabetes prevention, suggests that middle-aged individuals often struggle to sustain preventive behaviours due to time constraints, financial pressures, and limited health literacy, this has not been explored in the context of dementia prevention (Sun et al., 2020). Health-related and cultural inequities and disparities, such as accessibility to services, ethnicity and education, in dementia are well documented (Gove et al., 2021; Giebel et al., 2024). However, the impact of health inequalities and disparities on brain health interventions in midlife has not been explored.

There is also some conflicting evidence that suggests individuals with greater awareness of dementia risks are more likely to engage in brain health activities (Ngandu et al., 2015), while others indicate that awareness alone is insufficient (van Asbroeck et al., 2021).

Rationale for scoping review

Considering the identified research gaps, a systematic mapping of existing literature is needed to identify how younger individuals with mNCD maintain their brain health, as well as the barriers, facilitators and decision-making processes influencing their engagement. To ensure a comprehensive and inclusive approach to evidence synthesis, this scoping review will be informed by the Cochrane Equity Framework (Welch et al., 2024), which emphasises the importance of identifying and addressing health inequities across populations. Mapping evidence through an equity lens will help identify gaps in intervention reach, relevance, and adaptability across diverse populations. This aligns with the WHO’s call to prioritise equity in brain health initiatives as part of achieving universal health coverage and reducing health disparities globally (WHO, 2022) and the WHO’s Global Action Plan on the public health response to dementia 2017–2025 (WHO, 2017), by promoting tailored public health responses at both national and local levels.

Research aim & objectives

This study aims to systematically review the existing literature to provide a comprehensive understanding of the various brain health strategies used by this population. It seeks to evaluate the effectiveness of these approaches, identify patterns and gaps and highlight opportunities for future research and practice advancement of evidence-based interventions in brain health in published evidence

The objectives are to:

Design

This proposed systematic scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (Hadie, 2024; Peters et al., 2020) and recommendations from (Levac et al., 2010), which was built on previous the existing theoretical framework of Arksey and O’Malley (2005). This methodology was chosen due to its transparency, through publication of a pre-defined protocol and explicit data extraction and analysis, as well as its alignment with international reporting standards.

A five-stage process will be employed throughout the review process and has been used in the development of this scoping review protocol. Below is an overview of each stage, with section headings adapted from Levac et al. (2010). Reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Scoping Review extension (PRISMA-ScR) checklist, to ensure compliance with up-to-date PRISMA reporting guidance (Tricco et al., 2018).

Stage 1 Identifying the research question

The Population, Concept, Context (PCC) model (Peters et al., 2020), widely recommended for scoping reviews, was used to determine the focus of the research question and to formulate inclusion and exclusion criteria.

The primary research question is: "How do middle-aged individuals with mild neurocognitive disorder maintain brain health?”

The review will also address other secondary questions:

Population: This population of interest in this review includes adults aged between 40 and 65 years of all genders, ethnicities, and socioeconomic backgrounds diagnosed explicitly with a mild neurocognitive disorder. Individuals in this age group represent a distinct subgroup often described as having early-onset cognitive impairment, encompassing people in early or midlife adulthood, whose life circumstances, responsibilities, and coping strategies differ substantially from older individuals with late-onset cognitive disorders. Studies involving individuals with advanced or major neurocognitive disorders, such as dementia, will be excluded.

Concept: This review will focus on identifying and exploring specific strategies actively undertaken or adopted by individuals with mNCD to maintain or improve their brain health. These strategies will include individual, family, organisational, and population-level practices, approaches, activities, or interventions, such as lifestyle modifications, cognitive stimulation, social engagement, psychological approaches, using technological tools, and non-pharmacological methods. Studies involving strategies solely administered by health care professionals or researchers without active participant engagement or purely diagnostic measures will be excluded. The aim is to understand what people actively do in daily life contexts, reflecting choices and behaviours that can realistically support brain health.

Context: This review will include studies conducted globally in real-life settings, such as home-based, residential care, clinical and community to capture approaches realistically implemented by individuals with mNCD in their daily lives. Studies conducted exclusively in controlled laboratory environments will be excluded, as these interventions may not reflect the practical behaviours that individuals typically adopt to maintain brain health.

Stage 2 Identifying relevant studies

The scoping review will follow the three-step search strategy recommended by the JBI methodology (Hadie, 2024; Peters et al., 2020):

Five electronic databases will be searched: PubMed, Embase via Elsevier, CINAHL via EBSCOhost, PsycINFO and Cochrane Library. PubMed, Embase and CINHAL will be used as they index a number of medical and health science journals. PsycINFO will be used because it includes international literature on psychology which may provide important articles on the emotional processes and behavioural research. Grey literature sources such as publications from WHO, Lenus (the Irish Health Repository), National Institute for Health and Care Excellence (NICE) and Guideline Central will also be included.

2.1 Eligibility criteria

The inclusion and exclusion criteria for this scoping review is provided in Table 1 below.

2.1 Search strategy

The researchers will work with a librarian to refine the search strategy to ensure that relevant and key articles are found. The search strategy, including all identified keywords and index terms, will be adapted for each included database. The initial search strategy for PubMed is included in Table 2.

Stage 3 Study selection

Following the search, all identified citations will be collated and uploaded into Endnote 21 and uploaded into Covidence. EndNote 21 was chosen as citations can be efficiently uploaded into it from database searches, full texts can be attached to their citations and stored within it. Covidence is a software tool that streamlines the review process by enabling collaborative screening, data extraction, and quality assessment, while automatically identifying and removing duplicates (Babineau, 2014). It is available online (https://www.covidence.org). Covidence was chosen because it is compatible with EndNote. The study selection will be carried out in four stages:

The results of the search will be presented in a PRISMA flow diagram.

Stage 4 Data extraction

Once all articles have been reviewed for inclusion, data extraction will commence. Data extraction will be completed for each included full text article using a data extraction form via Microsoft Excel platform. The form will be developed using expertise within the team and pilot tested for applicability and usability (first five studies) and will be modified as necessary. Independent data extraction of 50% of included studies will be proposed to reduce errors in reporting. Variables to be extracted may be updated at this stage, if other salient data becomes apparent, and the data extraction form will be finalised. Data will be extracted on:

The evidence from included studies will be mapped for equity reporting, using the Cochrane PROGRESS-Plus tool, which identifies characteristics that stratify health opportunities and outcomes. PROGRESS-Plus is an acronym used to identify social, economic, and cultural characteristics that may influence health opportunities and outcomes (O’Neill et al., 2014). It refers to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, social capital, personal characteristics, features of relationships and time-dependent relationships. It is available online (https://methods.cochrane.org/equity/projects/evidence-equity/progress-plus).

Stage 5 Summarising & Reporting results

All data extracted will be mapped into tabular format, based on descriptive headings in the data extraction form, and accompanied by a narrative summary of the results in line with the review objectives. A comparison of strategies and outcomes from mapping to equity tool will be included in the discussion.