Effectiveness of home-based cognitive training program on a cognitive level, the activity of daily living among elderly persons with mild cognitive impairment in selected community settings of Puducherry

Aging is a physiological process that leads to both biological and psychological changes. The brain undergoes structural changes as a part of aging. According to the investigator’s best knowledge and based on the extensive review, no structured study was conducted in India to test the effectiveness of cognitive training program. Hence, the present study was conducted to test the effectiveness of a home-based training program on select outcomes. A total of 314 elderly participants were recruited for the study after obtaining the written informed consent. After recruiting, the participants were randomly grouped into two groups, that is control and intervention groups, with 157 participants in each group. The intervention was administered to the experimental group. The present study results suggest that the home-based cognitive training program is effective in improving cognitive functions and daily life activities. The study recommends further detailed and multi-centered studies in this area to recommend the implementation of the program in the management of the cognitive impairments of the elderly.


INTRODUCTION
Aging is a physiological process that leads to both biological and psychological changes. The brain undergoes structural changes as a part of aging. However, these changes in the brain are not the same in all the areas, and these changes affect the different cognitive domains in a different way (Craik and ., 1992). Aging is a natural process where the ability of the cells of the body declines. Along with the other cells, the brain cells also affected, which accounts for a decrease in the cognitive functions (Harada et al., 2013). Cognitive functions are essential for the management of daily life activities in the elderly population (Barnes and Yaffe, 2011). Cognitive therapies have shown to have a positive impact on the cognitive functions in the elderly population. It improves synaptic transmission and prevents the formation of the Beta-amyloid proteins. This prevents the initiation of age-related decline in cognitive impairment and thus improves the cognitive functions and day-to-day functioning.
The home-based cognitive therapy was reported to act through the principle called neuronal plasticity as the brain has the capability to habituate and learn. So, if the brain is trained properly, then the lost functions can be restored. Improvement in the major cognitive domains like attention, memory was observed, followed by home-based cognition therapy (Jamuna and ShibuPillai, 2010). A fur-ther advantage of this therapy is that it reduces the number of hospital visits. It also reduces the cost and hence affordable to all classes of the population. The present lack of effective drug therapy for these conditions makes it imperative to investigate other potential therapeutic interventions. Cognitive training has been described as possibly useful in improving cognitive function in elderly subjects with mild impairment and early dementia. However, there have been few well-designed studies to date, and the results are equivocal. Further to date, according to the investigator's best knowledge and based on the extensive review, no structured study was conducted in India to test the effectiveness of cognitive training program. Hence, the present study was conducted to test the effectiveness of a home-based training program on select outcomes.

Study design
Experimental study

Study setting
The present study was conducted at selected community settings of Puducherry.
After recruiting, the participants were randomly grouped into two groups, that is control and intervention groups, with 157 participants in each group.

Home Based cognitive Training Programme
Each training session comprised the following steps

Orientation in time and space
Performed using external aids such as a calendar and the day's newspaper, whereby participants determined the current day, month, and year.

Presentation of the names
Participants and the researcher presented their names. Verbal associations were elicited between the person's name and their appearance.

Visual and auditory attention exercises
The visual attention task entailed identifying details in photographs, letters, or igures amongst several stimuli spread out on a single printed sheet, as well as spotting differences between two similar photographs, among other activities. The auditory attention exercises included tasks such as detecting words in songs and identifying whether two consecutively repeated sequences of numbers or words matched or differed.

Memory exercises using visual aids
The categorization strategy with ecological tasks were used, i.e., simulated activities of daily living, graded from simple to more complex. Grocery items were used in the early stages of training progressing to supermarket item lists only, by the end of the training.

Transfer task
Practical tasks from activities of daily living were used, such as to the supermarket, giving and checking change, etc. The older adults were expected to calculate the total cost of the purchase and offer change or check the change received.
Cognitive training was given to all eligible subjects individually two sessions weekly continuously for a period of 1 month i.e., a total of 8 sessions. Each session will take approximately 1 hour.

Ethical considerations
The present study protocol was approved by the institutional human ethical committee. The study was conducted as per the guidelines of ICMR.

Data analysis
Data was analyzed using SPSS 20.0. Data were expressed in frequency and percentage and mean and SE. The paired and unpaired t-test was used to observe the signi icance of the difference. A chisquare test was used to observe the association. A probability value of less than 0.05 was considered signi icant.  The mean difference was 3 and the p-value 0.618. Here parametric test, paired 't' test and unpaired 't' test used to assess the existing relationship between the variables among the level of cognition, the activity of daily living, quality of life, and caregiver burden among persons with mild cognitive impairment.

RESULTS AND DISCUSSION
Regarding the level of cognition, in paired' test pvalue of control group 0.005 and in an experimental group more than 0.001. In the unpaired t-test, the comparison between the control pretest and experimental pretest, the p-value was 0.143. And the comparison between the control post-test and the experimental post-test p-value was more than 0.001. Regarding the activity of daily living, in paired't' test, the control group p-value 0.002 and the experimental group p-value more than 0.001. In the unpaired 't' test, the control and experimental pretest p-value were 0.753. And between the control group and the experimental group, the p-value was more than 0.001 (Table 2).
Cognitive skills play an important role in the day to day functions of the old people. However, as a process of aging, the cognitive functions decline (Harada et al., 2013;Reichman et al., 2010;Craik, 2006). The risk factors responsible for the decline in the cognitive functions are classi ied as modi iable and non-modi iable factors. Modi iable factors include lifestyle, education, metabolic disorders (Norton et al., 2014). Though this condition can be managed medically, still the treatment is not affordable to most of the public. Hence, there is a strong need for affordable treatment or management of cognitive functions in the elderly population. Home-based cognitive therapy is simple, affordable, and easy to implement, even in the elderly population. As it minimizes the cost of the treatment, it is also preferred by many of the people (Salthouse, 1996).
The present study was undertaken to observe the effectiveness of the Home Based cognitive Training Programme on Cognitive level, Activity of daily living among Elderly persons with mild Cognitive Impairment in Selected Community Settings of Puducherry. There was a signi icant improvement in the cognition level and cognitive impairment in the experimental group when compared with the control group. Earlier studies reported that Home Based cognitive Training Programme is very effective for improving cognition in the elderly (Rapp et al., 2002;Belleville et al., 2007). However, there are certain controversies in this aspect as some studies reported that Home Based cognitive Training Programme is bene icial (Salthouse, 1996;Belleville et al., 2006) other studies reported there is no improvement in the cognition followed by the intervention program (Sunderland et al., 1989;Levine et al., 2007). These differences in the results may be due to the inclusion of the participants with different age groups and from different areas. Further, there are differences in the application of training programs. The training program was reported to be bene icial when applied on a long-term basis (Belleville, 2008). It was reported that there was a signi icant increase in the attention score, execution speed followed by the intervention (Olchik, 2008;Hampstead et al., 2008;Kurz et al., 2009). Our study results are in accordance with earlier studies as we have observed signi icant improvement in the cognitive functions followed by the intervention.

CONCLUSION
The present study results suggest that the homebased cognitive training program is effective in improving cognitive functions and daily life activities. The study recommends further detailed and multi-centered studies in this area to recommend the implementation of the program in the management of the cognitive impairments of the elderly.