Environmental Enrichment to Strengthen Intrinsic Capacity for Older Adults with Stroke and Multimorbidity: A Community-Based Cluster-Randomized Controlled Trial

Abstract

Background: Older adults living with stroke and multimorbidity often need sustained, function-centred support beyond acute care. Environmental enrichment (EE) provides a multidomain paradigm with evidence from preclinical work and small inpatient studies, but community translation remains limited. We developed a Community-Empowerment and Environmental Enrichment–based Co-management (CEEEC) model and evaluated its implementation and effects in Kunshan, China.Methods: Following formative work (stakeholder interviews and pilot testing), we conducted a 2×2 factorial cluster-randomised controlled trial across 32 community health stations. Community-dwelling adults aged ≥60 years with prior stroke and comorbid hypertension and/or diabetes were allocated by cluster to cognitive enrichment, physical enrichment, combined enrichment, or usual-care control. The 20-week “vitality camp” comprised four family physician–led activation sessions (Weeks 1–7) and four nurse/community health volunteer–led reinforcement activities (Weeks 8–20). The primary outcome was intrinsic capacity (IC) at 20 weeks, analysed according to randomised assignment using mixed-effects models.Results: A total of 455 participants completed baseline assessment, and 412 were included in the primary complete-case analysis. Delivery through routine community health stations achieved substantial participant exposure (mean attendance 6.31 of 8 sessions). In the primary factorial analysis, physical enrichment improved IC at 20 weeks (adjusted mean difference [AMD] 0.155, 95% CI 0.035 to 0.276). The cognitive enrichment main effect was smaller and less precise (AMD 0.087, 95% CI −0.035 to 0.208). There was no clear evidence of interaction between the cognitive and physical components, with the interaction estimate close to null (AMD −0.047, 95% CI −0.289 to 0.194). Physical enrichment also improved SPPB (AMD 0.715, 95% CI 0.173 to 1.257) and EQ-5D index (AMD 0.030, 95% CI 0.003 to 0.057).Conclusions: An EE-informed community co-management model can be delivered through existing primary care infrastructure with substantial participant exposure. Over 20 weeks, physical enrichment showed the clearest evidence of benefit on IC, whereas the cognitive enrichment effect was directionally positive but less precisely estimated. No clear departure from additivity was detected. These findings support further optimisation and longer-term evaluation of EE-informed community delivery for function-centred management in older adults living with stroke and multimorbidity.