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Advances in Alzheimer’s Disease, 2018, 7, 93-102
http://www.scirp.org/journal/aad
ISSN Online: 2169-2467
ISSN Print: 2169-2459
DOI:
10.4236/aad.2018.74007 Nov. 15, 2018 93 Advances in Alzheimer’s Disease
Cognitive and Brain Reserve (CBR) Tools to
Reduce the Risk of Dementia and Alzheimer
Mosad Zineldin
Department of Medicine and Optometry, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
Abstract
The study was performed to examine and assess the impact of the education,
occupation and leisure time on building brain and cognitive reserves (CBR).
A cross sectional study of 132 persons at age between 40 to 70 years old has
been conducted. A structured
questionnaire covering multiple constructs was
used to collect the data. Multivariate regression results show that the three
independent variables (LE, OC and ED)
were statistically significant in the
models with CBR as dependent variable. Leisure time and
activities (LE)
make
the strongest unique contribution (0.683) followed by occupation
(0.261) and the weak contribution of the education (0.198) to explain
the
dependent variable cognitive and brain reserve (CBR).
The Brain and
Cognitive Reserve hypotheses
assumes that a rich intellectual measures and
abilities a person have during her/his life enable this person to cope
with
difficult cognitive tasks and social events in life.
Keywords
Cognitive Reserve, Brain Reserve, Dementia, Alzheimer, Quality,
Quality of Life, Neurological Brain
1. Background
Patient safety and good quality of care are considered to be the right of all pa-
tients [1]. According to World Alzheimer Report (2015), it is estimated that in
2015 over 10 million people in Europe and over 36 million people worldwide
had dementia. The number of people with dementia is forecast to be 66 million
in 2030 and 115 million by 2050 [2].
The percentage of US people with Alzheimer’s dementia increases intensely
with age: 3% of people age 65 - 74, 17% of people age 75 - 84 and 32% of people
age 85 or older have Alzheimer’s dementia [3]. It should be noted that older age
How to cite this paper:
Zineldin, M.
(201
8)
Cognitive and Brain Reserve (CBR)
Tools to Reduce the Risk of Dementia and
Alzheimer
.
Advances in Alzheimer
’
s Di
s-
ease
,
7
, 93-102.
https://doi.org/10.4236/aad.2018.74007
Received:
September 19, 2018
Accepted:
November 12, 2018
Published:
November 15, 2018
Copyright © 201
8 by author and
Scientific
Research Publishing Inc.
This work
is licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
M. Zineldin
DOI:
10.4236/aad.2018.74007 94 Advances in Alzheimer’s Disease
alone is not sufficient to cause Alzheimer’s dementia but older women are most
affected by Alzheimer’s in the US. According to the estimates of Alzheimer Eu-
rope, the number of people with dementia in Belgium in 2012 was 191,281,
representing 1.8% of the entire population. According to the Swedish Alzheimer
Association (2014), approx. 1.5% of all Swedish people have some type of de-
mentia [4]. The number is higher in Finland and 54 people die per 100,000 in
the Finnish population every year due to Alzheimer’s and different type of de-
mentias. Although, there is not much official sources of Alzheimer’s statistics in
the Middle East, the WHO dementia report states that the Middle East and
North Africa will see a 125% t increase of elderly people in cases by 2050 and es-
timates that almost 6% of those over 60 years old suffer from it [5].
Thus, new medical, social and economic strategies to prevent or delay AD and
dementia symptoms are critically needed. Pharmacologic and lifestyle interven-
tions can delay the disease [6] [7]. However, a considerable number of old and
recent studies have found a correlation between brain reserve (
i.e
. neurological
brain and behavioral or cognitive brain) level of and prevalence of dementia [8]
[9] [10].
The term “reserve” was introduced in the late 1980s to describe the ability of
different individuals to cope with physiological and or pathological cognitive de-
cline. Brain reserve is the prevalent construct of the potential ability of the brain
to cope with neuronal damage [11]. Reserve can also be defined as the brain’s re-
silience: that is, the possibility of the brain itself coping with increasing the brain
damage; the brain reserve hypothesis is primarily a passive-quantitative model
related to individual differences (e.g., brain size and synapse count). The authors
mean that a greater brain reserve is considered as a protective factor, and a lower
one indicates vulnerability [12].
It should be noted that dementia causes many changes in people’s lives. De-
mentia can take different forms depending on the damaged part of the brain.
Some of the symptoms are impaired memory and lack of the ability to plan and
carry out everyday tasks. Problems in language, time perception and orientation
are other impaired cognitive abilities. Anxiety and behavioral changes can be-
long to the dementia. Other problems are attention, recognition, executive activ-
ities, and speech problems. Depression, apathy and aggression are also comorbid
symptoms [13].
The treatment of cognitive decline and dementia should be seen from a holis-
tic perspective as it includes medical, neurological, cognitive and behavioral as
well as technical, technological and social tools and strategies. The cognitive or
behavioral brain reserve hypothesis argues that the brain actively attempts to
cope with damage by using pre-existing cognitive processes or enlisting com-
pensatory strategies [11] [12] [14].
Cognitive brain reserve (CBR) means that a complex mental activity across
the lifespan allows flexible cognitive repertoires to be deployed in the face of
underlying neural dysfunction. Accordingly, people with a high CBR can with-
M. Zineldin
DOI:
10.4236/aad.2018.74007 95 Advances in Alzheimer’s Disease
stand more age-related changes and disease-related pathologies by effectively
and flexibly using cognitive paradigms or compensatory brain networks [15].
Behavioral or cognitive reserve according to epidemiological studies can be es-
timated from autobiographical and demographic data such as age, sex, education
levels, occupational complexity and frequency of mentally stimulating lifestyle
pursuits [9] [10].
Education, occupation, leisure time and other higher lifelong mental stimula-
tion can be indicators of intelligence may exert a direct protective effect by en-
hancing the brain’s reserve capacity, e.g. by increasing neocortical synapse den-
sity. Adverse conditions for neurocognitive development in early life may lower
cognitive ability, reduce the likelihood of higher educational attainment, and in-
crease the susceptibility to neurodegenerative disease in old age [16] [17] [18].
Leisure activities, lifelong learning and other cognitive activities can be effi-
cient tools and working mechanism for informal carers to increase the cognitive
reserve of elderly persons as effective interventions for dementia. Previous stu-
dies show that there are associations between dementia and reduced participa-
tion in leisure activities in midlife, as well as between cognitive status and par-
ticipation in leisure activities in old age. People with higher educational levels
are more resistant to the effects of dementia as a result of having greater cogni-
tive reserve and increased complexity of neuronal synapses [11] [19].
Like education, participation in exercises, leisure and physical activities may
lower the risk of dementia by improving cognitive reserve. Physical activities and
exercises can help preserve cognitive function and decrease dementia risk and
Alzheimer’s disease and vascular dementia because the physical activities and
exercises can increase in brain-derived neurotrophic factor which is a molecule
that increases neuronal survival, enhances learning, and protects against cogni-
tive decline [20] [21].
Although Alzheimer’s has a strong genetic component, lifestyle and environ-
mental factors play a strong role in shaping its expression and timing of onset.
Still, more research and studies are needed to identify the optimal way to inter-
vene to increase brain and cognitive reserves and prevent Alzheimer’s disease
[9]. This study attempts to examine and assess the impact of the education, oc-
cupation and leisure time (OEL) on building brain and cognitive reserves (CBR).
A preventive strategy using OEL tools might entail augmenting brain and cogni-
tive reserve to enable favorable clinical and behavioral outcomes for any given
level of pathology.
2. Hypothesis
The research model is illustrated in Figure 1. Based on the literature review and
foregoing discussion, the following hypotheses, stated in formal fashion, are
proposed:
H1: there is a positive relationship between CBR and education;
H2: there is a positive relationship between CBR and occupation/intellectuality
M. Zineldin
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Figure 1. Research model: Structural framework of the
theoretical relation.
level;
H3: there is a positive relationship between CBR and leisure activities.
3. Method
3.1. Participants and Data Collection
A random sample of 243 persons were contacting personally using different
modes such as telephone, mail and face to face in random places and times dur-
ing March-April 2017 and ask them to complete the survey. When it was possi-
ble, some respondents have completed the survey in restaurants, sport clubs,
theatres and universities, etc. Out of the 243 distributed questioners, 132 were
returned and usable, resulting in a response rate of 54.32 percent.
The criteria for selecting participants were: age between 40 and 59 years (30%)
and between 60 and over 70 years (70%); physically independent person,
i.e.
,
able to walk between 1 - 3 km without assistance; and lack of cognitive impair-
ment; disorders interfering with psychometric assessment. The participation was
voluntary. All participants were fully informed about the confidentiality, content
and aim of the study.
Some scales of the current study were adapted from the Alzheimer’s Dis-
ease-related Quality of Life scale (QoL-AD). QoL-AD is a 13-item validated scale
(National chronic care consortium and the Alzheimer’s association, 2003) [22].
QoL-AD is a disease specific in some areas and health related in other areas [23].
Some other scales were adapted from Dementia Population Risk Tool (Dem-
PoRT) developed [24]. Some scales used in the current study are:
Self-rated health such as:
I have no chronic diseases;
I have good explicit memory (stores facts “special events”);
I have good short-term memory (work memory): numbers, words, visualiza-
tions.
New item scales were also developed such as:
I’m quite happy with the most of my life experiences;
I’m good at training my brain (Physical Activity, Mind Stimulants, etc.).
Respondents answered the questionnaire by agreeing or disagreeing with the
statement using a Likert scale from 1 = strongly disagree to 5 = strongly agree.
M. Zineldin
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The data were analyzed using regression analysis via the Statistical Package for
Social Sciences (SPSS) program version 21.0. To analyses the descriptive data of
the respondents and the investigated variables, this research utilized a number of
steps: descriptive analysis, assessment of reliability and validity, correction anal-
ysis and regression analysis.
3.2. Statistical Data Analysis
The demographic details of this study show that 72 women (54.5%) and 60 men
(45.5%) were included in this study. Their age ranged from 40 to >70 years old.
30.3% were between 40 - 59 and 43.9% was 60 - 69 and 25.8% was >70 years old.
The level of education for respondents included 12% lower than high school,
28% had high school education, 41% had formal higher education, 13% had
master and 6% had doctoral degrees. Seven percent had chief/head/ or senior
manager positions, 25% middle manager, 47% average positions, 12% were un-
employed and 8% have own businesses or self-employees.
92% of the participants were healthy, 7% with some neurological, genetic or
psychiatric illness and 1% had other illness. The participants did not receive any
compensation for taking part in the study. The names and identities of the par-
ticipants were anonymous. All data were collected from March to April 2015.
3.3. CBR Scale Construction
The CBR includes some demographic data such as gender, age, and marital sta-
tus and 25 items grouped into three sections, education, life style including own
health education and promotion and, and leisure time, each of which returns a
sub score.
CBR—education: Years of formal education plus possible lifelong learning or
training courses; reading scientific and nonscientific works, Multilanguage skills
(at least 3 languages).
CBR—occupation or working life: Five different levels of working activities
are intellectual involvement and personal responsibility (professors, top manag-
ers, etc.), middle managers, manual or technical work and own and professional
occupation (e.g., consult, lawyer, psychologist, physician, engineer).
CBR—pleasure and leisure time: Cognitively stimulating activities carried
out during pleasure and leisure time (after work). Ten items were related to this
construct (e.g., actively participated in cultural activities, stimulator movies,
Theaters, museums, travel, arts, play music, listen to music, actively joining so-
cial and social media activities and physical activities such as sports and dancing.
4. Reliability and Validity
The research instrument was tested for internal consistency with a particular
scale and reliability using Cronbach’s coefficient alpha estimate. As shown in
Table 1, the values for all items ranges from 0.70 to 0.74, exceeding the mini-
mum alpha of 0.60 which is considered to be acceptable [25].
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Table 1. Reliability data for scales.
Cronbach’s Alpha if Item Deleted
Gender 0.71
Age (A) 0.72
Education 0.71
Pleasure and Leisure 0.70
Working/Intellectual
CBR
0.72
0.74
Pearson correlations were calculated to identify the correlations between each
of the dependent variable CBR and independent variables. Table 2 shows that
the majority of the bivariate correlations are positive and statistically significant.
The raw scores of the three independent variables were correlated with CBR
(correlation r = 0.271 for education; r = 0.363 for occupation/working activity
and r = 0.716 for leisure time activity).
5. Hypotheses Testing, Results and Discussion
Hypotheses Testing and Results
A separate regression model was conducted to assess the research hypotheses.
The model as illustrated in Table 3 shows that the dependent variable CBR
shows association with leisure activities, the education level as well as the occu-
pation which is related to the intellectual and skills levels as well as how people
spend their leisure time. The model only involves statistically significant va-
riables.
Leisure time and activities (LE) makes the strongest unique contribution
(0.683) followed by occupation (0.261) and the weak contribution of the educa-
tion (0.198) to explaining the dependent variable cognitive and brain reserve
(CBR). Hypotheses I-III were verified and accepted. Result infers that R2 = 65%
of the variation in LE explained participants CBR. The result is also consistent
with the clinical investigation conducted by Foubert
et al
. 2012) to identify the
influence of education (ED), occupation (OC), and leisure activities (LE) on the
brain reserve capacity. The voxel-based morphometry (VBM) technique was
used in 331 nondemented people. The study shows that there is a positive and
significant association between these factors (
i.e
. ED, OC and LE) and the cere-
bral volume which is the marker of brain reserve and hence the cognitive per-
formance on Isaac’s test. Only education, according to the authors, was signifi-
cantly associated with a cerebral volume including gray and white matter. The
difference in gray matter volume was located in the temporoparietal lobes and in
the orbitofrontal lobes bilaterally. Both this study and Foutbert
et al.
, (2012)
study reveals that education, occupation, and leisure activities were found to sig-
nificantly but differently contribute to brain reserve capacity. Leisure activities
and education could play a role in the constitution of cerebral reserve capacity.
The result is also consistent with the empirical research findings by Nucci1
et al
.
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Table 2. Correlation between scale variables.
1
2
3
4
5
CBR Pearson Correlation 1
AGE Pearson Correlation 0.178* 1
ED Pearson Correlation 0.271** 0.240** 1
OC Pearson Correlation 0.363** 0.123 0.147 1
LE Pearson Correlation 0.716** 0.059 0.029 0.97 1
*Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed).
Table 3. Regression model for CBR.
Variables
β
R2
P
0.647
ED 0.198 0.000
OC 0.261 0.000
LE 0.683 0.000
(2011) and Bickel and Curz (2009).
6. Conclusions
This study demonstrates strong associations of Leisure activities, Occupation
and Education (LOE) and CRB and hence dementia diagnosis. While dementia
is, yet, difficult or sometimes impossible to be cured, there are promising LOE
strategies that may alleviate symptoms and enhance compensatory mechanisms
(CBR) for those with memory or other cognitive impairments. There are also
tools to increase safety and improve quality of life, daily functions, and engage-
ment in lifestyles activities throughout the stages of the dementia and Alzhei-
mer’s disease.
Cognitively engaging leisure, mental, and physical activities, intellectually
stimulating employment, and higher education and lifelong learning, are lifestyle
traits that may augment brain and cognitive reserve (CBR), that may further al-
low those with dementia and AD increased ability to compensate for disease and
further contribute to a better quality of life.
The CBR components studied included three main sources: education, ccupa-
tion or working activity, and pleasure and leisure time activities. This study as
well as other research studies have found a clear and consistent correlation be-
tween social capital, LOE and brain and cognitive reserve (Gregory and Rentz;
2013; Foutbert
et al.
, 2012) [26] [27] [28]. Higher education, intellectually chal-
lenging employment and leisure activities are associated with a reduced preva-
lence of dementia. The data indicated that all three constructs of the CBR ga-
thered distinct and non-redundant information on lifestyles of the participants.
The correlation and significances between the CBR and the three constructs illu-
strated in Table 4 are shown in the following.
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Table 4. Correlation and significance between study variables.
Variables
β
r
P
LE 0.683 0.716 0.000
OC 0.261 0.363 0.000
ED 0.198 0.271 0.000
The Brain and Cognitive Reserve hypotheses assume that a rich intellectual
measures and abilities a person have during her/his life enable this person to
cope with difficult cognitive tasks and social events in life. Also, many clinical
trials have found that cognitive exercise may enhance cognitive reserve provid-
ing a potentially effective intervention that may help to prevent longitudinal
cognitive and functional decline.
Ethics and Patient Consent
The participation was voluntary, and each of the participants could withdraw
from the study at any time. All participants were fully informed about the confi-
dentiality, content and aim of the study.
Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this pa-
per.
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