Development of a memory center for older adults in Almaty,Kazakhstan: Innovative Practice

Abstract

Recognizing the economic and health-outcome value of early cognitive assessment and intervention among its older citizens has guided the Innovative Research School in Gerontology of the SD Asfendiyarov Kazakh National Medical University to begin the process of establishing its nation’s first memory center in Almaty, Kazakhstan. Life expectancy in Kazakhstan, which continues to undergo health-care reform since its independence in 1991 from the former Soviet Union, has steadily risen from 64.4 years in 1996 to 68.67 in 2009. With increased life expectancy has been a corresponding rise in cognitive impairments among older adults. The components of the Memory Center, which comprises assessment, education and support, non-pharmaceutical and pharmaceutical interventions, are described.

Keywords

cognitive training dementia neuroplasticity memory center mild cognitive impairment

Introduction

There are nearly 900 million people over the age of 60 worldwide with projected increases ranging between 56% for higher income countries and 239% for lower income nations by the year 2050 (Alzheimer’s Disease International, 2015). As countries have aged, related chronic diseases have also risen to epidemic proportions. In the US, for example, 80% of those over 65 have at least one chronic condition, while 50% have two (Centers for Disease Control and Prevention, 2004). Of the chronic diseases, dementia has been identified as a leading cause of disability and dependence among older adults internationally (World Health Organization, 2015). As life expectancy continues to increase, so will the occurrence of dementia and mild cognitive impairment. In some countries, where the proportion of people over 65 has been lower than most industrialized nations, public policy to manage a growing prevalence of age-related health conditions is still in the early stages of development. In Kazakhstan, which continues to undergo health-care reform since its independence in 1991 from the former Soviet Union, life expectancy remains below the average of EU countries but has steadily risen from 64.4 years in 1996 to 68.67 in 2009 (Katsaga, Kulzhanov, Karanikolos, & Rechel, 2012). Compared to other nations, Kazakhstan is just beginning to formulate strategies to confront the cognitive health problems of an aging populace. In particular, the implementation of wellness and health promotion services is a relatively new approach to health care. Realizing the importance of early detection and intervention to improve cognitive outcomes has led some nations to increase community awareness to healthy behaviors through outreach and accessible care. A trend emerging internationally is the establishment of “memory centers” that targets both healthy and cognitively impaired elderly for assessment, support and intervention. A primary feature of memory centers is the application of non-pharmaceutical interventions that focus on increasing healthy behaviors such as diet, exercise, mental stimulation and social interaction. The effect of positive lifestyle behaviors on cognition is well supported in the literature (Colcombe & Kramer, 2003; Rebok et al., 2014; Singh et al., 2014; Smith et al., 2009; Tesky, Thiel, Banzer, & Pantel, 2011). For Kazakhstan, the significance of promoting non-pharmaceutical interventions cannot be overstated for a country which has traditionally relied almost exclusively on drug therapy for its health care, similar to other post-soviet republics.

In the US, where the use of non-pharmaceutical interventions is more established, there has been a proliferation of memory centers in both the profit and non-profit sector. For example, the Memory Training Centers of America has, since 2001, provided professional outreach to thousands of individuals living in elder living communities throughout the US (Memory Training Centers of America, 2015), while others such as the University of Wisconsin’s Alzheimer’s Disease Institute (2015) and the Memory Disorders Center at the University of Cincinnati Neuroscience Institute (2015) serve as resource hubs for elders with memory loss.

Recognizing the economic value of early cognitive assessment and intervention along with the potential of improving the quality of life among its older citizens consistent with the Madrid International Plan of Action on Aging (United Nations, 2002) has guided the Innovative Research School in Gerontology of the SD Asfendiyarov Kazakh National Medical University to begin the process of establishing a Memory Center in Almaty, Kazakhstan. The purpose of this paper is to outline the planning processes being implemented by the School.

Location and building

In collaboration between the Eastern Michigan University’s Aging Studies Program and the Innovative Research School in Gerontology within the SD Asfendiyarov Kazakh National Medical University the initial stages in the organization of a memory center for the Almaty region has begun. Following are the primary elements planned for the memory center.

Almaty, Kazakhstan is the most populated city and serves as the main commercial, cultural and intellectual hub of the country. The memory center will utilize space within the city’s Veterans Hospital. The Veterans Hospital is a 350 bed facility that offers free health care and a permanent residence for those without family for qualifying veterans and families residing in the region. The memory center space within the hospital will include indoor and outdoor areas, kitchen and dining facilities, social areas, recreation/fitness rooms and cognitive assessment areas. Services offered in the memory center will include: cognitive assessment, education, patient/family support, pharmaceutical and non-pharmaceutical interventions and research. Staffing will vary depending on the services described below. A core team of seven health-care professionals within the Veterans Hospital have been identified for the memory center and include medical doctors, psychologists, nurses and social workers. All core team members will receive training in concepts of interdisciplinary principles and approaches.

Both internal and external sources of revenue will be utilized in collaboration with the Kazakh National Medical University, the Ministry of Health, the World Health Organization and affiliated universities both domestically and internationally. User-fees prorated on a sliding scale based on financial ability of the memory center participants will also be considered based on models developed in the US.

The memory center will serve as a research hub for students, educators from the SD Asfendiyarov Kazakh National Medical University along with local professionals in the area of cognition. Collaborative research between affiliated universities both domestically and internationally will be ongoing. Initial areas of investigation will include the effect of lifestyle modification and medications on cognitive health, and the effect of patient education on quality of life for community dwellers.

Cognitive assessment

Cognitive assessment is considered the first and most important component of the memory center, since early detection of cognitive deterioration is critical in achieving optimal outcomes in treatment. The memory center will provide participants from both the hospital and Almaty community with three levels of cognitive testing. Level 1 assessment will provide cognitive screening using the Mini Mental State Exam (MMSE) to determine the need for further evaluation. The MMSE is well known within the Kazakhstan medical community and already serves as an assessment tool used by the Veterans Hospital. The MMSE demonstrates strong construct validity and can be administered by a variety of health-care professionals trained in its use (Beer, 2006). Level 2 assessment will assess specific cognition functions using a battery of neuropsychological tests including the Cambridge Neuropsychological Test Automated Battery (Cantab Research Product Guide, 2015), which measures several important functions including processing speed, psychomotor speed, attention, episodic memory, working memory and executive functions. The Cantab meets the criteria described by Papp, Walsh, and Snyder (2009), who suggested a battery of tests that survey the key cognitive domains and lead to an omnibus composite score which would remove the heterogeneity of mixed instrumentation commonly used in cognitive outcome research. Other measures include scales that test depression, anxiety and sleep quality. Level 3 assessment will use neuroimaging technology, such as a brain CT or MRI scan, to determine a specific diagnosis or whether a certain medical condition is having a negative effect on cognition.

In addition to early detection, assessment will serve as a baseline for measuring progress in cognition after interventions are initiated and to evaluate any progression of cognitive decline. The infrastructure currently exists in the Veterans Hospital for brain imaging and can be incorporated into the assessment process of the memory center. Cognitive assessment will be conducted by a neuro-psychologist and neurologist from within the hospital.

Education and support

Another aspect of program development is the provision of education and support. The “education” component will provide, both healthy and cognitively impaired elders and family, information on establishing and maintaining healthy behaviors along with a better understanding of dementia. Education of healthy behaviors will include increasing knowledge of appropriate foods associated with cognitive health, exercise techniques and resources, assessment of meaningful recreation interests and mentally stimulating activities and increasing awareness of community resources for social interaction. In addition to 1:1 and small group staff interactions with the memory center participants, information will be disseminated through a website developed by the Innovative Research School in Gerontology.

The “support” component will allow participants the opportunity to express concerns and needs through peer and/or professionally facilitated interactions in both individual and small group sessions. Staffing for this component of the memory center will include psychologists, clinical social workers and nurse educators.

Interventions

In addition to receiving knowledge about healthy behaviors, the memory center will also facilitate the practice of behaviors among the participants. Research has demonstrated that experiential learning that allows direct practice of acquired knowledge is more effective in changing behaviors than didactic learning only (Rustad & Smith, 2013). The following interventions have strong empirical support for both preventive and treatment outcomes.

Diet

Nutritional intake that is low in fat and high in Omega-3s fatty acids, such as the Mediterranean and similar diets have been found to improve cognition (Martinez-Lapiscina et al., 2013; Psaltopoulou et al., 2013; Singh et al., 2014; Wengreen et al., 2013). The memory center will provide opportunities for patients to practice healthy meal preparation and consumption of food under the supervision of a trained nutritionist.

Exercise

Extensive evidence supports the effect of exercise and in particular high-intensity exercise on cognitive health (Colcombe & Kramer, 2003; Jedrziewski, Ewbank, Wang, & Trojanowski, 2010; Sofi et al., 2010; Van Gelder et al., 2004).The memory center will provide opportunities for patients to practice and learn fitness behaviors using state-of-the-art exercise equipment currently located in the Veterans Hospital under the guidance of a trained exercise physiologist (Figure 1).

Figure 1.

Exercise room at the memory center, Almaty, Kazakhstan.

Mental stimulation

Recreation activities and computer games will be offered for patients to challenge their mental functions. Major studies in the US (ACTIVE study and IMPACT study) support the use of mentally engaging activities in maintaining and improving cognition based on the theory of neuroplasticity (Rebok et al., 2014; Smith et al., 2009). Assessment of the meaningfulness of activities to each participant will be administered to best match the individual to his/her preferences. Clinical social workers and nurses will facilitate this component of the memory center under the supervision of a psychologist (Figure 2).

Figure 2.

Mental stimulation and social opportunities at the memory center, Almaty, Kazakhstan.

Social interaction

Research supports the relationship between satisfying social relationships in maintaining and improving cognitive function (Tesky, Thiel, Banzer, & Pantel, 2011). The memory center will offer organized opportunities for social engagement along with creating a physical milieu conducive to socialization. Staffing for this component will include clinical social workers and nursing assistants.

Pharmaceuticals

The memory center will follow best-practice guidelines for the administration of medication in the treatment of cognitive decline. Medical doctors will be available from the Veterans Hospital and from the Kazakh National Medical University.

Conclusion

As Kazakhstan confronts an aging population and its corresponding increase in age-related cognitive impairments, strategies for early detection and intervention become increasingly important. This paper discussed the development of a memory center by the Innovative Research School in Gerontology within the SD Asfendiyarov Kazakh National Medical University in collaboration with Eastern Michigan University’s Aging Studies Program. Having a memory center will offer elders in the Almaty region the opportunity for cognitive testing, education, support and both non-pharmaceutical and pharmaceutical interventions. Recognizing a need for managing an aging population has led the Innovative Research School in Gerontology in Almaty, Kazakhstan to establish the country’s first memory center to prevent, maintain and treat cognitive problems among its elders.

Footnotes

Authors’ contributions

DWT was responsible for conceptualizing the components of the memory center and drafting the manuscript. AY, AA, GU, AA and VC were responsible for providing information about the hospital and staffing for the memory center in addition to editing the manuscript. All authors read and approved the final version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Both internal and external sources of revenue will be utilized in collaboration with the Kazakh National Medical University, the Ministry of Health, the World Health Organization and affiliated universities both domestically and internationally. User-fees prorated on a sliding scale based on financial ability of the MC participants will also be considered based on models developed in the US.

Dr David W Thomas is a professor of Therapeutic Recreation and Aging Studies within the School of Health Sciences at Eastern Michigan University. He is widely consulted in environmental design and activity interventions for people with dementia.

Dr Ainur Yeshmanova is the director of the Institute of Gerontology within the S.D. Asfeniyarov Kazakh National Medical University, Almaty, Kazakhstan.

Dr Assiya Akanova, Dr Gulmira Umutbayeva and Dr Akmaral Abikulova are research partners at the Institute of Gerontology within the S.D. Asfeniyarov Kazakh National Medical University, Almaty, Kazakhstan.

Dr Vera Chaikovska is affiliated with the Institute of Gerontology in Kiev, Ukraine and Visiting Scholar at the Institute of Gerontology in Almaty, Kazakhstan.

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