Is a program to improve grocery-shopping skills clinically effective in improving executive function and instrumental activities of daily living of patients with schizophrenia?

Journal Pre-proof Is a program to improve grocery-shopping skills clinically effective in improving executive function and instrumental activities of daily living of patients with schizophrenia? Yong-sup Kim, Jin-Hyuck Park

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https://doi.org/10.1016/j.ajp.2019.101896

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Please cite this article as: Kim Y-sup, Park J-Hyuck, Is a program to improve grocery-shopping skills clinically effective in improving executive function and instrumental activities of daily living of patients with schizophrenia?, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101896

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Is a program to improve grocery-shopping skills clinically effective in improving executive function and instrumental activities of daily living of patients with schizophrenia?

Yong-sup Kim

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Jin-Hyuck Park Soonchunhyang University

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[email protected]

Highlights

We study the effect of grocery shopping skill training in patients with schizophrenia.

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Executive function and instrumental activities of daily living were improved significantly after training.

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Grocery shopping skill training might be useful to improve Executive function and instrumental activities of daily living of patients with schizophrenia.

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Abstract

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To date, cognitive intervention to improve executive function for patients with schizophrenia has not been ecologically validated. Our main objective was to investigate the effectiveness

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of grocery shopping skill program on executive function and instrumental activities of daily living (IADL) of patients with schizophrenia. Among 20 patients with schizophrenia who received conventional rehabilitation, 10 patients were allocated to an experimental group and they additionally performed the program to improve grocery shopping skill in a real situation for eight sessions. The rest of participants were assigned to the wait-list group. To identify the effects on executive function, the Korean version of the Executive Function Performance

Test (EFPT-K) was used. IADL was evaluated using the Korean Instrumental Activities of Daily Living (K-IADL). After the sessions, the EFPT-K (p<.001) and K-IADL (p<.05) were significantly improved in the experimental group. These results indicate that the program to improve grocery shopping skills might be clinically beneficial to enhance executive function and IADL of patients with schizophrenia.

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Key words: Schizophrenia, Executive function, Occupational therapy intervention, Occupational

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performance, cognitive function

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1. Introduction

Schizophrenia is a chronic disease with frequent recurrence and occurs mainly

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between 15 and 44 years of age (Lincoln, Lüllmann & Rief, 2007). Chronic schizophrenia can impair independent life skills, social functioning, and professional performance (Levaux

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et al., 2012), which in turn affect the lives of family members and other people, resulting in high social costs (Combs, Mueser, & Drake, 2014).

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Because the provision of services for patients with mental illnesses, including schizophrenia, has shifted from hospitals to communities, intervention has expanded from a

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medical model focusing on reducing symptoms to a rehabilitation model involving functioning of the psychological domain (Davidson et al., 2005). The rehabilitation model is a long-term process, and its ultimate goal is to ensure that patients with mental illness are actively involved in community activities independently (Katz, 2005). However, schizophrenia is accompanied by cognitive impairments, such as decreased attention and memory, slowed information processing, and impaired executive function, leading to

limitations in independent daily life (Katz, 2005). Specifically, executive dysfunction is one of the most common features of patients with schizophrenia (Giraldo-Chica et al., 2018), reducing the ability to integrate planning, preparation, execution, and coordination in order to adapt appropriately (Josman, Schenirderman, Klinger, & Shevil, 2009). Accordingly, patients with schizophrenia have difficulties in processing information at a higher level of function, such as problem solving,

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which restricts daily-life participation in complex situations (Baum et al., 2008). Therefore, in previous studies, cognitive interventions have been implemented to improve executive function for independent daily life of patients with schizophrenia (Rodriguez-Blanco, Lubrini, Vidal-Marino, & Rios-Lago, 2017).

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In most previous studies, cognitive training for improving the executive function of

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patients with schizophrenia was implemented to strengthen the sub-elements of executive function, such as problem-solving skills, cognitive flexibility, planning, and working memory

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(Medalia, Revheim, & Casey, 2001; Lawlor-Savage & Goghari, 2014). However, these interventions and assessments were not implemented in the actual environment in which

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patients with schizophrenia live, so their ecological validity is limited (Josman & Katz, 2006). Therefore, it is necessary to predict daily living activities (ADL) of patients with

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schizophrenia more sensitively by using training methods and evaluating their performance in a real environment.

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In order to obtain ecological validity, cognitive interventions using grocery shopping

have been carried out for patients with schizophrenia in previous studies (Mak et al., 2019). These studies found that cognitive intervention using grocery shopping increased accuracy and reduced duplicate purchase, indicating an improvement in the executive function of patients with schizophrenia (Brown, Rempfer, & Hamera, 2002). Additionally, grocery shopping is significantly related to the level of independent living (Rempfer, Hamera, Brown,

& Cromwell, 2003). Indeed, in some studies, grocery shopping has been used to improve executive function (d'Amato et al., 2011; Mak et al., 2019). Specifically, in order to find items to buy, patients with schizophrenia had to classify items, and they were careful when selecting items based on details such as the size and shape of items. In addition, they also had to remember the items they wanted to purchase and their locations. Taken together, core elements of executive function are needed for grocery shopping (Nir-Hadad, Weiss, Waizman,

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Schwartz, & Kizony, 2017). Nevertheless, there is a lack of research on cognitive intervention using grocery shopping in real environments to improve the executive function of patients with schizophrenia. Therefore, our purpose was to investigate the effects of the grocery shopping

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instrumental activities of daily living (IADL).

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improvement (GSSE) program in a real environment on the executive function and

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2. Method 2.1. Design

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This study was a nonequivalent control group pretest-posttest design. Both the experimental and the waitlist control group received conventional rehabilitation programs

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provided by the mental-health welfare center. All subjects were allocated randomly to the

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experimental or control group by using a random number generated by the Python computer language. The experimental group additionally participated in the GSSE program, whereas the waitlist control group patients participated after this study in the same shopping program as did the experimental group. We measured outcomes at baseline and at the end. Intervention consisted of eight sessions implemented twice a week for four weeks. This study was registered at the Thai Clinical Trials Registry ID: TCTR20190915001 after approval by the institutional review board of Soonchunhyang University (1040875-201801-SB-004).

2.2. Participants A total of 20 patients with schizophrenia were recruited at the mental-health welfare center in Taean, South Korea. The inclusion criteria were for those who (1) had been diagnosed with schizophrenia by psychiatrists, (2) had 2 years or more after the diagnosis of schizophrenia, (3) were between 19 and 55 years old, (4) had no severe impairments in social,

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psychological, and personal function due to psychological disorder defined by a score on the Global Assessment of Functioning (GAF) > 50, (5) were clinically stable as confirmed by having no change in antipsychotic pharmacological treatment in the last month, and (6) could read questionnaires and respond properly.

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The exclusion criteria were for those who (1) were diagnosed with a mental illness

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other than schizophrenia or (2) had auditory, visual, or language impairments. Sample-size estimation was calculated by using G*Power 3.1.3 (Informer

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Technologies, Dusseldorf, Germany). According to a previous study, the effect size (ES) was set at 0.45, the α error at a probability of 0.05, and the power at 0.80 (Cha, 2009). A minimum

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of 10 subjects was required in each group. All participants provided informed consent before

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participating in this study according to the Declaration of Helsinki (2004).

2.3. Intervention

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The GSSE program and the conventional rehabilitation programs consisted of a total

of eight sessions, two days a week for four weeks. All sessions were conducted by one occupational therapist who had more than five years of clinical experience in occupational therapy. The GSSE program was implemented in addition to the conventional rehabilitation programs that were held by the center. The GSSE program was developed through panel

meetings to verify the validity of its contents. The panel consisted of a professor with experience in schizophrenia rehabilitation and occupational therapists with clinical experience in cognitive training of schizophrenia. The validity of the contents was verified through three Delphi surveys, and then the feasibility study was done to finally choose the contents. The details about the GSSE program that the experimental group received are presented table 1.

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The program based on the grocery-shopping process components aimed to improve the shopping skills of patients with chronic schizophrenia living in communities (Hamera and Brown, 2002). The first component was strategy guided by internal or external memory for searching for goods. When shopping at a familiar store, search strategy could be mainly

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implemented by internal memory, making decisions with minimal effort. In contrast, if people

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are not familiar with the placement of merchandise in a store, a search strategy is performed by external memory, which requires considerable effort (Hamera and Brown, 2002). The

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second component is the time spent on shopping. Factors that influence decisionmaking include time constraints or pressure that increase arousal or stress level (Isenber, 1981),

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impeding the search strategy needed to remember familiar information. If people feel time pressure, they may not be able to accurately understand a store environment and find favorite

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products, which increases the chances of choosing other products. The third is a higher level of executive function that allows people to organize and plan the first and the second

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components. Therefore, the GSSE program needs to involve a process for generalizing learned skills in a real environment, not just in a simulated situation, for patients with schizophrenia who have difficulty in dealing with complex environment stimuli (Cornblatt & Keilp, 1994) and impaired short-term memory (Knight, 1993), resulting in a difficulty in blocking a chaotic situation (McDow, Filion, Harrison, & Braff, 1993) and a lack of ability to maintain consistency (Hemsley, 1996).

The GSSE program was implemented in grocery shops in the local community for 50 minutes a session. During each session, the experimenter observed the participant’s behavior and checked whether the participant selected proper products in a timely manner. On the other hand, the conventional rehabilitation programs consisted of physical exercise, socialskill training, and social-adaptation training. These programs were conducted at the mentalhealth welfare center for three hours a session; in order to reduce the participant’s fatigue, a

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10-minute break was given to the participant every hour.

2.4. Measurement

The clinical measurements were completed before and after the intervention to assess

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executive function, IADL, and global cognitive function by the experimenter who conducted

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the GSSE program.

We measured executive function using the Korean version of the Executive Function

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Performance Test (EFPT-K), which was developed to measure executive function by observing the level of assistance required to complete four tasks: cooking (making instant

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porridge), making a phone call (ordering food for delivery), taking medicine (taking vitamins), and paying bills. The EFPT-K assesses a person’s executive functions, consisting

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of initiation, organization, sequencing, safety, judgment, and completion while he or she performs the tasks. The EFPT-K uses the standardized five levels of cueing system: 0 (no cue

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required); 1 (verbal assistance); 2 (gestural assistance); 3 (direct verbal assistance); 4 (physical assistance), and 5 (doing for subjects). Its scores range from 0 to 100, and a higher score indicates more severe impairment in executive function. The inter-rater reliability was .91, and the internal consistency was .94 (Baum, Morrison, Hahn, & Edwards, 2003). To assess IADL, we used the Korean Instrumental Activities of Daily Living (KIADL), which consists of 11 items (shopping, transportation, ability to handle finances,

housekeeping, preparing food, ability to use a telephone, responsibility for own medication, recent memory, hobbies, watching television, and fixing things around the house) using a Likert scale ranging from 0 to 3 points. The total of scores ranges from 0 to 33 points, and the higher scores subjects get, the more independent in IADL they are. Its internal consistency (Cronhach’s alpha = .96) and the test-retest reliability (r = .94) were high (Kang et al., 2002). We used the Korean version of the Montreal Cognitive Assessment (MoCA-K) to

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measure global cognitive function. The Korean version of the MoCA developed to quickly screen mild cognitive impairment (MCI) and consists of 12 items in six cognitive domains. Its scores from 0 to 30 points, where higher scores mean better cognitive function and a score below 23 indicates cognitive impairment corresponding to MCI (Lee et al., 2008). Its internal

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consistency and test-retest reliability were .81 and .75, respectively.

2.5. Statistical analysis

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We analyzed all data using the SPSS 22.0 version (SPSS, Inc., Chicago, USA). To analyze demographic characteristics of the groups, we used the Chi-square test and the

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independent t test. We used the paired t test to identify the effects of the GSSE program in each group, and the analysis of covariance to investigate differences in outcome measures

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between the groups after the eight sessions. Statistical significance was accepted at p < .05.

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3. Results

3.1. Characteristics of participants There were no significant differences in demographic characteristics between the

groups (p > .05) (Table 2). However, there was a significant difference only in the K-IADL between the groups, indicating that the participants in the experimental group was more dependent in IADL than were those of the control group (Table 2).

3.2. Executive function Whereas the experimental group showed a significant improvement in the EFPT-K after the intervention, there was no significant improvement in the EFPT-K in the control group (Table 3). The ANCOVA with the scores in the EFPT-K at pre-test as a covariate indicated that there was a significant difference in the EFPT-K between the groups. These

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results indicated that there were significant differences in executive function between the groups.

3.3. Instrumental activities of daily living

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After the intervention, there was a significant improvement in the K-IADL in the

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experimental group but not in the control group (Table 3). The ANCOVA with the scores in the K-IADL at pre-test as a covariate indicated that there was a significant difference in the

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between the groups.

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K-IADL between the groups, showing that there were significant differences in IADL

3.4. Global cognitive function

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After the intervention, there was a significant improvement in the MoCA-K in the experimental group but not in the control group (Table 3). The analysis of variance showed

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that there was a significant difference in the MoCA-K between the groups, suggesting that there were significant differences in global cognitive function between the groups.

4. Discussion This study was designed to examine the effects of the GSSE program on executive function and IADL of patients with schizophrenia. After the eight-week intervention, we

observed significant differences in executive function, IADL, and global cognitive function between the experimental group that participated in the GSSE program in addition to the conventional rehabilitation program and the control group that performed the conventional rehabilitation program alone. These results are consistent with the results of previous studies (d’Amato et al., 2011; Mak et al., 2019). One of the most challenging skills for patients with schizophrenia is grocery

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shopping, since this task requires the selection of affordable products in an environment that encourages impulse buying (Hamera & Brown, 2000). Successful grocery shopping must involve remembering what to buy, finding out where desired products are, and buying them at an affordable price, indicating that executive function is necessary for grocery shopping

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(Hamera & Brown, 2000; Lavaux et al., 2012). Therefore, in previous studies, grocery

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shopping was selected as a test or training method for improving executive function of patients with schizophrenia (d’Amato et al., 2011; Mak et al., 2019).

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Accordingly, in the present study, grocery shopping was used to improve executive function. Beneficial effects of the GSSE program were demonstrated, as is consistent with the

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results of previous studies on effects of cognitive training using grocery shopping (d’Amato et al., 2011; Michalopoulou et al., 2015; Mak et al., 2019). However, in most of the previous

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studies, grocery shopping was implemented in a virtual environment by using computerized tasks, whereas the GSSE program was carried out in a real-life setting (d’Amato et al., 2011;

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Michalopoulou et al., 2015; Mak et al., 2019). Formats including decontextualized stimuli in computerized tasks are disconnected from the real-life settings where patients with schizophrenia live, which limits transferring the effectiveness of intervention (Levaux et al., 2012). Therefore, in previous studies, the transfer of gains differed across neuropsychological assessments (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). In contrast, in this study, the effects of the GSSE program were found for both IADL and executive function in the

experimental group but not in the control group. Indeed, the K-IADL includes not only shopping but also a variety of activities that require executive function, such as financial management and an ability to use a telephone (Kang et al., 2002). The previous study supported this result by suggesting that executive processes, such as problem solving, working memory, and planning, are necessary for behavioral adaptation in daily life that is rarely addressed in laboratory settings (Levaux et al., 2012). In addition, beneficial effects of

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the GSSE program were demonstrated on the MoCA-K, indicating that the effects of the GSSE program were generalized into global cognitive function. Indeed, in the MoCA-K, not only executive function but also various cognitive domains, such as attention, memory, and abstraction, are involved (Lee et al., 2008). Conversely, a previous study reported that,

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although subjects received 14 two-hour sessions of cognitive training by using computerized

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shopping tasks, there was no significant improvement in areas that were not trained (d’Amato et al., 2011). On the whole, generalization of the GSSE program’s effects on IADL and global

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cognitive function was manifested as improvements in the tasks that were not targeted during the program.

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Some limitations can be mentioned. First, since the experimental group performed the GSSE program in addition to the conventional rehabilitation programs, it is difficult to be

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sure that the improvements in executive function and IADL were induced by the GSEE program alone. Second, the assessor was not blinded, as was not feasible, because the

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assessments were implemented as part of a rehabilitation program. Nevertheless, all assessments need to be blinded. Third, in this study, because there were only a few participants and clinical subtypes of schizophrenia, such as paranoid and hebephrenic types, were not considered, it is difficult to generalize the results of this study. Future directions will need to analyze the effects of grocery-shopping training in a real-life setting with randomized controlled trials considering the limitations of this study. In addition, since executive function

mainly depends on the structure and activity of the prefrontal cortex (Giraldo-Chica, Rogers, Damon, Landman, & Woodward, 2018), brain-imaging devices also need to be used in order to confirm grocery-shopping training for improving executive function. In conclusion, we confirmed that that grocery shopping in a real-life situation could be useful in improving executive function and IADL of patients with schizophrenia. These results suggest that the GSSE program combined with conventional rehabilitation for patients

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with schizophrenia who have difficulties in everyday activities because of executive dysfunction might be more effective. Given these results, in order to acquire ecological validity of rehabilitation and transfer of its effects, it is necessary to apply a variety of

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training, not only in clinical settings but also in a real environment.

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Conflict of interest statement

Role of the funding source

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The authors declare that there is no conflict of interest

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This work was supported by the Soonchunhyang University Research Fund in 2019. This manuscript was proofread by this funding. In addition, this funding was used to rent

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places and meals when we had several meetings.

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Acknowledgement

This work was supported by the Soonchunhyang University Research Fund in 2019.

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Table 1. The GSSE program for patients with chronic schizophrenia Area

Session

Theme

Contents

Stabilization technique

Before each session

Relaxation

Breath-relaxation How to locate products in a store?

Skills for grocery shopping

1

Where is products?

2

Is it what I want?

e.g., asking for help or using information sign How to find what you’re looking for? e.g., size, packing or option

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How to find reasonable price items? 3

Is it the reasonable price

e.g., scanning strategy Non-food item

5

Canned, bottled, frozen goods

6

Agricultural products, meat, and dairy products

Strategy integration

7

Usage of all strategies

Selection products cooking

8

Selection of products

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Distinguish different kinds of products

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and

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food

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Different types

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4

Based on all strategies, locate differentiate products in a store

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Examine selected items and write the name and price of them

Table 2. Demographic and clinical characteristics of the groups Characteristics

χ2 / t

Experimental group (n = 10)

Control group (n = 10)

Male

4 (40.0%)

5 (50.0%)

Female

6 (60.0%)

5 (50.0%)

Age (years)

42.50 ± 10.59

46.80 ± 9.25

39.500

Education period (years)

11.80 ± 2.39

12.10 ± 1.66

49.500

Onset time (years)

10.80 ± 2.25

11.10 ± 2.23

46.500

EFPT-K

54.10 ± 3.54

55.20 ± 5.86

.508

K-IADL

14.20 ± 1.68

19.90 ± 1.79

7.325***

MoCA-K

8.20 ± 1.61

9.60 ± 2.17

1.635

Demographic characteristics

.202

ro of

Sex

-p

Clinical characteristics

***

Jo

ur

na

lP

re

p<.001, EFPT-K, Korean version of Executive Function Performance; K-IADL, Korean Instrumental Activities of Daily Living; MoCA-K, Korean version of Montreal Cognitive Assessment

Table 3. Comparison of executive function, instrumental activities of daily living, and global cognitive function in both groups Experimental group (n = 10)

Control group (n = 10)

Pre-intervention

54.10 ± 3.54

55.20 ± 5.86

Post-intervention

40.00 ± 1.88

54.10 ± 5.84

-14.10 ± 2.96 (-16.21; 11.98) ***

-1.10 ± 2.80 (-3.10; -.90)

Pre-intervention

14.20 ± 1.68

19.90 ± 1.79

Post-intervention

20.10 ± 2.92

20.60 ± 2.27

5.90 ± 2.42 (4.16; 7.63) ***

.70 ± 2.21 (-.88; 2.28)

Pre-intervention

8.20 ± 1.61

9.60 ± 2.17

Post-intervention

12.50 ± .070

10.00 ± 1.70

4.30 ± 1.76 (3.03; 5.56) ***

.40 ± 1.35 (-.56; 1.36)

Variables

Between-group differences

F

13.000 (10.28; 15.71)

52.797***

EFPT-K (score)

Within-group changes

Jo

ur

na

lP

Within-group changes

re

MoCA-K (score)

5.200 (3.01; 7.38) *

5.454*

-p

Within-group changes

ro of

K-IADL (score)

3.900 (2.42; 5.37) *

18.443***