Effectiveness of Non-Face-to-Face Dementia Prevention Program on Cognitive function and Depression in Community-dwelling Elderly during the COVID-19 Pandemic in Korea

DOI: https://doi.org/10.21203/rs.3.rs-2368250/v1

Abstract

Background: Continuous participation of dementia prevention program is important to the community-dwelling elderly. Therefore, reducing treatment gaps using non-face-to-face program is important in COVID-19. The aim of this study is to introduce evidence-based non face-to-face dementia prevention program in Korean context, and to identify the effect of non-face-to-face dementia prevention program on cognitive function and depression of community-dwelling elderly during the COVID 19 pandemic.

Methods: A total of 101 community-dwelling elderly without dementia participated in 12 sessions of a non-face-to-face dementia prevention program designed by occupational therapist. Cognitive functions and depression were tested.

Results: Every item of cognitive function was maintained, and memory increased. The symptoms of depression decreased significantly. From the opinions of the participants, participation in new activities, reduction of boredom, communication, and reminisce were benefits of this program.

Conclusions: Non-face-to-face dementia prevention program is an effective method to maintain and increase cognitive function and prevent depression on community-dwelling elderly. The community-based non-face-to-face occupational therapy program of this study is useful to give chance to participate in continuous activities during the COVID 19 pandemic.

Background

During the COVID-19 pandemic, limitations to access to public health services and to participate in classic patterns of treatments and community services are common[1, 2]. These situations affect negatively motor, cognitive, and psychosocial functions in the elderly[3, 4]. Especially, the elderly need continuous rehabilitation to maintain functions[2, 5] and are particularly vulnerable to COVID-19[5, 6].

Non-face-to-face rehabilitation is a useful treatment strategies during the COVID-19 pandemic. Continuous rehabilitation and community services is essential to the elderly, mild cognitive impairment (MCI), dementia, and stroke[6]. Especially comprehensive daily activities and keeping diary in non-face-to-face rehabilitation increases cognitive function, independent living, participation, mental health, and quality of life[3, 5, 7].

Non-face-to-face rehabilitation is widely used in community-based cognitive rehabilitation and dementia prevention[1]. Dementia prevention and management for community-dwelling elderly is a major part of the local health system[7]. Non-face-to-face rehabilitation is effective to maintain cognition, prevent and delay cognitive impairment in elderly patients with MCI and dementia[1, 7, 8, 9, 10].

Furthermore, non-face-to-face rehabilitation is useful method to manage depression in community-dwelling elderly. Lack of participating in community activities is significantly correlated with depression[11]. Depression affects social roles, health, and social wellbeing[12]. Daily activities like keeping diary decreases depression symptoms of chronic rehabilitation patients[9].

The American Psychiatric Association(APA) suggested a comprehensive dementia prevention program including behavior, emotion, cognition, and stimulus-oriented approaches[13]. Comprehensive treatments compose of cognitive training and periodic cognitive activities such as writing a diary, and daily occupational activities[1416]. Especially, occupational activities are effective to cognition, affect, daily life participation, satisfaction, and quality of life in elderly with MCI and dementia[2.16.17]. In occupational therapy theory, occupational participation allows individuals to engage in the environment, perform occupational activities, and maintain their occupation[18].

Previous studies has proved the effect of non-face-to-face cognition rehabilitation to the elderly with MCI or dementia. In Korea, face-to-face dementia prevention programs were usually conducted at public health center. Especially, Occupational therapist play major role in designing and performing dementia prevention program for community-dwelling elderly in Korea context. Dementia prevention program is one of the major part in Korean public health center. Therefore, sharing and introducing ideas of evidence-based dementia prevention program is important. However, studies about identifying the effectiveness of non-face-to-face dementia prevention programs through participation in daily activities and cognitive activities for the normal elderly in a community environment is insufficient.

The aim of this study was to introduce non-face-to-face dementia prevention program based on APA guidelines and to identify the effect of non-face-to-face dementia prevention programs on cognitive function and depression in community-dwelling elderly in Korean context.

Methods

Participants

101 community-dwelling elderly participated at one public health center in Gyeonggi-do, Korea. Inclusion criteria were above 60 years old, normal cognitive function including MCI, being able to use smartphones, ability to read and wright, the internet installation at home, and without hearing or visual limitations. The exclusion criteria were dementia, difficulties in using smartphones, and no internet connection at home.

Procedures

Non face-to-face dementia prevention program was conducted once a week, 1 hour a day, for 12 weeks (12 sessions). This program was designed by two authors (the first and second) based on APA guidelines. And, second author recorded every program and uploaded on NAVER Band App. Participants watched programs and did their cognitive activity diary and brain health book. Participants performed daily task by keeping diary and brain health book. Before and after the program, cognitive functions and depression were assessed.

Outcome Measures

1. Cognitive Impairment Screening Test (CIST)

CIST is a cognitive function screening test developed by the Ministry of Health and Welfare and the Central Dementia Center in Korea[19]. It consists of 13 items including orientation, attention, visuospatial function, executive function, memory, and language function. Scoring system is 0–2 points for each question, a total score is 30 points. Interpretation is according to age and years of education. A higher score indicates a higher cognition. Results is divided into normal cognitive function and suspected cognitive decline.

2. Short Geriatric Depression Scale-Korean version (SGDS-K)

SGDS-K is a Korean version of elderly depression scale[20] based on the Geriatric Depression Scale(GDS)[21]. It consists of 15 yes or no questions and a total score is 15 points. Higher scores means higher levels of depression. Above 10 points is a high-risk depression group. The correlation with GDS-K was r = .95.

3 Subjective opinions

Subjective opinions were collected through open questions.

Treatment

Non-face-to-face dementia prevention program was designed by 2 authors based on the APA Dementia Clinical Practice Guidelines including behavior, emotion, cognition, and stimulus-oriented approaches. Program consists of weekly program on NAVER Band App and daily participation and occupational activities(Table 1). Participants took part in daily task with cognitive activity diary and brain health playbook.

Second author recorded the program video every week and uploaded it on NAVER Band App. Participants watched videos and did daily tasks using cognitive activity diary and brain health playbook. Lastly, participants uploaded their task results on the NAVER Band App. Contents of cognitive activity diary were writing down the date, weather, plan, medication of the day and coloring activity. And, cognition training like memory activities, naming and matching tasks was in the brain health playbook.

Table 1

Contents of Programs

Approaches

Activities

Contents

▪Cognition-Oriented Approaches

·Cognitive skill training

▪Behavior-Oriented Approaches

·Scheduled Habit training

▪Emotion-Oriented Approaches

·Reminiscence activities

Structured cognition activities diary

·Write down every date, weather, plan and, Medication

·Daily schedules arrangement

·Recalling morning cognitive activities

·Coloring activities

Brain health playbook

·Cognition training workbook

·Planning monthly and daily schedule

·Orientation, attention, memory, executing function training

▪Stimulation-Oriented Approaches

·Occupational activities

·Recreational activities

·Multisensory stimulation

Coloring book

Making soap

Planting

Puzzle

Cooking

·Sensory : Tactile, taste, smell

·Activities : Fine motor, learning new skills

·Cognition : Attention, memory, visuospatial, executive function, communication skills

·Psychosocial : Psychological stability, sense of achievement

 

Statistical analysis

Descriptive statistical analysis was used for the general information on subjects. The effect of the program was performed by t-test. Significance was set at p < 0.05. Window SPSS version 24.0 was used for all analyses.

Results

Study participants

Table 2 presents characteristics of 101 participants of this study. 5 participants assessed MCI by CIST in the initial assessment.

Table 2

Status of Participants (N = 101)

 

Variables

N

%

Gender

Male

17

16.8

Female

84

83.2

Age

60–69

30

29.7

70–79

58

57.4

80–89

13

12.9

Range

60–85

Average

72.63 ± 4.95

Year of Education

0

1

1.0

1–5

1

1.0

6–8

22

21.8

9–11

20

19.8

12–15

41

40.6

16–20

16

15.8

Range

0–20

Average

10.77 ± 3.65

Cognitive function

Normal

96

95.0

MCI

5

5.0

 

Result Of The Cognitive Function

Based on the raw score of CIST, orientation maintained and other cognitive function items improved. Memory and total score improved significantly. Two out of five subjects with MCI at the initial assessment returned to normal cognitive levels after treatment (Table 3).

Table 3

Result of Cognitive Impairment Screening Training (CIST)

Variables

Baseline

Post treatment

t

p-value

Orientation

4.89 ± .32

4.89 ± .47

0.00

1.000

Attention

2.59 ± .64

2.73 ± .68

1.82

.070

Visuospatial function

1.90 ± .39

1.97 ± .30

1.54

.127

Executive function

4.98 ± .97

5.03 ± 1.03

0.43

.667

Memory

8.49 ± 1.84

8.97 ± 1.78

2.39

.019*

Language function

3.65 ± .52

3.73 ± .49

1.81

.073

Total

26.45 ± 2.88

27.33 ± 2.76

3.55

.001*

P < 0.05

 

Result Of The Depression

Symptom of depression was significantly reduced from 3.35 ± 3.09 to 2.15 ± 3.06 (t = 4.49, p = .000) by SGD-K.

Subjective Opinions Of Participants

Subjective opinions were divided into four categories; 1) meaning in the activity itself; 2) cognitive stimulation; 3) reminiscence; and 4) a sense of achievement through challenge and achievement from acquisition of new skills (Table 4).

Table 4

Opinions of Participants

Categories

Individual Opinion

Meaning in the activity itself

·During the COVID-19 pandemic, I could get away from the stuffy daily life and get more vitality.

·Raising and eating my own leek was a meaningful activity.

·It was fun to color without noticing the passage of time.

Cognitive stimulation

·It was good for stimulating memory because I could check my activities while writing a

diary.

·It was good to know my previous activities while looking at the diary.

Reminiscence

·I felt like I was returning to my childhood by reminiscing or the childhood of my children in the activities of coloring, diary, and brain health playbook.

Challenging

Achievement from acquisition of new skills

·It was interesting to do new activities, such as soap making, puzzles, and finding texts.

·It was difficult to find the puzzle, but I enjoyed it after completing it.

·It was difficult to use the App and upload photos, but it became easier as I did it.

Discussion

This study was conducted to introduce daily activity based non-face-to-face dementia program and to investigate the effect of a non-face-to-face dementia prevention program on cognitive function and depression of community-dwelling elderly. This program was designed based on APA Dementia Clinical Practice Guidelines, and it consists of daily tasks using cognitive activity diary and brain health playbook. The program gave community-dwelling elderly a chance to participate daily tasks and was effective on cognitive function and depression. Especially, two out of five participants with MCI improved to normal cognitive levels after the program. Therefore, continuous dementia prevention program is essential to the community-dwelling elderly.

Comprehensive dementia prevention therapy program is effective to the elderly. In the study of Lee et al. (2022), 10 sessions of dementia prevention program were effective on 26 elderly (15 in the experimental group and 11 in the control group) in day and night care facilities.22 CIST and SGD-K was assessed same as this study. In the study of Avila et al. (2004), the effect of the 12 weeks cognitive training program was identified in the five elderly with mild dementia[14]. The program was comprehensive including memory training, motor movement, language activity, and daily life training. Using diary was major activities in daily life training. Positive effects were identified in cognition, depression, anxiety, and quality of life. These results support the effectiveness of the comprehensive dementia prevention program and daily participation of this study.

Participation in the daily task was effective in cognitive function and depression. In the Kim’s study (2015), 8 week daily task participation program improved daily life, cognitive ability, satisfaction and orientation in 43 people with early dementia[16]. Especially, repetitive daily tasks using paper and pencil, calendars, personal memory notebooks, and mobile phones were effective in improving orientation. Among daily task activities, diary writing activity led to significant improvement in memory, concentration, language ability, temporal and spatial perception, and executive function[15]. And, it reduced depressive symptoms in chronic rehabilitation patients and their caregivers[9]. In this study, we found the significant effects in preventing memory decline of normal elderly without dementia.

Social participation decreased depression[11]. In the study of Lee et al.(2022) and Avila et al.(2004), dementia prevention program and cognitive program decreased depression[14, 22]. In this study, daily task participation decreased symptoms of depression in the normal elderly. During Covid-19 pandemic, social participation is major problems among the elderly. Therefore, non-face-to-face program could be good substitutes.

Non-face-to-face rehabilitation programs are effective to various functions in the elderly. In the study of Jelcic et al. (2014), language ability, episodic, verbal, and working memory were significantly improved after 3 months of a remote cognitive rehabilitation program in 27 individuals with mild memory impairment[23]. Antonietti et al. (2016) stated that a comprehensive remote rehabilitation approach, called ABILITY improved motor and cognitive skills for early dementia[7]. In the study of Mosca et al. (2020), 31 elderly with MCI and vascular cognitive impairment participated in a computer-based non-face-to-face rehabilitation program called GOAL Tele-R, which consisted of cognitive, physical, and social activities for 8 weeks[24]. They were effective in preventing the deterioration of cognition, memory, and daily living functions. Therefore, the effect of a comprehensive non-face-to-face dementia prevention program in this study was supported.

A strength of this study was that large sample size were recruited. And, the effectiveness of non-face-to-face dementia prevention program of the normal elderly was examined in community-based rehabilitation. Lastly, the program of this study was based from APA dementia prevention guidelines and consists of comprehensive sub-programs. Therefore, clinicians in community-based rehabilitation could provide evidence-based non-face-to-face dementia prevention occupational therapy programs.

Limitation of this study was that generalization was difficult because participants were collected in one public health center. Also, this study was not a randomized control study. And the program consisted of many sub-programs. Therefore, it was difficult to determine which factors were most effective. Therefore, study about identifying the effect of the application of a non-face-to-face cognitive rehabilitation program for patients with dementia in the future. Identifying various areas such as daily life, performance function, quality of life, and stress is necessary in future studies. Furthermore, development of a specialized program for non-face-to-face rehabilitation would be necessary.

Conclusions

Non-face-to-face dementia prevention program is effective on cognition and symptoms of depression for normal community-dwelling elderly during the COVID-19 pandemic. And chance to participate in daily tasks is meaningful. The dementia prevention program is an important service in community-based occupational therapy in Korea. Clinicians in Community rehabilitation settings need to be more interested in non-face-to-face dementia prevention program and to provide evidence-based therapy.

Declarations

Ethics approval and consent to participate

Approval for the study was obtained from the ethics committee of the Institutional Review Board of Wonkwang University in Korea(WKIRB-202201-HR-001). All procedures in this study were performed in accordance with the ethical standards of the institutional and/or national research committees and the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Parents and/or legal guidance of all participants provided informed consent to participate in the study.

Consent for publication

Not Applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was supported by Wonkwang University (2021).

Author’s Contributions

All authors contributed to the study conception and design. KC and EH designed the non-face-to-face program in this study. All authors chose the cognitive activity diary and brain health playbook. EH conducted whole program from recruiting participants to carry out program. Material preparation, data collection was performed by EH. Data analysis was conducted by KC. HS made substantial contributions to revise the manuscript critically for important intellectual content and supervise all process. The first draft of the manuscript was written by KC and all authors reviewed the manuscript. Review and editing was performed by HS. Supervised by HS. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

References

  1. Manenti R, Gobbi E, Baglio F, et al. Effectiveness of an innovative cognitive treatment and telerehabilitation on subjects with mild cognitive impairment: a multicenter, randomized, active-controlled study. Front Aging Neurosci. 2020;12:1–15. DOI:10.3389/fnagi.202.585988.
  2. Rudnick A. Remote Psychosocial Rehabilitation (rPSR): A Broad View. J Psychosoc Rehabil Ment Health. 2020;7:119–20. DOI:10.1007/s40737-020-00175-8.
  3. Chang MC, Boudier-Revéret M. Usefulness of telerehabilitation for stroke patients during the COVID-19 pandemic. Am J Phys Med. 2020;1–5. DOI:10.1097/PHM.0000000000001468.
  4. Mantovani E, Zucchella C, Bottiroli S, et al. Telemedicine and virtual reality for cognitive rehabilitation: a roadmap for the COVID-19 pandemic. Front Neurol. 2020;11:1–8. DOI:10.3389/fneur.2020.00926.
  5. Velayati F, Ayatollahi H, Hemmat M. A systematic review of the effectiveness of telerehabilitation interventions for therapeutic purposes in the elderly. Methods Inf Med. 2020;59:104–9. DOI:10.1055/s-0040-1713398.
  6. Bloem BR, Dorsey ER, Okun MS. The coronavirus disease 2019 crisis as catalyst for telemedicine for chronic neurological disorders. JAMA Neurol. 2020;77:927–8. DOI:10.1001/jamaneural.2020.1452.
  7. Antonietti A, Gandolla M, Rossini M, et al. Interference between cognitive and motor recovery in elderly dementia patients through a holistic tele-rehabilitation platform. International Conference on Wireless Mobile Communication and Healthcare. 2016;359–366.
  8. Hong YJ, Jang EH, Hwang J, et al. The efficacy of cognitive intervention programs for mild cognitive impairment: a systematic review. Curr Alzheimer Res. 2015;12:527–42. DOI:10.2174/1567205012666150530201636.
  9. Smith CE, Holcroft C, Rebeck SL, et al. Journal writing as a complementary therapy for reactive depression: A rehabilitation teaching program. Rehabil Nurs. 2000;25:170–6. DOI:10.1002/j.2048-7940.2000.tb10901.x.
  10. Yao S, Liu Y, Zheng X, et al. Do nonpharmacological interventions prevent cognitive decline? a systematic review and meta-analysis. Transl Psychiatry. 2020;10:1–11.
  11. Hao G, Bishwajit G, Tang S, et al. Social participation and perceived depression among elderly population in South Africa. Clin Interv Aging. 2017;12:971–6. DOI:10.2147/CIA.S137993.
  12. Fiske A, Wetherell JL, Gatz M. Depression in older adults. Ann Rev Clin Psychol. 2000;5:363–89. DOI:10.1146/annurev.clinpsy.032408.153621.
  13. American Psychiatric Association. Practice guideline for the treatment of patients with Alzheimer’s disease and other dementia. Second Edition. Available at https://psychiatiryonline.org/guidlines. Assessed June 6, 2022.
  14. Avila R, Bottino CMC, Carvalho IAM, et al. Neuropsychological rehabilitation of memory deficits and activities of daily living in patients with Alzheimer's disease: a pilot study. Braz J Med Biol Res. 2004;37:1721–9. DOI:10.1590/s0100-879x2004001100018.
  15. Kim JY, Kim YH. A study on application of cognitive function improvement program in older adults. Healthc Nurs. 2013;40:62–5.
  16. Kim S. Cognitive rehabilitation for elderly people with early-stage Alzheimer’s disease. J Phys The Sci. 2015;27:543–6. DOI:10.1589/jpts.27.543.
  17. De Vreese LP, Neri M, Fioravanti M, et al. Memory rehabilitation in Alzheimer's disease: a review of progress. Int J Geriatr Psychiatry. 2001;16:794–809. DOI:10.1002/gps.428.
  18. Vik K, Lilja M, Nygård L. The influence of the environment on participation subsequent to rehabilitation as experienced by elderly people in Norway. Scand J Occup Ther. 2007;14:86–95. DOI:10.1080/11038120600971047.
  19. Ministry of Health and Welfare. Central Dementia center. Cognitive Impairment Screening Test Manual; 2021.
  20. Bae JN, Cho MJ. Development of the Korean version of the Geriatric Depression Scale and its short form among elderly psychiatric patients. J Psychosom Res. 2004;57:297–305. DOI:10.1016/j.jpsychores.2004.01.004.
  21. Yesavage JA, Sheikh JI. Geriatric depression scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73. DOI:10.3109/09638288.2010.503835.
  22. Lee SE, An MY, Kim IJ, et al. The effect of the non-face-to-face real-time cognitive activity book play program on cognitive function and depression among the elderly in day care center. J Korean Gerontological Soc. 2022;42:119–35.
  23. Jelcic N, Agostini M, Meneghello F, et al. Feasibility and efficacy of cognitive telerehabilitation in early Alzheimer’s disease: a pilot study. Clin Interv Aging. 2014;9:1605–11. DOI:10.2147/CIA.S68145.
  24. Mosca IE, Salvadori E, Gerli F, et al. Analysis of feasibility, adherence, and appreciation of a newly developed tele-rehabilitation program for people with MCI and VCI. Front Neurol. 2020;11:1–10. DOI:10.3389/fneur.2020.583368.