To ensure the sustainability and efficacy of national health and social care systems, challenged by demographic aging, it has become necessary to develop strategies that focus on promoting healthy lifestyles and enable the maximization of disability-free life expectancy for as long as possible (European Innovation Partnership on Active and Healthy Ageing, 2012; World Health Organization, 2014). The proposal of a shift of health paradigm from acute intervention to prevention, discussed at an international level, emphasizes the need for an integrated and personalized healthcare approach, prioritizing citizens' encouragement and empowerment in taking responsibility for their own well-being (Cesari et al., 2016). The importance of including societal, community and clinical contexts to respond to the person’s real needs and to increase the transparency and impact of the proposed treatments was also highlighted (Gwyther et al., 2018). In this context, the European Commission identified a condition of frailty (an age-related and transitional state of decreased physiological reserves that increases the risk of adverse health outcomes, as defined by Rodriguez-Manas et al., 2013) as one of the priority issues, fostering the establishment of good practices that aim at preventing the early loss of cognitive and physical functionality (Apóstolo, Bobrowicz-Campos, Holland, & Cano, 2018).
There are several non-pharmacological alternatives to prevent the progression of physical frailty. These alternatives include interventions based on physical exercise, nutritional supplementation, and multicomponent interventions that combine multidisciplinary approaches (Apóstolo et al., 2018). However, scientific and practical knowledge about the interventions to reverse, minimize or prevent cognitive frailty is still insufficient. This study presents the results on the effectiveness of two non-pharmacological interventions to prevent cognitive frailty progression and discuss their implication for clinical practice.
Objective
To assess the clinical effectiveness of the reminiscence-based program and cognitive stimulation, both provided in group, for cognitively frail older adults who attend community day centers.
Method
Design and setting. A multicenter study was conducted in the Central Region of Portugal between May 2017 and April 2018. The study sample was recruited from nine day centers.
Inclusion and exclusion criteria. Persons considered for inclusion in the trial had to be aged 65 years or more, be able to give informed consent, be able to remain in a group for 45-60 minutes, and have sufficient auditory and visual capabilities to participate actively in the tasks proposed during the intervention program. Persons with unstable clinical condition or who were currently taking cholinesterase inhibitors and/or antipsychotic medication or who had severe cognitive decline were excluded from the study.
Selection and allocation of the participants in the treatment groups. Of 118 older adults screened for inclusion and exclusion criteria, 84 were considered eligible for the study, being allocated to the reminiscence-based program or cognitive stimulation. The selection of the intervention for each day center was made in a random way, using a computer generated algorithm. All persons who did not meet the inclusion criteria were offered the possibility to participate in structured discussions on current national and international events.
Interventions. The reminiscence-based program consists of activities that focus on topics related to childhood, school, professional life, travels, festive time and historical moments, among others. These activities enable the access to memories of meaningful life events and to integrate them into the person’s autobiographical narrative (Gil et al., 2017). The cognitive stimulation, developed based on the program “Making a Difference” (Spector, Thorgrimsen, Woods, & Orrell, 2006; adapted to Portugal by Apóstolo & Cardoso, 2014), offers a sequence of activities that focus on different cognitive domains. The activities, besides stimulating the older person’s cognition, promote socialization and the experience of sharing and belonging to a group, and enhance their self-efficacy and self-esteem. Both interventions are composed by 14 sessions with a duration of 45-60 minutes, being provided in group. The sessions are conducted twice a week for seven weeks.
Main outcome measures and assessment points. For screening purpose the 6-item Cognitive Impairment Test and Lawton and Brody Instrumental Activities of Daily Living Scale were used. The primary outcome was cognitive frailty, measured using the Tilburg Frailty Indicator (TFI), Montreal Cognitive Assessment (MoCA) and Trail Making Test–form A (TMT-A). Secondary outcomes were depressive symptomatology assessed through the 10-item version of the Geriatric Depression Scale (GDS-10), and quality of life assessed based on the short version of the scale World Health Organization Quality of Life - module for older adults (8-item WHOQOL-OLD). The outcomes of interest were assessed at baseline and after the 7-week intervention.
Ethical Considerations. The study complied with the principles of the Declaration of Helsinki and its recommendations, and received formal Ethics Committee approval. Each participating institution gave formal authorization for the development of the study. All subjects who agreed to participate in the study gave their written and informed consent.
Statistical analyses. Given the absence of a normal distribution of the results obtained, comparative analyses were made based on non-parametric statistical tests. The analysis of simple variances of ordinal variables for two groups was performed using the Mann - Whitney test. For the comparison of the results obtained by each group before and after the intervention, the Wilcoxon test was used. The probability levels of .05 were considered as significant.
Results
Socio-demographic characteristics of participants. The study was concluded by 70 older adults. From those, 44 (32 females and 12 males, with a mean age of 80.20±6.61 years, and mean education of 3.07±1.91 years) were integrated into the reminiscence-based program, and 26 (23 females and 3 males, with a mean age of 83.46±7.64 years, and mean education of 4.50±3.08 years) received cognitive stimulation. Fourteen participants dropped out from the study, mainly due to health problems.
Cognitive frailty. Both intervention programs (reminiscence-based and cognitive stimulation) improved the performance of older adults on the delayed memory task from MoCA. There were no significant differences in scores obtained on other tasks assessing cognitive functioning. In addition, the participants integrated into the reminiscence-based program showed a non-significant trend towards the reduction of physical frailty measured by TFI. In the participants included in the cognitive stimulation, a non-significant trend towards an increase in psychological frailty was observed.
Depressive symptomatology. There were no significant differences in the depressive symptomatology between the reminiscence-based program and cognitive stimulation immediately following the intervention. The within-group comparisons of the GDS-10 scores obtained before and after the intervention also revealed the absence of significant differences.
Quality of life. There were no significant differences in the quality of life between the reminiscence-based program and cognitive stimulation after the completion of the intervention. Within-group analyses also showed no significant differences in the 8-item WHOQOL-OLD score from baseline to post-intervention.
Conclusion
Both the reminiscence-based program and cognitive stimulation were shown to have a positive impact on postponing the progression of cognitive frailty in older adults attending day centers. The reminiscence-based program was also shown to be potentially beneficial in the reduction of physical frailty. Further studies are needed to confirm and reinforce the utility of both programs in preventing the early loss of cognitive and physical functionality. These studies should preferably use a randomized controlled design and be performed in different health and social care settings; in addition, these studies should aim for larger samples.
Implications for clinical practice
To enable the spreading and scaling up of the strategies aiming at the maximization of disability-free life expectancy, it is necessary to create structured and evidence-based protocols that can be easily assimilated into clinical practice. Such protocols should be adapted in order to be implemented by multidisciplinary teams without the involvement of additional resources and should offer an effective approach to produce positive health outcomes. The use of protocols with community-based practices and centered on the person’s individual needs has also been recommended. The reminiscence-based program and cognitive stimulation have all these properties.
Moreover, by being provided in a group, these non-pharmacological interventions create opportunities for learning and having fun, enhancing the experiences of inclusion, sharing, involvement and fellowship. They also foster proximity between the intervention providers and the persons being cared, reinforcing their sense of auto-control and effectiveness. All these advantages, together with an improved cognitive functioning, contribute to the empowerment of the older adults, enhancing their ability and autonomy to self-care. Such reality potentiates their quality of life and well-being.
For all these reasons, the reminiscence-based program and cognitive stimulation can be considered as appropriate strategies to promote successful aging. Their implementation in day centers on a regular basis may postpone or avoid unnecessary/premature institutionalization, contributing significantly to the sustainability and efficiency of the national health and social care systems.