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Keywords:

  • aged;
  • attention;
  • cognition;
  • family;
  • rehabilitation;
  • treatment effects

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Background:  While there is a growing interest in cognitive rehabilitation for older adults, not enough data is available regarding its feasibility and effectiveness in an older population. The present study implemented a home-based cognitive rehabilitation program for older adults in order to explore the program’s feasibility and effectiveness.

Methods:  The 8-month rehabilitation program consisted of multiple workbooks targeted at improving attention, memory and executive function. Study participants worked on the workbooks at home with family members, while professional cognitive rehabilitation staff periodically evaluated their progress. Attention, memory and executive function were evaluated at outset, at month 4 and at the end of month 8.

Results:  The nine initial participants had histories of subarachnoid hemorrhage or traumatic brain injury, or were outpatients of a memory clinic who had memory impairment. Six participants (66.7%) completed the 8-month program; one subject intentionally withdrew from the program while two others withdrew due to hospitalization. Among the six remaining participants, attention improved significantly between the month 4 and month 8 evaluations, and between the initial and month 8 evaluations. Within subsets of the attention test, significant improvement was seen in the visual selective attention domain. There was no change in memory or executive function, as well as the subjective difficulties in daily lives.

Conclusions:  This study suggests that a home-based cognitive rehabilitation program for older adults is feasible and may improve attention, especially visual selective attention. An 8-month rehabilitation program may have been of insufficient duration to generate significant improvements in memory or executive function.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

While there is a growing interest in cognitive rehabilitation for older adults, not enough data is available regarding its effectiveness in an older population, or for that matter, regarding what constitutes ideal rehabilitation training. To date, a variety of intervention programs for cognitive rehabilitation have been reported, with some positive results.1–7 Cicerone and others reviewed 171 reports on cognitive rehabilitation for traumatic brain injury (TBI)8 and post-stroke patients and recommended several approaches. However, most literature targets young adults with TBI, and data evaluating the applicability of these approaches to a population of older adults are limited. In Japan, programs for older people with cognitive impairment have mostly focused on group activities such as art therapy or group reminiscence therapy.9,10 These programs do not generally specifically target cognitive function itself. The limited programs that do focus on cognitive function aim mainly at creating a protective environment or minimizing the negative consequences of impairment, rather than attempting to restore the impaired cognitive functions.11

Another gap in the literature is that most studies describe a limited intervention period, such as an interval of 4 to 10 weeks. It has been suggested that a training time shorter than 100 h might not yield meaningful outcomes.12 Cognitive rehabilitation may require much longer implementation periods to evaluate its effect, especially among older adults.

The present study attempted an 8-month-long, home-based cognitive rehabilitation program for older adults with cognitive impairment, and explored the feasibility and effect of the program. The 8-month program represented approximately 160–200 h of rehabilitation training.

METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Subjects

The subjects of this study were older adults with cognitive impairment secondary to subarachnoid hemorrhage, TBI, or were outpatients of a memory clinic who had memory impairment. Subjects were recruited from the TBI Rehabilitation Research Center in Tokyo and through clinics that specialize in memory deficits or neurosurgery.

TBI cognitive rehabilitation program

The home-based cognitive rehabilitation program implemented in this study was developed by the TBI Rehabilitation Research Center in Tokyo, Japan, which, in turn, was inspired by the Brainwave-R program.13 The content of the workbooks was adapted in order to reflect Japanese culture. Altogether, 15 workbook series, with varying content and levels of difficulty, are currently available for use in long-term cognitive rehabilitation therapy.14 The TBI cognitive rehabilitation program is restorative rather than compensatory; that is, it is aimed at the re-structuring and re-organization of impaired cognitive function, rather than at developing skills to minimize negative consequences of impairment.

The contents of the workbook are targeted at training attention, memory and executive function. Examples of attention training exercises are to circle designated letters of the alphabet (e.g. all ‘a’s or all ‘a’s and ‘b’s) within a paragraph, or to copy a series of numbers in reverse. A memory training exercise may be to study a sentence and write it from memory on the next page. Several of the memory tasks use word or picture cues. An example of an executive function training exercise is to develop a plan for a birthday party, including making lists of party supplies, gifts and games to be played. There are five to seven distinct daily assignments, and although, within a given textbook, the format of the problems is constant, the contents changed each day.

Subjects were assigned workbooks based on an initial neuropsychological evaluation, as well as individual preference as suggested by initial subject and family interviews. Generally, the program first aims at improving attention, then memory and, finally, executive function. Subjects and participating family members were trained in appropriate use of the workbooks by a nurse or psychologist specializing in cognitive rehabilitation. Subjects, with family assistance, were expected to engage in the independent training activities for 30–60 min daily, 5 days a week, for an 8-month period. In addition to the workbooks, some subjects also engaged in an attention-training modality in which they listened to tape-recorded stories and transcribed them, word-for-word.

Families play a vital role in this program, by encouraging subjects to continue the program and helping them to solve the problems. When the workbooks using auditory functions are used, the family may read the problems, while the subject writes down the answers.

In order to enhance subject participation, cognitive rehabilitation professionals coached subjects and participating family members throughout the 8-month period. A nurse or psychologist visited some subjects in their homes; other subjects met with staff at the TBI Rehabilitation Research Center. In the one-hour home- or office-visit sessions, the nurse or psychologist taught the use of the workbooks, evaluated progress, identified which workbook to use next, answered questions regarding the program and provided general encouragement to subjects and families. Emotional support was provided by actively listening to the difficulties of subjects and families as it was needed. Visit frequency varied according to the needs of the subject and family; in the initial phase of the program visits were most frequent (weekly) and reduced, in most cases, to once a month, by the program’s end.

Evaluation tools

Neuropsychological tests used to examine cognitive function were the Japanese version of the Mini-Mental State Examination (MMSE),15 the Japanese version of the Rivermead Behavioral Memory Test (RBMT),16 the Behavioral Assessment of the Dysexecutive Syndrome (BADS), Japanese edition,17 and the Test of Everyday Attention (TEA).18

The MMSE is a simple scored form of the overall cognitive mental status examination, which includes such tasks as orientation, verbal recall and calculation. The score ranges from 0 to 30, with a direct correlation between score and cognitive function. The cut-off point for possible cognitive impairment is usually set at 23.15 The RBMT, an assessment tool for memory function, consists of 11 tasks including picture-recall, immediate and distant story recall and orientation to place and time. For the purposes of this study, the overall (profile) score was utilized, with a range from 0 to 24, and a direct correlation between score and memory function. The cut-off point for possible impairment for the RBMT is set at 16 for test-takers above the age of 60 years.16 The BADS is an assessment tool of executive function, consisting of six tasks, and yields a standardized score that directly correlates with executive function; the cut-off point for possible impairment is set at 70.18

Finally, the TEA instrument assesses attention, using eight everyday activity tasks to evaluate multiple components of attention: selective, sustained, or divided attention, attention switching and working memory.18 It also measures auditory and visual attention separately (Table 1). No Japanese version has been established for the TEA; thus a Japanese translation was developed by one of the authors (M.F.) with permission from the original publisher. Nine age-standardized subtest scores are represented as 19 point scales with a mean of 10 and a cut-off point of 5 for abnormality. The score of one subtest (‘Elevator Counting’) is not standardized, ranging from 0 to 7 with a cut-off point of 5 for abnormality. In this study, the sum TEA score (nine standardized scores plus one non-standardized score) was calculated. It directly correlates with level of attention.

Table 1.  Test of everyday attention (TEA) task scores at outset, month 4 and month 8 of program
TaskContentMean Score (SD)
OutsetMonth 4Month 8
  • *

    P < 0.1 (Wilcoxon Signed Rank Test).

Map search (1 min)Visual selective attention/speed6.67 (4.37)7.83 (2.99)8.33 (5.89)
Map search (2 min)Visual selective attention/speed7.67 (5.39)*8.67 (5.47)10.83 (5.12)*
Elevator countingSustained attention5.83 (2.04)5.83 (2.40)6.33 (1.63)
Elevator counting with distractionAuditory-verbal working memory/auditory selective attention9.17 (3.54)9.50 (3.27)9.17 (4.07)
Visual elevator number correctAttentional Switching9.17 (4.12)9.33 (6.22)8.67 (4.37)
Visual elevator timing scoreVisual selective attention/speed5.83 (5.85)6.00 (5.14)7.33 (5.92)
Elevator counting with reversalAuditory-verbal working memory/auditory selective attention9.33 (3.27)9.17 (5.91)11.17 (5.19)
Telephone searchVisual selective attention/speed6.00 (5.40)6.00 (4.86)6.17 (4.71)
Telephone search while countingSustained attention7.50 (5.32)7.83 (5.67)8.50 (6.32)
LotterySustained attention5.50 (3.89)6.50 (5.05)5.67 (4.23)

Procedure

Prior to the study, subjects and their families were informed about the aim and contents of the program by either the first or the second author, and written consent was obtained from all subjects. Initial neuropsychological evaluations, using the four instruments described above, were conducted over a 2-day period at the outset; individual results determined the appropriate type and level of workbook assigned to each subject. Subjects were re-evaluated at the end of the fourth and eighth months. A brief questionnaire survey was also implemented on the same occasions. It assessed the level of daily difficulties and functions of activities of daily living.

The program was designed to take 8 months to complete. Based on Prigatano’s notion that 100 h is the minimum amount of training to yield meaningful outcomes,12 we set 4 months as the minimum length of the rehabilitation period, and doubled that duration in order to examine the long-term effects of the program.

The results of the neuropsychological evaluation and the questionnaire survey were compared between the initial evaluation and those at months 4 and 8 and between the month 4 and month 8 data points, using the Wilcoxon signed rank test.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

A total of nine participants, and their families, originally consented to participate in the program. Of the initial participants, six (66.7%) completed the full 8 months of the program (Table 2). One person withdrew because he did not wish to continue the program; the other two were hospitalized. All of the remaining participants were male, with an age range of 59–78 years. Four had histories of subarachnoid hemorrhage, one suffered from TBI and one had memory impairment. The average time between disease onset and the start of the program reported by the subject/family was 21 months. The primary participating family members, in all cases, were subjects’ wives, with an age range of 55–74 years.

Table 2.  Demographic characteristics of the subjects
 Age (years)GenderCausal diseaseMonths from disease onsetParticipating family memberAge of family member (years)
  1. SH, subarachnoid hemorrhage; MI, memory impairment; TBI, traumatic brain injury.

ID 171MaleSH21Wife67
ID 278MaleMI30Wife74
ID 367MaleSH14Wife63
ID 459MaleSH10Wife55
ID 563MaleTBI31Wife58
ID 670MaleSH20Wife65
Average68.0  21.0 63.7

All the participants missed at least some days of training. Although the program is divided into daily assignments, each subject ultimately engaged in the workbook activities at his own pace, as determined by the subject’s own enthusiasm and health and the difficulty of the material. Some worked on the workbooks for 2 to 3 h per day (completing much more than the daily assignments), but did not work at all on other days. One subject completed 2 weeks of assignments in a day, but then did not open the book for the next 2 weeks. However, most participants worked consistently through the 8-month study period. The total number of pages completed by each subject varied, depending on workbook-type and the subject’s level of cognitive impairment.

There was no change on the MMSE, RBMT and BADS scores between the outset, month 4 and month 8 evaluations (Table 3). However, TEA scores showed an improvement between month 4 and month 8 (76.7 ± 38.7 vs 82.2 ± 38.2; P < 0.1) and between outset and month 8 (72.7 ± 32.8 vs 82.2 ± 38.2; P < 0.05). All six subjects improved their TEA scores between the initial evaluation and the end of the 8-month period (Fig. 1).

Table 3.  Neuropsychological test scores at outset, month 4 and month 8 of program
 Mean score (SD)
OutsetMonth 4Month 8
  • *

    P < 0.1;

  • **

    P < 0.05 (Wilcoxon Signed Rank Test).

Mini-Mental State Examination25.3 (4.7)25.2 (5.5)25.3 (3.8)
Rivermead Behavioral Memory Test (n = 5)12.4 (9.4)13.6 (8.4)12.0 (8.4)
Behavioral Assessment of Dysexecutive Syndrome84.7 (35.2)87.7 (27.7)90.5 (34.7)
Test of everyday attention72.7 (32.8)**76.7 (38.7)*82.2 (38.2)*,**
image

Figure 1. Test of everyday attention (TEA): Individual scores. Footnote: The TEA consists of eight tasks, which evaluate selective, sustained, or divided attention, attention switching and working memory. The TEA measures auditory and visual attention separately.

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Improvement was observed in most TEA subtasks, with the exception of elevator counting with distraction, visual elevator and lottery (Table 1). Only the improvement in map search (2 min) scores showed statistical significance between the initial and 8-month evaluations. A breakdown of individual scores showed that map search scores showed improvement in the majority of participants (Fig. 2), while other tasks showed mixed results. There were no obvious differences among subjects with stroke, MCI or TBI with regard either to initial scores or the effect of the training regimen on scores.

image

Figure 2. Map search task: Individual scores. Footnote: The map search task of the TEA asks the participant to locate and mark as many examples as possible of a given symbol (e.g. a restaurant symbol) on a color map within two minutes. It assesses visual selective attention and attention speed.

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The questionnaire survey and informal interview with the subjects and families of this study revealed no significant improvement in subjects’ daily struggles or in function of activities of daily living.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The present study shows that a home-based cognitive rehabilitation program using TBI rehabilitation workbooks is feasible and may be effective not only for younger patients with TBI, as previously shown, but for older adults as well.

We found that the cognitive rehabilitation program could be successfully implemented in the home setting. Some authors have reported that cognitive rehabilitation is more effective in the inpatient setting than at home, because program adherence is difficult to maintain at home,19 but others have found no difference in efficacy between the inpatient and home settings.20 The home-based program is a viable option for cognitive rehabilitation for older adults who may have limited access to long-term inpatient programs.

In this study only one person intentionally withdrew from the program. One of the factors responsible for the low attrition rate seems to be the careful, personalized coaching. Most family members also earnestly encouraged subjects to continue the program. Another factor may be the regular neuropsychological evaluations subjects underwent to assess their progress; objective evidence of improvement appeared to have a motivating effect. Thus, three factors—individual coaching, family support and regular neuropsychological evaluation—appear essential to the success of an in-home cognitive rehabilitation program.

The results of this study also suggest that the program may effectively improve attention in older adults. Attention is often impaired consequent to age-related diseases such as stroke;21 moreover, the literature suggests that attention can be effectively enhanced with cognitive rehabilitation.8,22 However, there is limited data reporting on the cognitive rehabilitation of older adults in the home setting, nor are there any studies that use a restorative approach, such as the workbook method used in this study, to improve attention among older adults. Most cognitive rehabilitation programs in use today are based on a compensatory approach; thus, our findings, that attention scores can be improved by means of a restorative approach, are especially interesting.

The map search task, the specific attentional subtask that showed significant improvement in this study, is related to visual selective attention. Many authors have conceptualized attention as multicomponential. For example, Sohlberg et al. describe components of sustained,22 selective, alternating and divided attention. Yet, past studies on the effect of rehabilitation on attention have been mostly conducted on young subjects with TBI and have treated attention as one-dimensional. A recent case-control study by our research group, implementing an identical cognitive rehabilitation program in a young TBI population, showed similar results to the present study, with visual selective attention improved in the intervention group after 1 year (Matsuoka & Fujii, unpubl. data, 2005). It is unclear whether the workbooks specifically target and strengthen the visual selective attention facility or whether visual selective attention is the most susceptible to improvement by cognitive rehabilitation. Alternatively, the map search task may be most sensitive among the subtests of the TEA. Another author has suggested that only the map and telephone searches, among all TEA subtests, differentiate between persons with TBI and age- and education-matched controls.23 More studies are needed to explicate the mechanisms of this improvement.

No significant improvements were seen in memory, executive function or overall cognitive function (per MMSE). These functions may require much longer intervention periods. Or it may be that the efficacy of the workbooks is limited to those patients with particular disease types, levels or locations. The small number of subjects in this study limits further speculation. It is also important to assess the impact of cognitive improvement on the daily lives of patients, but the subjects and families of this study revealed no significant improvement in the daily lives of subjects. Actual improvement in daily life may require much more improvement in cognitive function. This issue also should be examined in future studies.

The present paper reports one of the first attempts to implement a home-based cognitive rehabilitation program for community-dwelling older adults in Japan. The majority of participants completed the program, and significant improvement was obtained in visual selective attention among those who completed the program. The study uniquely targets the restructuring and re-organization of cognitive function, and involves a longer intervention period (8 months) than most other cognitive rehabilitation projects for older adults reported to date. The limited cognitive rehabilitation programs available in Japan to date are costly and mainly targeted at inpatients. This study suggests a new framework of cognitive rehabilitation for older adults that can be implemented at home.

This study is just the beginning of the exploration of the feasibility for home-based cognitive rehabilitation programs. The number of subjects was limited and heterogeneous and no control group was available. The long-term effect of the program, beyond the 8-month completion mark, remains to be seen. Further examination, with a larger number of subjects and a control group, is essential. We also need to focus on a specific condition, such as Alzheimer’s disease, in a single study, in order to evaluate the effectiveness of the program on such clients. The possibility of further improvement of cognitive function, including memory, as well as the impact of the measured cognitive improvement on the daily life of older adults, will be the focus of our further investigations.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

This paper is supported by grants from the France Bed Medical Home Care Foundation and the Mitsui Sumitomo Welfare Foundation of Japan. The authors would like to thank Drs Seigo Inoue, Masako Matsuba, Ryoichi Shiozawa and Masatake Uno who kindly introduced the participants to the first author. A portion of this paper was presented at the 24th Conference of the Japan Gerontological Society, where it received the Best Poster Award in the division of the Japanese Psychogeriatric Society.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHODS
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
  • 1
    Doornhein K, DeHaan DHF. Cognitive training for memory deficits in stroke patients. Neuropsychol Rehabil 1998; 8: 393400.
  • 2
    Gasparrini B, Satz P. A treatment for memory problems in left hemisphere CVA patients. Clin Neuropsychol 1979; 1: 137150.
  • 3
    Gianutsos R, Gianutsos J. Rehabilitating the verbal recall of brain-injured patients by mnemonic training: an experimental demonstration using single-case methodology. Clin Neuropsychol 1979; 1: 117135.
  • 4
    Fujita K, Fujii M, Shikimori H. A home-based memory training for severe traumatic brain injury through the use of training books and dictation tasks. Brain Inj 2003; 17 (Suppl 1): 120.
  • 5
    Leftoff S. Learning functions for unilaterally brain damaged patients for serially and randomly ordered stimulus material: analysis of retrieval strategies and their relationship to rehabilitation. Clin Neuropsychol 1981; 3: 301313.
  • 6
    Towle D, Edmans JA, Lincoln NB. Use of computer-presented games with memory-impaired stroke patients. Clin Rehabil 1988; 2: 303307.
  • 7
    Wilson B. Success and failure in memory training following a cerebral vascular accident. Cortex 1982; 18: 581594.
  • 8
    Cicerone KD, Dahlberg C, Kalmar K et al. Evidence-based cognitive rehabilitation: recommendations for clinical practice. Arch Phys Med Rehabil 2000; 81: 15961615.
  • 9
    Kubota K, Sakatsume K. Ninti rihateki rekureisyon katudou dounyu niyoru chihousyou koureisya no chitekikinou no henka [Change of cognitive function of the elderly with dementia by recreation activities oriented to cognitive rehabilitation]. Ninchi Rihabil 2003; 2025.
  • 10
    Onodera A, Watanabe H, Agatsuma K et al. Keido Arutuhaimaa gata chihou kanjya ni taisuru ninchi rihabiriteisyon teki kainyuu no kokoromi [An attempt for cognitive rehabilitation for mild Alzheimer’s dementia]. Rounen Seishin Igaku Zasshi 2001; 12: 10471054.
  • 11
    Matsuda O. Koureisya to sono kazoku no shinri kea. Koureisya to kazoku no kokoro wo sasaeru memory training byousyoki no arutuhaimaabyou kanjya to sono kazoku eno approach [Psychological care for the elderly and their families]. Gerontology New Horizon 2003; 15: 133136.
  • 12
    Prigatano GP. Commentary: beyond statistics and research design. J Head Trauma Rehab 1999; 14: 308311; discussion 322–4.
  • 13
    Malia K, Bewick KC, Raymond MJ, Bennet TL. Brainwave-R: Cognitive Strategies and Techniques for Brain Injury Rehabilitation: User’s Guide. Texas: PRO-ED, 1997.
  • 14
    Fujii M, Nenohi T, Matusuoka K. Nosonsho no Rihabiriteshon no Houhou: Sirizu 2 Miru Chuiryoku no Renshucho I–IV [Rehabilitation Method for Brain Injury: Series 2 Workbook on Visual Attention I–IV]. Tokyo: Shinko Igaku Shuppansha, 2004.
  • 15
    Mori E, Mitani Y, Yamadori A. Shikeishikkan kanjani okeru nihongo ban Mini-Mental State testo no yuyosei [The utility of the Japanese version of the Mini-Mental State examination for patients with neurological disease]. Shinkei Shinrigaku 1985; 1: 8290.
  • 16
    Watamori Y, Hara H, Miyamori T, Eto F. Nihon Ban Ribaamiido Koudou Kioku Kensa [Japanese Version Rivermead Behavioral Memory Test]. Tokyo: Chiba Test Center, 2002.
  • 17
    Kashima H, Mimura M, Tabuchi H, Moriyama Y, Kato M. Suikou kinou syougai syoukougun no koudou hyoka nihon ban [Behavioural Assessment of the Dysexecutive Syndrome, Japanese edition]. Tokyo: Shinko Igaku Shuppansha, 2003.
  • 18
    Robertson IH, Ward T, Ridgeway V, Nimmo-Smith I. The Test of Everyday Attention Manual. London: Harcourt Assessment, 1994.
  • 19
    Ozdemir F, Birtane M, Tabatabaei R, Kokino S, Ekuklu G. Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings. Arch Phys Med Rehabil 2001; 82: 13751379.
  • 20
    Warden DL, Salazar AM, Martin EM, Schwab KA, Coyle M, Walter J. A home program of rehabilitation for moderately severe traumatic brain injury patients. The DVHIP Study Group. J Head Trauma Rehabil 2000; 15: 10921102.
  • 21
    McDowd JM, Filion DL, Pohl PS, Richards LG, Stiers W. Attentional abilities and functional outcomes following stroke. J Gerontol B Psychol Sci Soc Sci 2003; 58: 4553.
  • 22
    Sohlberg MM, Mateer CA. Effectiveness of an attention-training program. J Clin Exp Neuropsychol 1987; 9: 117130.
  • 23
    Bate AJ, Mathias JL, Crawford JR. Performance on the Test of Everyday Attention and standard tests of attention following severe traumatic brain injury. Clin Neuropsychol 2001; 15: 405422.