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The effectiveness of a cognitive training program in people with mild cognitive impairment: A study in urban community
Accepted Manuscript Title: The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment: A Study in Urban Community Authors: Chalermpong Sukontapol, Sasithorn Kemsen, Sirintorn Chansirikarn, Daochompu Nakawiro, Orawan Kuha, Unchulee Taemeeyapradit PII: DOI: Reference:
S1876-2018(17)30622-6 https://doi.org/10.1016/j.ajp.2018.04.028 AJP 1423
To appear in: Received date: Revised date: Accepted date:
6-9-2017 18-4-2018 20-4-2018
Please cite this article as: Sukontapol C, Kemsen S, Chansirikarn S, Nakawiro D, Kuha O, Taemeeyapradit U, The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment: A Study in Urban Community, Asian Journal of Psychiatry (2010), https://doi.org/10.1016/j.ajp.2018.04.028 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment: A Study in Urban Community 1.Chalermpong Sukontapol*, M.D., Thai Board of Community Mental Health. Medical Doctor, expert level. Community Mental Health Care Leadership. Director of Vachira Phuket Hospital. Muang District, Phuket, 83000, Thailand. Email: [email protected]
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2Sasithorn Kemsen**, BNS. Geriatric Psychiatric Clinic. Songkhlarajanakarindra Psychiatric Hospital. Muang District, Songkhla, 90000, Thailand. Email: [email protected]
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3Sirintorn Chansirikarn***, M.D. Assistant Professor of Medicine Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Ratchathewi, Bangkok 10400, Thailand Email:[email protected]
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4Daochompu Nakawiro***, M.D. Assistant Professor of Psychiatry Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Ratchathewi, Bangkok 10400, Thailand Email: [email protected] 5. Orawan Kuha****,BNS, MSc Institute of Geriatrics Medicine.
Department of Medical Service, Ministry of Public Health. Muang District, Nonthaburi11000, Thailand . Email:[email protected]
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6. Unchulee Taemeeyapradit**, MD, FRCPsyT. Songkhlarajanakarindra Psychiatric Hospital Muang District, Songkhla, 90000, Thailand Email: [email protected]
Corresponding author: Unchulee Taemeeyapradit*, MD, FRCPsyT Geriatric Psychiatric Clinic. Songkhlarajanakarindra Psychiatric Hospital Muang District, Songkhla, 90000,Thailand
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Email: [email protected]
The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment : A Study in Urban Community Highlights
To assess effect of Cognitive Training Program, using concept of community mental health, in people with MCI.
There were any significant effects in enhancing global cognitions; increased MoCA score and decreased
Improvement of cognitions sustained for 6 months after 3-month intervention. The program was shown to be easily conducted with participation of community.
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depressive score.
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Abstract Objective: To assess the effectiveness of a cognitive training program on global cognition among people with mild cognitive impairment. Methods: In this experimental study, using purposive sampling, 60 participants age 50 years and over who complained of subjective memory impairment were screened in their communities by public health volunteers with the Abbreviated Mental Test. Those with dementia were excluded as well as those with depression, which were screened out by the Thai Geriatric Depression Scale (TGDS-15). Mild cognitive impairment was diagnosed and confirmed by the Montreal Cognitive Assessment (MoCA) and joint agreement between a psychiatrist and a neurologist. The participants were alternately assigned to receive a cognitive training program (intervention group) while the other half received their normal usual therapy (control group). The program involved training of 4 aspects of cognition through 6 sessions; 2 sessions per month for 3 months. The MoCA and TGDS-15 scales were given at baseline and again at week 13, and at months 6 and 9. Independent t-tests were used to compare changes in global cognition among the two groups. Results: MoCA scores at 9 months were significantly higher than at baseline in both groups. However, the mean difference in intervention group was significantly higher than control group. TGDS-15 scores at 6 months was significantly lower than at baseline among the intervention group but not the control group. Conclusion: This cognitive training program helped to improve global cognition and reduce depressive symptoms. Key words: cognitive training program, mild cognitive impairment, community mental health
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1. Introduction Thailand is becoming an aging society. The proportion of elderly increased from10.3% in women and 8.7% in men in 2005 to 12.8% and 10.6%, respectively, in 2010. By2020, the proportion of elderly women and men are estimated to increase to 18.5% and 15%, respectively (Institute for Population and Social Research, Mahidol University, 2017). This is a challenge that needs a supporting plan as economic and caring burdens will occur due to age-related health problems, including cognitive decline. Mild Cognitive Impairment (MCI) is the phase between normal aging and dementia and is defined as a cognitive decline of more than expected at a given age and educational level without interference of daily functioning. The pathology of brain cells in those with MCI is similar to that of Alzheimer's disease, i.e., fewer brain cells in the enthorhinal cortex and the hippocampus (Petersen, 2011). This pathology lasts approximately 20-30 years before symptoms of Alzheimer's disease develop. MCI includes impairment of memory, attention, visuospatial function, language, social and executive function. Progression to Alzheimer's disease is higher in people with than those without MCI, although some affected individuals may become stabilized or even enter remission. Other associated factors include diet, lifestyle, physical and mental activities, genetics, and other co-morbidities. Alzheimer's disease not only affects the individual, but the caregivers, families, and society; thus, preventive strategies at all levels are very important (Muangpaisan, 2017,2009; Muangpaisan et al.,2008, 2008). The prevalence of MCI among those aged 60 years and over from Thai national mental health surveys was 4% in 2010 (Nawamongkolwatana et al., 2012) and increased to 10.3% in 2013(Rungsihirunrut et al., in press). A survey in urban areas found a higher prevalence of 21.5% (Senanarong et al., 2001). The prevalence also varies by type of study design, study population, and diagnostic instruments used. However, there is currently no study that included subjects aged younger than 60 years, at which prevention of dementia, especially Alzheimer's disease, is expected to be more effective and feasible. Studies in other countries showed that cognitive training such as physical and mental activities, social interactions, reading, listening to music, group activities and problem solving, and either supported by healthcare personnel or caregivers, improved cognition among the older adults with or without MCI and reduced the risk of Alzheimer's disease(Karp et al., 2006 ; Wilson et al., 2007; Valenzuela et al., 2009 ; Karp et al., 2009 ; Yaffe et al.,2009).Although many countries have prioritized MCI as a health problem, few studies have been conducted to assess cognitive function among people with MCI (Moro et al., 2012). Most studies involved cognitive training among subjects with Alzheimer's disease (Woods et al.,2012).One experimental study of a cognitive training program for those with MCI and mild to moderate Alzheimer's disease included 80 participants, the intervention group (n=40) and control group (n=40). The intervention group received a cognitive training program combined with movement, psycho-social therapy and Cholinesterase inhibitor drugs, while the control group did not receive the stated program. After 1 year of follow-up, it was found that the intervention group had significantly better cognition and emotions than the control group (Olazaran et al., 2004). Multimedia and computer-based cognitive interventions have also been shown to improve cognitive functions and emotions (Barnes et al., 2009; González-Abraldes et al.,2010; Cruz et al.,2013; Faucounau et
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al.,2010). Another small study compared the effectiveness of a memory training intervention between those with MCI and normal elderly persons. Associative memory but not logical memory function was significantly more improved among the MCI group (Wenisch et al.,2007). Studies in Thailand pertaining to cognitive training are conducted mostly in Alzheimer's patients and only in certain aspects of cognition such as memory and attention (Aebthaisong, 2010; Wicheantong, 2002; Jaiwongphab et al., 2011).A quasi-experimental study developed a cognitive training program for 25 elderly persons aged 60-80 years with MCI. The sessions lasted 45-60 minutes and were held twice a week for 7 weeks. Memory and cognition were found to improve after the program was completed (Suwanmosi and Kaspichayawattana, 2016).However, there has been no study among MCI cases aged less than 60 years nor over a long-term period. Moreover, some studies involved advanced and expensive technology and did not involve network participation. This study therefore aims to assess the effectiveness of a cognitive training program on global cognition among people aged 50 years and older with MCI.The hypothesis is that individuals with MCI who receive this preventive program will have higher global cognitive scores than those who do not receive the program.
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2. Materials and methods This experimental study is a part of the Cognitive Training Program in MCI Project, conducted by the research team from The Institute of Geriatrics Medicine and Department of Psychiatry and Geriatrics Medicine Unit at Ramathibodi Hospital in Bangkok, Thailand. In this project270 participants were enrolled from across the four regions of the country. Research sites in each region were led by medical professionals, e.g. geriatric/psychiatric nurses, who received training during a 5-day workshop, held in February 2014, by the main research team. The workshop covered both clinical and instrumental assessment of cognitive function and method of delivering the cognitive training program. The detailed procedure of the main project can be found in the study of Kuha et al (Kuha and Phongchaturawit, 2016).
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2.1. Subjects Subjects in this study were from the southern region of Thailand. Purposive sampling was used to recruit participants who complained of subjective memory impairment whilst seeking care at primary care centers in Muang district of Songkhla and Phattalung provinces, during April-July 2014. Participants were assessed by public health volunteers (PHVs) and community health professionals, e.g. nurses and community mental health doctors. Participants aged at least 50 years and diagnosed with MCI and willing to participate in all activities of the 6-month study were eligible for the study. Those unable to read or write in the Thai language were excluded. Participants were also excluded if they had taken any cognitive enhancement drugs or had any conditions affecting participation in program activities, e.g. balancing problems, hearing Impairment as well as any psychiatric illness.
.An alternating treatment allocation scheme was used to assign the intervention to half of the 60 study subjects. All subjects were then given an explanation about the protocol of their allocated group. Those who refused to fully attend all required activities were excluded from the study. Recruitment was continuously done until the number of participants reached 30for each group. There was no loss to follow-up during the entire course of study.
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2.2 Materials 2.2.1Study Tools 1.1 A general questionnaire was developed by the main research team to collect demographic characteristics of the subjects. 1.2 The Abbreviated Mental Test (AMT) (Jitapunkul et al.,1991) is a screening tool consisting of 10 questions and used by primary health volunteers to assess the level of cognition among people in the community. Dementia is screened out if participants correctly answered 8 or more questions. 1.3 The 2002 Mini-Mental State Examination - Thai Version (MMSE-Thai 2002)(Neurological Institute Department of Medical Services, 2008)is a screening tool used by well-trained nurses for detecting probable dementia. Further investigation by physicians must be done if a subject scores ≤ 22, ≤ 17 and ≤ 14 out a possible 30 among those with a secondary, primary, and less than primary education levels, respectively. Those who achieve normal scores are subsequently screened for MCI using the MoCA, while those with abnormal scores are referred to a community mental health doctor for further investigation. 1.4The Montreal Cognitive Assessment (MoCA) (Julayanont et al., 2015) is a screening tool for detecting cognitive impairment by assessing various domains of cognition including attention, executive function, memory, language, visuospatial skills, conceptualization, calculation, and orientation. Subjects who achieve scores less than 26 out of a possible 30, with normal MMSE and AMT tests results, are suspected for MCI. 1. 5 Basic Activity Daily Living (BADL) (Jitapunkul et al., 1994) assesses a subject's ability to eat, dress, bathe, and use the latrine, with scores ranging from 0 to 20. Those achieving scores of11or less are considered to have a high level of dependency or required assistance. 1 . 6 Instrumental Activity Daily Living (IADL) assesses the ability of an elderly person to perform complex tasks such as calculating change. The Chula ADL Index (Jitapunkul et al.,1994) is the Thai version a n d was used in this study under the term IADL. The IADL indicates the ability to exist in the community independently, including the ability to perform daily tasks. Scores range from0 to 9. 1.7The 15-item Thai Geriatric Depression Scale (TGDS-15) (Shiekh and Yesavage, 1986; Wongpakaran and Wongpakaran,2011)is a depression assessment tool that was developed in Thai . Scores range from 0 to 15. Those achieving a score between 6 and 10 are potentially deemed to have depression, and those achieving a score of 11 or more are generally considered to have depression. Those achieving a score of 5 or less are considered to have some depression but are not mentally unwell.
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2.2.2Intervention Tools This study's Cognitive Training Program consisted of a set of cognitive training activities known as the Training of Executive Function, Attention, Memory and Visuospatial Perception (TEAM-V) to stimulate 4 important domains of cognition among patients with MCI: 1) memory (training the patient to be attentive of the information with repetitive recalls); 2) attention (constant attention to subjects of interest); 3) spatio-temporal reasoning (training of spatio-temporal vision with depth perception), and; 4) management (logic and decisionmaking process, and organization to improve memory). Group activities were held across6 sessions, 3 hours per session, with a 2-week interval between each session. Each session involved training of different domains of cognition: 1st Session: Stimulating name and facial recognition; 2nd session: Stimulating attention and longterm memory; 3rd session: Stimulating spatio-temporal reasoning; 4th session: Stimulating short-term memory; 5th session: Stimulating management skills; 6th session: Stimulating overall ability. After each session, there would be follow-up activities in order for the participants to practice the skills at home, e.g. writing one's own biosketch, diary, and drawing a family tree (Nakawiro et al., 2017; Kuha and Phongchaturawit, 2016).
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2.3. Procedure 2.3.1 Protection of Rights and Research Ethics This study was approved by the Human Research Ethical Review Board from The Institute of Geriatric Medicine and Songkhla Rajagarindra Psychiatric Hospital (SKPH). Before the study began, researchers introduced themselves to the study participants, explained the objective, study methodology, data collection method, length of time for participation, expected benefits and inconveniences from participation in this study, and informed them that acceptance or refusal to participate in the study would have no consequences on their benefits for access to healthcare facilities. Participants were also told that their responses would be kept strictly confidential and would be used only for research purposes. Participants would be identified by a code rather than their names. Participants were also told that they could opt to leave the study before the end of the study period at any time without giving any reason or explanation. After each participant understood the objectives and verbally agreed to participate, a researcher asked the participant to sign the consent form.
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2.3.2 Preparation phase The study settings were selected based on the principle of community mental health. According to public hearings and stakeholder interviews prior to the study, health personnel from primary healthcare centers as well as local governments in Muang Songkhla and Phattalung communities reported that they still lacked confidence and expertise in case-finding and prevention of mental health problems related to cognitive disorders. Also, case-finding still lacked complete coverage, and healthcare referral system is unclear. These issues were selected as they are among the first priorities for the locals in urban areas. Community leaders in these two areas were ready to engage in the study and stakeholders at all levels were
supportive and aware of these problems. We developed the knowledge with the stakeholders, and the communities reached a consensus to find the at-risk groups and engage in selective prevention using an intervention program that is easy to deliver and suitable to the local contexts. Hence, we chose the cognitive training program for those with MCI (Nakawiro et al., 2017).
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2.3.3 Intervention Phase The trained nurses delivered the knowledge and technique of the cognitive training program to registered nurses in charge of psychiatric geriatric clinics and primary health care centers under Songkhla Hospital and Phattalung Hospital. The training program lasted 3 days. The stated team then delivered the knowledge to 6 primary health volunteers responsible for the elderly in their communities over a period of 2 days. The study population and samples were from communities in Muang Songkhla and Muang Phattalung districts. Those with MCI included participants achieving a MMSE-Thai 2002scoreof more than 22, 17, and 14 among those with a secondary, primary, and less than primary education, respectively (Neurological Institute Department of Medical Services, 2008), with a recall score less than 3/3 and a MoCA score of less than 25 (Julayanont et al., 2015). MCI wasconfirmed by joint agreement between a psychiatrist and a neurologist. 1. The research team met with community leaders to coordinate and explain the data collection procedures. The community played a role in recruiting potential participants using the screening tool, as well as getting the local administrative organizations and stakeholders to provide support. Primary health volunteers also played an important role, with facilitation from medical personnel, in mobilizing and sustaining activity in their communities. 2 .The primary health volunteers, under the primary care units of Songkhla Hospital and Phattalung Hospital, used the AMT screening test form for participants age 50 years and over who complained of impaired subjective memory. Participants who achieved AMT and MMSE-Thai 2002 scores on or below the cut-off points were excluded from the study and referred to a community mental health doctor for further investigation. Those who achieved a MMSE-Thai 2 0 0 2 score higher than the cut-off points based on their education level and who achieved a MoCA score lower than 2 6 with recall memory lower than 3 / 3 were confirmed as having MCI. 3. Activities were conducted according to group allocation. The control group received general care appropriate for their level of health. The intervention group received the cognitive training program. The study was held from August to October 2014, with 6 sessions at SKPH over 3 months (2 sessions per month), with 2-3 hours per session. The program was led by a well-trained nurse with help from6 primary health volunteers at the geriatric psychiatric clinic of SKPH. In each session, two health volunteers were assigned to be coleaders and the others were assigned to be observers. In each following session, two of the observers were then alternately assigned to be co-leaders- hence all volunteers were given an equal chance to gain experience in this program. 4. Both groups were given the MoCA test 1 week after the 6 th session (3 months after baseline)and every 3 months for 9 months. The TGDS-15was assessed in parallel with the MoCA up to 6 months. We also
made measurements. Both instruments were measured by a nurse who was blinded to the participant's group allocation.
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2.4. Data analysis Descriptive statistical analyses included frequencies and percentages. The mean differences in MoCA scores between the two groups at each follow-up was tested using independent t-tests and the mean difference in TGDS-15 scores between baseline and post-intervention within each group was tested using paired t-tests. Data analysis was conducted using R software version 3.3.0.
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3. Results Table 1 compares the general characteristics of participants in the two groups. Most participants were women (76.6% in the intervention group vs. 53.3% in the control group), aged 61-70 years (36.6% vs. 33.3%), and Buddhist (100.0% vs. 96.7%). Among the intervention group, most had a university-level education (60.0%) while among the control group the majority had a primary level (56.6%). Most participants had a medical condition (70.0% in intervention group vs. 56.6% in the control group)such as metabolic diseases (66.7% vs. 43.3%), and overweight (40.0% vs. 33.3%), while most participants were non-smokers (86.7% vs. 96.7%) and non-drinkers, most had hobbies that involved strategies and planning (63.3% vs. 53.3%), exercised almost daily (36.7% vs. 40.0%),and participated in 15-20 social activities per month (46.7% vs. 56.7%). Table 2 compares differences in MoCA scores between baseline and follow-up in both groups. Compared to the baseline level, MoCA scores significantly increased at 13 weeks in the intervention group but not in the control group. At 6 months, significantly higher scores were maintained in the intervention group but again not for the control group. At 9 months, sustained higher scores were again seen for the intervention group (mean±SD: 4.4±2.0) and moderately higher scores for the control group (2.7±2.1), compared to baseline. Table 3 compares changes in TGDS-15 scores over time in both groups. Subjects in the intervention group had significantly lower TGDS-15 scores at 6months compared to baseline (mean±SD: 1 . 9 ±1.5 vs 1.03±1.14, p < 0.01). In the control group, the TGDS-15 score decreased slightly from 3.6 ±1.94to3.33±1.27 (p=0.44).
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4.Discussion Women with high education and medical conditions were more likely to be in the intervention group than the control group. These imbalances might be explained by propensities to join the of intervention group. Women, higher education and being comorbid with medical conditions were found to be associated with health concerns (Mackenzie et al., 2006).Women in communities also tend to work at home and were more available than men. Hence the counterparts were more likely to refuse if they had to attend intervention
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activities, as compared to less intensive control group. Participants aged 50-60 years accounted for 30 percent of all participants while the rest were older than 60 years of age. Many individuals aged 50-60 years might still be in active employment, and thus would either refuse or were not ready to complete all activities. Other general characteristics of the two groups were similar. This study used clinical symptoms as the main criteria for joint diagnosis by a neurologist and a psychiatrist. The MoCA score served as a screening tool before referral to physicians for diagnosis.MCI diagnosis was made according to consensus between both specialists. The items in the MoCA scale may have been difficult for some participants to understand, particularly those with a low level of education and limited verbal skills. Additionally, results of the subgroup analysis which excluded participants with low education did not differ from that of the main analysis. The cognitive training program for MCI patients was found to be highly effective. The results were in accordance with the study hypothesis. The program could effectively improve cognition among those with MCI in accordance with the theory and theoretical framework of Spector which posits that continuous cognitive training in the elderly can help to stimulate cerebral function and delay the degeneration (Spector et al., 2010). Training also increases the branching and the number of axons and, in turn, allows the higher number and functioning of neurotransmitters near the synapses and enables better memory, attention, management skills, linguistics, spatio-temporal reasoning, and better overall cognitive function. MoCA scores at 9 months were significantly higher than at baseline in both groups. However, the mean difference in intervention group was significantly higher than control group. The intervention group participated in as many as activity sessions with take-home assignments for 3 months, which supposedly enabled the participants to improve themselves with regard to attention, memory, and their lifestyle, e.g., increasing their physical activity, socialization, and critical thinking, which enabled them to have a higher level of cognition compared to the control group. Although at baseline, compared to the control group, the intervention group had a higher prevalence of metabolic diseases, a known risk factor for MCI, the difference in level of cognition at 9 months follow-up concurred with the results of Morro and colleagues (Moro et al., 2012). Morro’s cross-over study involved providing the first MCI group with a 6-month cognitive training program while the second group received no intervention. After the groups crossed over at 6 months, the intervention was found to result in a higher level of cognition, and at the 12-month follow-up period the first group had longer-lasting cognition than the second group. An experimental study by Suwanmosi and colleagues in elderly MCI cases age 60-80 years with a developed cognitive training program showed that, after 14 sessions conducted over 7 weeks, the participants’ MoCA score was significantly higher than the MoCA score before the intervention. In our study, the control group had a moderately but significantly increased score at 9months, possibly because of their daily lifestyle, e.g., physical activity, socialization, and hobbies that required strategy and planning, all of which could help to train cognitive functions, a result similar to some other studies. Familiarity with taking multiple MoCA tests might also have helped to increase their MCI scores.
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The intervention group had a significantly lower mean TGDS-15 score at the 6-month follow-up compared to their baseline score, a result not seen in the control group. The cognitive training program thus helped to improve the mental health of participants and reduced their depression. Study participants with depression were excluded from the study, and those included in the study had a baseline score of 7 or lower, which indicated little or no depression. There could have been some participants who had symptoms of depression according to some items, and thus considered to have sub-threshold depression or minor depressive disorder. At follow-up, the item-specific symptoms decreased. Interaction with others during group activities and other program activities could have helped participants improve their self-esteem, setting targets in their lives, and enjoying activities that helped them to achieve a better mental health. This is similar to the results of an experimental study in 270 participants by Kuha and colleagues (Kuha and Phongchaturawit, 2016) which found that cognitive training program activities helped to improve the participants mental health and reduced their depression. An experimental study by Olazaranand colleagues (Olazaranet al., 2004) also found benefits from cognitive and movement training programs and psycho-social therapy in combination with cholinesterase inhibitors. At 1-year follow-up, the intervention group had significantly higher cognitive function and better mood than the control group (Olazaran et al., 2004). The strengths of this study were that the diagnosis of MCI was confirmed by both a neurologist and a psychiatrist, and the study was conducted based on the principle of community mental health and community participation, in which the communities were empowered to be aware of the problems, take part in screening problems, and find potential solutions along with other stakeholders. In addition, a vast majority of the elderly (95.6%) were not screened and diagnosed for MCI. Integration of such a proactive system in the community will increase number of at risk people into appropriate care (Muangpaisan, 2013). This intervention can also serve as a model for improving the mental health of people in other communities. In addition, the participants remained enrolled in the study throughout the study period; there was no loss to follow-up. The study demonstrated the importance of selective prevention among MCI cases who were at risk of dementia based on the proactive and community-based collaborative efforts of primary health volunteers who played a role in finding cases, mobilizing the Cognitive Training Program, and enhancing its sustainability in the community.
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The study has some limitations which should be acknowledged. First, selection bias might have occurred due to the alternating treatment allocation scheme. as seen from difference of few baseline characteristics between two groups. For instance, the intervention group had more individuals with higher level education than the control group. Education is known to be a protective factor for cognitive decline hence the intervention group is expected to perform better due to the prior education level itself (Mistridis et al, 2017). This could be even better if full randomization was used but it was obstructed by our concerns with the readiness and willingness of participants to join the study.
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Our program requirement of regular participation in several long sessions may have limited the feasibility to join the study among individuals in outreach areas, those who could not afford to travel, and those who did not have time to participate in the activities. Alternative programs should be considered as appropriate to improve accessibility among these individuals, e.g. adjusting activities so that it could be conducted in remote areas by the local communities. Activities could also be adjusted for the elderly or those who have mobility problems. In addition, further studies could assess the benefit of the program in other groups, e.g., the elderly without MCI, or psychiatric cases with cognitive impairment. Further studies should be done in other groups, e.g. psychiatric patients with MCI and the elderly. This cognitive training program can be transferred to all levels of the community and can be used to improve cognition and prevent mental health problems in other groups, e.g., normal elderly persons, at-risk groups, and psychiatric patients with cognitive problems, with primary health volunteers as the main drivers for the activity. Conflict of interest None.
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Acknowledgement We extend our gratitude to the participants who sacrificed their time for the project, as well as the primary health volunteers and community leaders who helped to make this project successful. We also would like to thank the Institute of Geriatric Medicine for allowing the research team to be a part of the larger study and conducted project activities in the Southern region of Thailand.
Table 1.General Characteristics of Study Participants by Group Allocation Characteristic
Intervention Group (n=30)
Control Group (n=30)
Male Female Age (years) 50-60 61-70 71-80 81-82 Religion
7 (23.3%) 23 (76.6%)
14 (46.6%) 16 (53.3%)
9 (30.0%) 11 (36.6%) 10 (33.3%) 0 (0.0%)
9 (30.0%) 10 (33.3%) 10 (33.3%) 1 (3.3%)
Buddhism Islam Marital Status
30 (100.0%) 0 (0.0%)
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Less than or equal to 6 years 7-12 years Associate's degree or equivalent Bachelor's degree Graduate degree Number of household members 1 person 2-3 persons 4-5 persons 6 persons or more
Existing medical conditions Metabolic conditions (diabetes, hypertension, dyslipidemia)
Other medical conditions(Cardiovascular, Digestive diseases)
29 (96.7%) 1 (3.3%)
2 (6.7%) 15 (50.0%) 13 (43.3%)
1 (3.3%) 20 (66.7%) 9(30.0%)
6 (20.0%) 1 (3.3%) 4 (13.3%) 18 (60.0%) 1 (3.3%)
17 (56.7%) 5 (16.7%) 2 (6.7%) 6 (20.0%) 0 (0.0%)
6 (20.0%) 14 (46.7%) 8 (26.7%) 2 (6.7%)
3 (10.0%) 15 (50.0%) 10 (33.3%) 2 (6.7%)
20 (66.7%)
13 (43.3%)
26 (86.7%)
24 (80.0%)
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Single Married Other† Highest level of education
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Sex
Characteristic
Intervention Group (n=30)
Control Group (n=30)
< 18.5 (underweight) 18.5 - 22.9 (normal) 23.0 - 24.9 (overweight) 25.0 - 29.9 (obese) >= 30.0 (severely obese) Smoking status
0 (0.0%) 9 (30.0%) 12 (40.0%) 8 (26.7%) 1 (3.3%)
2 (6.7%) 7 (23.3%) 10 (33.3%) 9 (30.0%) 2 (6.7%)
Never Occasionally Almost daily Former Drinking behavior
28 (93.3%) 0 (0.0%) 0 (0.0%) 2 (6.7%)
Never Occasional / Social Daily, 360ml or more Former drinker Hobbies
26 (86.7%) 3 (10.0%) 0 (0.0%) 1 (3.3%)
29 (96.7%) 0 (0.0%) 1 (3.3%) 0 (0.0%)
None Strategy/Planning activities (playing games, arts and crafts) Entertainment (music, movies) Volunteer work / Community service Frequency of exercising(for 15 minutes or more)
3 (10.0%) 19 (63.3%)
3 (10.0%) 16 (53.3%)
3 (10.0%) 5 (16.7%)
4 (13.3%) 2 (6.7%)
None 1-2 times per week 3-4 times per week Almost daily/daily Participation in social activities
8 (26.7%) 5 (16.7%) 6 (20.0%) 11 (36.7%)
9 (30.0%) 3 (10.0%) 6 (20.0%) 12 (40.0%)
None Some(1-2 times per month) Often(15-20 times per month) Ability to carry out daily tasks
4 (13.3%) 12 (40.0%) 14 (46.7%)
12 (40.0%) 7 (23.3%) 11 (36.7%)
27 (90.0%) 0 (0.0%) 2 (6.7%) 1 (3.3%)
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Characteristic Pre-test Post-test IADL (mean)
Intervention Group (n=30) 20.00 20.00
Control Group (n=30) 19.90 20.00
7.97 8.00
7.27 7.23
Pre-test Post-test
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†Widowed, separated, divorced.
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BADL: Basic Activity Daily Living. IADL: Instrumental Activity Daily Living
Table 2. Mean (SD) scores in MoCA at baseline, 13 weeks, 6months and 9monthsand differences from baseline 13 weeks
Difference*
P-value
21.37 ±2.04
26.17 ±1.46
4.80 ±2.18
<0.001
Control group
18.43 ± 4.06
18.6 ± 4.08
0.17 ± 1.67
0.60
P-value
4.03 ±2.39
<0.001
18.77 ± 4.35
0.03 ±2.74
0.52
Difference***
P-value
9months 25.73 ±1.39
4.37 ±2.06
<0.001
21.17 ± 4.07
2.73 ±2.13
<0.001
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Intervention group
Difference** 6months 25.40 ±1.58
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Baseline
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MoCA: Montreal Cognitive Assessment. SD: Standard deviation. *Mean difference between intervention and control groups at 13 weeks vs. baseline (p-value < 0.001) **Mean difference between intervention and control groups at 6 months vs. baseline (p-value < 0.001) ***Mean difference between intervention and control groups at 9months vs. baseline (p-value < 0.01)
Table 3. Mean difference inTGDS-15 scores* at 13 weeks and 6months compared to baseline
Control group
13 weeks
Difference*
P-value
6months
Difference*
P-value
1.87 ± 1.48 3.60 ± 1.94
1.77 ±0.99 3.53 ± 1.38
-0.10 ±1.19 -0.07 ± 1.61
0.66
1.03 ±1.14 3.33 ± 1.27
-0.83 ±1.29 -0.27 ± 1.84
<0.01
0.83
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Baseline
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*In the intervention group, compared to baseline, the difference in TGDS-15 score at 13 weeks (p-value = 0.66) and at 6 months (p-value < 0.01) In the control group, compared to baseline, the difference in TGDS-15 score at 13 weeks (p-value = 0.83) and at 6 months (p-value = 0.44).
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References Aebthaisong, O. (2010).A Synthesis of Research on Memory Training in Older Adults with Dementia(Master’s thesis). Mahidoluniversity, Bangkok. Barnes, D. E., Yaffe, K., Belfor, N., Jagust, W. J., DeCarli, C., Reed, B. R., & Kramer, J. H. (2009). Computer-based cognitive training for mild cognitive impairment: results from a pilot randomized, controlled trial. Alzheimer disease and associated disorders, 23(3), 205. Cruz, V. T., Pais, J., Bento, V., Mateus, C., Colunas, M., Alves, I., ...& Rocha, N. P. (2013). A rehabilitation tool designed for intensive web-based cognitive training: Description and usability study. JMIR research protocols, 2(2). Faucounau, V., Wu, Y. H., Boulay, M., De Rotrou, J., &Rigaud, A. S. (2010). Cognitive intervention programmes on patients affected by Mild Cognitive Impairment: A promising intervention tool for MCI?. The journal of nutrition, health & aging, 14(1), 31-35. González-Abraldes, I., Millán-Calenti, J. C., Balo-García, A., Tubío, J., Lorenzo, T., &Maseda, A. (2010). Accesibility and usability of computer-based cognitive stimulation: Telecognitio. Revistaespanola de geriatria y gerontologia, 45(1), 26-29. Institute for Population and Social Research, Mahidol University. (2017). Mahidol Population Gazette . Vol. 26.Rertieved from: http://www.ipsr.mahidol.ac.th/ipsrbeta/th/Gazette.aspx
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Jaiwongphab, J.,Erawan, P.,&Boonchai, P.(2011).The result of using focus group exercise to increase the efficiency of adult’s memory based on the concept of Kawashima.Journal of Educational Measurement MahasarakhamUniversity,17(2),127-137. Jitapunkul, S.,Pillay, I., &,Ebrahim, S. (1991). The abbreviated mental test: its use and validity. Age and ageing, 20(5), 332-336. Jitapunkul, S., Kamolratanakul, P., &Ebrahim, S. (1994). The meaning of activities of daily living in a Thai elderly population: development of a new index. Age and Ageing, 23(2), 97-101. Julayanont, P., Tangwongchai, S., Hemrungrojn, S., Tunvirachaisakul, C., Phanthumchinda, K., Hongsawat, J., ...&Nasreddine, Z. S. (2015). The Montreal Cognitive Assessment—Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low‐Educated Elderly Adults. Journal of the American Geriatrics Society, 63(12), 2550-2554. Karp, A., Andel, R., Parker, M. G., Wang, H. X., Winblad, B., &Fratiglioni, L. (2009). Mentally stimulating activities at work during midlife and dementia risk after age 75: follow-up study from the Kungsholmen Project. The American Journal of Geriatric Psychiatry, 17(3), 227-236. Karp, A., Paillard-Borg, S., Wang, H. X., Silverstein, M., Winblad, B., &Fratiglioni, L. (2006). Mental, physical and social components in leisure activities equally contribute to decrease dementia risk. Dementia and geriatric cognitive disorders, 21(2), 65-73. Kuha, O. &Phongchaturawit, P.(2016).Research Report: Cognitive Stimulation with Mild Cognitive Impairment in People.Bangkok: The Institute of Geriatric Medicine, Department of Medical Services, Ministry of Public Health.
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Mistridis, P., Mata, J., Neuner-Jehle, S., Annoni, J.M., Biedermann, A., Bopp-Kistler, I., Brand, D., Brioschi Guevara, A., Decrey-Wick, H., Demonet, J.F. et al. (2017). Use it or lose it! Cognitive activity as a protective factor for cognitive decline associated with Alzheimer’s disease. Swiss Med. Wkly. 147, w14407. Moro, V., Condoleo, M. T., Sala, F., Pernigo, S., Moretto, G., &Gambina, G. (2012). Cognitive stimulation in a-MCI: an experimental study. American Journal of Alzheimer's Disease& Other Dementias®, 27(2), 121-130. Muangpaisan,W.Assessment and Diagnosis of People with Cognitive Impairment.In: W. Muangpaisan. (ed.).(2017). Gerontology and geriatrics for primary care practice.p159-178.Bangkok:Parbpim Printing. Muangpaisan,W. Dementia in the Older Population and prevention. In: P.Assantachai . (ed.). (2009). Common Health Problems in the Older Population and Prevention.p125-157. Bangkok: Union Creation. Muangpaisan, W., Intalapaporn, S., &Assantachai, P. (2008). Neuropsychiatric symptoms in the community‐based patients with mild cognitive impairment and the influence of demographic factors. International journal of geriatric psychiatry, 23(7), 699-703.
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Muangpaisan, W., Assantachai, P., Intalapaporn, S., &Pisansalakij, D. (2008). Quality of life of the community‐based patients with mild cognitive impairment. Geriatrics & gerontology international, 8(2), 80-85. Muangpaisan,W. (2013).Dementia: prevention, assessment and care.Bangkok:Parbpim Printing. Nakawiro, D., Chansirikarnjana, S., Srisuwan, P., Aebthaisong, O., Sudsakorn, P., Vidhyachak, C., &Visajan, P. (2017). Group-Based Traning of Executive Function, Attention, Memory and Visuospatial Function (Team-V) in Patients with Mild Neurocognitive Disorder. J Psychiatr Assoc Thailand, 62(4), 337-348. Nawamongkolwatana, B., Kittirattanapaiboon, P., &Kenbubpha, K. (2012). The survey of cognitive impairment in elderly Thai people: national survey 2008.Journal of Mental Health of Thailand , 18(1), 1-13. Neurological Institute Department of Medical Services.(2008).Clinical practice guideline for Dementia.(2nded). Bangkok: Ministry of Public Health, Thailand. Olazaran, J., Muniz, R., Reisberg, B., Peña-Casanova, J., Del Ser, T., Cruz-Jentoft, A. J., ...&Galiano, M. (2004). Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease.Neurology, 63(12), 2348-2353. Petersen, R. C. (2011). Mild cognitive impairment. New England Journal of Medicine, 364(23), 22272234. Rungsihirunrut, M., Nanchaing, M., Songrong T., et al.(in press).Quality of Life and Associated Factors with Cognitive Impairment in Elderly Thai People: National Mental Health Survey 2013.Journal of Mental Health ofThailand. Senanarong, V., Poungvarin, N., Sukhatunga, K., Prayoonwiwat, N., Chaisewikul, R., Petchurai, R., ...&Viriyavejakul, A. (2001). Cognitive status in the community dwelling Thai elderly. Journal of the Medical Association of Thailand= Chotmaihetthangphaet, 84(3), 408-416. Shiekh, J., &Yesavage, J. (1986). Geriatric Depression Scale: recent findings and development of a short version. Clinical gerontology: A guide to assessment and intervention, 165-173. Spector, A., Orrell, M., & Woods, B. (2010). Cognitive Stimulation Therapy (CST): effects on different areas of cognitive function for people with dementia. International journal of geriatric psychiatry, 25(12), 12531258 Suwanmosi, P., &Kaspichayawattana, J.(2016).The Effect of Cognitive Stimulation Program on Memory of Community-Dwelling Older Persons With Mild Cognitive Impairment. Journal of the Police Nurses,8(2),45-57. Valenzuela, M., &Sachdev, P. (2009). Can cognitive exercise prevent the onset of dementia? Systematic review of randomized clinical trials with longitudinal follow-up. The American Journal of Geriatric Psychiatry, 17(3), 179-187. Wenisch, E., Cantegreil-Kallen, I., De Rotrou, J., Garrigue, P., Moulin, F., Batouche, F., ...&Rigaud, A. S. (2007). Cognitive stimulation intervention for elders with mild cognitive impairment compared to normal aged subjects: preliminary results. Aging clinical and experimental research, 19(4), 316-322
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Wicheantong, E. U. (2002). The Effect of Memory Training Program on Memory Function in the Elderly with Mild Dementia.The Journal of Psychiatric Nursing and Mental Health, 16(2), 47-59. Wilson, R. S., Scherr, P. A., Schneider, J. A., Tang, Y., & Bennett, D. A. (2007). Relation of cognitive activity to risk of developing Alzheimer disease. Neurology, 69(20), 1911-1920. Woods, B., Aguirre, E., Spector, A. E., &Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. The Cochrane Library.Retrieved from: http://onlinelibrary.wiley.com/enhanced/doi/10.1002/14651858.CD005562/ Wongpakaran, T. &Wongpakaran, N. (2011).Factor Structure and Measurement Invariance of the Geriatric Depression Scale‐15, Presentation at the InternationalPsychogeriatric Association congress in Amsterdam,Netherland. Yaffe, K., Fiocco, A. J., Lindquist, K., Vittinghoff, E., Simonsick, E. M., Newman, A. B., ... & Harris, T. B. (2009). Predictors of maintaining cognitive function in older adults The Health ABC Study. Neurology, 72(23), 2029-2035.
S1876-2018(17)30622-6 https://doi.org/10.1016/j.ajp.2018.04.028 AJP 1423
To appear in: Received date: Revised date: Accepted date:
6-9-2017 18-4-2018 20-4-2018
Please cite this article as: Sukontapol C, Kemsen S, Chansirikarn S, Nakawiro D, Kuha O, Taemeeyapradit U, The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment: A Study in Urban Community, Asian Journal of Psychiatry (2010), https://doi.org/10.1016/j.ajp.2018.04.028 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment: A Study in Urban Community 1.Chalermpong Sukontapol*, M.D., Thai Board of Community Mental Health. Medical Doctor, expert level. Community Mental Health Care Leadership. Director of Vachira Phuket Hospital. Muang District, Phuket, 83000, Thailand. Email: [email protected]
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2Sasithorn Kemsen**, BNS. Geriatric Psychiatric Clinic. Songkhlarajanakarindra Psychiatric Hospital. Muang District, Songkhla, 90000, Thailand. Email: [email protected]
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3Sirintorn Chansirikarn***, M.D. Assistant Professor of Medicine Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Ratchathewi, Bangkok 10400, Thailand Email:[email protected]
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4Daochompu Nakawiro***, M.D. Assistant Professor of Psychiatry Department of Psychiatry, Faculty of Medicine, Ramathibodi Hospital, Mahidol University Ratchathewi, Bangkok 10400, Thailand Email: [email protected] 5. Orawan Kuha****,BNS, MSc Institute of Geriatrics Medicine.
Department of Medical Service, Ministry of Public Health. Muang District, Nonthaburi11000, Thailand . Email:[email protected]
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6. Unchulee Taemeeyapradit**, MD, FRCPsyT. Songkhlarajanakarindra Psychiatric Hospital Muang District, Songkhla, 90000, Thailand Email: [email protected]
Corresponding author: Unchulee Taemeeyapradit*, MD, FRCPsyT Geriatric Psychiatric Clinic. Songkhlarajanakarindra Psychiatric Hospital Muang District, Songkhla, 90000,Thailand
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Tel: +66 74 317400
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Fax: +66 74 323202
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Email: [email protected]
The Effectiveness of a Cognitive Training Program in People with Mild Cognitive Impairment : A Study in Urban Community Highlights
To assess effect of Cognitive Training Program, using concept of community mental health, in people with MCI.
There were any significant effects in enhancing global cognitions; increased MoCA score and decreased
Improvement of cognitions sustained for 6 months after 3-month intervention. The program was shown to be easily conducted with participation of community.
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depressive score.
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Abstract Objective: To assess the effectiveness of a cognitive training program on global cognition among people with mild cognitive impairment. Methods: In this experimental study, using purposive sampling, 60 participants age 50 years and over who complained of subjective memory impairment were screened in their communities by public health volunteers with the Abbreviated Mental Test. Those with dementia were excluded as well as those with depression, which were screened out by the Thai Geriatric Depression Scale (TGDS-15). Mild cognitive impairment was diagnosed and confirmed by the Montreal Cognitive Assessment (MoCA) and joint agreement between a psychiatrist and a neurologist. The participants were alternately assigned to receive a cognitive training program (intervention group) while the other half received their normal usual therapy (control group). The program involved training of 4 aspects of cognition through 6 sessions; 2 sessions per month for 3 months. The MoCA and TGDS-15 scales were given at baseline and again at week 13, and at months 6 and 9. Independent t-tests were used to compare changes in global cognition among the two groups. Results: MoCA scores at 9 months were significantly higher than at baseline in both groups. However, the mean difference in intervention group was significantly higher than control group. TGDS-15 scores at 6 months was significantly lower than at baseline among the intervention group but not the control group. Conclusion: This cognitive training program helped to improve global cognition and reduce depressive symptoms. Key words: cognitive training program, mild cognitive impairment, community mental health
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1. Introduction Thailand is becoming an aging society. The proportion of elderly increased from10.3% in women and 8.7% in men in 2005 to 12.8% and 10.6%, respectively, in 2010. By2020, the proportion of elderly women and men are estimated to increase to 18.5% and 15%, respectively (Institute for Population and Social Research, Mahidol University, 2017). This is a challenge that needs a supporting plan as economic and caring burdens will occur due to age-related health problems, including cognitive decline. Mild Cognitive Impairment (MCI) is the phase between normal aging and dementia and is defined as a cognitive decline of more than expected at a given age and educational level without interference of daily functioning. The pathology of brain cells in those with MCI is similar to that of Alzheimer's disease, i.e., fewer brain cells in the enthorhinal cortex and the hippocampus (Petersen, 2011). This pathology lasts approximately 20-30 years before symptoms of Alzheimer's disease develop. MCI includes impairment of memory, attention, visuospatial function, language, social and executive function. Progression to Alzheimer's disease is higher in people with than those without MCI, although some affected individuals may become stabilized or even enter remission. Other associated factors include diet, lifestyle, physical and mental activities, genetics, and other co-morbidities. Alzheimer's disease not only affects the individual, but the caregivers, families, and society; thus, preventive strategies at all levels are very important (Muangpaisan, 2017,2009; Muangpaisan et al.,2008, 2008). The prevalence of MCI among those aged 60 years and over from Thai national mental health surveys was 4% in 2010 (Nawamongkolwatana et al., 2012) and increased to 10.3% in 2013(Rungsihirunrut et al., in press). A survey in urban areas found a higher prevalence of 21.5% (Senanarong et al., 2001). The prevalence also varies by type of study design, study population, and diagnostic instruments used. However, there is currently no study that included subjects aged younger than 60 years, at which prevention of dementia, especially Alzheimer's disease, is expected to be more effective and feasible. Studies in other countries showed that cognitive training such as physical and mental activities, social interactions, reading, listening to music, group activities and problem solving, and either supported by healthcare personnel or caregivers, improved cognition among the older adults with or without MCI and reduced the risk of Alzheimer's disease(Karp et al., 2006 ; Wilson et al., 2007; Valenzuela et al., 2009 ; Karp et al., 2009 ; Yaffe et al.,2009).Although many countries have prioritized MCI as a health problem, few studies have been conducted to assess cognitive function among people with MCI (Moro et al., 2012). Most studies involved cognitive training among subjects with Alzheimer's disease (Woods et al.,2012).One experimental study of a cognitive training program for those with MCI and mild to moderate Alzheimer's disease included 80 participants, the intervention group (n=40) and control group (n=40). The intervention group received a cognitive training program combined with movement, psycho-social therapy and Cholinesterase inhibitor drugs, while the control group did not receive the stated program. After 1 year of follow-up, it was found that the intervention group had significantly better cognition and emotions than the control group (Olazaran et al., 2004). Multimedia and computer-based cognitive interventions have also been shown to improve cognitive functions and emotions (Barnes et al., 2009; González-Abraldes et al.,2010; Cruz et al.,2013; Faucounau et
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al.,2010). Another small study compared the effectiveness of a memory training intervention between those with MCI and normal elderly persons. Associative memory but not logical memory function was significantly more improved among the MCI group (Wenisch et al.,2007). Studies in Thailand pertaining to cognitive training are conducted mostly in Alzheimer's patients and only in certain aspects of cognition such as memory and attention (Aebthaisong, 2010; Wicheantong, 2002; Jaiwongphab et al., 2011).A quasi-experimental study developed a cognitive training program for 25 elderly persons aged 60-80 years with MCI. The sessions lasted 45-60 minutes and were held twice a week for 7 weeks. Memory and cognition were found to improve after the program was completed (Suwanmosi and Kaspichayawattana, 2016).However, there has been no study among MCI cases aged less than 60 years nor over a long-term period. Moreover, some studies involved advanced and expensive technology and did not involve network participation. This study therefore aims to assess the effectiveness of a cognitive training program on global cognition among people aged 50 years and older with MCI.The hypothesis is that individuals with MCI who receive this preventive program will have higher global cognitive scores than those who do not receive the program.
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2. Materials and methods This experimental study is a part of the Cognitive Training Program in MCI Project, conducted by the research team from The Institute of Geriatrics Medicine and Department of Psychiatry and Geriatrics Medicine Unit at Ramathibodi Hospital in Bangkok, Thailand. In this project270 participants were enrolled from across the four regions of the country. Research sites in each region were led by medical professionals, e.g. geriatric/psychiatric nurses, who received training during a 5-day workshop, held in February 2014, by the main research team. The workshop covered both clinical and instrumental assessment of cognitive function and method of delivering the cognitive training program. The detailed procedure of the main project can be found in the study of Kuha et al (Kuha and Phongchaturawit, 2016).
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2.1. Subjects Subjects in this study were from the southern region of Thailand. Purposive sampling was used to recruit participants who complained of subjective memory impairment whilst seeking care at primary care centers in Muang district of Songkhla and Phattalung provinces, during April-July 2014. Participants were assessed by public health volunteers (PHVs) and community health professionals, e.g. nurses and community mental health doctors. Participants aged at least 50 years and diagnosed with MCI and willing to participate in all activities of the 6-month study were eligible for the study. Those unable to read or write in the Thai language were excluded. Participants were also excluded if they had taken any cognitive enhancement drugs or had any conditions affecting participation in program activities, e.g. balancing problems, hearing Impairment as well as any psychiatric illness.
.An alternating treatment allocation scheme was used to assign the intervention to half of the 60 study subjects. All subjects were then given an explanation about the protocol of their allocated group. Those who refused to fully attend all required activities were excluded from the study. Recruitment was continuously done until the number of participants reached 30for each group. There was no loss to follow-up during the entire course of study.
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2.2 Materials 2.2.1Study Tools 1.1 A general questionnaire was developed by the main research team to collect demographic characteristics of the subjects. 1.2 The Abbreviated Mental Test (AMT) (Jitapunkul et al.,1991) is a screening tool consisting of 10 questions and used by primary health volunteers to assess the level of cognition among people in the community. Dementia is screened out if participants correctly answered 8 or more questions. 1.3 The 2002 Mini-Mental State Examination - Thai Version (MMSE-Thai 2002)(Neurological Institute Department of Medical Services, 2008)is a screening tool used by well-trained nurses for detecting probable dementia. Further investigation by physicians must be done if a subject scores ≤ 22, ≤ 17 and ≤ 14 out a possible 30 among those with a secondary, primary, and less than primary education levels, respectively. Those who achieve normal scores are subsequently screened for MCI using the MoCA, while those with abnormal scores are referred to a community mental health doctor for further investigation. 1.4The Montreal Cognitive Assessment (MoCA) (Julayanont et al., 2015) is a screening tool for detecting cognitive impairment by assessing various domains of cognition including attention, executive function, memory, language, visuospatial skills, conceptualization, calculation, and orientation. Subjects who achieve scores less than 26 out of a possible 30, with normal MMSE and AMT tests results, are suspected for MCI. 1. 5 Basic Activity Daily Living (BADL) (Jitapunkul et al., 1994) assesses a subject's ability to eat, dress, bathe, and use the latrine, with scores ranging from 0 to 20. Those achieving scores of11or less are considered to have a high level of dependency or required assistance. 1 . 6 Instrumental Activity Daily Living (IADL) assesses the ability of an elderly person to perform complex tasks such as calculating change. The Chula ADL Index (Jitapunkul et al.,1994) is the Thai version a n d was used in this study under the term IADL. The IADL indicates the ability to exist in the community independently, including the ability to perform daily tasks. Scores range from0 to 9. 1.7The 15-item Thai Geriatric Depression Scale (TGDS-15) (Shiekh and Yesavage, 1986; Wongpakaran and Wongpakaran,2011)is a depression assessment tool that was developed in Thai . Scores range from 0 to 15. Those achieving a score between 6 and 10 are potentially deemed to have depression, and those achieving a score of 11 or more are generally considered to have depression. Those achieving a score of 5 or less are considered to have some depression but are not mentally unwell.
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2.2.2Intervention Tools This study's Cognitive Training Program consisted of a set of cognitive training activities known as the Training of Executive Function, Attention, Memory and Visuospatial Perception (TEAM-V) to stimulate 4 important domains of cognition among patients with MCI: 1) memory (training the patient to be attentive of the information with repetitive recalls); 2) attention (constant attention to subjects of interest); 3) spatio-temporal reasoning (training of spatio-temporal vision with depth perception), and; 4) management (logic and decisionmaking process, and organization to improve memory). Group activities were held across6 sessions, 3 hours per session, with a 2-week interval between each session. Each session involved training of different domains of cognition: 1st Session: Stimulating name and facial recognition; 2nd session: Stimulating attention and longterm memory; 3rd session: Stimulating spatio-temporal reasoning; 4th session: Stimulating short-term memory; 5th session: Stimulating management skills; 6th session: Stimulating overall ability. After each session, there would be follow-up activities in order for the participants to practice the skills at home, e.g. writing one's own biosketch, diary, and drawing a family tree (Nakawiro et al., 2017; Kuha and Phongchaturawit, 2016).
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2.3. Procedure 2.3.1 Protection of Rights and Research Ethics This study was approved by the Human Research Ethical Review Board from The Institute of Geriatric Medicine and Songkhla Rajagarindra Psychiatric Hospital (SKPH). Before the study began, researchers introduced themselves to the study participants, explained the objective, study methodology, data collection method, length of time for participation, expected benefits and inconveniences from participation in this study, and informed them that acceptance or refusal to participate in the study would have no consequences on their benefits for access to healthcare facilities. Participants were also told that their responses would be kept strictly confidential and would be used only for research purposes. Participants would be identified by a code rather than their names. Participants were also told that they could opt to leave the study before the end of the study period at any time without giving any reason or explanation. After each participant understood the objectives and verbally agreed to participate, a researcher asked the participant to sign the consent form.
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2.3.2 Preparation phase The study settings were selected based on the principle of community mental health. According to public hearings and stakeholder interviews prior to the study, health personnel from primary healthcare centers as well as local governments in Muang Songkhla and Phattalung communities reported that they still lacked confidence and expertise in case-finding and prevention of mental health problems related to cognitive disorders. Also, case-finding still lacked complete coverage, and healthcare referral system is unclear. These issues were selected as they are among the first priorities for the locals in urban areas. Community leaders in these two areas were ready to engage in the study and stakeholders at all levels were
supportive and aware of these problems. We developed the knowledge with the stakeholders, and the communities reached a consensus to find the at-risk groups and engage in selective prevention using an intervention program that is easy to deliver and suitable to the local contexts. Hence, we chose the cognitive training program for those with MCI (Nakawiro et al., 2017).
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2.3.3 Intervention Phase The trained nurses delivered the knowledge and technique of the cognitive training program to registered nurses in charge of psychiatric geriatric clinics and primary health care centers under Songkhla Hospital and Phattalung Hospital. The training program lasted 3 days. The stated team then delivered the knowledge to 6 primary health volunteers responsible for the elderly in their communities over a period of 2 days. The study population and samples were from communities in Muang Songkhla and Muang Phattalung districts. Those with MCI included participants achieving a MMSE-Thai 2002scoreof more than 22, 17, and 14 among those with a secondary, primary, and less than primary education, respectively (Neurological Institute Department of Medical Services, 2008), with a recall score less than 3/3 and a MoCA score of less than 25 (Julayanont et al., 2015). MCI wasconfirmed by joint agreement between a psychiatrist and a neurologist. 1. The research team met with community leaders to coordinate and explain the data collection procedures. The community played a role in recruiting potential participants using the screening tool, as well as getting the local administrative organizations and stakeholders to provide support. Primary health volunteers also played an important role, with facilitation from medical personnel, in mobilizing and sustaining activity in their communities. 2 .The primary health volunteers, under the primary care units of Songkhla Hospital and Phattalung Hospital, used the AMT screening test form for participants age 50 years and over who complained of impaired subjective memory. Participants who achieved AMT and MMSE-Thai 2002 scores on or below the cut-off points were excluded from the study and referred to a community mental health doctor for further investigation. Those who achieved a MMSE-Thai 2 0 0 2 score higher than the cut-off points based on their education level and who achieved a MoCA score lower than 2 6 with recall memory lower than 3 / 3 were confirmed as having MCI. 3. Activities were conducted according to group allocation. The control group received general care appropriate for their level of health. The intervention group received the cognitive training program. The study was held from August to October 2014, with 6 sessions at SKPH over 3 months (2 sessions per month), with 2-3 hours per session. The program was led by a well-trained nurse with help from6 primary health volunteers at the geriatric psychiatric clinic of SKPH. In each session, two health volunteers were assigned to be coleaders and the others were assigned to be observers. In each following session, two of the observers were then alternately assigned to be co-leaders- hence all volunteers were given an equal chance to gain experience in this program. 4. Both groups were given the MoCA test 1 week after the 6 th session (3 months after baseline)and every 3 months for 9 months. The TGDS-15was assessed in parallel with the MoCA up to 6 months. We also
made measurements. Both instruments were measured by a nurse who was blinded to the participant's group allocation.
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2.4. Data analysis Descriptive statistical analyses included frequencies and percentages. The mean differences in MoCA scores between the two groups at each follow-up was tested using independent t-tests and the mean difference in TGDS-15 scores between baseline and post-intervention within each group was tested using paired t-tests. Data analysis was conducted using R software version 3.3.0.
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3. Results Table 1 compares the general characteristics of participants in the two groups. Most participants were women (76.6% in the intervention group vs. 53.3% in the control group), aged 61-70 years (36.6% vs. 33.3%), and Buddhist (100.0% vs. 96.7%). Among the intervention group, most had a university-level education (60.0%) while among the control group the majority had a primary level (56.6%). Most participants had a medical condition (70.0% in intervention group vs. 56.6% in the control group)such as metabolic diseases (66.7% vs. 43.3%), and overweight (40.0% vs. 33.3%), while most participants were non-smokers (86.7% vs. 96.7%) and non-drinkers, most had hobbies that involved strategies and planning (63.3% vs. 53.3%), exercised almost daily (36.7% vs. 40.0%),and participated in 15-20 social activities per month (46.7% vs. 56.7%). Table 2 compares differences in MoCA scores between baseline and follow-up in both groups. Compared to the baseline level, MoCA scores significantly increased at 13 weeks in the intervention group but not in the control group. At 6 months, significantly higher scores were maintained in the intervention group but again not for the control group. At 9 months, sustained higher scores were again seen for the intervention group (mean±SD: 4.4±2.0) and moderately higher scores for the control group (2.7±2.1), compared to baseline. Table 3 compares changes in TGDS-15 scores over time in both groups. Subjects in the intervention group had significantly lower TGDS-15 scores at 6months compared to baseline (mean±SD: 1 . 9 ±1.5 vs 1.03±1.14, p < 0.01). In the control group, the TGDS-15 score decreased slightly from 3.6 ±1.94to3.33±1.27 (p=0.44).
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4.Discussion Women with high education and medical conditions were more likely to be in the intervention group than the control group. These imbalances might be explained by propensities to join the of intervention group. Women, higher education and being comorbid with medical conditions were found to be associated with health concerns (Mackenzie et al., 2006).Women in communities also tend to work at home and were more available than men. Hence the counterparts were more likely to refuse if they had to attend intervention
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activities, as compared to less intensive control group. Participants aged 50-60 years accounted for 30 percent of all participants while the rest were older than 60 years of age. Many individuals aged 50-60 years might still be in active employment, and thus would either refuse or were not ready to complete all activities. Other general characteristics of the two groups were similar. This study used clinical symptoms as the main criteria for joint diagnosis by a neurologist and a psychiatrist. The MoCA score served as a screening tool before referral to physicians for diagnosis.MCI diagnosis was made according to consensus between both specialists. The items in the MoCA scale may have been difficult for some participants to understand, particularly those with a low level of education and limited verbal skills. Additionally, results of the subgroup analysis which excluded participants with low education did not differ from that of the main analysis. The cognitive training program for MCI patients was found to be highly effective. The results were in accordance with the study hypothesis. The program could effectively improve cognition among those with MCI in accordance with the theory and theoretical framework of Spector which posits that continuous cognitive training in the elderly can help to stimulate cerebral function and delay the degeneration (Spector et al., 2010). Training also increases the branching and the number of axons and, in turn, allows the higher number and functioning of neurotransmitters near the synapses and enables better memory, attention, management skills, linguistics, spatio-temporal reasoning, and better overall cognitive function. MoCA scores at 9 months were significantly higher than at baseline in both groups. However, the mean difference in intervention group was significantly higher than control group. The intervention group participated in as many as activity sessions with take-home assignments for 3 months, which supposedly enabled the participants to improve themselves with regard to attention, memory, and their lifestyle, e.g., increasing their physical activity, socialization, and critical thinking, which enabled them to have a higher level of cognition compared to the control group. Although at baseline, compared to the control group, the intervention group had a higher prevalence of metabolic diseases, a known risk factor for MCI, the difference in level of cognition at 9 months follow-up concurred with the results of Morro and colleagues (Moro et al., 2012). Morro’s cross-over study involved providing the first MCI group with a 6-month cognitive training program while the second group received no intervention. After the groups crossed over at 6 months, the intervention was found to result in a higher level of cognition, and at the 12-month follow-up period the first group had longer-lasting cognition than the second group. An experimental study by Suwanmosi and colleagues in elderly MCI cases age 60-80 years with a developed cognitive training program showed that, after 14 sessions conducted over 7 weeks, the participants’ MoCA score was significantly higher than the MoCA score before the intervention. In our study, the control group had a moderately but significantly increased score at 9months, possibly because of their daily lifestyle, e.g., physical activity, socialization, and hobbies that required strategy and planning, all of which could help to train cognitive functions, a result similar to some other studies. Familiarity with taking multiple MoCA tests might also have helped to increase their MCI scores.
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The intervention group had a significantly lower mean TGDS-15 score at the 6-month follow-up compared to their baseline score, a result not seen in the control group. The cognitive training program thus helped to improve the mental health of participants and reduced their depression. Study participants with depression were excluded from the study, and those included in the study had a baseline score of 7 or lower, which indicated little or no depression. There could have been some participants who had symptoms of depression according to some items, and thus considered to have sub-threshold depression or minor depressive disorder. At follow-up, the item-specific symptoms decreased. Interaction with others during group activities and other program activities could have helped participants improve their self-esteem, setting targets in their lives, and enjoying activities that helped them to achieve a better mental health. This is similar to the results of an experimental study in 270 participants by Kuha and colleagues (Kuha and Phongchaturawit, 2016) which found that cognitive training program activities helped to improve the participants mental health and reduced their depression. An experimental study by Olazaranand colleagues (Olazaranet al., 2004) also found benefits from cognitive and movement training programs and psycho-social therapy in combination with cholinesterase inhibitors. At 1-year follow-up, the intervention group had significantly higher cognitive function and better mood than the control group (Olazaran et al., 2004). The strengths of this study were that the diagnosis of MCI was confirmed by both a neurologist and a psychiatrist, and the study was conducted based on the principle of community mental health and community participation, in which the communities were empowered to be aware of the problems, take part in screening problems, and find potential solutions along with other stakeholders. In addition, a vast majority of the elderly (95.6%) were not screened and diagnosed for MCI. Integration of such a proactive system in the community will increase number of at risk people into appropriate care (Muangpaisan, 2013). This intervention can also serve as a model for improving the mental health of people in other communities. In addition, the participants remained enrolled in the study throughout the study period; there was no loss to follow-up. The study demonstrated the importance of selective prevention among MCI cases who were at risk of dementia based on the proactive and community-based collaborative efforts of primary health volunteers who played a role in finding cases, mobilizing the Cognitive Training Program, and enhancing its sustainability in the community.
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The study has some limitations which should be acknowledged. First, selection bias might have occurred due to the alternating treatment allocation scheme. as seen from difference of few baseline characteristics between two groups. For instance, the intervention group had more individuals with higher level education than the control group. Education is known to be a protective factor for cognitive decline hence the intervention group is expected to perform better due to the prior education level itself (Mistridis et al, 2017). This could be even better if full randomization was used but it was obstructed by our concerns with the readiness and willingness of participants to join the study.
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Our program requirement of regular participation in several long sessions may have limited the feasibility to join the study among individuals in outreach areas, those who could not afford to travel, and those who did not have time to participate in the activities. Alternative programs should be considered as appropriate to improve accessibility among these individuals, e.g. adjusting activities so that it could be conducted in remote areas by the local communities. Activities could also be adjusted for the elderly or those who have mobility problems. In addition, further studies could assess the benefit of the program in other groups, e.g., the elderly without MCI, or psychiatric cases with cognitive impairment. Further studies should be done in other groups, e.g. psychiatric patients with MCI and the elderly. This cognitive training program can be transferred to all levels of the community and can be used to improve cognition and prevent mental health problems in other groups, e.g., normal elderly persons, at-risk groups, and psychiatric patients with cognitive problems, with primary health volunteers as the main drivers for the activity. Conflict of interest None.
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Acknowledgement We extend our gratitude to the participants who sacrificed their time for the project, as well as the primary health volunteers and community leaders who helped to make this project successful. We also would like to thank the Institute of Geriatric Medicine for allowing the research team to be a part of the larger study and conducted project activities in the Southern region of Thailand.
Table 1.General Characteristics of Study Participants by Group Allocation Characteristic
Intervention Group (n=30)
Control Group (n=30)
Male Female Age (years) 50-60 61-70 71-80 81-82 Religion
7 (23.3%) 23 (76.6%)
14 (46.6%) 16 (53.3%)
9 (30.0%) 11 (36.6%) 10 (33.3%) 0 (0.0%)
9 (30.0%) 10 (33.3%) 10 (33.3%) 1 (3.3%)
Buddhism Islam Marital Status
30 (100.0%) 0 (0.0%)
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Less than or equal to 6 years 7-12 years Associate's degree or equivalent Bachelor's degree Graduate degree Number of household members 1 person 2-3 persons 4-5 persons 6 persons or more
Existing medical conditions Metabolic conditions (diabetes, hypertension, dyslipidemia)
Other medical conditions(Cardiovascular, Digestive diseases)
29 (96.7%) 1 (3.3%)
2 (6.7%) 15 (50.0%) 13 (43.3%)
1 (3.3%) 20 (66.7%) 9(30.0%)
6 (20.0%) 1 (3.3%) 4 (13.3%) 18 (60.0%) 1 (3.3%)
17 (56.7%) 5 (16.7%) 2 (6.7%) 6 (20.0%) 0 (0.0%)
6 (20.0%) 14 (46.7%) 8 (26.7%) 2 (6.7%)
3 (10.0%) 15 (50.0%) 10 (33.3%) 2 (6.7%)
20 (66.7%)
13 (43.3%)
26 (86.7%)
24 (80.0%)
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Single Married Other† Highest level of education
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Sex
Characteristic
Intervention Group (n=30)
Control Group (n=30)
< 18.5 (underweight) 18.5 - 22.9 (normal) 23.0 - 24.9 (overweight) 25.0 - 29.9 (obese) >= 30.0 (severely obese) Smoking status
0 (0.0%) 9 (30.0%) 12 (40.0%) 8 (26.7%) 1 (3.3%)
2 (6.7%) 7 (23.3%) 10 (33.3%) 9 (30.0%) 2 (6.7%)
Never Occasionally Almost daily Former Drinking behavior
28 (93.3%) 0 (0.0%) 0 (0.0%) 2 (6.7%)
Never Occasional / Social Daily, 360ml or more Former drinker Hobbies
26 (86.7%) 3 (10.0%) 0 (0.0%) 1 (3.3%)
29 (96.7%) 0 (0.0%) 1 (3.3%) 0 (0.0%)
None Strategy/Planning activities (playing games, arts and crafts) Entertainment (music, movies) Volunteer work / Community service Frequency of exercising(for 15 minutes or more)
3 (10.0%) 19 (63.3%)
3 (10.0%) 16 (53.3%)
3 (10.0%) 5 (16.7%)
4 (13.3%) 2 (6.7%)
None 1-2 times per week 3-4 times per week Almost daily/daily Participation in social activities
8 (26.7%) 5 (16.7%) 6 (20.0%) 11 (36.7%)
9 (30.0%) 3 (10.0%) 6 (20.0%) 12 (40.0%)
None Some(1-2 times per month) Often(15-20 times per month) Ability to carry out daily tasks
4 (13.3%) 12 (40.0%) 14 (46.7%)
12 (40.0%) 7 (23.3%) 11 (36.7%)
27 (90.0%) 0 (0.0%) 2 (6.7%) 1 (3.3%)
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BMI
Characteristic Pre-test Post-test IADL (mean)
Intervention Group (n=30) 20.00 20.00
Control Group (n=30) 19.90 20.00
7.97 8.00
7.27 7.23
Pre-test Post-test
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†Widowed, separated, divorced.
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BADL: Basic Activity Daily Living. IADL: Instrumental Activity Daily Living
Table 2. Mean (SD) scores in MoCA at baseline, 13 weeks, 6months and 9monthsand differences from baseline 13 weeks
Difference*
P-value
21.37 ±2.04
26.17 ±1.46
4.80 ±2.18
<0.001
Control group
18.43 ± 4.06
18.6 ± 4.08
0.17 ± 1.67
0.60
P-value
4.03 ±2.39
<0.001
18.77 ± 4.35
0.03 ±2.74
0.52
Difference***
P-value
9months 25.73 ±1.39
4.37 ±2.06
<0.001
21.17 ± 4.07
2.73 ±2.13
<0.001
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Intervention group
Difference** 6months 25.40 ±1.58
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Baseline
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MoCA: Montreal Cognitive Assessment. SD: Standard deviation. *Mean difference between intervention and control groups at 13 weeks vs. baseline (p-value < 0.001) **Mean difference between intervention and control groups at 6 months vs. baseline (p-value < 0.001) ***Mean difference between intervention and control groups at 9months vs. baseline (p-value < 0.01)
Table 3. Mean difference inTGDS-15 scores* at 13 weeks and 6months compared to baseline
Control group
13 weeks
Difference*
P-value
6months
Difference*
P-value
1.87 ± 1.48 3.60 ± 1.94
1.77 ±0.99 3.53 ± 1.38
-0.10 ±1.19 -0.07 ± 1.61
0.66
1.03 ±1.14 3.33 ± 1.27
-0.83 ±1.29 -0.27 ± 1.84
<0.01
0.83
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Intervention group
Baseline
0.44
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*In the intervention group, compared to baseline, the difference in TGDS-15 score at 13 weeks (p-value = 0.66) and at 6 months (p-value < 0.01) In the control group, compared to baseline, the difference in TGDS-15 score at 13 weeks (p-value = 0.83) and at 6 months (p-value = 0.44).
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