By Dianne Augelli, MD
Synopsis: This study showed improvement in sleep and cognitive endpoints in patients with sleep disorders and mild cognitive impairment (MCI) treated with a combination of repetitive transcranial magnetic stimulation and tai chi chuan.
Source: Liu Z, Zhang L, Bai L, et al. Repetitive transcranial magnetic stimulation and tai chi chuan for older adults with sleep disorders and mild cognitive impairment. JAMA Netw Open. 2025;8(1):e2454307.
The study explored the effects of combining repetitive transcranial magnetic stimulation (rTMS) with tai chi chuan (TCC) on older adults experiencing mild cognitive impairment (MCI) and sleep disorders. Given the increasing concern that sleep disorders may worsen cognitive decline, the study sought to assess nonpharmacological strategies to improve cognitive function and sleep. TCC previously had been shown to improve cognition for patients with MCI and early stage dementia.1 A separate study concluded that the use of TCC and rTMS positively affected sleep in older adults with insomnia.2 The study authors postulated that combining TCC and rTMS could further enhance sleep effects of TCC and potentially improve the durability of response.
This study was a two-arm, sham-controlled, assessor-masked randomized clinical trial conducted at a university hospital in China. The researchers enrolled 110 participants aged 60 to 75 years with diagnosed primary insomnia and MCI. Participants were randomly assigned to either an experimental group (TCC + 1-Hz rTMS) or a sham group (TCC + sham rTMS). The intervention involved 30 sessions of TCC over six weeks, alongside rTMS targeting the right dorsolateral prefrontal cortex (DLPFC).
The primary outcomes were sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI), and global cognitive function, assessed using the Montreal Cognitive Assessment (MoCA). Secondary outcomes included objective sleep actigraphy, anxiety and depression scales, and additional cognitive measures. Assessments were conducted at baseline, post-intervention (six weeks), and at a follow-up (12 weeks).
The experimental group demonstrated improvements in both primary outcome measures compared to the sham group: PSQI scores were lower in the experimental group post-intervention (mean difference: -3.1; 95% confidence interval [CI], -4.2 to -2.1; P < 0.001), suggestive of better sleep quality. MoCA scores showed statically significant improvement in the experimental group (mean difference: 1.4; 95% CI, 0.7-2.1; P < 0.001), suggesting enhanced cognitive function. These primary measures showed improvement through the 12-week follow-up period.
Secondary outcomes measured by the Epworth Sleepiness Scale (EPSS) showed a decrease in daytime sleepiness. A decrease in depression scores also was noted in the treatment group, as measured by the Hamilton Depression Rate Scale (HDRS). Improved memory function as indicated by the Wechsler Scale-Revised memory quotient (mean difference: 8.8; P < 0.001) also was noted. Objective measure of sleep was recorded via actigraphy for the first six weeks. No significant adverse events were noted with this combination of interventions.
Commentary
This study was the first to explore the combination of rTMS and TCC as a potential intervention for patients with MCI and insomnia. Medication management in this population is challenging, given the concern for worsening of cognitive function because of burdensome medication side effects. As a result, new nonpharmacological pathways are important areas of future research. This study showed promising improvement in cognition, perceived sleep quality, and mood. However, research regarding the efficacy of rTMS for insomnia remains mixed.3
Objective sleep data were limited to wrist actigraphy and only in the first six weeks, with no follow-up monitoring through the duration of the trial. This limitation restricts the ability to quantify more objective measures of sleep and to assess the durability of those changes. Although the treatment group showed a 1% improvement in sleep efficiency, there were no significant changes observed in sleep duration, wake after sleep onset, or sleep latency. Additionally, there was improvement in depression scores. A well-established bidirectional relationship exists between sleep and mood. Thus, it is difficult to discern if observed cognitive and sleep benefits resulted from intrinsic sleep changes or from mood improvements.
Further studies using neuroimaging, biomarkers, electroencephalography, and extended objective sleep monitoring are needed to further clarify these findings. Nevertheless, this study does introduce a safe and novel therapeutic pathway for patients with both insomnia and MCI.
Dianne Augelli, MD, is Assistant Professor of Clinical Medicine, Weill Cornell Medical Center.
References
1. Jasim N, Balakirishnan D, Zhang H, et al. Effects and mechanisms of tai chi on mild cognitive impairment and early-stage dementia: A scoping review. Syst Rev. 2023;12(1):200.
2. He J, Chan SH, Lin J, Tsang HW. Integration of tai chi and repetitive transcranial magnetic stimulation for sleep disturbances in older adults: A pilot randomized controlled trial. Sleep Med. 2024;122:35-44.
3. Oroz R, Kung S, Croarkin PE, Cheung J. Transcranial magnetic stimulation therapeutic applications on sleep and insomnia: A review. Sleep Science Practice. 2021;5(3). doi:10.1186/s41606-020-00057-9
This study showed improvement in sleep and cognitive endpoints in patients with sleep disorders and mild cognitive impairment (MCI) treated with a combination of repetitive transcranial magnetic stimulation and tai chi chuan.
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