PUBLIC PERSPECTIVES & ENGAGEMENT IN COGNITIVE STIMULATION ACTIVITY TO PRESERVE COGNITIVE RESERVE AMONG ELDERLY IN MALAYSIA

Introduction

All humans experience a decrease in the cognitive levels as their age progresses with signs and symptoms such as forgetfulness, decrease in attention span (focus), decreased ability to solve problems etc. A lack of attention to these symptoms may lead the individual to develop serious mental illnesses such as dementia, depression or Alzheimer’s disease. Cognitive reserve (CR) refers to the reduction in symptomology by the ability of the coping mechanism of the brain to pathologies of the brain brain pathologies (Solé-Padullés et al., 2009). In view of this it has been hypothesised that schooling and the level of occupation directly relates to a reserve mechanism, wherein the education and occupation component form the basis of the reserve capacity especially in the case of behavioural variant Fronto Temporal Dementia (bvFTD). The study further indicates that such components if acquired may help in forestalling the genetic-based disease in individuals who are at risk (Borroni et al., 2009). Besides counteraction, cognitive reserve has also been known to delay such age related changes (Wang et al., 2002). The concept of cognitive reserve accounts for the lack of connection between the amount of brain pathology and the symptomology. It suggests that, each individual has a varying capacity to cope under pathology with more capacity for some more than others in relation to task performance (Stern, 2009). Stern (2009) specifically refers to plasticity of the brain in its ability to cope using compensatory mechanisms or adaptive networks. Hence the ability of a person to cope depends on his cognitive reserve; the more amount of CR relates to better ability to cope and vice versa. It can hence be stated here that an increased amount of participation in cognitive stimulating activities can directly result in the prevention in the development of serious mental illness. (Wilson et al., 2002). These activities may be intellectual, physical, social, leisurely or even nutritional (Barnes et al., 2013; Williams & Kemper, 2010; Scarmeas et al., 2001).

Literature review

Understanding the age associated structural and functional changes that occur as we age is key to improving aging successfully. A most unique feature of the brain whether it is aged or not is its plasticity. The brain retains a high level of plasticity even though the brain age is high. Therefore, to attain successful aging, this plasticity that is the interlinking of the neural structure, function and experience may be recruited and harnessed so as to prevent age related decline in cognition as well as co-morbidities (Jessberger & Gage, 2008).

Reserve in general can be classified as passive and active. The reserve of the brain falls into the category of passive model, where the reserve is dependent on size of the brain and count of the neurons. In view of this, it has been depicted that the larger the brain, more the insult it can withstand. This can be attributed to the fact that a larger brain constitutes for a larger neuronal base and this in turn ensures the delay of the onset of a clinical deficit. This can further be elaborated upon in terms of a brain reserve capacity as depicted in the threshold model. The very basis of the model is that every brain is different as each of them has a threshold only beyond which a clinical deficit can occur in conjunction with a function deficit as well. However, a threshold model may be considered to be a passive model. The mainstay reason behind this is that it assumes a cut-off or threshold where anyone experiences a deficit. This can be instanced in the case of Alzheimer’s disease which can largely be attributed to the decrease in the amount of synapses. Another reason they can be passive is that they are largely quantitative. This is because the threshold measures the sum of the instances of brain damage that has occurred and also operates on the assumption that each type of brain damage will have the same effect on any individual it occurs in. With respect to this, it can be stated that differences between individuals occur only in terms of brain capacity and whether or not a deficit has occurred for damage to take place. However, the model does not take into consideration the differences in how each individual processes tasks of functionality and cognition when the said damage occurs. On the other hand, the active models such as CR demonstrate that in the face of damage, the brain using its reserves of cognition and functionality attempts to salvage the situation by such compensatory mechanisms (Stern, 2002). This model also puts emphasis on the fact that patients with a larger CR will be able to tolerate larger lesions irrespective of his brain capacity as compared to another individual. It can thus be stated here that while the passive model bases itself on the measures of the brain, the active model conversely places emphasis on the processes of the brain and hence its networks (Solé-Padullés et al., 2009). In view of this, neural implementation can thus take place via two modalities; the neural reserve and the neural compensation. Here, neural reserve refers to the processes of the brain in normal function while neural compensation refers to the coping mechanism of the brain in the presence of a pathology (Stern, 2009).

Two studies examined the CR in patients with the help of MRIs. The first study investigated the relationship of CR proxies against the measures of brain functions. The study findings in this case presented that if the brain showed a decreased activity during cognitive processing, then better the cerebral networks and on the flipside a large brain was associated with a high CR. However, this high CR meant that the volume of the brain was decreased especially in the cases of AD or cognitive impairment (mild). The brain function is also suggested to be higher in patients with AD. On the whole an inverse relation for healthy and pathological aging groups emerged between brain structure and function and CR variables (Solé-Padullés et al., 2009). The second study investigated the relationship between CR, grey matter and brain activity and this study too concluded the same with increased neural efficiency in higher CR (Bartrés-Faz et al., 2009).

Three studies one by Langlois et al. (2013 one by Williams and Kemper (2010) and the other by Barnes et al. (2013) evaluated the association of cognitive functioning and physical activity. All the studies here came to the conclusion that activity in any form resulted in a significant positive difference in the cognition of the elderly and the type of activity did not matter as much as the activity itself. Similarly, two studies conducted separately by (Verghese et al., 2003) and by Scarmeas et al. (2001) investigated if engaging seniors in leisure activities had an impact on the incidence of dementia. The study findings revealed that the incidence of dementia reduced as the leisure activities formed a CR. Furthermore, it helped to delay the onset of dementia.

A study conducted in Sweden followed up for 9 nine years in the elderly and evaluated that if the individuals were active cognitively, physically or socially the risk for dementia was lowered. However, if the individuals were actively functioning on all these fronts then the risk was further lowered (Rue, 2010). From the literature it can be concluded that engaging in different types of activities builds the CR thereby reducing the risk of or delay of onset of serious mental illness.

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Aim

To evaluate public perspectives & engagement in cognitive stimulation activity to preserve cognitive reserve among elderly in Malaysia.

Research objectives

Primary Objectives

• To determine the level of awareness on cognitive stimulating activity in view of protective effect on cognitive reserve among the elderly in Malaysia.
• To determine the different perspectives on cognitive stimulating activity in relation to preserving cognitive reserve among the elderly in Malaysia.
• To determine engagement in different types of cognitive stimulating activity in relation to preserving cognitive reserve among the elderly in Malaysia.

Secondary Objectives

• To associate between different level of cognitive function and acceptance to engage in cognitive stimulation activity. (Example the higher the IQ CODE score the more acceptance seen to engage in cognitive stimulating activity.)

Research questions

• 1. What is the perspective among elderly in Malaysia including awareness and acceptance on cognitive stimulating activity and its role to preserve cognitive reserve?
• 2. How is the engagement among elderly in Malaysia towards cognitive stimulating activity for maintaining cognitive reserve?

Research methodology

6.1 Research Design

The study design that can be used most appropriately for medical research for the purpose of public health planning is a cross sectional one. The main aim of cross sectional studies is to discern the prevalence rates for any given intervention/outcome across a population. This is to further assist in actions to be taken at the level of community health planning. In this case, collection of data can take place involving factors such as risk factor exposure, specific characteristics of individuals, and also the outcome on the whole. A cross sectional study hence captures the overall outcome as assessed within a population within a specified period of time.

Other aspects of a cross sectional study, is that they are often descriptive and are conducted with the employ of a survey technique. In this type of study, hypothesis are not formulated but are rather based on the description of a specific group of population in terms of risk factors, intervention and eventual outcome. The purpose of this study hence remains the same. However, as cross sectional studies measure the association of risk to outcome, it can aid in the development of hypothesis for future research (Levin, 2006). The pilot study hence adopts a cross sectional survey based on the Cognitive Reserve Index Questionnaire (CRIq).

6.2 Sampling

For the purpose of this study simple random sampling has been used based on previous studies. Simple random sampling represents the target group with the least bias (Marshall, 1996). The study will be conducted on general public population among the elderly aged between 55 and 70 years who do not exhibit cognitive disability disorders.

6.3 Sample size

From data from the previous studies such as those conducted by Barnes et al. (2013) and Langlois et al. (2013) a sample size of 150 participants will be recruited.

6.4 Data collection methods

The study employs a survey technique that is to be conducted face to face. Here, the interviewer is present at the time that data is collected and will form the interview process by asking the set questions. This type of face to face interviewing bears many an advantage as opposed to other modes such as mail or telephonic surveys as the validity of the research can be better confirmed and the quality of the responses are too enhanced. Also, the interview lasts for a longer period of time which gives the interviewer an opportunity to make interpretations that are not solely restricted to the questionnaire itself. This in turn is more valuable from the aspects of the findings of the study. Another advantage is that the respondents will answer with more interest to the questions which may not be the case with the mail or telephone, the answers also will be more spontaneous and genuine which further goes into the validation of the data quality. Also, as the interviewer themselves records the data the chances of ‘missing data’, ambiguous markings, and illegible handwriting that plague mail surveys are eliminated. Due to this, a face to face survey pattern for administering the questionnaire has been adopted.

6.5 Validation and credibility of the questionnaire

The use of IQCODE a standardised questionnaire in a community setting composed of older adults is more preferred to the traditional tests due to better accuracy and objectivity of the questions, making the respondent more comfortable to answer them. On the other hand even though IQCODE has been considered the norm in such settings, there are higher chances for such events like misdiagnosis or conversely false assurance that all is good. Previous studies hence depict that issues pertaining to the heterogeneity, bias and a subpar reporting quality with this IQCODE. In view of this, there are tools that exist to assist the initial diagnosis for dementia; however which is deemed better than the other remains unknown. Therefore, as the most commonly used tool for the preliminary assessments for dementia still remains Informant questionnaire on Cognitive Decline in the Elderly (IQCODE), the same was adopted for the present study.

As for the measurement of cognitive reserve, the study by Nucci et al., 2012 used a tool known as the Cognitive Reserve Index questionnaire (CRIq) on 588 healthy people from the ages of 18-102 grouped into the young, the adults and the elderly on the basis of age and also gender. The CRIq consists of three sections that cover work, education and time for relaxation. The findings of this study finds basis in further use in future experimental studies and eventually clinical practice. The present study thereby employs the CRIq to measure the cognitive reserve. Reserve of the brain is a term that broadly encompasses both healthy function and the coping mechanism in a pathology. It specifically refers to aspects realted structurally such as synapse count and the size of the brain. Hence, The methodological standardized validated instrument to measure cognitive reserve used is the Cognitive Reserve Index Questionnaire.(CRIq)

6.6 Conducting the study

Every patient will be directed to answer a questionnaire, which will assess the public perspectives & engagement in cognitive stimulation activity to preserve cognitive reserve among elderly in Malaysia after an informed consent process. The methodological standardize validated instrument to measure cognitive reserve used in the questionnaire will be the Cognitive Reserve Index Questionnaire (CRIq). Social demographic characteristic such as age, gender, race, and ethnicity, information regarding employment and pastime activities will also be recorded.

Data analysis

The primary data will then be collected and analysed using SPSS, where the continuous variables will be assessed used ANOVA and the categorical variables tested using the Chi square test, where p<0,05. At the end of the study, a project paper with the interpreted results will be written.

Ethical considerations

To be obtained through The Director (UCSI), Centre of Excellence for Research, Value Innovation and Entrepreneurship.

Reference

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