Effect of cognitive and aerobic training intervention on older adults with mild or no cognitive impairment: a derivative study of the nakajima project.

Abstract

An increasing elderly population in Japan requires effective cognitive intervention programs for dementia. This study demonstrates the effectiveness of such programs for older adults.
The participants were local community-dwelling non-demented older adults and adults with mild cognitive impairment who underwent executive function and group aerobic training. In addition, a non-intervention group participated in activity sessions involving handicraft, Skutt ball matches, and cooking. The four criteria for assessment were cognitive function, instrumental activities of daily living, human relationships, and physical function.
The participants in both intervention groups showed a significant improvement in their memory function compared with the non-intervention group.
Early rehabilitation intervention using executive function and aerobic training programs may improve memory.

Full text

Page 1

69
© 2012 S. Karger AG, Basel
www.karger.com/dee
Original Research Article
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Effect of Cognitive and Aerobic Training
Intervention on Older Adults with Mild
or No Cognitive Impairment: A Derivative
Study of the Nakajima Project
Keiko Sugano
Chiaki Dohmoto
Daisuke Yanase
Masahito Yamada
a Masami Yokogawa
c Mitsuhiro Yoshita
c Kazuo Iwasa
c
b Sohshi Yuki
c Tsuyoshi Hamaguchi
c Kiyonobu Komai
c
c
d
a Department of Occupational Therapy, Faculty of Health Sciences, Bukkyo University,
Kyoto , b Department of Physical Therapy, School of Health Sciences, College of Medical,
Pharmaceutical and Health Sciences, and c Department of Neurology and Neurobiology
of Aging, Graduate School of Medical Science, Kanazawa University, and d Department of
Neurology, Ioh Hospital, National Hospital Organization, Kanazawa , Japan

Key Words
Community-based study ? Dementia ? Cognitive rehabilitation ? Aerobic exercise ?
Non-pharmacological therapies ? Reasoning ? Memory performance/appraisal
Abstract
Background: An increasing elderly population in Japan requires effective cognitive interven-
tion programs for dementia. This study demonstrates the effectiveness of such programs for
older adults. Methods: The participants were local community-dwelling non-demented older
adults and adults with mild cognitive impairment who underwent executive function and
group aerobic training. In addition, a non-intervention group participated in activity sessions
involving handicraft, Skutt ball matches, and cooking. The four criteria for assessment were cog-
nitive function, instrumental activities of daily living, human relationships, and physical func-
tion. Results: The participants in both intervention groups showed a significant improvement
in their memory function compared with the non-intervention group. Conclusion: Early reha-
bilitation intervention using executive function and aerobic training programs may improve
memory.
Copyright © 2012 S. Karger AG, Basel
Published online: March 20, 2012
E X T R A
Keiko Sugano, OTR, PhD
This is an Open Access article licensed under the terms of the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online
version of the article only. Distribution for non-commercial purposes only.
Department of Occupational Therapy
Faculty of Health Sciences, Bukkyo University
96 Kitahananobo-cho, Murasakino Kita-ku, Kyoto 603-8301 (Japan)
Tel. +81 75 491 2141, E-Mail sugano @ bukkyo-u.ac.jp

Page 2

70
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
Introduction
A rise in healthcare expenditure especially because of a de facto aging society has re-
cently become a major cause of concern in Japan and other industrialized countries. The
expenditure encompasses, among other factors, the yearly increase in care for older adults
with dementia. Consequently, interventions to delay the onset and progression of dementia
have attracted the attention of healthcare professionals who are attempting to develop suit-
able methods for their application in the treatment of the condition. Regarding prevention
of onset and progression of dementia, interventions can be approached from two aspects:
firstly, selective prevention, targeting persons ‘at risk’, and secondly, universal prevention,
targeting persons without dementia. Older adults with mild cognitive impairment (MCI) are
ten times more likely to develop dementia compared to healthy older adults [1] . Selective pre-
vention aims at delaying the onset of dementia by means of aggressive intervention in ‘at risk’
individuals who show early signs of MCI.
There have been a few successful cognitive interventions carried out in persons with
MCI: cognitive and social interventions, such as reality orientation and reminiscence, have
resulted in an immediate improvement of cognitive function, and continuous improvement
has been noted 9 months later [2] ; improvement in the participants’ memory was achieved
on termination of mnemonic training and was seen to be maintained at 6-month follow-up
[3] ; and the intervention of nutrition counseling, cognitive function, and physical training
exhibited an immediate improvement in the participants’ cognitive function [4] . These in-
terventions proved to be successful to a certain degree in their effect on MCI. In addition, a
study on cognitive rehabilitation was carried out by Sugano et al. [5] , which involved 5 par-
ticipants (3 women and 2 men), 2 of whom had MCI and 3 Alzheimer’s disease (AD). The
intervention administered was a 1-hour executive function and mnemonic training program
once per week for 8 weeks. As a result, the participants with MCI showed an overall improve-
ment in their cognitive function, which was maintained at 6-month follow-up. This finding
may indicate that early cognitive intervention can be effective for individuals with MCI.
Universal prevention has also been implemented by regimes, such as ‘breath-of-life’,
‘purpose’, and ‘task execution’. However, there have been few studies utilizing these regimes
due to the difficulty in measuring the effects because of difficulties in maintaining the con-
sistency of the intervention and procuring long-term participants. Also, it is not productive
to continue universal prevention if the set task is inappropriate to the participants’ ability.
According to a meta-analysis by Colcombe et al. [6] of 18 studies carried out between 1996
and 2001, aerobic training was found to be effective for improvement of cognitive function.
However, a combination of aerobic and strength training was found to be more effective than
aerobic training alone, and executive function tasks were most effective.
In a double-blind trial involving 60-year-old healthy individuals, Mahncke et al. [7] im-
plemented a 60 min/day task execution regime 5 times a week for 8–10 weeks with the use of
computers. The comparison between the intervention, placebo, and non-intervention groups
yielded a significant improvement in the training group not only in the targeted cognitive
function, but also in memory, which was significantly maintained at 3-month follow-up. Ac-
cording to Mahncke et al. [7] , these results suggested that AD could possibly be prevented.
However, Mahncke et al. [7] also stated that, with regard to the study design, it was not pos-
sible to use a true placebo control for a behavioral training program because a single active
ingredient cannot, in general, be removed from the experimental condition. Furthermore,
an improvement in memory performance/appraisals was only possible when a targeted
memory was trained. However, executive function training was found to be superior because
improvement could not only be achieved in the trained executive functions, but also in mem-
ory performance and appraisals [8] . Mahncke et al. [7] have stated that a brain plasticity-

Page 3

71
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
based training program targeting degraded sensory processing and the down-regulation of
neuromodulatory control nuclei may produce stronger, more sustained and more general-
ized improvement in cognitive function. However, opinions on this subject remain divided
due to insufficient clinical evidence.
The purpose of our study was to examine the efficacy of cognitive function and physical
function programs for the elderly with and without MCI.
Methods
This study was carried out in collaboration with the Nakajima Project by the Depart-
ment of Neurology and Neurobiology of Aging, Kanazawa University, Graduate School of
Medical Science, Japan. The project was concerned with the early detection of dementia and
the effectiveness of intervention for dementia in the town of Nakajima in the Nanao district
of Ishikawa Prefecture, Japan. The participants’ flowchart for the trial is shown in figure 1 .
Participants
From 2006 to 2007, 947 older adults underwent a mass-screening program for brain
function in the Nanao district. This resulted in 806 individuals being selected as potential
candidates for a trial that was to be carried out in 2007. On closer examination, candidates
who showed abnormal findings, such as the presence of somatic disorders, brain disease or
dementia, were eliminated from the program. The tests performed for the more detailed ex-
amination were the following: past and present medical history taking, blood testing, Mini-
Mental State Examination (MMSE ! 25), and administration of a Revised Version of Hasega-
Fig. 1. Participants’ flowchart for the trial.

Page 4

72
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
wa’s Dementia Scale (HDS-R ! 23) [9, 10] . Of the 806 individuals who were selected as pos-
sible participants, only 67 (45 women and 22 men) signed a written informed consent to
participate in the trial. Their mean 8 SD age was 74.1 8 5.8 years (range 64–87) with a mean
8 SD of 11.0 8 7.5 years of education. These participants were randomly assigned to either
the cognitive function program (18 women and 14 men) or physical function program (27
women and 8 men). Eleven women and 9 men out of the 806 individuals who decided not to
participate in the intervention program agreed to be assessed for their cognitive and physical
functions and also to participate in the non-intervention group. Their mean 8 SD age was
71.8 8 2.3 years (range 65–77) with a mean 8 SD of 9.7 8 2.5 years of education. This non-
intervention group participated in activity sessions involving handicraft, Skutt ball matches
(a modified form of putting golf invented in Japan), and cooking.
Procedures
The first four authors of this study carried out the various forms of evaluation and ex-
ecuted the two programs for this trial. Pre-intervention assessment was carried out within a
3-week period prior to the commencement of the program, and post-intervention assessment
within 2 weeks of completion of the program. The 4 criteria for assessment were cognitive
function, instrumental activities of daily living (IADL), social and human relationships, and
physical function.
The participants’ cognitive function was assessed by the 5 cognitive tests (5-Cog). This
is a set of tests developed by the Tokyo Metropolitan Institute of Gerontology, Japan, the cri-
teria of which include the presence of subjective gradual cognitive decline (over a period of
at least 6 months) and objective evidence of abnormal performance in any principal domain
of cognition, i.e., memory and learning, attention and concentration, reasoning, verbal flu-
ency, or visuospatial functioning [11, 12] . The 5-Cog was proposed by the International Psy-
chogeriatric Association in 1993 and designed to meet one of the diagnostic criteria stated
above for the screening of aging-associated cognitive decline (AACD) that is a precursor to
dementia. Furthermore, the 5-Cog has the advantage of being easy to administer for mass
examinations. The results from the 5-Cog were graded into 3 levels by means of adjusted
standard deviation scores for the participants’ age, gender, and years of education. These re-
sults determined whether or not the examinee had dementia or a precursor to it. Specifi-
cally, the adjusted standard deviation scores for each task were ranked as follows: ! 35 as rank
1, from 35 to 40 as rank 2, and 1 40 as rank 3, respectively. The total rank score was calcu-
lated by the sum of the rank scores for each of the 5 cognitive domains with the exception of
the one for the motor function tasks for the hands. A total rank score of 5–10 was defined as
‘probable dementia’, 11–14 as ‘probable AACD’, and 15 as ‘normal’.
The assessment tasks for the 5-Cog for the diagnosis of AACD are composed of 5 do-
mains: memory/learning, attention, verbal fluency, visuospatial function, and reasoning.
MCI in this study was defined according to Petersen et al. [1] : (1) memory complaint; (2) nor-
mal activities of daily living; (3) normal general cognitive function; (4) abnormal memory
for age, and (5) not demented. Also, the criteria for assessing cognitive decline in this study
were the same as those used by Petersen [13] who classified them into amnestic MCI, multi-
ple-domain MCI and single non-memory domain MCI. Therefore, in this paper, AACD was
defined by the 5-Cog as MCI. The participants’ IADL was measured using the IADL scale
that corresponds to the 5-Cog. The Lubben Social Network Scale (LSNS) [14] was used to
measure the participants’ social and human relationships revolving around older adults. The
participants’ physical function was assessed by the use of the Physical Fitness Test for the
Elderly [15] that has been extensively used for the assessment of older adults’ physical func-
tion [16] . The test battery for persons aged 65–79 years includes grip strength, sit-ups, sit and
reach, one-leg balance with eyes open, a 10-meter obstacle walk, and a 6-min walk. Each item

Page 5

73
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
was tested according to the implementation guidance manual, and the results were classified
into 10 levels. The scores were summed for each classified item, determining the total score
as a comprehensive evaluation that was ultimately used to divide the participants’ physical
function into 5 categories (A, B, C, D, and E).
The cognitive function and physical function programs were implemented as a means
of intervention in order to assess their effectiveness on dementia. The purpose of these pro-
grams was explained to all participants at the first session.
In the cognitive function program, emphasis was placed on improving executive func-
tion, although other cognitive functions, such as episodic memory and alternating attention,
are also likely to deteriorate in individuals with a precursor to dementia. After the first ses-
sion, the participants in the cognitive function program were divided into groups of 5–6 and,
from the 2nd to 6th sessions, they drew up a travel plan. At the 7th session, they conducted
a coach tour according to their travel plan and, at the 8th session, they revised this travel plan
for the coach tour.
With regard to the physical function program, group aerobic training was implemented
because this has been demonstrated to be effective for improving cognitive function in a
number of previous studies. The following items were also implemented from the second to
final (8th) session: (1) measurement of blood pressure and confirmation of the participants’
subjective feeling concerning their physical condition during the current and previous
session(s); (2) warm-up exercises lasting 10–20 min, which included one muscle strengthen-
ing exercise for the lower limbs and one exercise selected from the following three: making
a pose using the whole body, exercises using a ball, or selected rhythmical movements, all of
which were taken from the Television Program Exercise for Everyone run by the Japan Broad-
casting Corporation; (3) 10-min walking synchronized with music at the initial session, in-
creasing to 15 min from the 7th to final sessions depending on the participants’ physical
capability for daily activities, and (4) calisthenics accompanied with slow breathing and
stretching of all limbs and the trunk for the purpose of cool down. All exercises were per-
formed within the participants’ aerobic capacity, and each session lasted 25–45 min. These
exercises were considered ‘moderate’ in view of absolute exercise intensity for the elderly [17] ,
which is equivalent to 3.5 METs for the warm-up, 3.0– 3.3 METs for walking, and 3.0 METs
for calisthenics according to the Research Committee on Exercise and Physical Activity
Guidelines by the Ministry of Health, Labour and Welfare of Japan, 2006 [18] .
Both the cognitive function and physical function programs were carried out once per
week, and the participants spent approximately 1 h at each session. The period of implemen-
tation for the trial was approximately 2 months or 8 sessions.
Statistics
The pre- and post-trial scores were compared using the Student t test for the 5-Cog test-
ing and Physical Fitness Test for the Elderly, and the Wilcoxon test for IADL and LSNS. The
statistical outcome for cognitive function was further tested by a multiple comparison of
Bonferroni. An ? level of 0.05 was selected for statistical significance in this study. The com-
puter software used for the trial was the Statistical Package for Social Sciences version 16.0J
(SPSS Japan Inc.).
Ethics
The medical ethics review board of Kanazawa University approved this study.

Page 6

74
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
Results
Rate of Participation and Characteristics of the Participants
Of the 67 participants who had decided to participate in the intervention programs, 21
did not attend any session, which led to their elimination from the analysis. The number of
those who actually participated in the trial was 46, with an attendance rate of 79% for the
cognitive function program and 66% for the physical function program.
The final assessment was carried out in only 31 participants who had attended the inter-
vention programs more than once and who had undergone both the initial and final assess-
ments ( table 1 ). Among the 3 groups in the trial, there was no statistically significant differ-
ence in the age and years of education of the participants.
The Scores for the Cognitive Function, Physical Function, and Non-Intervention
Programs
Figure 2 presents the comparison of the pre-/post-trial total rank scores for the 31 par-
ticipants (19 women and 12 men) in the two intervention groups and the 13 participants (7
women and 6 men) in the non-intervention group. Among the participants of the cognitive
function program, 23% (3/13) of ‘normal’ participants deteriorated to ‘probable AACD’ on
Cognitive function
program
(n = 17)
Physical function
program
(n = 14)
Non-inter-
vention group
(n = 13)
Women, %
Age, years
Education, years
47.1
72.083.7
10.482.0
78.6
73.985.8
10.181.7
53.8
72.583.2
9.382.5
Table 1. D emographic data
Fig. 2. Change in the total pre-/post-trial rank scores for the 5-Cog tasks.

Page 7

75
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
the final assessment, but 50% (2/4) of ‘probable AACD’ participants improved to ‘normal’.
No participants classified as ‘normal’ and ‘probable AACD’ deteriorated to ‘probable demen-
tia’. Among the participants of the physical function program, all ‘normal’ participants
maintained the same status, 29% (2/7) of ‘probable AACD’ participants improved to ‘nor-
mal’, and 100% (1/1) of ‘probable dementia’ participants improved to ‘probable AACD’.
Among the participants in the non-intervention group, 17% (1/6) of ‘normal’ participants
deteriorated to ‘probable AACD’, and 17% (1/6) of ‘probable AACD’ participants deteriorat-
ed to ‘probable dementia’. However, 50% (3/6) of ‘probable AACD’ participants improved to
‘normal’, and 100% (1/1) of ‘probable dementia’ participants improved to ‘probable AACD’.
Table 2 presents the pre-/post-trial raw scores for the 5-Cog tasks in the two intervention
groups and the non-intervention group. For the participants in the cognitive function pro-
gram, the scores for the cued recall (memory) tasks significantly increased from 13.4 to 17.1.
Furthermore, in the physical function program, the scores for the cued recall (memory) tasks
significantly increased from 12.4 to 15.6. However, no significant change was noted in the
raw scores for any of the 5-Cog tasks in the non-intervention group.
Comparison of Post-Trial Changes in the Scores for the IADL, LSNS, and Physical
Function
There was no significant pre/post-trial change in the scores for IADL and LSNS. As for
the participants’ physical function scores, the total score decreased significantly after the
trial (from 31.6 8 8.5 to 28.8 8 8.8; p ! 0.05), suggesting that there was no specific trend.
The total score did not yield a significant difference, demonstrating that there was no item
that showed statistical significance. Also, there was no significant difference in the post-tri-
al scores among the tasks for the non-intervention group.
Discussion
Efficacy of Cognitive Rehabilitation
This study compared the efficacy of cognitive rehabilitation in local community-dwell-
ing older adults with and without MCI with a non-intervention group. There have been a
number of studies that have focused on improvement in cognitive function of healthy older
adults and older adults with MCI and early-onset AD [19–23] . Many of these studies have
demonstrated that the memory performance and appraisals of healthy older adults and old-
Table 2. Mean 8 SD of the raw scores for the motor function and 5-Cog tasks
Motor function and 5-Cog tasksCognitive function
program (n = 17)
before
intervention
Physical function
program (n = 14)
before
intervention
Non-intervention group
( n = 13)
before
intervention
after
intervention
after
intervention
after
intervention
Finger movement (motor function)
A set-dependent activity (attention)
Cued recall (memory)
Clock drawing (visuospatial function)
Verbal fluency (language)
Similarity1 (abstract reasoning)
22.485.6
22.387.4
13.486.5
6.481.0
15.783.7
9.484.5
24.886.3
22.587.2
17.186.1**
6.880.8
16.884.8
9.585.1
19.486.6
19.487.7
12.487.3
6.181.2
13.783.8
8.484.4
22.786.4
21.987.5
15.685.7*
6.581.1
13.984.2
9.483.3
22.685.7
19.087.5
12.285.6
6.181.2
15.387.1
7.284.0
24.285.2
21.187.5
14.686.6
6.181.1
15.086.4
8.183.8
1 Similarity subset of the Revised Wechsler Adult Intelligence Scale. * p < 0.05; ** p < 0.01.

Page 8

76
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
er adults with MCI improved significantly following the intervention, which is in agreement
with the results of this study. Talassi et al. [24] verified the efficacy of systematic cognitive
function training, together with a physical training group as a control. Their study incorpo-
rated persons with MCI and mild dementia. The training consisted of a cognitive interven-
tion by the use of a computer-based program so as to focus on specific cognitive areas. Both
groups received occupational therapy with emphasis on ADL as well as behavioral therapy.
Any changes in cognitive function, behavior, ADL, IADL, and physical function were mea-
sured for the efficacy of the intervention. The results yielded an improvement in memory
performance and appraisals and a significant reduction in symptoms for depression and
anxiety in the persons with MCI. For those with mild dementia, there was a significant im-
provement in their global cognitive status and also a significant reduction in symptoms for
depression and anxiety. However, the study by Talassi et al. [24] consisted of participants who
were attending a day hospital. Contrary to Talassi et al.’s study, this study was aimed at
healthy community-dwelling older adults and older adults with MCI, none of which were on
any medication for alleviating dementia. Therefore, any improvement in the participants’
cognitive function achieved in this study could not be attributed to the effect of medication,
but was due to the effect of the intervention.
How long can efficacy of cognitive rehabilitation be maintained? In general, some posi-
tive effects have been demonstrated, lasting from 6 months to 5 years; they are as follows: (1)
not only improvement in memory was noted, which was the principal focus of the training,
but also improvement in ADL was seen, with a positive change in mood lasting up to 1 month
[25] ; (2) improvement in memory performance and appraisals lasting 6 months was ob-
served, even though these were not the principal foci of the training [19] ; (3) increased use of
mnemonic skills was noted, using training tasks such as cueing, categorization, chunking
and method of loci, consequently improving the targeted memory performance and apprais-
als lasting 6 months [3] ; (4) no improvement in overall cognitive function and ADL or ap-
parent reduction in nursing care was observed, but the skills to use the memory support
system improved, lasting 6 months [23] ; (5) a series of 10 group training sessions over a 5- to
6-week period with a follow-up 11 months later of 4 booster training sessions over a 2- to
3-week period resulted in a lasting effect of 2 years [26] , and (6) the targeted cognitive out-
comes for participants were maintained at a 5-year follow-up of an interventional study for
memory, reasoning, and speed-of-processing training [21] . Although only the immediate
resultant effect of this study has been presented in this paper, it would be of scientific inter-
est to carry out a follow-up evaluation so as to investigate its long-term effect on the partici-
pants living in the town of Nakajima.
What class of participants was the cognitive rehabilitation effective for? It was found that
a comparison between the two intervention groups and the non-intervention group did not
yield much change in the participants who were classified as ‘normal’ in terms of cognitive
function. However, the negative changes that occurred in the participants classified as ‘prob-
able AACD’ tended to be small for the two intervention groups. Therefore, the intervention
may be effective for improving the cognitive function of individuals with MCI. Among pre-
vious studies, Kurz et al. [25] have demonstrated that cognitive rehabilitation has not pro-
duced any significant effect on individuals with mild AD, but has been effective for those
with MCI. In addition, Unverzagt et al. [22] have demonstrated that cognitive interventions
have been effective for improving memory performance/appraisals, reasoning, and speed of
processing in individuals with normal memory. However, among the three aforementioned
tasks in memory-impaired individuals, only memory performance/appraisals did not yield
any improvement. Thus, cognitive techniques have been shown to be effective for persons
with MCI.

Page 9

77
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
Cognitive Rehabilitation Program vis-à-vis Executive Function
This study consisted of a cognitive function and physical function program. After con-
ducting the programs, the outcomes were compared. The cognitive function program was
designed by monitoring executive function of the participants. It was observed whether or
not they could plan and execute an event with an emphasis on their ability to modify it. As
for the physical function program, it was constructed with an emphasis on aerobic training,
so that it would especially influence the executive domain of the participants’ cognitive func-
tion. As a result, both programs were effective not only for the targeted executive functions,
but also for improving targeted memory performance/appraisals that were the principal foci
of this study. Thus, this study demonstrated that training of executive function used as the
target of the cognitive rehabilitation programs could lead to possible improvement in mem-
ory function.
It is a well-known fact that the principal characteristic symptom in persons with MCI
and early AD is a decrease in memory function. The present common interventions for treat-
ment of such persons are mnemonic training as stated by Brooks III et al. [27] and Hamp-
stead et al. [28] , a combination of memory and relaxation skills as stated by Rapp et al. [4] ,
or combined interventions including mnemonic training, physical exercises, and creative
activities as stated by Kurz et al. [25] . Memory performance and appraisals have been used
both as a content and measure of mnemonic training, and many investigators have demon-
strated improvement in memory following these interventions. However, it is difficult to ex-
clude the learning effect during evaluation. Furthermore, impact on other cognitive aspects
has rarely been addressed because these aspects are seldom employed for evaluation. Ball et
al. [26] have compared mnemonic training and the type of training in which other cognitive
aspects have been utilized. The following is an example of the principal focus they used for
training of cognitive function: (1) memory (verbal episodic memory); (2) reasoning (ability
to solve problems that follow a serial pattern), and (3) speed of processing (visual search and
identification). The measures they employed were pre-/post-training changes in the princi-
pal/non-principal foci and their application to ADL. The results showed that if the targeted
function was memory, then memory improved, and if it was reasoning, then reasoning im-
proved. However, Ball et al. [26] have demonstrated that if the targeted function was memo-
ry, then reasoning, speed of processing, and ADL did not improve, although improvement
in targeted function was maintained at 2-year follow-up.
A study that conducted a comprehensive program for cognitive rehabilitation that in-
cluded mnemonic training, physical exercises, and creative activities resulted in the im-
provement of many aspects of cognitive function, such as memory, ADL, and emotion, in
individuals with MCI, but this improvement was not apparent in the non-participants with
MCI [25] . These results suggest that the efficacy of cognitive rehabilitation may extend to
other aspects of cognitive functions. Therefore, in order to improve non-targeted cognitive
function by means of cognitive intervention, a combined program is desirable, so that ex-
ecutive function programs may be the most applicable to achieve this goal.
Participation in the executive function and physical function programs demonstrated
improvement in the participants’ memory performance/appraisals. This statement can be
explained as follows: the transitional process to early dementia from MCI is a process in
which a slow deterioration of the neural network takes place. By means of incorporating an
intervention into a cognitive rehabilitation program for individuals with MCI, a stage at
which mental deterioration is at a minimum, it may be possible to slow down or prevent de-
terioration [29] .
In a program with emphasis on executive function, a person requires a complex cogni-
tive function, i.e., not only being capable of accomplishing a single task such as memorization
of a subject, but also memorizing the process of a task, such as depicting a map in one’s mind

Page 10

78
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
References
1 Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E: Mild cognitive impairment:
clinical characterization and outcome. Arch Neurol 1999;
2 Sugimura M, Nakano S, Kinoshita T, Yamada T: Prevention of dementia among community-dwell-
ing elderly using non-pharmacological interventions for mild cognitive impairment: the Ajimu proj-
ect (in Japanese). Jpn J Geriatr Psychiatry 2005;
3 Ishizaki J, Meguro K, Ohe K, Kimura E, Tsuchiya E, Ishii H, Sekita Y, Yamadori A: Therapeutic psy-
chosocial intervention in a community of elderly subjects with early stage of Alzheimer disease: the
Tajiri Project. Alzheimer Dis Assoc Disord 2002;
4 Rapp A, Brenes G, Marsh AP: Memory enhancement training for older adults with mild cognitive
impairment: a preliminary study. Aging Ment Health 2002;
56:
303–308.
16:
1387–1393.
16:
261–269.
6:
5–11.
and calculating the required time for its execution. This leads one to take advantage of the
neural network already in existence, while at the same time establishing a new one. This may
bring about improvement not only in the targeted function of the training, but also in ad-
ditional functions, such as memory performance and appraisals. As for the aerobic training
program, if rats were subjected to low intensity exercise at below-lactic-acid threshold, this
brought about activation of the hippocampal neurons and an increase in the local blood flow
of the brain with consequent improvement in memory [30] .
Although the period of intervention was only 2 months, some degree of improvement,
such as that in memory, was achieved. In this way, we demonstrated a certain measure of
success in a short period of time, despite a dearth of studies concerning intervention periods
for cognitive rehabilitation.
The relevance of preservation and improvement of cognitive function for the incidence
of dementia has not been examined extensively. With regard to AACD, Ball et al. [26] have
stated that a 2-year maintenance of memory and reasoning abilities is comparable with the
expected decline over a 7- to 14-year interval in elderly persons without dementia, so an
intervention could be effective for maintaining cognitive function, consequently delaying
the onset of dementia. Many investigators of previous studies have concentrated only on
the relationship between the intervention and maintenance/improvement of cognitive
function. They have, however, not directly examined the relationship between mainte-
nance/improvement of cognitive function and its relevance to the incidence of dementia.
This study, too, has described nothing besides the immediate effect of intervention without
further investigating the incidence of dementia. It is therefore important to further inves-
tigate the incidence of dementia in a community of non-demented individuals with and
without any intervention. By observing a decrease in the incidence of dementia in such a
community, the implementation of such an intervention would demonstrate its long-term
efficacy.
Acknowledgements
The study was supported by a grant from the Knowledge Cluster Initiative ‘High-Tech-
nology Sensing and Knowledge Handling Technology (Brain Technology)’ of the Ministry
of Education, Culture, Sports, Science and Technology of Japan, and also by a special re-
search grant from Bukkyo University, Kyoto, Japan. The contents of this paper were pre-
sented at the 24th Congress of the Japanese Psychogeriatric Society in Yokohama, Japan,
2009.

Page 11

79
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
5 Sugano K, Suzuki E, Shinohara M, Ono K, Iwasa K, Mimura M, Yamada M: Effectiveness of cogni-
tive rehabilitation in persons with mild cognitive impairment in the early stage of Alzheimer disease
(in Japanese). Dementia Japan 2006;
6 Colcombe S, Kramer AF: Fitness effects on the cognitive function of older adults: a meta-analytic
study. Psychol Sci 2003;
7 Mahncke HW, Connor BB, Appelman J, Ahsanuddin ON, Hardy JL, Wood RA, Joyce NM, Boniske
T, Atkins SM, Merzenich MM: Memory enhancement in healthy older adults using a brain plasticity-
based training program: a randomized, controlled study. PNAS1 2006;
8 Mimura M, Sugano K: Factors responsible for efficiency of learning in patients with mild dementia
(in Japanese). Psychiatria et Neurologia Japonica 2005;
9 Katoh S, Simogaki H, Onodera A, Ueda H, Oikawa K, Ikeda K, Kosaka A, Imai Y, Hasegawa K: De-
velopment of the revised version of Hasegawa’s Dementia Scale (HDS-R) (in Japanese). Jpn J Geriatr
Psychiatry 1991;
10 Jeong JW, Kim KW, Lee DY, Lee SB, Park JH, Choi EA, Choe JY, Do YJ, Ryang JS, Roh HA, Park YS,
Choi Y, Woo JI: A normative study of the revised Hasegawa dementia scale: comparison of demo-
graphic influences between the revised Hasegawa dementia scale and the Mini-Mental Status Ex-
amination. Dement Geriatr Cogn Disord 2007;
11 NPO Dementia Prevention Support Center: Mass Examination of the Elderly Using the Five Cogni-
tive Tests (in Japanese). Tokyo Metropolitan Institute of Gerontology, 2008.
12 Miyamoto M, Kodama C, Kinoshita T, Yamashita F, Hidaka S, Mizukami K, Kakuma T, Asada T:
Dementia and mild cognitive impairment among non-responders to a community survey. J Clin
Neurosci 2009;
13 Petersen RC: Conceptual overview; in Petersen RC (ed): Mild Cognitive Impairment; Aging to Alz-
heimer’s Disease. New York, Oxford University Press, 2003, pp 1–14.
14 Lubben JE: Assessing social networks among elderly populations. Fam Community Health 1988;
42–52.
15 Ministry of Education, Culture, Sports, Science and Technology in Japan: Guideline for New Physi-
cal Fitness Test (in Japanese). 2000. http://www.mext.go.jp/amenu/sports/stamina/03040901.htm
(accessed March 10, 2007).
16 Yokoya T, Demura S, Sato S: Three-year follow-up of the fall risk and physical function characteristics
of the elderly participating in a community exercise class. J Physiol Anthropol 2009;
17 Pollock ML, Gaesser GA, Butcher JD, Despres J, Dishman RK, Franklin BA, Garber CE: ACSM posi-
tion stand: the recommended quantity and quality of exercise for developing and maintaining car-
diorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;
975–991.
18 Research Committee on Exercise and Physical Activity Guidelines, the Ministry of Health, Labour
and Welfare of Japan: Exercise and Physical Activity Guide for Health Promotion (in Japanese). 2006.
http://www.mhlw.go.jp/bunya/kenkou/undou01/pdf/data.pdf (accessed August 9, 2010).
19 Neely AS, Bäckman L: Effect of multifactorial memory training in old age: generalizability across
task and individuals. J Gerontol 1995;
20 Jobe JB, Smith DM, Ball K, Tennstedt SL, Marsiske M, Willis SL, Rebok GW, Morris JN, Helmers KF,
Leveck MD, Kleinman K: ACTIVE: a cognitive intervention trial to promote independence in older
adults. Controlled Clinical Trials 2001;
21 Willis SL, Tennstedt SL, Marsiske M, Ball K, Elias J, Koepke KM, Morris JN, Rebok GW, Unverzagt
FW, Stoddard AM, Wright EW: Long-term effects of cognitive training on everyday functional out-
comes in older adults. JAMA 2006;
22 Unverzagt FW, Kasten L, Johnson KE, Rebok GW, Marsiske M, Koepke KM, Elias JW, Morris JN,
Willis SL, Ball K, Rexroth DF, Smith DM, Wolinsky FD, Tennstedt SL: Effect of memory impairment
on training outcomes in ACTIVE. J Int Neuropsychol Soc 2007;
23 Greenaway MG, Hanna SM, Lepore SW, Smith GE: A behavioral rehabilitation intervention for am-
nestic mild cognitive impairment. Am J Alzheimers Dis Other Demen 2008;
24 Talassi E, Guerreschi M, Feriani M, Fedi V, Bianchetti A, Trabucchi M: Effectiveness of a cognitive
rehabilitation program in mild dementia (MD) and mild cognitive impairment (MCI): a case control
study. Arch Gerontol Geriatr 2007;suppl 1:
25 Kurz A, Pohl C, Ramsenthaler M, Sorg C: Cognitive rehabilitation in patients with mild cognitive
impairment. Intern J Geriatr Psychiatry 2009;
20:
181.
14:
125–130.
03:
12523–12528.
107:
1314–1319.
2:
1339–1347.
24:
288–293.
16:
270–276.
11:

28:
55–62.
30:

50:
134–140.
22:
453–479.
296:
2805–2814.
13:
953–960.
23:
451–461.
391–399.
24:
163–168.

Page 12

80
Dement Geriatr Cogn Disord Extra 2012;2:69–80
DOI: 10.1159/000337224
Published online: March 20, 2012
E X T R A
Sugano et al.: Interventional Program for Mild or No Cognitive Impairment
www.karger.com/dee
© 2012 S. Karger AG, Basel
26 Ball K, Berch DB, Helmers KF, Jobe JB, Leveck MD, Marsiske M, Morris JN, Rebok GW, Smith DM,
Tennstedt SL, Unverzagt FW, Willis SL: Effect of cognitive training interventions with older adults:
a randomized controlled trial. JAMA 2002;
27 Brooks III JO, Friedman L, Pearman AM, Gray C, Yesavage JA: Mnemonic training in older adults:
effects of age, length of training, and type of cognitive pretraining. Int Psychogeriatr 1999;
28 Hampstead BM, Sathian K, Moore AB, Nalisnick C, Stringer AY: Explicit memory training leads to
improved memory for face-name pairs in patients with mild cognitive impairment: results of a pilot
intervention. J Int Neuropsychol Soc 2008;
29 Meguro K: Issues in community-dwelling elderly with mild cognitive impairment: a neuropsycho-
logical basis and possibility of cognitive rehabilitation (in Japanese). Geriatr Med 2002–3;
342.
30 Nishijima T, Soya H: Evidence of functional hyperemia in the hippocampus of the rat during tread-
mill running with mild intensity. Neurosci Res 2006;

288:
2271–2281.
11:
75–84.
14:
883–889.
40:
333–
54:
186–191.