Electronic ISSN 2287-0237

VOLUME

EFFECT OF A COGNITIVE STIMULATION THERAPY PROGRAM ON COGNITIVE ABILITY OF DEMENTED OLDER ADULTS

FEBRUARY 2019 - VOL.15 | ORIGINAL ARTICLE

Cognition, the ability to process thought, entails perceiving,saving, recalling and using information. The World HealthOrganization (WHO) lists components of cognition as language,thought, memory, executive function, judgment, attention, and perception.1Preserving multidimensional cognitive structure allows older adults tomaintain social connectedness, an ongoing sense of purpose, the abilityto function independently, functional recovery from illness or injury,and the ability to cope with residual functional deficits.2 The brain maybe able to achieve new or regain lost functions by changing its internalconnectivity network. Due to interaction between neuronal plasticityand cognitive plasticity, the aging brain can reorganize cognitive demandor cognitive plasticity as needed.3 However, cognitive ability declinedoes occur, and includes memory disorders, neuropsychiatric symptoms,orientation disorder, aphasia, apraxia, agnosia, executive functiondisorder, and personality change.4,5

Dementia is a group of symptoms characterized by significantcognitive decline from a previous level of performance in one or morecognitive domains, such as learning and memory, language, executivefunction, complex attention, perceptual-motor, and social cognition.6,7Dementia results from a variety of diseases and injuries that primarilyor secondarily affect the brain; it is chronic and progressive.1 Globally,over 47 million people have dementia and over 7 million new cases arerecorded every year.8,9 The prevalence of dementia is much greater in institutionalized elderly than among community-dwellingelderly; one German study found dementia in 51.8 %of nursing home residents compared to 2.7 % in communitydwellingelderly.10 In Indonesia, while there are no records ofthe total population of nursing home elderly, it was reportedthat in 2016 there were 1.2 million Indonesians living withdementia.11,12 The growing prevalence of dementia hassubstantial macro- and micro-level effects. Dementia affectsnot only the older adult’s life physically, psychologically andsocially, but also the family, economy and society.1,13

Dementia affects each older adult in a different way,depending on the type, level, and area of the brain affected,and the personality of the older adult before becoming ill. Theprogression of dementia is assessed by instruments withvarying rating schemes, such as the Global Deterioration Scale7, the Functional Assessment Staging Test 7, the ClinicalDementia Rating, and the Mini Mental State Examination. TheMini Mental State Examination, used in this research, is athree-stage model: early, middle, and late stages. Early stagetraits include forgetfulness, losing track of time and becominglost in familiar places. Middle stage features forgetting recentevents and people’s names, becoming lost at home, havingincreasing difficulty with communication, needing help withpersonal care, and experiencing behavior changes includingwandering and repeated questioning. Late stage is characterizedby becoming unaware of time and place, having difficultyrecognizing relatives and friends, having an increasing needfor assisted self-care, having difficulty walking, and experiencingundesirable behavior changes that may escalate and includeaggression.1 A social consequence of dementia is that olderadults with dementia are often dehumanized due to beingperceived as having lost autonomy, dignity and control andthus respectability.13

Dementia caregiving, especially for often-untrainedfamily members, is difficult.14 A study of 401 dementia familycaregivers, found that 64.26 % have ambivalent feelings.Caregiving can affect the mental health of family caregivers,e.g., depression and/or anxiety. This is especially true for familycaregivers who have to deal with the behavioral and psychologicalsymptoms of dementia (BPSD) such as agitation (e.g., aggression,screaming), psychiatric symptoms (e.g., delusions, hallucinations),personality changes (e.g., inappropriate sexual behavior,disinhibiting), mood disturbances (e.g., apathy, depression,euphoria, emotional lability), aberrant motor movements (e.g.,pacing, rummaging, wandering), and neuro-generativechanges (e.g., appetite changes, sleep disturbances).15 Cognitivedeterioration thus has significant challenges for family andprofessional caregivers, and anything that can preserve orprolong cognitive ability is highly desirable.

There is currently no cure for dementia. Several newtreatments are in various stages of clinical trials.1 Since a cureis not possible, pharmacological and non-pharmacologicaltherapies are aimed at slowing cognitive decline. Caring for older adults with dementia often is a combination ofpharmacological and non-pharmacological approaches.2Pharmacological therapy often focuses on replacing dopamineand cholinesterase inhibitors (CIs). Non-pharmacologicaltherapies, too, are constantly being developed and evaluated.16Several studies that reviewed non-pharmacological therapiesconclude that their efficacy is limited.17-19

Non-pharmacological therapies such as cognitive-based,psychosocial, movement or sensorial therapies have been suggestedto help slow or manage the progression of dementia.Cognitive-based interventions rely on brain plasticity theoryand include cognitive training, cognitive rehabilitation, andcognitive stimulation.20 Cognitive stimulation has producedsignificant improvement as measured by the mini mentalstatus examination (MMSE) and Alzheimer’s DiseaseAssessment Scale-cognitive subscale (ADAS-Cog).21 Realityorientation and CST could significantly improve MMSE,ADAS-Cog, and Quality of Life in Alzheimer’s Disease(QoL-AD) scores, and was also cost-effective.22

Cognitive stimulation is a therapy that engages the personwith dementia in a range of group activities and discussionsdesigned to enhance cognitive and social functioning. It is anon-pharmacological group intervention whose sessionsinclude topics such as life history and current events.CST-Hong Kong reported that seven weeks of CST improvedcognition, communication, and quality of life in older peoplewith mild to moderate cognitive impairment.23 CST is usuallydelivered in clinical or other health care settings, but it couldeasily be adapted and integrated into non-institutional routinepractice.23 CST was found, even from the perspective ofstakeholders, to improve communication, enhance socialization,intensify commitment, strengthen self-efficacy, and improveinterpersonal relationships.23 CST-J (Japanese version),concluded that benefits included improved cognition andquality of life of people with dementia.16 In Indonesia there isno formal program such as CST in nursing homes; there are,however, nurse-led group activities such as art therapy (drawingand singing), playing games (puzzles, guessing an animal byits sound), and exercise (“healthy gym”).

CST is non-pharmacological, so it often costs less thanpharmacological therapy. In addition, it is easily administeredsince there are no side effects for demented older adults. InIndonesia there are few dementia studies, especially ofnon-pharmacological therapies. There are few if anygovernment or private agency created guidelines fornon-pharmacological therapy for people with dementia. Butthere appears a need for such therapy. In nursing homes, theliterature revealed that older residents had moderate cognitiveimpairment.16 To add to a very limited database, this studyexamined the effects of a CST program on the cognitiveability of older nursing home residents with mild to moderatedementia, using the “Making A Difference” manual.24

A quasi-experimental design was used in this study.Demented older adult participants from two nursing homes indifferent cities (randomly assigned as experimental andcontrol) were randomly chosen from those residents meetinginclusion criteria. Nursing home staff collected data beforeand after the intervention. The nursing homes are similar indesign, function and activities. The population for this studywas Indonesian adults aged 60 and over with mild or moderatecognitive impairment based on the MMSE Indonesian version.The sampling frame was mild-to-moderate demented olderadults in two nursing homes in East Java, Indonesia. Thefollowing inclusion criteria were applied:

  1. Mild to moderate dementia (MMSE Indonesian version;score of 20-25 is mild cognitive impairment, 10-20 ismoderate cognitive impairment)
  2. Able to speak and write in Indonesian
  3. No mobility limitation that would interfere with participation
  4. No auditory or visual impairment that would interferewith participation

There was one exclusion criterion: A chronic disease (e.g.,heart or respiratory condition) that could be exacerbated byparticipation.

Sampling

From five nursing homes in two East Java cities, theresearchers randomly chose one from each city. One nursinghome was randomly chosen to be the experimental group site;the other was the control group site. Simple random samplingtechnique was used to select participants, as described below:

Research instruments

The instruments used in this study were a demographicquestionnaire, the MMSE Indonesian version, and CST(consisting of the program and supporting materials).

  1. Demographic Questionnaire, developed by theresearchers, gathered data on age, gender, education,most recent employment status, and duration ofdementia.
  2. Mini Mental Status Examination (MMSE), Indonesianversion: This instrument measures cognitive ability. Its30 items are divided into dimensions of orientation (10items), registration (3 items), attention and calculation(5 items), recall (3 items), and language (9 items). Itthus measures orientation, language, concentration,constructional praxis, and memory. In this study theresearchers focused on degree of impairment in thisresearch. Impairment categories and their scores were25-30 (questionable significance), 20-25 (mildimpairment), 10-20 (moderate impairment), 0-10(severe impairment).
  3. CST Program: The CST program was delivered, perthe manual, in 14 sessions: three 45-minute sessions perweek for five weeks (including the first, non-CSTsession, when the MMSE was administered).

Ethical Considerations

  1. The research was approved by the Institutional ReviewBoard (IRB approval 06-02-2561) of the Faculty ofNursing for Graduate Studies, Burapha University, Thailand.
  2. Approval was received from the directors of the nursinghomes in East Java, Indonesia.
  3. After participants were informed verbally and via aninformation sheet about the topic and purpose of thestudy, a written informed consent document was signedby each participant.
  4. The researchers ensured that participants’ identities andall data obtained would be kept confidential andaccessible only by the researchers.
  5. The researchers ensured the rights and privacy of theparticipants.6. Participants were informed that they receive no financialor other type of remuneration by participating in this study.

Data collection procedures

Data collection was carried out by the researchers withassistance from nursing home staff, who administered theMMSE. Data collection proceeded as follows:

Data analysis

Data entry and statistical analysis was performed usingSPSS version 18. The significant level of statistical tests wasset at 0.05. Descriptive and t-test statistics were used.Kolmogorov-Smirnov was used to test for normal distribution.Age, MMSE pre-test and MMSE post-test were normallydistributed. Descriptive statistics describing the sample weremeans, standard deviations, frequencies, and percentdistributions. Paired t-tests assessed the differences in cognitiveability mean scores at pre-test and post-test within theexperimental and control groups. Independent t-test assessedthe difference in cognitive ability mean scores from pre-testto post-test between experimental and control groups.

Characteristics of the sample: Table 1 shows demographicdata for the fifty-four participants who met the inclusioncriteria and comprised the sample for the study. About half theolder adults in both experimental and control groups were aged70-79. A majority of the control group was male (59.3%),while the same majority in the experimental group was female(59.3%). In both groups a solid majority had experienced12-24 months of dementia (85.2% in the control group, 70.4%in the experimental group). A plurality of the control groupand a majority of the experimental group had completed highschool and more than high school (77.8% and 74.1%respectively). Over 80% in both groups were married, and themajority of older adults in both groups had worked in theprivate sector worker and laborers (Table 1).3. After participants were informed verbally and via aninformation sheet about the topic and purpose of thestudy, a written informed consent document was signedby each participant.4. The researchers ensured that participants’ identities andall data obtained would be kept confidential andaccessible only by the researchers.5. The researchers ensured the rights and privacy of theparticipants.6. Participants were informed that they receive no financialor other type of remuneration by participating in this study.Data collection proceduresData collection was carried out by the researchers withassistance from nursing home staff, who administered theMMSE. Data collection proceeded as follows:

At the pre- test period, the mean cognitive ability score ofthe control and experimental groups were not significantlydifferent (p = 0.161). Regarding cognitive ability, we canpresume both groups were statistically similar. However, atthe post-test period, mean cognitive ability score in theexperimental group was significantly higher than that in thecontrol group (p < 0.001) Table 2.

In the control group, pre-test and post-test meancognitive ability scores were not significantly different(p = 0.058). Whereas in the experimental group, post-testmean cognitive ability score was significantly higher than thepre-test mean cognitive ability score (p < 0.001). The groupreceiving CST improved cognitive ability significantly at theend of the intervention, and the improvement was significantcompared to any improvement in the control group (Table 3).

In this research, consistent with some previous studies, aCST program significantly improved the cognitive ability ofdemented older adults. While dementia inherently meanscognitive impairment, through CST older adults appear torecapture cognitive ability via enjoyable, nonjudgmental,unpressured group social activities, supervised by staff butoften with a participant acting as the leader. The implicationis that, for one reason or another, people with mild to moderatedementia may perform below their true cognitive level, andCST motivates them to return to their maximum cognitivefunctioning.16,22

Table 1: Characteristics of the sample.

Table 2: Pre-test and Post-test mean cognitive ability scores ofexperimental and control groups.

Table 3: Control and Experimental group pre-test and post-test meancognitive ability scores.

Via CST, new learning seems to occur inside meaningfulconversation in small groups. In the therapeutic context,reality orientation was the most used during the 14 CSTsessions. (A description of the 14 sessions is in Appendix A.)It is possible that reality orientation encourages the dementedbrain to reorganize to satisfy cognitive demand, enhancing theformation of new neuronal pathways between brain regions.3The result is improvement in verbal abilities, cognition,memory, learning, information and orientation.20,25

Reminiscence therapy, in this case group discussion ofexperiences and events, is also in evidence. Recountingpleasant experiences and sharing memories of happiness couldimprove dopamine production and stimulate neuronal activity,expanding brain synapses.3 This could improve cognitiveabilities, enhancing social interaction, coping skills,communications skills, and relationships, and decreaseinappropriate and undesirable behaviors.20,26 Verbally sharinggood experiences ¯ for example, favorite places or songs ¯seemed the preferred activity for the older adults in this program.

The shared experiences and values that come withmembership in a common cohort means participants candiscuss experiences and feelings others can understand andempathize with. This facilitates quality interaction andrelationship-building.

Validation therapy was used throughout the program.Initially each group chose a name and a group song, whichthey sang before each session. In addition, at the start of eachsession the leader asked participants to recall the group’s name,the group song, the name of their nursing home, the date andthe city in which they live. This helped participants tocommunicate and express their feelings and emotions with theother participants. No matter how nonsensical or illogical itseemed, it was viewed as an attempt to facilitate interpersonalconnection. Throughout the CST program, communicationbetween participants improved as they met three times perweek, promoting conversation, sharing activities, allowing theexpression of mutual respect, and assisting each other whenone of them had a moment of cognitive failure.

In conclusion, CST, which utilizes reality orientation,reminiscence therapy, and validation therapy, provided 14sessions of activities stimulating cognitive functioning. Theresults of this quasi-experiment in East Java, Indonesia showedsignificant improvement in the cognitive ability of dementedolder adults. Therefore, nurses and health care teams couldapply this program for enhancing cognitive ability of olderadults in Indonesia. In addition, future research can focus notonly on moderate and mild cognitive impairment but onvarious dementias.