Exercise-based interventions for cognitive frailty in older adults: a systematic review and network meta-analysis

Cognitive frailty is a potentially reversible geriatric condition characterized by the coexistence of physical frailty or prefrailty and cognitive impairment in the absence of dementia. Exercise-based interventions may improve both cognitive and physical function, but their comparative effects across different exercise modalities remain uncertain. This systematic review and network meta-analysis was conducted according to PRISMA-NMA guidance and prospectively registered in PROSPERO. PubMed, Embase, the Cochrane Library, Web of Science, MEDLINE via Ovid, Scopus, CNKI, Wanfang, VIP, Google Scholar, and ProQuest were searched from inception to August 16, 2026. Randomized controlled trials involving older adults with cognitive frailty were included. Bayesian random-effects network meta-analyses were performed for MoCA, MMSE, TUG, grip strength, and SPPB. Risk of bias was assessed using RoB 2, and certainty of evidence was evaluated using CINeMA. Nineteen publications representing 17 independent randomized trial datasets and 1,691 unique participants were included. For MoCA, multicomponent exercise (ME) showed the most favorable ranking profile (MD = 4.81, 95% CrI − 0.27 to 10.66), whereas Baduanjin combined with cognitive training (BCCT) was the only intervention whose 95% CrI excluded the null (MD = 4.25, 95% CrI 0.22 to 8.39). Daily living rehabilitation training ranked highest for MMSE, Otago exercise for TUG, ME for grip strength, and Tai Chi for SPPB; however, the corresponding credible intervals all included the null. Substantial heterogeneity was observed for MoCA, while several physical-function networks were sparse and formal inconsistency assessment was frequently not possible. Sensitivity analyses generally preserved the main ranking patterns, although several leading nodes were supported by limited evidence. The certainty of evidence was predominantly moderate to low, with some comparisons rated as very low. Exercise-based interventions showed potentially favorable but outcome-specific effects in older adults with cognitive frailty. ME and BCCT showed favorable signals for cognitive outcomes, while OE, ME, and TC ranked relatively highly for selected physical outcomes. However, sparse networks, imprecise estimates, substantial heterogeneity, and moderate-to-low certainty limit confidence in treatment rankings. These findings should therefore inform future comparative trials rather than be interpreted as definitive evidence for individualized exercise prescriptions.