1. Introduction
With an increase in the proportion of older adults worldwide, there has been increased attention to the mental health of older adults. Cognitive decline is one of the most common challenges faced by the aging population. As a result, even healthy older adults who do not suffer from dementia often experience memory problems in their everyday lives. Older adults with cognitive complaints are more likely to progress to mild cognitive impairment (MCI) and Alzheimer’s disease (AD) compared with those without cognitive complaints.[1] MCI is considered an intermediate stage between age-related cognitive decline and dementia.[2]
However, based on the current knowledge, therapies aimed at restoring cognitive impairments have not yet been successful. Although numerous studies have been conducted to evaluate the efficacy of treatments for dementia, pharmacological interventions have achieved limited success in alleviating symptoms and slowing disease progression.[3] Therefore, it is important to provide evidence for effective non-pharmacological interventions. In particular, cognitive intervention, a non-pharmacological therapy, has the potential to aid in the prevention and treatment of AD and improve cognitive function in older adults who are healthy and those with MCI.[4,5]
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Cognitive interventions can be classified as cognitive stimulation, cognitive training, or cognitive rehabilitation, depending on the methods that are employed.[6] Cognitive training involves the structured practice of standardized tasks that are developed to improve specific cognitive functions, such as working memory, attention, or executive function.[7] Cognitive stimulation refers to participation in non-specific activities that stimulate cognitive and social functioning. These activities include orientation reality, reminiscence therapy, paper folding, creating a topiary or ceramic item, and playing a musical instrument.[8] It has been reported that cognitive stimulation and cognitive training improve cognitive function in healthy older adults and older adults with MCI.[9] However, as their therapeutic value is restricted to the trained cognitive areas, these interventions are limited in their effectiveness for reducing the discomfort of daily life and improving the quality of independent living. Cognitive rehabilitation is defined as the rehabilitation of people with cognitive impairments and it focuses on not only improving or maintaining cognitive function related to the performance of everyday tasks but also compensating for impairments and supporting independent living.[6]
Cognitive rehabilitation was originally developed primarily through the training of young people with traumatic brain injury but it has also been applied to people with cognitive impairments such as MCI or dementia.[6] Cognitive rehabilitation has been used for years in patients with traumatic brain injury or stroke, and several evidence-based studies have demonstrated its effectiveness.[10] Although several studies have shown that cognitive rehabilitation is effective in people with cognitive impairments,[11,12] there are relatively few well-designed studies on the development and effectiveness of programs that involve cognitive rehabilitation in people with MCI. Cognitive rehabilitation is considered as one of the most effective interventions in slowing down the progression of cognitive decline,[13] and as these interventions have been administered relatively recently, additional studies are needed to assess and verify their therapeutic effects.
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Cognitive rehabilitation methods include restorative approaches and compensatory methods.[14] Restorative approaches are based on retained abilities and employ a range of techniques to promote learning and relearning. Compensatory methods are based on a range of aids to support function and overcome the limitations resulting from cognitive impairments.[15] According to a methodological review of cognitive rehabilitation, this approach uses not only learning strategies, such as mnemonic skills, but also compensatory strategies that use external memory aids.[16] Mnemonic skills are systematic procedures for enhancing memory and cognitive tools that facilitate the organization and association of new information.[16] One of the most prominent mnemonic skills is the method of loci, an ancient technique used extensively by Greek and Roman orators.[17] The method of loci utilizes well-established memories of visuospatial routes. During encoding, the to-be-remembered lists are visualized at fixed locations within a route, then they are mentally retraced during recall.[18] Memory recall is enhanced when the method of loci is applied to memorize word lists.[19,20] Cognitive interventions, including mnemonic skills, facilitate learning and memory enhancement in healthy older adults and people with MCI.[21,22] These skills also improve quality of life by promoting active transfer to everyday cognitive tasks.[23] Compensatory strategies use environmental cues to enhance memory and everyday functioning using external memory aids, such as notes, calendars, and cell phones.[24] People with MCI can improve their functional ability and memory self-efficacy using a notebook or calendar.[25]
Previous studies have shown that cognitive interventions can improve the functioning of trained cognitive domains. However, only a few studies have assessed the aspects of daily functioning or quality of life; the results have been inconsistent across studies and the effect sizes were small.[26,27] In addition, cognitive interventions focused on memory compensatory strategies improved daily functioning but did not show a clear improvement in cognitive functions.[25] Therefore, we developed a cognitive rehabilitation program that combined mnemonic skills and memory compensatory strategies to overcome the limitations of previous studies, which have only independently used mnemonic skills or compensatory strategies.[16,21,22,24,25] In particular, we focused on training to memorize a password for a bankbook, a door-lock password, and a person’s name that older adults could easily forget in their daily life using mnemonic skills rather than training tasks related to specific cognitive domains such as memory, attention, and executive function. We also tried to improve daily function by employing memory compensatory strategies using various tools, such as calendars or cell phones, which are widely available in the vicinity. This made it easier for older adults to apply the strategies in daily life. This pilot study aimed to reduce memory problems that can cause discomfort in everyday life and improve the quality of life among community-dwelling older adults. This study also evaluated the effects of our proposed cognitive rehabilitation program on subjective memory discomfort, objective cognitive function, depressive mood, and quality of life.
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