Cognitive function of elderly residents in long-term institutions: effects of a physiotherapy program

Abstracts

The increase in the size of the elderly population demands new knowledge about the process of healthy and active aging. Cognitive disorders are directly associated with aging, and therefore represent a public health problem. A longitudinal and interventional study with a quantitative approach was performed with the aim of analyzing the effects of a physical therapy program aimed at health promotion on the cognitive ability of institutionalized elderly women. Data was collected using a sociodemographic and clinical form and the Mini Mental State Examination (MMSE) at three time points (baseline, after 10 interventions and after 20 interventions). The health promotion program consisted of 20 recreational group activities in weekly meetings lasting an hour. Statistical analysis used the paired Student's t-test and Analysis of variance, with a significance level of p<0.05. The sample consisted of 24 elderly persons, with a mean age of 80.04 years. The results showed improvement in the performance of the elderly, both in overall MMSE score (T0=19.22 vs. T2=28.33, p=0.01) and in the evaluated subcategories "time orientation" (T0=3.35 vs. T2=3.57, p=0.02), "record" (T0=2.61 vs. T2=2.95, p<0.01), "memory recall" (T0=1.78 vs. T2=2.71, p<0.01), "read and execute" (T0=0.43 vs. T2=0.67, p=0.01) and "copy diagram" (T0=0.26 vs. T2=0, 48, p=0.02). These findings suggest that physical therapy for health promotion purposes enables improvement in performance of cognitive activities of institutionalized elderly persons, thus contributing to a better quality of life.

Elderly; Cognition; Physical Therapy Specialty; Homes for the Aged

O aumento da população idosa mundial demandou novos conhecimentos sobre o processo de envelhecimento saudável e ativo. Os transtornos cognitivos estão diretamente associados ao envelhecimento, sendo, portanto, um problema de saúde pública. Nesse sentido, objetivou-se analisar os efeitos de um programa de fisioterapia para promoção à saúde sobre a capacidade cognitiva de mulheres idosas institucionalizadas. Estudo longitudinal, intervencionista, com abordagem quantitativa. Os dados foram coletados por meio de formulário sociodemográfico e clínico, além do Miniexame do Estado Mental (MEEM) em três tempos (pré, após 10 e após 20 intervenções). O programa de promoção à saúde consistiu em 20 atividades lúdico-coletivas, em encontros semanais com duração de uma hora. Na análise estatística, utilizou-se o teste t Student pareado e Análise de Variância, em que se admitiu como nível de significância p<0,05. A amostra foi composta por 24 idosas, com idade média de 80,04 anos. Os resultados mostraram melhora no desempenho das idosas no MEEM tanto na pontuação geral (T0=19,22 vs. T2=28,33; p=0,01), quanto nas subcategorias: "orientação temporal" (T0=3,35 vs. T2=3,57; p=0,02), "registro" (T0=2,61 vs. T2=2,95; p<0,01), "memória de evocação" (T0=1,78 vs. T2=2,71; p<0,01), "ler e executar" (T0=0,43 vs. T2=0,67; p=0,01) e "copiar diagrama" (T0=0,26 vs. T2=0,48; p=0,02). Tais achados sugerem que as ações de Fisioterapia para promoção da saúde possibilitaram melhora no desempenho de atividades cognitivas das idosas institucionalizadas, contribuindo, assim, para uma melhor qualidade de vida.

Idoso; Cognição; Fisioterapia; Instituição de Longa Permanência para Idosos

INTRODUCTION

Global populations are undergoing a rapid process of aging, a demographic change which occurs more rapidly in low and middle-income countries and has a significant impact in the healthcare, social and economic sectors of all countries.¹ As with every human situation, aging has an existential dimension, which modifies a person's relationship with time, generating changes in their relations with the world and with their own history.²

Levels of cognitive disorder increase as a population ages, meaning that there is a current global rise in the same, constituting a major mental health problem.³ In this sense several studies^4-6 have highlighted the relationship between aging and the onset of cognitive disorders (dementia, reaction time, memory deficit, understanding and learning), also describing how such disorders can be influenced by factors such as age, education, physical activity and income. ^4,6

The assessment of cognitive ability has arisen, therefore, as a new health paradigm, of particular importance for the elderly, originating from the concept of health and quality of life, combined with increased life expectancy.⁷ One method for checking the health conditions of the elderly is the application of instruments that allow the overall assessment of these individuals by a health team, addressing their individual, family and social conditions and their relationship with functional, cognitive and affective capacity.⁸

Thus, evaluation of the cognitive capacity of institutionalized elderly persons -enables the selection of appropriate interventions to combat foreseeable dependencies and allows the promotion of a more active and healthy lifestyle.⁹

Faced with an aging population, measures of early intervention by health professionals become necessary in order to prevent cognitive harm and to change misguided attitudes that endanger the health of the elderly, thus providing greater autonomy and a better quality of life.¹⁰

Taking the above into consideration, the present study aimed to analyze the effects of a physiotherapy program for the promotion of health based on the cognitive capacity of institutionalized elderly women.

METHOD

A longitudinal, interventional and analytic study with a quantitative approach was conducted from December 2013 to April 2014 in two private and philanthropic long-term care facilities for the elderly (LTCFEs) with exclusively female patients, located in the city of Fortaleza, in the state of Ceará. This study formed part of the Programa de Extensão Promoção da Saúde (Program for the Extension of Health Promotion) (PROSA) of the course of Physiotherapy, Universidade Federal do Ceará (Federal University of Ceará).

The sample consisted of elderly persons aged 65 and over and resident in at least one of the LTCFEs. A single researcher addressed these individuals verbally and explained the purpose of the study to them. Having agreed to participate in the survey they were evaluated for a basic knowledge of mathematics (in other words that they were able to perform mental calculations) and that they were willing to attend 75% of the activities developed for the promotion of health.

Any individuals who had proven medical diagnosis of previous and/or progressive neurodegenerative disorders, alteration of allopsychic and autopsychic orientation in relation to personal contact, or who were using specific medications for the improvement of cognitive function were excluded. The directors of the LTCFEs were consulted and informed about the feasibility of the study, and agreed to let it be carried out.

Data collection took place in three stages: initial diagnosis (T0) assessment for review of the intervention plan (T1) and final evaluation (T2). The initial diagnosis was performed using a formula for socio-demographic and nosological characterization of the sample, prepared by the authors of the study, together with the Mini Mental State Examination (MMSE), an instrument originally proposed by Folstein et al.¹¹ in 1975, validated for use in Portuguese in 1994 by Bertolucci et al. ¹² and modified by Brucki et al.¹³ in 2003 (Chart 1) for cognitive assessment of the elderly. The MMSE consists of questions grouped into seven categories (orientation to time, orientation to place, registration, attention and calculation, memory recall, language and visual constructive capacity). Total score can range from zero to a maximum of 30 points. In this test, values of higher than 27 points are considered normal with values indicating dementia being those lower than or equal to 24 points. In patients with less than four years of schooling, the cutoff point is 17, rather than 24 points.¹⁴

Chart 1.
Mini Mental State Examination (MMSE).

Chart 2.
Intervention protocols, themes, activities performed and therapeutic objectives. Fortaleza, CE, 2014.

The second test was performed after the execution of 10 activities (T1) and the third after 20 activities (T2); with the MMSE being reapplied in both cases.

The interventions were carried out by two academics from the Federal University of Ceará; supervised by professional physiotherapists from the planning stage of the promoted activities until their execution. The program had a total duration of five months and was carried out in weekly meetings lasting at least one hour. It is worth noting that the performance of the activities normally took the minimum amount of time.

During the execution of the activities, group techniques were utilized in order to ensure a collective perspective and interactive manner with the elderly individuals (Table 2). The exercises were carried out with the help of physiotherapy equipment, such as elastic bands, bats and balls, and homemade materials, such as plastic bottles and strings, in accordance with the aim set for the week's activity. The interventions were carried out in the main hall of each LTCFE. The instruments used in the intervention plan were: a fieldwork diary (for making important notes during the interventions), the oral reports of the elderly persons, participant observation, intervention protocol and action reports (describing all the actions performed at the end of each intervention).

Table 1.
Characteristics of the elderly persons studied. Fortaleza, CE, 2014.

Variables	Fa	F%
Socio-demographic Characteristics
Age group
65 to 69 years	3	12.50
70 to 79 years	6	25.00
80 to 90 years	15	62.50
Civil Status
Married	1	4.17
Divorced	1	4.17
Single	16	66.66
Widowed	6	25.00
Education
Illiterate	8	33.33
Elementary incomplete	7	29.17
Elementary complete	4	16.67
Secondary complete	3	12.50
Higher complete	2	8.33
Profession
Autonomous	3	12.50
Salaried	12	50.00
From home	9	37.50
Place of birth
Fortaleza	7	29.17
Municipalities in the state interior	14	58.33
Municipalities in other states	3	12.50
Clinical characteristics
Visual deficit	15	62.50
Auditory deficit	6	25.00
Use of medications	20	83.33
Clinical trials: Whisper test	7	29.17
Alcohol use	1	4.17
Tobacco use	3	12.50
Cognition
Presence of forgetfulness	12	50.00
Previous change in functioning	5	20.83
Progressive worsening of forgetfulness	10	41.67
Mental state
Oriented and follows simple instructions	23	95.83
Disoriented, but can obey simple instructions.	1	4.17
Time institutionalized
Less than 1 year	4	16.67
1 to 5 years	8	33.33
6 to 10 years	10	41.67
More than 10 years	2	8.33

• Fa= absolute frequency; F%= relative frequency.

Table 2.
Comparing responses to the Mini Mental State Examination (MMSE) of elderly persons from long-term care facilities before and after 10 and 20 physiotherapy care sessions. Fortaleza, CE, 2014.

Variables	T0	T1	T2	p****
MMSE (general)	19.22±6.35	23.43±7.35	28.33±7.95	0.11
Orientation of time	3.35±1.87	3.14±1.88	3.57±1.66	0.70
Orientation of place	3.83±1.56	3.90±1.70	3.90±1.67	0.98
Register	2.61±0.72	2.90±0.44	2.95±0.22	0.09
Attention and calculation	0.87±1.84	0.38±1.16	2.29±1.10	0.34
Memory recall	1.78±1.17	2.62±0.80	2.71±0.72	<0.01
Name two objects	2.00±0.00	1.95±0.22	2.00±0.00	0.62
Repeat	0.91±0.29	1.10±0.44	1.05±0.50	0.60
Stage command	2.78±0.74	2.38±1.02	2.71±0.72	0.37
Read and execute	0.43±0.51	0.48±0.51	0.67±0.48	0.16
Speak back a phrase	0.39±0.50	0.57±0.51	0.52±0.51	0.49
Copy diagram	0.26±0.45	0.38±0.50	0.48±0.51	0.36

• T0= evaluation of baseline (average±standard deviation); T1= evaluation after 10 physiotherapy sessions (average±standard deviation); T2= evaluation after 20 physiotherapy sessions (average±standard deviation); ****ANOVA.

It is also worth noting that researchers made no payment to the participants with respect to proposed activities, and the participants did not know the purpose of the study. The data was analyzed jointly according to the consensus of the researchers.

For comparison between groups (T0, T1 and T2) the Student t-test was used, paired with the Analysis of Variance (ANOVA), with a significance level of p<0.05 (5%) and a confidence interval of 95%.

The ethical questions of the study were dealt with in Resolution No. 466/12.¹⁵ The study was approved by the "Comitê de Ética em Pesquisa da Universidade Federal do Ceará" (Research Ethics Committee of the Universidade Federal do Ceará), (Protocol 327/11) and all participants signed a Free and Informed Consent Form.

RESULTS

The sample consisted of 24 elderly women (n=19 from LTCFE 1 and n=5 from LTCFE 2), with an average age of 80.42±7.95 years [min=65 and max=90], 62.5% of whom were aged between 80 and 90. Most came from municipalities in the interior of the state of Ceará (58.33%), were single (66.66%) and had either a low level of education or no education (62.50%). All were retired (100%). Most made continuous use of medication (83.33%), with hypoglycemic and antihypertensive drugs the most commonly used.

When cognition was investigated, the elderly individuals were almost all identified as oriented, and able to obey simple instructions (95.83%). However, there was a presence of recurring forgetfulness (50%), with a progressive worsening in the frequency of forgetfulness (41.67%), which manifested itself in previous cognitive alterations in just 20.83% of cases (Table 1).

There was a general increase in MMSE scores before and after the physiotherapeutic intervention (T= 19.22; T1= 23.43; T2= 28.33), although this was not statistically significant between the three time periods evaluated (p=0.11). In all subcategories, increases in values between T0 and T2 were observed. However, progressive gains (T0-T1-T2) were seen only in the following subcategories: "register" (2.61; 2.90; 2.95), "memory recall" (1.78; 2.62; 2.71), "read and execute" (0.43; 0.48; 0.67) and "copy diagram" (0.26; 0.38; 0.48); with a statistically significant difference found only in "memory recall" (p<0.01) (Table 2).

A statistically significant improvement in MMSE performance before and after 20 physiotherapeutic interventions was observed (T0=19.22 vs. T2=28.33, p=0.01). In all subcategories increases were observed between T0 and T2, except in "name two objects" (2.00; 2.00) and "stage command" (2.78, 2.71). There was a significant difference between "orientation of time" (3.35; 3.57; p = 0.02); "register" (2.61, 2.95; p<0.01); "memory recall" (1.78; 2.71; p <0.01), "read and execute" (0.43; 0.67; p=0.01) and "copy diagram" (0.26; 0.48; p=0.02) (table 3).

Table 3.
Comparing the responses to the Mini Mental State Examination (MMSE) of elderly persons from long-term care facilities before and after 10 and 20 physiotherapy sessions. Fortaleza, CE, 2014.

Variables	T0	T2	p***
MMSE (general)	19.22±6.35	28.33±7.95	0.01
Orientation of time	3.35±1.87	3.57±1.66	0.02
Orientation of place	3.83±1.56	3.90±1.67	0.40
Register	2.61±0.72	2.95±0.22	<0.01
Attention and calculation	0.87±1.84	2.29±1.10	0.09
Memory recall	1.78±1.17	2.71±0.72	<0.01
Name two objects	2.00±0.00	2.00±0.00	0.16
Repeat	0.91±0.29	1.05±0.50	0.21
Stage command	2.78±0.74	2.71±0.72	0.42
Read and execute	0.43±0.51	0.67±0.48	0.01
Speaking back a phrase	0.39±0.50	0.52±0.51	0.09
Copy diagram	0.26±0.45	0.48±0.51	0.02

• T0= evaluation of baseline (average±standard deviation); T2= evaluation after 20 physiotherapy sessions (average±standard deviation); ***Student t-test paired for T0 and T2.

DISCUSSION

The sample consisted exclusively of elderly females, aged between 65 and 90 years, with predominance of those aged 80 or over and single, who were illiterate or poorly educated, and retired. This data points to a tendency towards aging among the elderly population, especially among women, suggesting an increase in the life expectancy of the population in various regions of Brazil, further evidenced by studies conducted in the cities of Fortaleza-Ceará,¹⁶ Recife-Pernambuco,¹⁷ João Pessoa-Paraíba,¹⁸ Brasília-Distrito Federal,¹⁹ Diamantina-Minas Gerais²⁰ and Porto Alegre-Rio Grande do Sul.²¹

In this context, the predominance of elderly females can be attributed to their lower exposure to certain risk factors, especially at work, their lower prevalence of smoking and drinking, differences in their ability to cope with diseases and disabilities and, lastly, to the higher levels of coverage afforded by gynecological and obstetric care.^22,23 The low or non-existent educational level of the elderly population is socio-demographically relevant as studies²⁴ report that these elderly individuals are between 4.5 to 5 times more likely to develop moderate/severe dependence, compromising their functionality and consequently their quality of life. The longer life expectancy of the group aged ≥80 has been attributed mainly to the greater concern and care they tend to show in relation to diseases and preventive health care, to new patterns of behavior and to the attainment of a healthier lifestyle, as well as the national pattern of the increased feminization of old age. ^25,26

A considerable number of the elderly persons presented visual defects or reported ringing in their ears and obtained a positive result in the whisper test, while a few admitted having some hearing impairment. These results are similar to those found in the studies by Floriano & Dalgalarrondo,²⁷ Borges et al.²⁸ and Menezes et al.²⁹ These disorders lead to a reduction in communication capacity and to functional incapacity, which creates restrictions on mobility and subsequently leads to dependence, resulting in an even greater likelihood of falls and traumas in general.³⁰ Most sensory changes associated with aging are inevitable; however, they may be tackled with a preventive, corrective and sometimes even curative approach, enabling at least the delay of these dysfunctions.

In the present study, the elderly population was classified almost entirely as oriented, and capable of obeying simple instructions; however, about half reported recurring forgetfulness and progressive worsening of its frequency. No studies were found which evaluated such cognitive characteristics specifically, with the assessment of cognitive function solely through utilization of cognitive tests to evaluate skills being common in literature.^4,6 For Borges et al.,³¹ elderly persons living in LTCFEs become increasingly sedentary and lose much of their autonomy which, allied to the aging process, can enhance cognitive decline. However, the study by Carneiro et al.,¹⁶ performed with 59 elderly residents in two LTCFEs in the city of Fortaleza, Ceará, demonstrated that the elderly showed independence in carrying out their daily activities (food, personal hygiene, bathing, mobility and sphincter control), needing help just with movement on stairs and with small defects in memory.

The present study found that health promotion strategies carried out with institutionalized elderly persons provided improvements in their MMSE performance. These findings suggest that programs of guided intervention in health promotion activities, carried out through physiotherapy, are effective in optimizing the cognitive function of elderly residents of LTCFEs.

Irigaray et al.³² and Alves³³ obtained results similar to the present study observing the effectiveness of group programs for cognitive rehabilitation. Apóstolo et al.³⁴ also found that the development of a stimulation program for elderly people had positive effects on cognition. The authors applied the "Fazer a diferença" (PEC-FD) a Cognitive Stimulation Program (the Portuguese version of Making a Difference: An Evidence-based Group Program to Offer Cognitive Stimulation Therapy (CST) to People with Dementia), which addressed the following themes: physical games, sounds, childhood, food, current issues, portraits/scenes, word association, creativity, object classification, orientation, use of money, playing with numbers, playing with words and team games, with two 45 minute sessions a week for seven weeks among a sample of 14 elderly persons, and showed that the group undergoing the PEC-FD program showed significant improvements in cognition, enhancing their autonomy and functional capacity.

Another study,³⁵ regarding the cognitive responsiveness of elderly participants in a cognitive training program, developed with 21 elderly persons over eight sessions using simulations of everyday tasks such as shopping - involving memorizing a grocery shopping list and simple mathematical calculations - as an approach strategy obtained results that pointed to a cognitive improvement mainly related to memory.

Some of the categories evaluated in this study showed no change or improvement, even after 20 interventions. Some observations are important in this respect: (1) there were elderly women whose initial performance was optimal in certain items and who were therefore unable to register improvement in their score in post-intervention data collection; (2) some elderly individuals had auditory and visual disorders that may have compromised their personal performance in the activities, with resultant repercussions on the overall evaluation of the LTCFE; (3) certain skills assessed by the MMSE, such as "attention and calculation", "read and execute" and "repeat a phrase" are partially dependent on and influenced by level of education, and as such these items revealed small changes or no alteration due to the fact that the study population was predominantly illiterate or poorly educated; (4) and finally, as the activities carried out with the elderly were not organized so that all the skills covered by the MMSE were taught in equal measure in each round of 10 sessions, it is possible that some categories were worked on more than others, explaining the superior performance associated with certain capabilities.

It is estimated that for each year lived above life-expectancy, six to nine months, or close to 80%, are spent in a state of incapacity.³⁶ Health promotion has developed as a response to this challenge of achieving old age without disability, encompassing actions directed at strengthening the physical and mental abilities of individuals, as well as actions directed at changes in social, environmental and economic conditions, in order to lessen their impact on public and individual health.³⁷ Hence the importance of the participation of older people in health promotion programs that focus on prevention of disabilities as a priority.

Finally, limiting factors for the study as a whole were the small sample size and the intervention plan, which was not organized to focus on all the assessed skills with the same intensity. Furthermore, it is important to highlight the scarcity of literature, especially Brazilian, focused on the impacts of health promotion intervention programs on cognitive performance in the elderly. However, despite this, this study may be considered valid, since the proposed objectives were achieved, further demonstrating to the academic community the importance of programs and of university extension projects to explain their positive effects on the health of the population.

For future studies, the use of the following is suggested: a type of instrument other than the MMSE for cognitive assessment; a larger sample of both genders with a more homogeneous clinical profile; a case-control program with greater methodological rigor, where the activities to be carried out are well defined and divided beforehand so that equal time is devoted to all the skills to be analyzed, always aimed at achieving results which remain relevant for the long term and can be generalized for the everyday cognitive challenges of the aging population.

It should be noted that an aging population also represents a greater burden of disease in the population, as well as higher levels of incapacity and increased use of health services. Prevention is the key to improving the current situation and has shown to be effective at every level, including in the later stages of life. Identifying the health status of the elderly enables targeted interventions in order to meet their demands and improve their quality of life. Proper planning, directed at the real needs of this population, contributes to the well-being, independence and dignity of such elderly individuals, in order to provide a more healthy aging process, in which quality of life is added to years, and not just years to life.

CONCLUSION

Performance in the Mini Mental State Examination improved after the performance of health promotion activities, optimizing the cognitive function of the institutionalized elderly persons, thus contributing to a better quality of life.

A number of issues related to interventional cognitive training for healthy elderly persons and/or patients with deficits of this nature remain little studied in Brazil. The relevance of these issues should be noted, as they are themes directly related to the health, independence, autonomy and quality of life of the elderly.

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• Study funding: Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (Cearense Foundation for the Support of Scientific and Technological Development) (FUNCAP), Programa Institucional de Bolsas de Iniciação Científica (Institutional Scientific Initiation Scholarship Program) (PIBIC), Public Notice nº 01/2013.

Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  11 July 2014
• Reviewed
  09 Apr 2015
• Accepted
  02 Oct 2015