Vol. 12 nº 4 - Oct/Nov/Dec de 2018
Original Article Pages 421 to 426
 

Effect of cognitive stimulation workshops on the self-esteem and cognition of the elderly: a pilot project
Efeito das oficinas de estimulação cognitiva na autoestima e cognição do idoso: um projeto piloto

Authors: Thais Sisti De Vincenzo Schultheisz1; Regiane Ribeiro de Aquino1; Ana Beatriz Ferreira Alves2,3; André Luis Maiera Radl4; Antonio de Pádua Serafim5-7

PDF

Descriptors: elderly, cognitive training, memory, attention, neuropsychological rehabilitation.
Descritores:
idoso, treinamento cognitivo, memória, atenção, reabilitação neuropsicológica.

ABSTRACT:
According to the WHO, by 2025 Brazil will be ranked sixth in the world in terms of proportion of elderly in the population. Within this scope, cognition plays a central role in the aging process, having an important association with quality of life, which suggests the need to develop intervention programs, such as cognitive training.
OBJECTIVE: To determine the effects of a program of cognitive stimulation workshops on the self-esteem and cognition of elderly people.
METHODS: Thirty-eight elderly subjects completed the three-step protocol: 1) Survey of demographic data and evaluation of cognition by a neuropsychological battery and of self-esteem using the Rosenberg Self-Esteem Scale (RSS), prior to training; 2) Participation in twelve cognitive stimulation workshops; and 3) Cognitive evaluation and RSS after the training.
RESULTS: Results showed that the use of training produced positive effects on cognitive test performance of the elderly with and without cognitive impairment. By extension, this demonstrates positive impact on their self-esteem.
CONCLUSION: These findings encourage investment in cognitive stimulation programs as a resource for improved cognition and quality of life for the elderly. Subjective cognitive complaint may have served as a predictor of decreased self-esteem; therefore, as training improved cognition, it also improved self-esteem.

RESUMO:
Segundo a OMS, em 2025 o Brasil ficará em sexto lugar no ranking mundial em termos de proporção de idosos na população. Nesse âmbito, a cognição desempenha um papel central no processo de envelhecimento, tendo uma importante associação com a qualidade de vida, o que sugere a necessidade de desenvolver programas de intervenção, como o treinamento cognitivo.
OBJETIVO: Determinar os efeitos de um programa de oficinas de estimulação cognitiva na autoestima e cognição de idosos.
MÉTODOS: Trinta e oito idosos completaram o protocolo de três etapas: 1) Levantamento de dados demográficos e avaliação da cognição por uma bateria neuropsicológica e de autoestima utilizando a Escala de Autoestima de Rosenberg (RSS), antes do treinamento; 2) Participação em doze oficinas de estimulação cognitiva; e 3) Avaliação cognitiva e RSS após o treinamento.
RESULTADOS: Os resultados mostraram que o uso de treinamento produziu efeitos positivos no desempenho do teste cognitivo de idosos com e sem comprometimento cognitivo. Por extensão, isso demonstra um impacto positivo em sua autoestima.
CONCLUSÃO: Estes resultados encorajam o investimento em programas de estimulação cognitiva como um recurso para melhorar a cognição e a qualidade de vida dos idosos. Queixa cognitiva subjetiva pode ter servido como um preditor de diminuição da autoestima; portanto, como o treinamento melhorou a cognição, também melhorou a autoestima.

The growth of the elderly population is a worldwide reality and therefore calls for investigations and actions to improve physical and psychological well-being, quality of life and legal capacity among this population.1,2 For example, the presence of subjective cognitive complaints, among other variables, may precede the diagnosis of Alzheimer's disease.3,4 Cognitive training can reduce impairments due to deficits resulting from brain injuries or neurodegeneration, and can also enhance cognitive functions.5-7 The authors emphasized that elderly people undergoing cognitive training have obtained improvement related to functional connectivity.8 This connectivity is promoted by the hierarchical structure of the training, which begins with the most basic attention functions and moves on to more complex ones. Thus, attention incorporates a range of cognitive functions: concentrated, sustained and divided attention, in addition to speed of information processing and consequently improvement in working memory. The study involved 321 elderly subjects, who presented mild to moderate Alzheimer's disease (AD), mild cognitive impairment (MCI), and no cognitive decline. Participants were divided into two groups: the training group and the control group. Both groups were given cognitive training. The results showed an improvement in the AD evaluation score, and in the functional capacity measured by the scale of instrumental activities of daily living. There were increased short-term verbal hearing and subjective memory complaints in subjects with MCI.9 A Brazilian study demonstrated that, after memorizing a list of words, there was an improvement in memory performance, associated with an increase in semantic strategy and activation of the prefrontal cortex of healthy older adults.10

The study presents the data from the pilot project involving a program of workshops on cognitive stimulation for the elderly in the ABC Paulista region, with the objective of training cognitive functions: attention, memory, and executive functions. In the present study, we report the results of the workshops on self-esteem and cognition of elderly people with and without cognitive complaints.


METHODS

Study design and sample


A cross-sectional study of an intervention in 38 elderly members of social programs in the ABC Paulista region was carried out. Participants were organized into two groups: a Control Group (CG) comprising 20 elderly without cognitive complaints; and a Training Group (TG) containing 18 elderly with self-reported cognitive complaints. The TG was introduced to compare performance between groups.

Inclusion criteria: age 60+, capacity to comprehend verbal commands, and absence of neuropsychiatric disturbances.

Instruments

Sociodemographic questionnaire.

To evaluate the results of the workshops on cognition and self-esteem, the following instruments were used before and after training:


• Mini-Mental State Examination - MMSE 11 (for cognitive screening).

• WAIS III, Digit span (working memory).12

• Trail Making Tests A and B - TMT- (executive functions).13

• Rey-Osterrieth Complex Figure Test - ROCFT (executive functions and memory).14

• Verbal Fluency-Animal category - VF-A (memory).15

• Logical Memory test from the Wechsler Memory Scale Revised - WMS-R (memory).16

• Rosenberg's Self-Esteem Scale (RSS) (for evaluation of self-esteem).17


Procedure

The project was introduced in social programs for the elderly and participation was voluntary, involving the following steps:

I. Collecting demographic, cognitive and self-esteem data individually.

II. Cognitive training: 12 workshops were held for 60 minutes once a week. The activities for each training session are outlined in Table 1.




III. One month after the 12th session, all participants were individually reassessed based on cognitive and self-esteem variables.

Ethics statement

The study was approved by the Ethics and Research Committee of UMESP (CAAE 61808616.0.0000.5508). All participants were required to sign a consent form.

Statistical analysis

The normality of the distribution of continuous data was verified using the Shapiro-Wilks test, the T-Student´s t-test for independent measures. The analysis showed that age and education presented a normal distribution between groups. For the evaluation of the association between groups and the categorical data, Fisher's exact test and the Chi-Square test were used. To verify differences between groups and between pre and post workshop performance in perceived cognitive and self-esteem, Multivariate ANOVA for estimated marginal means was used. The level of significance adopted was 5% (P<0.05).


RESULTS

Table 2 shows the sociodemographic data for the sample. A predominance of women can be observed in both groups. No significant differences were found in the evaluation of the association between groups and the demographic data. A similar result was observed for age range of the groups.




Application of the protocol revealed that self-reported complaints and performance on cognitive tests in the training group were lower than that of the control group (p<.05) (Student´s t-test) before the training. The comparison of groups after training demonstrates significant effects on cognitive performance regarding the group effect analysis, time and group interaction * Time in the two groups. The two groups showed improvement on the MMSE, copy and recall of the - ROCFT, an increase in the list of words on the VF-A, an increase in the memory context on the WMS-R and a reduction of the run time on the TMT A and B (p<0.05, test of the estimated marginal means). A similar result was observed in relation to increase in scores on the RSS (Table 3).




DISCUSSION

This study reports the partial results of a pilot cognitive training program for the elderly population with and without cognitive complaints. This program is the result of a partnership between a university in the ABC region of São Paulo and the psychiatry and neuropsychology unit of São Paulo hospital. The main objective is to verify the effects of this training on cognition, self-esteem and quality of life of this population with a follow up methodology for three years. Our main question is; can cognitive stimulation be established as a protective factor against cognitive impairment in the elderly?

The literature shows that, for cognitive decline caused by normal aging, injury damage, neurodegenerative conditions or subjective complaints, cognitive training has proven effective.18-22

In this study, two groups of elderly people were involved. The training group had self-reported complaints of cognitive deficit, with memory and cognitive performance significantly lower than the control group prior to the training program. Our results showed that the cognitive training, featuring one weekly session for three months, proved capable of promoting changes in the performance in both groups on cognitive exams. Improvement was evident in working memory, for both verbal and visual stimulus (WMS-R and ROCTT). A similar result was observed in the performance of complex visual screening, motor speed, in executive processes, inhibitory control and alternation of attention (TMT A and B). Although we did not assess pathological groups, the improvements on the cognitive tests, in some ways, corroborate the results of previous studies on older populations.6,9,10

How can our results be integrated into literature on the topic of cognitive training? Studies show that the human brain can change in response to lifelong experience. Therefore, the use of cognitive training might be considered a potential resource to improve cognitive decline associated with age.23,24 The evidence of cognitive improvement has been associated with the possible induction of neural plastic changes specific to training on both neural and behavioral levels.7,21,22,24 The literature has emphasized that the possible mechanism for cognitive improvement is related to neural plasticity. The argument for this can be found in studies that emphasize the complex brain's ability to change in response to both internal demand and external experience.25

There was also an increase in the self-esteem after training for both groups. Self-esteem represents the set of feelings and thoughts of the individual with regard to their own value, competence and adequacy; this is reflected in a positive or negative attitude towards one-self.17 Subjective cognitive complaints might be a predictor of decrease in self-esteem. Therefore, our results suggest that the perception of better cognitive performance in the CG and TG contributed to an improvement in the self-esteem indexes. These findings corroborate the results of other studies on quality of life, depression and anxiety26,27

Although this is a pilot study, the results corroborate those in the literature.7,22,24 We emphasize that the absence of a follow-up procedure for this study could have produced more consistent data of the effects of cognitive stimulation, representing an a priori limitation.

In conclusion, this study demonstrated that the use of cognitive training has positive effects on the cognitive performance of elderly without cognitive impairment, which by extension also positively impacts their self-esteem. The major challenge is to measure evidence of the effects of cognitive training in terms of consolidation over time. These findings support investment in cognitive stimulation programs as a resource for improving cognition and quality of life for the elderly. Therefore, these results are encouraging, warranting the conducting of further studies.

Author contributions. Thais Sisti De Vincenzo Schultheisz: devising study, running workshops, data analysis; Regiane Ribeiro de Aquino: data analysis; Ana Beatriz Ferreira Alves: intellectual contribution for writing the manuscript; André Luis Maiera Radl: data analysis; Antonio de Pádua Serafim: devising study, data analysis, intellectual contribution for writing the manuscript.


REFERENCES

1. Serafim AP. Aging, Cognitive Impairment and Autonomy. Is there a Possible Relationship? JEMHHR. 2015;17(2):569.

2. César KG, Brucki SM, Takada LT, Nascimento LF, Gomes CM, Almeida MC, et al. Prevalence of Cognitive Impairment Without Dementia and Dementia in Tremembé, Brazil. Alzheimer Dis Assoc Disord. 2016;30(3): 264-71.

3. de Oliveira FF, de Almeida SS, Chen ES, Smith MC, Naffah-Mazzacoratti MDG, Bertolucci PHF. Lifetime Risk Factors for Functional and Cognitive Outcomes in Patients with Alzheimer's Disease. J Alzheimers Dis. 2018;65(4):1283-99.

4. Studart A Neto, Nitrini R. Subjective cognitive decline: The first clinical manifestation of Alzheimer's disease? Dement Neuropsychol. 2016; 10(3):170-7.

5. Legault I, Allard R, Faubert J. Healthy older observers show equivalent perceptual-cognitive training benefits to young adults for multiple object tracking. Front Psychol. 2013;4:323.

6. Golino MTS, Flores-Mendoza CE. Desenvolvimento de um programa de treino cognitivo para idosos. Rev Bras Geriatr Gerontol. 2016;19(5): 769-85

7. Miotto EC, Balardin JB, Vieira G, Sato JR, Martin Mda G, Scaff M, et al. Right inferior frontal gyrus activation is associated with memory improvement in patients with left frontal low-grade glioma resection. PLoS One. 2014;9(8),e105987.

8. Sherman DS, Mauser J, Nuno M, Sherzai D. The Efficacy of Cognitive Intervention in Mild Cognitive Impairment (MCI): a Meta-Analysis of Outcomes on Neuropsychological Measures. Neuropsychol Rev. 2017;27(4),440-84.

9. Giuli C, Fattoretti P, Gagliardi C, Mocchegiani E, Venarucci D, Balietti M,et al. My Mind Project: the effects of cognitive training for elderly-the study protocol of a prospective randomized intervention study. Aging Clin Exp Res. 2017;29(3):353-60.

10. Miotto EC, Balardin JB, Savage CR, Martin Mda G, Batistuzzo MC, Amaro Junior E, Nitrini R. Brain regions supporting verbal memory improvement in healthy older subjects. Arq Neuropsiquiatr. 2014;72(9):663-70.

11. Folstein MF, Folstein SE, McHugh PR. Mini Mental state. J Psychiatr Res. 1975;12:189-98.

12. Wechsler D. WAIS III - Escala de inteligência Wechsler para adultos. São Paulo: Casa do Psicólogo; 2004.

13. Tombaugh TN. Trail Making Test A and B: Normative data stratified by age and education. Arch Clin Neuropsychol. 2004;(19)2:203-14.

14. Rey A. Figuras Complexas de Rey. São Paulo: Casa do Psicólogo; 2004.

15. Strauss E. A compendium of neuropsychological tests: Administration, Norms, and Commentary. Oxford: Oxford University Press; 2006.

16. Wechsler D. Wechsler Memory Scale - Revised: Manual. San Antonio, TX: Pshycological Corporation; 1987.

17. Hutz SC, Zanon C. Revisão da adaptação, validação e normatização da Escala de Autoestima de Rosenberg. Avaliação Psicológica. 2011;10(1):41-9.

18. Maki Y, Yamaguchi T, Yamagami T, Murai T, Hachisuka K, Miyamae F, et al. The impact of subjective memory complaints on quality of life in community-dwelling older adults. Psychogeriatrics 2014;14:175-181.

19. Balardin JB, Batistuzzo MC, Martin MGM, Sato JR, Smid J, Porto C, et al. Differences in prefrontal cortex activation and deactivation during strategic episodic verbal memory encoding in mild cognitive impairment. Front Aging Neurosci. 2015;7:147.

20. Assed MM, Carvalho MKHV, Rocca CCA, Serafim AP. Memory training and benefits for quality of life in the elderly: A case report. Dement Neuropsychol. 2016;10(2):152-5. 

21. Batini F, Toti G, Bartolucci M. Neuropsychological benefits of a narrative cognitive training program for people living with dementia: A pilot study. Dement Neuropsychol. 2016;10(2):127-33.

22. Nikolaidis A, Voss MW, Lee H, Vo LT, Kramer AF. Parietal plasticity after training with a complex video game is associated with individual differences in improvements in an untrained working memory task. Front Hum Neurosci. 2014;8:169.

23. Park DC, Bischof GN. The aging mind: neuroplasticity in response to cognitive training. Dialogues Clin Neurosci. 2013;15(1):109-19.

24. Leung NT, Tam HM, Chu LW, Kwok TC, Chan F, Lam LC, et al. Neural Plastic Effects of Cognitive Training on Aging Brain. Neural Plast. 2015: 535618.

25. Giuli C, Papa R, Lattanzio F, Postacchini D. The Effects of Cognitive Training for Elderly: Results from My Mind Project. Rejuvenation Res. 2016;19(6):485-94.

26. Casemiro FG, Rodrigues IR, Dias JC, Alves LCS, Inouye K, Gratão ACM. Impact of cognitive stimulation on depression, anxiety, cognition and functional capacity among adults and elderly participants of an open university for senior citizens. Rev Bras Geriatr Gerontol. 2016;19(4): 683-94.

27. Grasso MG, Broccoli M, Casillo P, Catani S, Pace L, Pompa A, Rizzi F, Troisi E. Evaluation of the Impact of Cognitive Training on Quality of Life in Patients with Multiple Sclerosis. Eur Neurol. 2017;78(1-2):111-7.










1. Estudante de Doutorado no Programa de Pós-Graduação em Psicologia da Saúde, Universidade Metodista de São Paulo, São Bernardo do Campo, SP, Brazil
2. Estagiária na Unidade de Neuropsicologia do Instituto de Psiquiatria - HCFMUSP, SP, Brazil
3. Estudante na School of Arts and Science, University of Miami - USA
4. Professor do Curso de Fisioterapia da Escola de Ciências Médicas Universidade Metodista de São Paulo, São Bernardo do Campo, SP, Brazil
5. Diretor da Unidade da Unidade de Neuropsicologia do Instituto de Psiquiatria - HCFMUSP, SP, Brazil
6. Professor Doutor Colaborador do Departamento de Psiquiatria, Universidade de São Paulo, SP, Brazil
7. Professor Titular do Programa de Pós-Graduação em Psicologia da Saúde, Universidade Metodista de São Paulo, São Bernardo do Campo, SP, Brazil

This study was conducted at the Unidade de Neuropsicologia do Instituto de Psiquiatria, Universidade de São Paulo, SP, Brazil and Programa de Pós-Graduação em Psicologia da Saúde, Universidade Metodista de São Paulo, SP, Brazil.

Antonio de Pádua Serafim
Rua Dr. Ovidio Pires de Campos, 785 / 1º andar
05403-010 São Paulo SP - Brazil
E-mail: a.serafim@hc.fm.usp.br

Received August 07, 2018
Accepted in final form October 26, 2018

Disclosure: The authors report no conflicts of interest.

 

Home Contact