Multicomponent intervention combining a cognitive stimulation group and tai chi to reduce cognitive decline among community-dwelling older adults with probable dementia: A multi-center,randomized controlled trial

Abstract

Objective

This research study aims to evaluate the effectiveness of a multicomponent intervention that combines a cognitive stimulation group and tai chi to reduce cognitive decline among community-dwelling Chinese older adults with probable dementia.

Methods

A multi-center, randomized controlled trial design was adopted in this study. In addition to treat as usual, the treatment group (n = 41) participated in a structured cognitive stimulation group followed by tai chi twice a week, with a total of 14 sessions held during the study period. The control group (n = 39) received treat as usual. Mattis Dementia Rating Scale and Mini-Mental State Examination were used for assessing the cognitive abilities of participants in the pre- and post-treatment periods.

Results

A 2 × 2 repeated measures analysis of covariance demonstrated that the treatment group was more effective than the control group on improving Dementia Rating Scale score (F = 7.45, p < .01) with a moderate effect size (partial eta square = .09) and Mini-Mental State Examination score (F = 9.96, p < .01) with a moderate to large effect size (partial eta square = .12) after controlling for age, gender, educational level, marital status, and number of physical illnesses.

Conclusion

The present study demonstrates the effectiveness of the multicomponent intervention on improving cognitive ability among community-dwelling older adults with probable dementia, suggesting that the multicomponent intervention can facilitate early identification, assessment, and treatment for community-dwelling older adults with probable dementia.

Keywords

multicomponent intervention cognitive stimulation therapy probable dementia randomized controlled trial tai chi

Introduction

In Chinese societies, including mainland China, Taiwan and Hong Kong, the prevalence rate of dementia is 5.4% for people aged 60 years and above (Wu et al., 2018). Among older adults with dementia in Chinese societies, over 80% suffer from mild-stage dementia and live in the community (Lam et al., 2008), but only 11% have been formally diagnosed with dementia (Lam et al., 2008). Those who are considered older adults with probable dementia, that is, older adults who meet the criteria for dementia but who have never received a medical diagnosis of it, are reluctant to seek a medical diagnosis and appropriate treatment due to a fear of being labeled as having a mental illness as well as the stigma of dementia (Lam et al., 2010; Mok, Lai, Wong, & Wan, 2007; Young, 2016; Young, Kwok, & Ng, 2014). Without receiving a formal diagnosis, assessment and treatment, older adults with probable dementia are at risk of experiencing further cognitive decline and progressing to moderate and severe stages of dementia. Thus, it is important to promote early identification and treatment for community-dwelling older adults with probable dementia to reduce their cognitive decline (WHO, 2015).

Community-dwelling older adults with probable dementia may have multiple risk factors in their daily lives for further cognitive decline, including physical inactivity and depressive symptoms (Baumgart et al., 2015). Accordingly, interventions aimed at reducing cognitive decline among older adults with probable dementia should include multiple components (Baumgart et al., 2015; Beattie et al., 2007; Graessel et al., 2011; Olanrewaju, Clare, Barnes, & Brayne 2015; Rakesh, Szabo, Alexopoulos, & Zannas, 2017). Recently, there has been a growing interest in developing multicomponent interventions that combine various non-pharmacological interventions, such as cognitive training, physical exercise, and social group activities, into one single intervention for older adults with probable dementia (Graessel et al., 2011; Han et al., 2017; Karssemeijer et al., 2017; Kim et al., 2016; Ngandu et al., 2015; Olazarán et al., 2010; Prick, De Lange, Scherder, Twisk, & Pot, 2017; Santos et al., 2015). Research evidences indicate that multicomponent interventions are effective at improving the cognitive abilities of older adults with probable dementia and older adults with dementia (Graessel et al., 2011; Han et al., 2017; Karssemeijer et al., 2017; Kim et al., 2016; Ngandu et al., 2015; Santos et al., 2015). More importantly, multicomponent interventions suggest that a combination of non-pharmacological interventions yields better effects on reducing cognitive decline than a single intervention alone (Beattie et al., 2007; Burgener et al., 2008; Graessel et al., 2011; Han et al., 2017; Olanrewaju et al., 2015). Additionally, multicomponent interventions have been shown to be effective at reducing depressive symptoms (Santos et al., 2015), reducing behavioral problems (Venturelli et al., 2016), enhancing activities of daily living (Graessel et al., 2011), and promoting health related quality of life (Han et al., 2017).

However, generalizations of the positive research results for multicomponent interventions have been limited due to various factors. First, there is great variety within multicomponent interventions. For example, different multicomponent interventions may have different intervention durations, ranging from eight weeks (Han et al., 2017) to 12 months (Graessel et al., 2011). Second, different multicomponent interventions have different emphases in their program elements. Some multicomponent interventions focus more on cognitive training and physical exercise (Burgener et al., 2008; Venturelli et al., 2016), while others provide more comprehensive and holistic services, such as computer-assisted cognitive training, social activities, art therapy, speech therapy, and physical exercise (Han et al., 2017; Kim et al., 2016; Santos et al., 2015). Third, the provision of multicomponent interventions should be culturally sensitive when applied to Chinese older adults with probable dementia. Differences in linguistic properties, cultures, and educational levels may impact the effects of training (Kwok et al., 2013). For example, Chinese older adults with probable dementia may not understand mnemonic strategies originally designed for Western patients. Thus, it is important to indigenize the content of multicomponent interventions in order to make them suitable for local cultures and contexts.

Of the various possible types of multicomponent interventions, those combining cognitive training and physical exercise have been widely implemented and have been shown to be feasible and effective at reducing cognitive decline among older adults with probable dementia and older adults with dementia in Western societies (Burgener et al., 2008; Karssemeijer et al., 2017; Venturelli et al., 2016). However, whether or not the combination of a cognitive stimulation therapy group and tai chi is effective on reducing cognitive decline among older adults with probable dementia remains uncertain as there is a lack of research in this area. Thus, it is worthwhile to examine the effectiveness of a multicomponent intervention that combines cognitive stimulation therapy and tai chi on reducing cognitive decline among community-dwelling older adults with probable dementia across different cultures and societies.

Aims

This study aims to evaluate the effectiveness of a multicomponent intervention that combines a cognitive stimulation therapy group and tai chi for community-dwelling older adults with probable dementia in the context of a Chinese society. Additionally, this study also intends to identify demographic variables that are related to improved outcome assessments after completing the multicomponent intervention.

Research methods

A multi-center, randomized controlled trial design was adopted in the present study. The participants with probable dementia were living at home and were recruited from five local elderly centers operated by different non-profit organizations in Hong Kong. The participants who gave their consent to participate in this research project were randomly assigned to either the treatment group or the control group. In addition to treatment as usual (TAU), the treatment group participated in a cognitive stimulation therapy group followed by tai chi twice a week, with a total of 14 sessions held during the study period. The control group received only TAU. A research assistant who was blind to the group assignments of the participants used standardized assessment tools to conduct outcome assessments in the pre- and post-treatment periods. Each participant received incentive payment with the amount of HK$100 after completing all the assessments. Data collection began in 2015 and was completed in 2017.

Subject inclusion and exclusion criteria

In this study, the target group was community-dwelling older adults with probable dementia, who were considered those living in their own homes who met the criteria for mild-stage dementia but who had never received a diagnosis of dementia. In line with the criteria for mild-stage dementia adopted in previous studies (Beattie et al., 2007; Burgener et al., 2008), the inclusion criteria for this study were as follows: (a) age 60 or above; (b) having never received a diagnosis of dementia/major neurocognitive disorder according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-V) (American Psychiatric Association, 2013); (c) meeting the criteria of dementia as assessed by the Mattis Dementia Rating Scale (DRS; Chan, Choi, Chiu, & Lam, 2003); (d) having a Mini-Mental State Examination (MMSE; Chiu, Lee, Chung, & Kwong, 1994) score of 18 or higher; (e) living in the community and receiving services from a local elderly center. The exclusion criteria were as follows: (a) having been previously diagnosed with dementia; (b) having severe losses of visual, auditory, or communicative abilities; (c) being unable to participate independently in a group setting, such as displaying disturbing behaviors.

Treatment group

In addition to TAU provided by the elderly centers, the treatment group participants attended a cognitive stimulation therapy group and tai chi sessions. The treatment group size was eight to 11 older adults with probable dementia.

In this study, the structure of the cognitive stimulation therapy group was adapted from the cognitive stimulation therapy group model that was developed in the UK (Spector et al., 2003; Spector, Woods, & Orrell, 2008) and implemented successfully across different cultures and societies (Aguirre et al., 2013; Mapelli, Rosa, Nocita, & Sava, 2013; Requena, Maestu, Campo, Fernández, & Ortiz, 2006; Yamanaka et al., 2013), including Chinese societies (Wong, Yek, Zhang, Lum, & Spector, 2018). Recent reviews of research evidence also support that cognitive stimulation (CST) groups are effective in improving cognitive function among older adults with probable dementia (Ballard, Khan, Clack, & Corbett, 2011; Kurz, Leucht, & Lautenschlager, 2011; Olazarán et al., 2010; Woods, Aguirre, Spector, & Orrell, 2012; Yu et al., 2009). A total of 14 group sessions were held, with two sessions held each week. Each session lasted for 60 minutes and included the following content: reality orientation, physical games, food, sounds, childhood, senses, faces, number games, word games, current events, categorizing objects, and using money.

In this study, tai chi was chosen for the physical exercise component because many Chinese older adults prefer practicing tai chi over aerobic exercise and because it has been recommended as a non-pharmacological intervention to reduce cognitive decline among older adults with probable dementia by researchers (Wayne et al., 2014). A particular form of tai chi called Baduanjin was adopted for this study. Baduanjin is a form of traditional Chinese Qigong exercises and has a history spanning more than 1000 years (Koh, 1982; Zou et al., 2017). Baduanjin exercises utilize just eight simple body movements based on traditional Chinese medicine theory (C. I. B. T. Corporation, 2012; Koh, 1982; Zou et al., 2017). Although Baduanjin has been shown to be effective in promoting physical health (Zou et al., 2017), there is a lack of research on the effectiveness of Baduanjin on improving cognitive ability for older adults with probable dementia. This form of tai chi was chosen for this study because it is simple, popular, easy to learn, and could be practiced at home and at the elderly center. In this study, the participants practiced Baduanjin exercises for 15–20 minutes at the end of each cognitive stimulation therapy group session.

The social workers who led the treatment groups received training in leading cognitive stimulation therapy groups from the author. They also received training in tai chi from a tai chi master who had taught it for more than five years. The tai chi master also had a PhD in social work and more than two years of experience working with the older adults.

Control group

The control group participants received the TAU provided by the elderly centers, including interest classes and recreational activities, but excluding cognitive training and tai chi.

Outcome assessment tools

The primary outcome is the improvement of cognitive ability, while the secondary outcome is the improvement of health related quality of life.

Primary outcome assessment

The Mattis DRS is a reliable and validated measure for the assessment of cognitive function in older adults with dementia (Shay et al., 1991). It was used in this study to assess the level of cognitive functioning of participants in five domains, including attention, initiation/perseverance, construction, conceptualization, and memory. The Chinese version of the DRS has been found to have satisfactory validity and reliability (α = .70–.90; Chan et al., 2003). The scores are summed in each domain, with higher scores indicating better cognitive abilities. According to a previous study, a DRS cut-off point of less than 112 is indicative of dementia (Chan et al., 2003). This cut-off point was adopted for this study.

The MMSE was used in this study to assess the general cognitive function of the participants. The MMSE has been used as the primary outcome measure in previous studies of the effectiveness of multicomponent interventions for reducing cognitive decline with satisfactory sensitivity, reliability, and validity (Graessel et al., 2011; Han et al., 2017; Kim et al., 2016; Santos et al., 2015). The Chinese version has been found to have satisfactory validity, internal consistency (α = .80–.95) and test–retest reliability (r = .72; Chiu et al., 1994). The score is summed over the items, with higher scores indicating better cognitive abilities.

Secondary outcome assessment

Although there is no common consensus on the definition of health related quality of life in dementia care (Banerjee et al., 2009; Cooper et al., 2012), researchers commonly agree that the assessment of health related quality of life should be multi-dimensional and subjective in nature (Ettema, Dores, De Lange, Mellenbergh, & Ribbe, 2005; Perales, Cosco, Stephan, Haro, & Brayne, 2013). In this study, health related quality of life is defined as the perception of an individual on the impact of a health condition on their everyday life (Perales et al., 2013; Young, 2016). Additionally, although older adults with probable dementia experience a decline in their cognitive ability, they can still provide meaningful data on their health related quality of life (Chan, Chu, Lee, Li, & Yu, 2011; Ettema et al., 2005; Moyle, Murfield, Griffiths, & Venturato, 2012). In this study, the Dementia Quality of Life (DQoL), which has been shown to be a reliable and validated measure for older adults with dementia (Brod, Stewart, Sands, & Walton, 1999), was used to assess the self-rated health related quality of life of participants. It consists of 29 items that assess five domains of life: self-esteem, positive affect, negative affect, belonging, and sense of aesthetics. The Chinese version has been found to have satisfactory validity, internal consistency (α = .82 to .92; Chiu, Shyu, Liang, & Huang, 2008). The scores are summed over the items, with higher scores indicate better health related quality of life.

Hypotheses

This study has the following hypotheses:

Hypothesis 1: the multicomponent intervention group is significantly more effective than the control group on improving cognitive abilities as assessed using the MMSE and DRS.

Hypothesis 2: the multicomponent intervention group is significantly more effective than the control group on improving quality of life as assessed using the DQoL.

Hypothesis 3: the improved outcome assessment scores (e.g. MMSE, DRS and/or DQoL scores) observed among those who participate in the multicomponent intervention are related to various demographic and clinical variables, especially age, educational level, and baseline outcome assessment scores.

Data analysis

An analysis was completed in accordance with the intention-to-treat principle; a last observation carried forward analysis was used for any missing data. The outcome assessments data were checked for normality, skewness, and kurtosis. The baseline demographic and clinical characteristics between the treatment and control groups were compared using chi-square (χ²) tests for the categorical variables and independent t tests for the continuous variables. The differences in the changes in outcome assessments between the treatment and control groups were analyzed using the general linear model 2 × 2 repeated measures analysis of covariance (ANCOVA), with the two groups (treatment and control) as between-subject factors and the outcome assessments (pre- and post-treatment scores) as within-subject factors, with adjustments made for age, gender, educational level, marital status, and number of physical illnesses. The effect size for the ANCOVA was calculated using the partial eta square, for which values of .01, .06, and .14 were considered small, moderate, and large effects, respectively (Cohen, 1988). The identification of demographic and clinical variables that were related to the improvements in the outcome assessments scores were conducted by using a one-way ANOVA for the categorical variables and Spearman’s correlation analysis for the continuous variables. For all the analyses, two-tailed p values of < .05 indicated statistical significance. Data analyses were performed using SPSS 23.0 (IBM Corporation, 2013).

Research results

This study involved 189 participants recruited from local elderly centers. However, 109 did not meet the inclusion criteria. The remaining 80 subjects were randomly assigned to the treatment group or the control group. Of these subjects, 41 were placed in the treatment group and 39 were assigned to the control group. Later, four participants dropped out of the treatment group due to deteriorating physical health (n = 2) or visiting relatives in mainland China (n = 2), while three participants in the control group lost contact with the researchers. Figure 1 illustrates the recruitment procedure.

Figure 1.

Flow of participants through each stage of the study.

Characteristics of the research subjects

Table 1 provides the baseline demographic and clinical characteristics of the treatment and control group participants with probable dementia (n = 80). The results of the t tests and chi-square tests revealed no significant differences between the treatment and control groups in any of the baseline demographic variables.

Table 1.

Baseline characteristics of all participants with probable dementia.

Characteristics	Total sample (n = 80)	Treatment group (n = 41)	Control group (n = 39)	t/χ²	p value
Age, mean ± SD (years)^b	80.44 ± 6.55	80.05 ± 6.17	80.25 ± 6.33	.272	.786
Female, n (%)^a	65 (81.3)	34 (82.9)	31 (79.5)	.155	.694
Number of physical illness, mean ± SD^b	1.15 ± .73	1.00 ± .83	1.08 ± .78	.842	.403
Educational level, n (%)^a				5.210	.074
None	35 (43.8)	23 (56.1)	12 (30.8)
Primary	40 (50.0)	26 (39.0)	24 (61.5)
Secondary	5 (6.2)	2 (4.9)	3 (7.7)
College or university	0 (0.0)	0 (0.0)	0 (0.0)
Marital status, n (%)^a				1.136	.768
Single	1 (1.3)	1 (2.4)	0 (0.0)
Married	24 (30.0)	13 (31.7)	11 (28.2)
Divorced, separated, widowed	55 (68.8)	27 (85.9)	28 (71.8)
Living with, n (%)^a				.571	.903
Alone	26 (32.5)	13 (31.7)	13 (33.3)
Family members	46 (57.5)	24 (58.5)	22 (56.4)
Family members & domestic helper	5 (6.3)	2 (4.9)	3 (7.7)
Domestic helper only	3 (3.8)	2 (4.9)	1 (2.6)
DRS overall, mean ± SD^b	99.22 ± 11.88	100.00 ± 10.00	99.60 ± 10.94	−.316	.573
DRS attention	31.95 ± 2.66	31.74 ± 2.28	31.85 ± 2.96	.311	.756
DRS verbal initiation	23.17 ± 5.78	22.13 ± 5.98	23.64 ± 5.86	−.728	.469
DRS construction	3.54 ± 1.63	3.13 ± 1.32	3.34 ± 1.49	1.228	.223
DRS conceptualization	28.24 ± 5.07	28.23 ± 4.09	28.24 ± 4.59	.013	.990
DRS memory	11.66 ± 3.07	12.69 ± 4.23	12.16 ± 3.70	−.1255	.213
MMSE overall, mean ± SD^b	20.41 ± 2.14	20.69 ± 1.98	20.55 ± 2.06	−.601	.549
DQoL overall, mean ± SD^b	93.78 ± 13.87	91.08 ± 15.99	92.46 ± 14.91	.809	.421
DQoL self-esteem	12.33 ± 3.25	12.46 ± 3.17	12.18 ± 3.37	.388	.699
DQoL positive affect	14.59 ± 3.10	15.00 ± 3.00	14.15 ± 3.18	1.224	.225
DQoL negative affect	43.35 ± 8.13	43.78 ± 7.95	42.90 ± 8.39	.483	.630
DQoL belonging	9.41 ± 2.38	9.54 ± 2.13	9.28 ± 2.64	.476	.636
DQoL aesthetic	12.79 ± 4.75	13.00 ± 5.07	12.56 ± 4.46	.408	.685

SD: standard deviation; DRS: Chinese Mattis Dementia Rating Scale; MMSE: Mini Mental State Examination (Chinese version); DQoL: Dementia Quality of Life (Chinese).

Pearson chi-square test; ^bIndependent sample t test; p value indicates the baseline difference between the treatment and control groups.

Among all of the participants, the mean age was 80.4 (SD = 6.6) years. The majority (81.3%, n = 65) were female, had a primary school education level or above (56.2%, n = 60), and lived with their family members (63.8%, n = 51). Two-thirds (68.8%, n = 55) were widowed, divorced or separated individuals, while most of the rest were married (30.0%, n = 24). Three-quarters (76.2%, n = 61) suffered from one or more physical illnesses.

Baseline assessment score

The skewness of the baseline MMSE score, post-treatment MMSE score, baseline DRS overall scores, post-treatment DRS overall scores, baseline DQoL overall scores, and post-treatment DQoL overall scores were −.12 (SD = .27), .10 (SD =. 27), .28 (SD = .27), .02 (SD = .27), −.31 (SD = .27), and .05 (SD = .27), respectively, indicating that the skewness values of these scores were non-significant. The kurtosis values of the baseline MMSE score, post-treatment MMSE score, baseline DRS overall scores, post-treatment DRS overall scores, baseline DQoL overall scores, and post-treatment DQoL overall scores were −.72 (SD = .53), −.68 (SD = .53), 1.08 (SD = .53), .35 (SD = .53), .10 (SD = .53), and .04 (SD = .53), respectively, indicating that the kurtosis values of these scores were also non-significant. Thus, normal distributions of the above data could be assumed.

As shown in Table 1, the independent t tests and chi-square analyses showed no significant differences between the treatment and control groups in all of the baseline clinical variables, including the baseline MMSE score, baseline DRS scores, and baseline DQoL scores. Among all the participants, a mean baseline MMSE score of 20.41 (SD = 2.14), a mean baseline DRS overall score of 99.22 (SD = 11.88), and a mean DQoL score of 93.78 (SD = 13.87) were observed. Additionally, as shown in Table 3, the baseline MMSE score was positively related to the baseline DRS overall score (ρ = .42, p < .01). Also, the MMSE score was related to educational level (F = 3.87, p < .05), while the DRS overall score was related to age (ρ = −.55, p < .01) and educational level (F = 4.98, p < .01). Thus, the baseline MMSE score and DRS overall score were higher for those who were younger and those who had higher educational levels, which is consistent with the findings of previous research studies (Chan et al., 2003; Tse et al., 2013).

Treatment Outcomes

Hypothesis 1

Table 2 summarizes the changes in the MMSE and DRS scores for both the treatment and control groups. The results of the 2 (group) × 2 (time) repeated measures ANCOVA demonstrated that the treatment group was significantly more effective than the control group in improving the MMSE score (F = 9.96, p < .01) with a moderate to large effect size (partial eta square = .12) and DRS overall scores (F = 7.45, p< .01) with a moderate effect size (partial eta square = .09) after controlling for age, gender, educational level, marital status, and number of physical illnesses. Additionally, the treatment group was significantly more effective than the control group in improving the DRS attention score (F = 15.86, p < .01), DRS construction scores (F = 11.00, p < .01), and DRS memory scores (F = 17.42, p < .01) after controlling for age, gender, educational level, marital status, and number of physical illnesses.

Table 2.

Comparison of change score on the outcome assessment scores between the treatment and control groups.

	Treatment group (n = 41)	Control group (n = 39)	Between group analysis
	Change score (Mean ± SD)	Change score (Mean ± SD)	F (p)	Partial eta square
DRS overall^a	9.66 ± 10.17	−1.51 ± 6.74	7.451 (.008)**	.093
DRS attention	1.12 ± 2.46	−.62 ± 2.35	15.864 (.000)**	.179
DRS verbal initiation	3.27 ± 4.90	.51 ± 5.13	.056 (.814)	.001
DRS construction	.68 ± 1.59	.05 ± 1.36	11.004 (.001)**	.131
DRS conceptualization	2.24 ± 4.96	−.62 ± 4.18	3.357 (.071)	.044
DRS memory	2.24 ± 3.11	−.77 ± 2.49	17.415 (.000)**	.193
MMSE^a	2.29 ± 2.15	−.87 ± 1.53	9.964 (.002)**	.120
DQoL overall^a	1.24 ± 11.28	2.95 ± 10.60	.334 (.565)	.005
DQoL self-esteem	.10 ± 2.26	.28 ± 3.23	.081 (.777)	.001
DQoL positive affect	−.51 ± 2.74	−.41 ± 2.56	1.343 (.250)	.018
DQoL negative affect	.20 ± 5.95	.87 ± 5.30	.192 (.663)	.003
DQoL belonging	.20 ± 2.15	.33 ± 2.22	.034 (.854)	.000
DQoL aesthetic	1.27 ± 4.91	1.87 ± 4.76	.027 (.870)	.000

SD: standard deviation; MMSE: Mini Mental State Examination (Chinese); DRS: Mattis Dementia Rating Scale (Chinese); DQoL: Dementia Quality of Life (Chinese).

2 × 2 repeated measures ANCOVA controlling for age, sex, education level, marital status, and number of physical illness.

**significant at p < .01.

Hypothesis 2

The results of the 2 (group) × 2 (time) repeated measures ANCOVA demonstrated that the treatment group was not significantly more effective than the control group in improving their DQoL overall scores and all DQoL subscale scores after controlling for age, gender, educational level, marital status, and number of physical illnesses (Table 2).

Hypothesis 3

Table 3 summarizes the variables related to improvements in MMSE and DRS overall scores. The results indicated that the improved MMSE score from pre-treatment to post-treatment were not related to any baseline demographic or clinical variables. The improved DRS overall scores from pre-treatment to post-treatment were not related to most baseline demographic or clinical variables, but were positively related to age (ρ = .34, p < .05) and negatively related to baseline DRS overall scores (ρ = −.47, p < .01).

Table 3.

Correlation between baseline outcome measures and change of outcome measures with baseline demographic and clinical variables.

	Whole sample (n = 80)				Treatment group (n = 41)
	MMSEt1		DRSt1		ΔMMSEt1 − t2		ΔDRSt1 − t2
Item	F/ρ	p value	F/ρ	p value	F/ρ	p value	F/ρ	p value
Age^b	−.181	.108	−.550	.000**	.019	.907	.335	.032*
Gendera	2.280	.135	2.514	.117	.033	.857	.094	.761
Educational levela	3.869	.025*	4.976	.009**	.984	.383	1.110	.340
Marital status^a	.435	.511	.000	.989	.953	.335	.910	.346
Living with^a	1.516	.217	2.429	.072	1.431	.249	.974	.415
No of physical illness^b	−.079	.488	−.030	.790	.009	.955	−.127	.430
MMSEt1^b	1.000	–	.424	.000**	−.149	.352	.014	.930
DRSt1^b	.424	.000**	1.000	–	−.017	.914	−.468	.002**
DQoL overall t1^b	−.012	.915	.002	.985	.022	.892	.172	.284

t1: baseline; t2: post-treatment; MMSE: Mini Mental State Examination (Chinese); DRS: Mattis Dementia Rating Scale (Chinese); DQoL: Dementia Quality of Life (Chinese); MMSEt1: MMSE score at baseline; DRSt1: DRS score at baseline; DQoL Overall t1: DQoL overall score at baseline; ΔMMSEt1 − t2: change of MMSE score from t1 to t2; ΔDRSt1 − t2: change of DRS overall score from t1 to t2.

One way ANOVA, ^bSpearman's rho.

Significant at p < .05; **significant at p < .01.

Discussion

Consistent with hypothesis 1, after completing the multicomponent intervention, the treatment group participants experienced significantly greater improvements to their MMSE score, DRS overall scores, and three DRS subscale scores compared to the control group participants. Older adults with probable dementia are reluctant to seek medical diagnoses and proper treatments due to their fear of being labeled as mentally ill along with the stigma of dementia (Lam et al., 2008, 2010; Young, 2016). Without receiving formal diagnoses, assessments and treatments, these individuals are at risk of experiencing further cognitive decline and progressing to the moderate and severe stages of dementia. This research study demonstrates that the multicomponent intervention that combines a CST group and tai chi can facilitate early identification, assessment, and intervention for community-dwelling older adults with probable dementia who may be unaware of the severity of their cognitive decline or reluctant to seek a medical diagnosis and treatment. However, whether or not the improved cognitive ability of participants due to the completion of the multicomponent intervention can be maintained for a long period of time remain unclear. Thus it is better to investigate the long-term treatment effect of this multicomponent intervention model for older adults with probable dementia.

Hypothesis 2 is not supported. This finding indicates that the short-term multicomponent intervention is unable to improve the health related quality of life of older adults with probable dementia. Perhaps it is because health related quality of life involves individual’s evaluation on multi-dimensional aspect of his/her life (Ettema et al., 2005; Perales et al., 2013), and that the multicomponent intervention did not address properly the multi-dimensional needs of older adults with probable dementia. Under traditional Chinese values, especially Confucianism, older adults with probable dementia are perceived as those who are not competent members of society, fail to comply with the five cardinal relations, and are those who cause “loss of face” and “shame” within the family and social systems (Lam et al., 2010; Mok et al., 2007; Young, 2016; Young et al., 2014), which affects their social status and relationships with family members and others. Thus, as shown in a local survey, these individuals expressed fear about being labeled as mentally ill, losing their status within the family, feeling guilty for being dependent, being a burden to their family, and feeling helplessness (Mok et al., 2007). Subsequently, older adults with probable dementia experienced a reduction of health related quality of life. Thus it is important for advocates of multicomponent intervention to address these special needs of Chinese older adults with probable dementia, by incorporating additional program elements such as accepting illness, adopting positive life attitude, maintaining a healthy lifestyle, strengthening social support, and improving communication skills with family caregivers (Young, 2016).

In relation to hypothesis 3, the treatment effects of the multicomponent intervention, mainly the improved DRS overall scores, are positively related to age and negatively related to baseline DRS overall score. On one hand, due to ceiling effects, it is not surprising to find that those with higher baseline DRS overall score experience fewer improvement in DRS overall score after completing the multicomponent intervention. On the other hand, these research results have an important implication of suggesting that those who are older and who have lower cognitive functions benefit more from the multicomponent intervention, which is consistent with the research results of a recent study by Aguirre et al. (2013). In Chinese societies, community-dwelling older adults with probable dementia usually live with their family caregivers, who tend to be overprotective and impose restrictions in their daily lives (Mok et al., 2007). This is particularly true for those who are older and who have lower cognitive functions, and they may receive less stimulation in general than their younger counterparts with better cognitive functions. Thus, they may benefit more from the stimulation provided by the multicomponent intervention.

There are a variety of activities within tai chi in terms of form, style, inclusion/exclusion of qi-gong, and frequency and duration of practice, which may contribute to the inconsistency of research results regarding the effectiveness of tai chi. For example, while a seated tai chi style was shown to be effective in improving the cognitive abilities of older adults with dementia living in a nursing home (Cheng et al., 2014), an adapted version of Yang style tai chi failed to yield improvements in cognitive abilities among older adults with dementia living in a nursing home (Dechamps, Onifade, Decamps, & Bourdel-Marchasson, 2009; Dechamps et al., 2010). Thus, it is important to identify a particular form of tai chi that is suitable for community-dwelling older adults with probable dementia to learn and practice at home and in elderly centers. In this study, Baduanjin exercises were found to be suitable for older adults with probable dementia to learn and practice under simple instruction. Baduanjin exercises are simple, brief, and popular, and can be self-learned and practiced at home and in elderly centers. Accordingly, Baduanjin exercises should be widely promoted for community-dwelling older adults with probable dementia.

This research study demonstrates that the multicomponent intervention that combines a CST group and tai chi can facilitate early identification, assessment, and intervention for community-dwelling older adults with probable dementia who may be unaware of the severity of their cognitive decline or reluctant to seek a medical diagnosis and treatment. In particular, this multicomponent intervention can be easily run by a social worker at local elderly centers so that many older adults with probable dementia can get access to the multicomponent intervention easily. Accordingly, this multicomponent intervention can be widely implemented in local community with a low cost. On the other hand, hundreds of thousands of older adults with probable dementia can benefit from this multicomponent intervention by improving their cognitive abilities to delay their progression to moderate and severe dementia so that they can prolong their community-dwelling at their own home and reduce their needs for residential care. Thus, it is estimated that this multicomponent intervention is cost effective and can save huge costs for medical, social and residential care in local society in the long run.

Several methodological limitations of this randomized controlled study require attention. First, the generalizability of the research results is limited by the fact that the studied subjects were those older adults with probable dementia, i.e. who met the assessment criteria of dementia but without receiving formal diagnosis of dementia from a medical officer. In fact, the cognitive decline of research subjects may due to dementia or other illness such as depression or brain injury. In the future, it is better to set up exclusion criteria and assessment tools to screen out those subjects whose cognitive decline are due to depression or brain injury. Second, the long-term treatment effect of this multicomponent intervention model remains unclear, and so whether or not this intervention model can reduce cognitive decline of older adults with probable dementia in the long run remains uncertain. In the future, it is better to investigate the long-term treatment effects of this intervention model by using randomized control study with a long-term follow up study period. Third, the existing research method does not allow for an analysis of the individual contributions of the Baduanjin exercises and CST group to the improvement of the cognitive abilities among older adults with probable dementia, so it will be important for future studies to include separate arms for CST group and tai chi exercises in order to determine the specific effects of these interventions.

Footnotes

Declaration of Conflicting Interests

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

Ethical approval

The ethical considerations for this study were evaluated and approved by the Research Committee of Hong Kong Baptist University (ref. no: HASC/14-15/0124). Written informed consent was obtained from all participants with probable dementia, as well as their family caregivers, on the day of the pretreatment assessment.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was generously fully sponsored by the General Research Fund of the Hong Kong Special Administration Region [HKBU_12606815].

Daniel Kim-Wan Young, PhD (Bristol University, UK, major in Social Work), Registered Social Workers (RSW), Approved Supervisor of Hong Kong Professional Counseling Association (HKPCA). Dr Young is currently working as Associate Professor, Department of Social Work, Hong Kong Baptist University, teaching courses of Master Social Work program, Master of Social Science in Counseling program, and Bachelor of Social Work program, such as psychiatric rehabilitation, child and adolescent mental health, mental health counseling for older people, and cognitive behavioral therapy, as well as supervising PhD students. The research interest of Dr Young includes mental health counseling, cognitive behavioral therapy, and dementia. In particular, he has conducted research studies on non-pharmacological interventions for elderly with mild cognitive impairment and dementia. For example, in a cross-sectional survey involving 57 elderly with dementia and their family caregivers recruiting from local elderly centres, non-clinical factors, such as self-esteem and caring burden, were found to be have higher predictive power for health-related quality of life than that of clinical factors, indicating the importance for non-pharmacological interventions (Young, Kwok, & Ng, 2017). In a 12-month longitudinal follow-up study of 90 elderly with dementia living in the community, research results demonstrated that dementia-specific day care service was effective in reducing caregiver’s burden, maintaining cognitive function and quality of life for participants (Kwok et al., 2013). In a randomized controlled trial involving 46 elderly with dementia and their family caregivers dyads recruiting from local eldery centres, a short-term and structured support group was shown to be effective in reducing depression for elderly with dementia (Young et al., 2014). In another randomized controlled trial funded by Hong Kong Baptist University [FRG1/14-15/050] involving 64 elderly with dementia recruiting from local elderly centres, a 10-session psycho-education group was effective on promoting health related quality of life for participants (Young, 2016). Furthermore, Dr Young has involved and conducted research studies on improving cognitive ability for elderly. In a quasi-experiment research study involving 176 elderly with decline cognitive functioning, research results supported the feasibility and effectiveness of an indigenized cognitive training group, named Active Mind, on improving the cognitive functioning of participants (Kwok et al., 2013). Also, in a randomized waitlist controlled trial funded by the General Research Fund of HKSAR [Reference No.: HKBU_12606815] on a 14-session indigenized cognitive stimulation therapy group involving 101 elderly with mild stage dementia recruiting from local elderly centres, research results supported the feasibility and effectiveness of the 14-session indigenized cognitive stimulation therapy group on improving the cognitive ability for participants with mild stage dementia (Young et al., 2018). Also, Dr Young has been a reviewer of manuscripts of international refereed journals such as Social Work in Mental Health and BMC Health Services Research. Also, he has been the member of editorial board of International Psychosocial Rehabilitation Journal.

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