Abstract
A quasiexperimental study was performed in three Colombian municipalities, Armenia and Genova in Quindío and Medellin in Antioquia. The aim of the study was to assess changes in cognitive function and life satisfaction in the elderly participants of memory and writing workshops, from the program Historias en Yo Mayor. Qualitative and quantitative methods were employed with 40 participants who received the narrative formation strategy. The assessment evidenced a tendency to improve cognitive function, most notably in the language component measured by the ability to mention words beginning with the same letter in a one minute span. Before the intervention, 60 percent of the study participants were able to mention 11 or more words, and after the intervention the proportion increased to 70 percent. No other clear tendencies were observed for the other study variables. Regarding the qualitative component, most study participants highlighted the importance of these kind of activities inside their community and reported being satisfied with the results of the workshops.
Background and Purpose
Due to an increase in life expectancy and a significant decrease in fertility rate the world’s population has been aging at an unprecedented rate since the 1950s. This has precipitated that the population over 60 years of age are the age group with the highest growth rate, and as a consequence, during the middle of the 21st century, there are going to be more people over 60 years of age than people under 15 years of age, for the first time in history (United Nations, 2013). The greatest consequence of these demographic transitions will be seen in developing countries, due to the fact that by 2050, these countries will be the home of 80 percent of the world’s population over 60 years of age (WHO, 2016).
This phenomenon will not happen without consequences in the physical and cognitive function of the population. Cognitive impairment becomes more common as people age, and in association with neurologic diseases, it has been identified as major cause of disability worldwide. (Toro, Yepes, & Palacios, 2010). This highlights the importance of cognitive interventions in the population over 60 years of age in order to have a positive impact in cognitive, physical, and social functioning, and ultimately quality of life.
Regarding normal cognitive changes that occur with aging, it has been widely documented that the brain is one of the most susceptible parts of the body to aging induced deterioration. One of the areas of cognition that is more prone to deteriorate is the part of the memory that relates to the temporal setting, meaning that the person can easily retrieve the memory of a given event, but has trouble identifying the time in which that event occurred (Parkin, Walter, & Hunkin, 1995). On the other hand, there’s evidence that when compared to young adults, elderly forget the source of information from which they acquired a memory more frequently (McIntyre & Craik, 1987).
The decline in cognitive function mentioned above, usually does not interfere with the ability to perform everyday tasks, and is unrelated to a decline in the quality of life. In spite of this, there is a relatively high proportion of the population over 60 years old, who may experience pathologic decline in cognitive function. These pathologic declines, or memory impairment, may be mild, as in Mild Cognitive Impairment (MCI) or moderate to severe, with associated impairment in the ability to perform everyday tasks, as occurs with dementia. Together with an advanced age, the presence of MCI is one of the most important risk factors for dementia (Toro, Yepes, & Palacios, 2010).
In Colombia, the prevalence of MCI is 15 percent among the elderly population, and its presence is associated with an advanced age and a poor educational level (Paredes-Arturo, Yarce-Pinzón, Rosero-Otero, & Rosas-Estrada, 2015). As for dementia, the prevalence is around 1.1 percent among the elderly population and it rises up to 4 percent in people over 80 years of age (ENDS, 2010).
Due to population aging the prevalence of this conditions is increasing, thus negatively impacting the quality of life of the elderly population. Taking this into account, it is important to design primary prevention strategies to prevent the appearance of cognitive impairment. There is evidence, that elderly people who are engaged in multiple activities have a 38 percent decreased risk of developing cognitive impairment (Stern, 2012). Also, there is a growing body of evidence on the effects of cognitive training in the elderly. Cognitive training, is a strategy that uses cognitive and socio-affective learning events, to enhance the functioning of neural networks in the brain. It may refer to any series of structured tasks that the person must perform regularly to enhance memory and executive functions (Keshavan, Vinogradov, Rumsey, Sherrill, & Wagner, 2014). Cognitive training activities have been shown to hasten the deterioration of cognitive functions in functional magnetic resonance imaging (fMRI) studies (Brodziak, Wolińska, Kołat, & Różyk-Myrta, 2015). On the other hand, cognitive training programs have been used in Latin American populations, most remarkably, in Mexico and Brazil. In Mexico, “Soy Activo,” a 16-session cognitive and nutritional education program, showed an improvement in the health status and quality of life of the elderly engaged in the program. Meanwhile, in Brazil, a study focused on the influence of active aging on mental diseases, evidenced that elderly people that regularly read and practiced regular physical activity, were less prone to depression, a condition associated with cognitive impairment (Galli, Moriguchi, Bruscato, Horta, & Pattussi, 2016).
Considering the growing body of evidence on cognitive training and its benefits in the elderly population, Fundación Saldarriaga Concha aimed to assess the effect of memory, reading, and writing workshops on the cognitive functions of the elderly in Colombia. These workshops were designed with the help of Farenheit 541 as part of the program Historias en Yo Mayor (see Intervention: Narrative Formation Strategy).
Methods
Study Population
The target population were adults over 60 years of age, from three municipalities in the central region of Colombia: Armenia and Genova in the administrative region of Quindío and the city of Medellin in the administrative region of Antioquia.
Intervention: Narrative Formation Strategy
The narrative formation strategy consisted of 26 weeks of two-hour workshops which were divided into three components. The first was a theoretical component in which participants were given tools to improve their story-telling ability, comprising of 40 percent of the total workshop time. For this component, the participants had to analyze the stories written by elderly participants for previous workshops, or classics from universal literature. The analysis emphasized on identifying the structure, source, characters, context, and topic of the stories. On the other hand, this component had some sessions that focused on literary history.
The second was a practical component in which the participants told their stories using oral narrative to their peers in the workshop. Throughout this component, the participants were given feedback on the tone of their voice, their expressions, and their body language. This component was developed into 40 percent of the total workshop time.
The final component of the workshops was a sustainability component, focused on developing mechanisms to establish the workshops as a long-term activity in the community. This component was developed into 20 percent of the total workshop time, taking place mostly during the final sessions. As part of this component, a designated participant was put in charge of selecting and organizing the materials that would be used in each of the sessions, the whole group had to select a name for the workshop, and participants were encouraged to propose mechanisms to preserve the workshop beyond the intervention period.
Study Design
A quasi-experimental design was performed in order to assess the efficacy of writing and memory workshops, to improve life satisfaction and cognitive function in the population over 60 years of age in three Colombian municipalities. In order to achieve this, qualitative and quantitative methods were employed with 40 participants. For the quantitative component, baseline measurements of sociodemographic data, and cognitive function, using the Montreal Cognitive Assessment (MoCA) were taken. Then the narrative formation strategy for the elderly, Historias en Yo Mayor (Stories in I Major) was applied to all of the study participants, without a control group due to the lack of a proper control intervention. Posterior measurements of the cognitive function, using MoCA, were taken halfway through the workshops, after 13 weeks, and at the end of the workshops. The qualitative component consisted of focus groups and interviews performed before the intervention, halfway through the workshops, and at the end, and the primary goal was to assess the satisfaction of the participants with the workshops.
Results
The study population consisted of 40 participants, residents from the departments (administrative regions) Antioquia and Quindio in Colombia. Most participants were residents from urban areas (62.5 percent), and the rest came from rural areas (37.5 percent). The mean age of the population was 70 years old (SD 8.3 years). Regarding the educational level, 7.5 percent of the study participants did not have any academic studies, and just 30 percent had college or advanced studies. As for changes in cognitive function, there was a tendency to improve language, assessed by saying words starting with the same letter in a one minute span. At baseline 60 percent of the participants were able to say more than 11 words, halfway 67 percent of the participants, and at the end of follow-up 70 percent of the participants.
There were no clear tendencies for the other variables of cognitive function. Regarding the qualitative component most of the participants reported being satisfied with the workshops and highlighted that these kind of activities helped them establish relations with other members of their community. Most of the study participants reported being satisfied with their participation on the workshops and emphasized the importance of those kind of spaces inside their communities.
Discussion
The results mentioned above are consistent with other findings in literature, showing mild improvements in cognitive function, particularly in the language component. This fact highlights the importance of using memory, reading, and writing workshops, as a tool to prevent cognitive decline associated with aging. On the other hand, these kind of community-centered interventions may help generate new networks inside the community and improve social cohesion, and are a potential opportunity to enhance intergenerational relations in the community.
Regarding the content of the workshops, it is important to highlight that due to their community-based nature, they must always be adjusted to the context where they are applied. Thus, it is important to consider the vocabulary, the history of the community, their educational level, among other variables. It is also important to mention that these workshops help preserve the cultural heritage of the members of the community, through the stories of the elderly.
In spite, of some promising results and observations, some limitations of the study should be mentioned. Due to the fact that the results come from a small sample, and the absence of the control group, the results cannot be extrapolated to the population from which we took the sample. On the other hand, the follow-up period was only six months, so further evidence is needed to prove the benefits of the use of cognitive training in the long-term.
Conclusion
Due to the fact that the population is aging, there is a need for interventions that help the elderly members of the society preserve their cognitive function. Writing and memory workshops, may improve or slow down the decline of cognitive function, particularly the language component, of elderly participants. On the other hand, these workshops are a good tool to generate new networks inside the communities, and may strengthen social cohesion and promote intergenerational encounters.
Author Bios
Juan Manuel Cotte, MD
Physician, Graduate Certificate in Epidemiology, Research Assistant at the Public Health Office, Fundación Saldarriaga Concha
Ana María Ortiz, MPH (c)
Major Degree in Psychology, MPH (c), Senior Coordinator at the Public Health Office, Fundación Saldarriaga Concha
Alejandro Andrés Díaz
Major Degree in Government, Analyst at the Public Health Office, Fundación Saldarriaga Concha
Lina María González, MD, MSc
Psychiatrist, MSc in Epidemiology, Public Health Officer, Fundación Saldarriaga Concha
Works Cited
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