The International Journal of Psychosocial Rehabilitation

The effects of a cognitive training program on trained and
untrained cognitive functions of non demented elderly and Alzheimer’s patients.



E., Tsantali, (1,3)

 M., Tsolaki, (2)

D., Economides.(3)


(1) School of Psychology
(2) 3rd University Department of Neurology, General Hospital ‘G. Papanikolaou’, Medical School
(3)  Geriatric Unit, 2nd Dept. Internal Medicine AUTH, Hippokration Hospital, Medical School   
Aristotle University of Thessaloniki, Thessaloniki, Greece


Citation:
Tsantali E, Tsolaki M, & Economides D.  (2009). The effects of a cognitive training program on trained and untrained cognitive
functions of non demented elderly and Alzheimer’s patients.  International Journal of Psychosocial Rehabilitation.
14 (1), 77-98
   


Corresponded author:
Tsantali, Eleni, PhD
MERKOURIOU 5
THESSALONIKI, 54655, GREECE

Acknowledgement to Professor A. Efklides and Professor G. Kiosseoglou (Cognitive and Ex-perimental Section of School of Psychology, Aristotle University of Thessaloniki, Greece ) for their useful suggestion and remarks for the design and the procedure of the study.



Abstract
Cognitive training (CT) prevents or slows the progression of dementia though there are many cases that CT improves cognitive functions especially in the early first stages of the disease through practicing tasks. The aim of our study was to improve naming deficits of Alzheimer’s disease (AD) patients and to maintain this improvement for a long period through a training program based on dual cognitive support and deep learning. Our final sample comprised of 4 groups; eleven mild AD patients and 10 non demented elderly as experimental groups and 11 AD patients and 10 non demented elderly as control groups. The training program lasted about 4 months with 3 hours individual sessions per week and home exercises for the rest of the weekdays. Our results indicate that mild AD patients improve their naming abilities applying trained memory strategies, they maintain this improvement for a long period (at least 11 months) and transfer it to other indirectly trained cognitive functions and abilities, such as episodic memory, attention, verbal fluency and semantic association.
Key words: Alzheimer Disease, Cognitive Intervention, cognitive training, aging, naming disorders.



Introduction   
Dementia of Alzheimer’s type (AD) has been known to cause cognitive and especially episodic and working memory deficits since the first stages of the disease (Brandt & Rich, 1998).  Memory difficulties are also present in cognitively non demented elderly people but they are not so serious as the elder people are still functional and communicative (Welsh, Butters, Hughes, Mohs, & Heyman, 1992). There are also naming deficits in AD patients indicated a semantic memory disorganization and/or an inability to access the lexical labels of the items (Hodges, Salmon, & Butters, 1992; Whatmough, Chertkow, Murtha, Templeman, Babins, & Kelner, 2003). The above deficits are accompanied progressively by functional disabilities (Morris, 1996).  

As AD is a degenerative type of dementia there is a debate about the usefulness of  cognitive support for the disease management . Most of the early rehabilitation studies used cognitive support achieved short-term effects after the training program (Abrahams & Camp, 1993; Bäckman & Herlitz, 1990). For this reason many researchers talked about the inefficiency of cognitive support (Small, Rabins, Barry, Buckholtz, DeKosky, Ferris, Finkel, et al., 1997), as there were mainly methodological problems. Specifically, the first studies did not include mild AD patients (Bäckman et al., 1990), they used various kinds of techniques to enhance memory performance such as organizational instructions, verbal mediators, more time for recall, or rich stimuli inputs. Among them there were tasks with internal organization and cohesion, self-generation activity or cognitive support only for encoding or for recall processing (Μorris, 1996). Their impacts were insufficient, as their main goal was not the real problem in AD which is the encoding and learning of new information. For all the previous reasons the results were short lived and restricted to the training tasks (Morris, 1996).

However, in recent years there have been many studies that achieved satisfactory or life long results using cognitive support (Abrahams et al.,1993; Bäckman, 1992, 1996; Bourgeois, 1990, 1992; Camp, Foss, O’ Hanlon,  & Stevens, 1996; Camp, Judge, Bye,  Fox, Bowden, Bell, Valencic, & Mattern, 1997; Camp, & Stevens,  1990; Clare, 1999; Clare, Wilson, Carter, Gosses, Breen &  Hodges, 2000; Loewenstein, Acevedo, Czaja & Duara, 2004; Quayhagen, Quayhagen, Corbeil, Roth, & Rodgers, 1995; Screiber, Schweizer, Lutz, Kalveram, & Jancke,1999; Talassi, Guerreschi, Feriani, Fedi, Bianchetti, & Trabucchi, 2007; Tarraga, Boada, Modinos, Espinosa, Diego, Morera, Guitart, et al., 2006; Tsantali, & Tsolaki, 2007; Woods, 1996a, 1996b). The enthusiasm was so great that there were studies suggested that cognitive intervention (CI) could even reverse the progress of AD. The general conclusion from the recent studies was that  mild AD patients could learn new information and maintain it for a considerable time and that CI should be designed for specific type of memory problems, should not produce memory load to the patients, and provide the appropriate cues for both encoding and recall processes (Bäckman, 1992; Woods,1996).

A meta analysis study of cognitive training programs in Alzheimer’s disease indicates medium effect sizes for learning, memory, executive functioning, activities of daily living, general cognitive problems, though small effects  in  visual learning and motor speed (Sitzer, Twamley, & Jeste, 2006). However, there is still the problem that patients do not transfer strategies and skills they learn to everyday life which is among the criteria for the success of the cognitive intervention programs.

The aims of the study
The aim of our study was to use a dual cognitive support training program to mild AD patients in order 1) to reduce naming disorders in the first stages of the disease for a considerable time, 2) to study the generalization of the training effects on untrained lexical items of the trained categories and 3) to investigate the transfer effects on non trained abilities. Dual cognitive support involves the provision of cues and the enhancement of the organization of the to-be-remembered information at both encoding and retrieval of the information (Mimura & Komatsu, 2007).

Method
Assessment of AD
The diagnosis of AD was based on clinical criteria, medical history, biological, physical, neuropsy-chological and neuroimaging assessment. The clinical assessment was ascertained by the NINCDS-ADRDA (McKhann, Drachman, Folstein, Katzman, Price, & Stadlan, 1984) and DSM- IV (American Psychiatric Association,1994) criteria. We also administered the Greek edition of Mini Mental State Examination (Folstein, Folstein, & McHugh, 1975; Fountoulakis, Tsolaki,  Chantzi, & Kazis, 2000), CAMDEX  (Roth, Huppert, Tym, & Mountjoy, 1988)  and the Clinical Dementia Rating (CDR) (Hughes, Berg, Danziger, Cohen, & Martin, 1982) scales in order to estimate the general level of cognitive state and the severity of AD. The Hachinski Scale (Hachinski, Iliff, Zihkla, duBoulay, McAllister, Marshall, Russell, & Symon, 1975) and the Geriatric Depression Scale (GDS) (Sheikh & Yesavage, 1986; Fountoulakis, Tsolaki, Iacovides, Yesavage , O’ Hara, Kazis, & Ierodiaconou, 1999) were administered for the assessment of vascular dementia and depression respectively. The diagnosis was posed by a disciplinary scientific team. Memory and attention disorders were assessed through an extended neuropsychological battery included the Pyramids & Palm Trees (Howard & Patterson, 1992), the Rivermead Behavioural Memory Test (Wilson, Clare, Baddeley, Cockburn, Watson, & Tate, 1998) and the Wisconsin Card Sorting Test (Heaton, Chelune, Talley, Kay, & Curtis,1981). Language deficits were measured by the Greek edition of the Boston Naming Test (Kaplan,  Goodlass, Weintraub, &  Segal, 1983; Tsantali, Lekka, Tsolaki, Kazi, & Kazis, 2003), subtests of the Psycholinguistic Assessment of Language Processing in Aphasia – PALPA (50, 51, 56, 58, 59) (Kay, Lesser, & Coltheart, 1992; Τsantali, Tsolaki, & Pita, 2003) and subtests of the Greek edition of the Boston  Diagnostic Aphasia Examination (BDAE) (Narrative Writing, Reading Comprehension of sentences and paragraphs, Comprehension of Comprehension of Oral spelling, Verbal Fluency-Animals) (Goodglass & Kaplan, 1983;Tsantali, Tsolaki, Efklides, Kiosseoglou, & Pita, 2001).

Participants
The final sample of 42 participants arose from a bigger sample of 90 outpatients and elderly volunteers through the rigorous application of the following criteria: 1) the stage of Alzheimer’s disease (mild, CDR=1), 2) the similar age and educational level, 3) the similar cognitive and naming profile, 4) the willingness and the consensus of engaging in a rehabilitation program, 5) the duration and the type of pharmacological intervention (inhibitors of cholinesterase). Then the 42 recruited participants randomized in four groups according to their cognitive state (demented-non demented). There were 2 control and 2 experimental groups. Specifically, the experimental groups consisted of 11 mild AD patients and 10 non demented elderly participated in the training program. The control groups included 11 and 10 participants respectively. The research was single-blind and the final sample was matched in age and education F (1,41) = 2.27, p > .05, F(1, 41) = 1.0, p > .05, respectively.

All participants came from the city of Thessaloniki in Greece and from the nearby rural areas. The patients recruited from the 3rd University Department of Neurology of ‘G. Papanikolaou’ hospital in Thessaloniki in Greece. Though the non demented elderly recruited from the Centers of Open Support of Elderly in Thessaloniki and the Geriatric Unit of Hippokration hospital in Thessaloniki. All participants were native Greek speakers, with no auditory or visual self-reported problems. They could read and recognize the visual items of the tasks and none of them was institutionalized or had alcoholic or drug abuse history. The patients also took inhibitors of cholinesterase for about 4-6 months according to their medical history before the beginning of the program. The demographic characteristics of the participants are shown in Table 1. The participants and their caregivers were informed about the details of the procedure and gave their oral consensus for the testing and intervention program without earning money.

Table 1. Demographic characteristics of the sample

DISORDER

CONDITION

N

AGE

MEAN SD

EDUCATION

ΜEAN SD

MMSE

ΜEAN SD

ALZHEIMER

EXPERIMENTAL

11

72.0    6.8

10       4.1

22.4    1.8  

CONTROL

11

75.7    5.4

8.3      4.5

23.5    1.5

 

NON DEMENTED

 

EXPERIMENTAL

 

10

 

72.4    5.1

 

7.4      3.9

 

27.2    1.6

 

CONTROL

 

10

 

70.2    4.2

 

8.4      4.0

 

27.6    1.3

TOTAL

 

42

72.6    5.3          

8.5      4.1

25.2    1.6



The stages of the study
The first stage of our study included the baseline clinical, neuropsychological  (table 2 and table 3), laboratory and neuroimaging assessment. It lasted 4 sessions and conducted by an expert team ignored the purpose of the study. During the second stage the participants were given a naming task with colorful real objects pictures of five categories (food, tool, fruit, vegetable, animal)(200 items). The items ranged in familiarity from very familiar, moderately familiar to less familiar and according to their accessibility, easy, moderately difficult and difficult considering the Greek reality. The third stage included the application of the 4 month cognitive training program, the fourth stage included the 3 month follow up naming assessment and finally, the fifth stage the 6 month follow up cognitive, language and naming assessment.

Design-Procedure of the cognitive training program.
During the first phase of the training program the examiner recorded the non named items by the participant without giving any cues. In the second phase, the experimental groups (AD and non demented) were practiced individually on memory strategies of remembering the faded or the ‘don’t know’ lexical labels emphasizing in the semantic coding and recall of the specific characteristics of the objects. The aim was to help the participants to learn how to activate and reorganize the intact memory information that pertained to objects of the pictures or to learn new information about the failed naming items in order to differentiate them from similar ones. According to the literature teaching of memory strategies on how to keep in memory the association between the meaning and the lexical labels of the items to be named would support the naming procedure. Memory strategies facilitated the reorganiza-tion of the semantic categories or the relearning of the meaning, the function and the lexical label of the fading items would help patients to associate the relearned information with their lexical labels of the items (Bushke,1984; Diesfeldt,1984; Martin, Brouwers, Cox, & Fedio, 1985a; Martin, & Fedio, 1983). Each naming confrontation picture depicted 4 items from the same superordinate category. During the third phase the participant was practiced until errorless learning was achieved (i.e., naming correctly about 90% of the session’s objects). This practice phase involved retrieval of information about the function, semantic relations, semantic associations, visual characteristics of the objects, as well as finding links between the items of the same superordinate category. Participants were also asked to associate all of the objects with their lexical labels. In this way the connections between semantic and phonological information were strengthened (Bushke,1984; Diesfeldt,1984; Martin et al.,1985a).    
 
Each session was individualized and lasted 60 minutes. The duration of the training program lasted four months with three hour/ week sessions and home exercises for the rest of the week days. This timing was arisen by the pilot study and was in congruence with the most of the recent cognitive training programs of the literature for Alzheimer’s patients. The examiner tested the effectiveness of the above memory strategies during the immediate and delayed recall of information and the processing of deep learning by hiding and recall four items per four successive pictures, e.g., one item for each picture (there were 4 items per picture). Then she was asking the participant to recall and name the hidden items bringing in mind the trained information about them and the associations with the non hidden items (for more details see Appendix). If the participant could not recall the object, the examiner gave semantic cues that were used in the encoding phase and the participant was trying again. If the participant was failed again, a phonological cue was given in order to facilitate the phonological access of the hidden item. After achieving errorless learning per 4 pictures, the examiner was increasing the level of difficulty and she was hiding 8 instead of four items in 4 sequencing pictures. She was asking the patient to recall and name them using the previously learned semantic associations and information (delay recall). This procedure was continued until achieved about 90% of correct naming. Home exercises were aimed to rehearse the learned or the reorganized information about the training items and to deep learning through recall objects of similar superordinate categories usually non trained objects during the intervention (Appendix).

A follow up after three and six months of the completion of the training program was also implemented. At the three months follow up we retested the naming of the baseline 200 items. Though, after a period of six months we also retested the participants to all the neuropsychological and psycholinguistic tests of the baseline condition.  

Table 2  Baseline neuropsychological assessment
  AD TOTAL NON DEMENTED TOTAL
ΝΕURO-PSYCHOLOGICAL TESTS CONTR. EXPERIM.      AD CONTROL EXPER. NON DEM
MEANSD ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD
MMSE 23.5   1.5 22.4     1.8 23.0     1.6 27.6     1.3 27.2     1.6 27.4    1.5
CAMCOG 75.8   8.5 76.8     6.7 76.3     7.6 91.2     9.1 85.0     9.3 88.1    9.6
CAMCOG- time 42.6   7.6 49.6     5.4 46.0     7.4 35.0     6.0 40.0     6.0 38.0    6.0
BNT no cue 32.7   6.6 35.0     5.9 33.9     6.2 42.9     7.3 41.5     6.2 42.0    6.6
BNT semantic cue 36.2   7.0 37.2     3.7 36.7     5.5 44.9     6.8 44.9     5.4 44.9    6.1
BNT phonological cue 41.8   8.3 43.4     3.5 42.6     6.3 49.5     7.1 50.9     7.1 50.3    5.5
BNT- time 18.0   4.5 17.8     5.5 17.9     4.9 13.9     5.7 14.5     6.6 14.3    6.1
PPT 45.3   3.0 44.7     3.0 45.0     3.0 48.9     1.5 48.4     2.5 48.6    2.0
PPT-time 14.2   1.6 12.2     2.4 13.2     2.2 10.6     4.0 11.4     5.2 11.0    4.6
Direct Story (RBMT) 8.8     2.2  7.3       3.1 8.0       2.7 14.5     2.3 15.2     2.6 14.9    2.5
Indirect Story (RBMT)     8.0     2.2  7.5       3.0 7.8       2.6 14.0     2.2 14.2     3.0 14.1    2.6
Direct Route (RBMT)     3.7     0.6 3.9       0.9 3.8       0.7 4.8       0.2 4.7       0.6 4.7      0.4
Indirect Route (RBMT)      3.5     0.5 3.8       0.4 3.7       0.5 4.7       0.5 4.7       0.6 4.7      0.6
Face Recognition (RBMT)     3.5     0.8 3.7       1.3 3.6       1.0 4.9       0.3 4.9       0.3 4.9      0.3
Object (RBMT)     1.1     1.0 1.4       0.9 1.2       0.9 1.2       0.5 1.2       0.4 1.2      0.4
Name- Face (RBMT)     0.3     0.2 0.3       0.3 0.3       0.2 0.9       0.2 1.0       0.3 1.0      0.3
Message (RBMT)     1.1     0.3 0.9       0.3 1.0       0.3 1.0       0.0 1.0       0.0 1.0      0.0
Indirect Message (RBMT)     0.4     0.8 0.0       0.0 0.2       0.6 0.9       0.2 1.0       0.0 0.9      0.2
Wisconcin 1.7     1.1 2.0       1.4 1.9       1.3 4.1       1.4 3.0       2.5 3.6      2.0
Wisconcin-time 20.4   3.7 22        6.5 21.2     5.2 11.2     2.5 11.4     6.6 11.3    4.6
GDS 4.3     2.7 4.3       1.2 4.3       2.0 2.6       0.7 3.3       1.1 3.0      1.0


Table 3. Baseline psycholinguistic assessment
Psycholinguistic Tests AD TOTAL NON DEMENTED TOTAL
CONTROL EXPERIM. AD CONTROL EXPERIM. NON DEM
ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD
MATCHING PICTURES-SENTENCE 48.7     5.9 47.0   1.9 47.9       4.4 53.4        1.4 52.0    3.7 52.5     3.0
TIME1 28.6   13.4 24.4   6.3 26.6     10.5 19.4        9.9 17.8   7.2 18.5     8.2
MATCHING PICTURE- PREPOSITIONS 17.4     2.5 17.6   1.4 17.5       1.9 19.9        1.9 19.3   2.9 19.5     2.5
TIME2   8.0     3.0   8.6   1.8   8.4        2.5   6.9        2.9   7.7   3.7   7.4     3.3
SYNONYMS CONCRETE 12.0     1.6 13.4   1.1 12.7       1.5 14.0        0.9 13.4   1.0 13.7     1.0
                        ABSTRACT 11.5     2.7 13      2.2 12.2       2.6 13.5        1.8 15.0   2.6 14.4     2.4
TIME3   9.2     2.9 8.0     1.9    8.5      2.5    6.6       2.9   7.9   3.6    7.4    3.3
SYNONYM JUDGMENT 54.0     3.9 55.3   1.6 54.6       3.0 57.8        2.7 56.3   1.8 56.9     2.2
TIME 4 10.0     4.2   6.6   2.0    8.4      3.7   6.1        3.4   5.9   2.7   6.0     2.9
NARRATIVE (BDAE)   3.8     0.7   4.2   0.3    3.9      0.6   4.8        0.3   4.9   0.3   4.9     0.3
ORAL SPELLING (BDAE)   3.8     0.6   3.9   0.8    3.9      0.7   6.5        1.6   6.0   1.3   6.3     1.4
READING COMPR. (BDAE)   6.3     0.9   3.9   0.8    6.5      0.8   8.9        0.8   8.0   0.9   8.3     1.0
VERBAL FLUENCY-(Animals) 12.3     1.8 12.7  2.5 12.5       2.1 19.4        3.2 19.3   1.6 19.3     2.4
           
Results
During the baseline condition the t-test for independent samples for the two AD groups indicated no statistically significant differences according to the age, the education, the cognitive state (MMSE) and the naming performance t (20) = 1.4, p > .05,  t (20) = .98, p > .05,  t (20) = .13, p > .05,  t (20)=.33, p > .05 respectively. So did the 2 non demented aging groups t (18) = 1.0, p > .05, t (18) = .56, p > .05,  t (18) = -1.99, p > .05,  t (18) = -2.0, p > .05, respectively.  Applying the one-way ANOVA in the baseline condition with independent variable the disease and dependent variable the neuropsychological and psycholinguistic performance for the two AD groups we observed no statistically significant difference p > .000 between subjects (table 4 and table 5). We also applied the one-way ANOVA three and six months after the baseline condition for the two AD groups, and we observed statistically significant differences in naming scores F (1, 21) = 130.3,  p=.000 (η2=.88, η2=.91, respectively). We followed the same procedure for the two non demented groups, 3 and 6 months after the baseline condition and we found statistically significant difference in naming performance too, F (1, 19)=802.7,  p=.000 (η2=.41, η2=.38 respectively).    

Table 4.   F values for the AD and Non demented aging groups in neuropsychological tests 
Νeuropsychological tests AD NON DEMENDED Neuropsychological tests AD
F df* F    df* F df*
MMSE 0.79 20 0.59 18 Indirect story recall 1.9 20
 (RBMT)    
CAMCOG 0.92 20 0.49 18 Direct Route (RBMT)     0.18 20
CAMCOG- time 45 20 0.21 18 Indirect Route (RBMT)      1.7 20
BNT no cue 0.62 20 0.01 18 Face Recognition (RBMT)     0.15 20
BNT semantic cue 3.7 20 0.29 18 Object (RBMT)     2.6 20
BNT phonological cue 7.3 20 0.92 18 Face-Name (RBMT)     0 20
BNT time 0.52 20 1.9 18 Direct Message (RBMT)     0 20
PPT 0.02 20 2.7 18 Indirect Messsage  25 20
(RBMT)    
PPT-time 0.19 20 0.6 18 Wisconcin 0.01 20
Direct story recall (RBMT) 1 20 2.9 18 Wisconcin- time 1.2 20
df* AD : 2, 20;    df* Non Demented: 2, 18;     p >.000 for AD;     p >.000 for Non Demented

Table 5.  F values for AD and Non Demented in psycholinguistics tests
Psycholinguistic tests      AD NON DEMENTED
F df    p F df           p
Matching pictures-sentences 7.6 20 >.000 6.4 18           >.000
Time 3.8 20 >.000 0.24 18           >.000
Matching pictures-sentences-prepositions 2 20 >.000 0.28 18           >.000 
Time 0.6 20 >.000 0.44 18           >.000
Synonyms- Concrete 0.1 20 >.000 1 18           >.000 
Synonyms- Abstract 0.14 20 >.000 0.46 18           >.000
Time 3 20 >.000 1 18           >.000
Synonym Judgment  6.7 20 >.000 0.78 18           >.000
Time 7.7 20 >.000 0.27 18           >.000
Narrative writing (BDAE) 6.2 20 >.000 0.08 18           >.000
Auditory  Syllabication 0.09 20 >.000 0.04 18           >.000
Reading Comprehension 0.1 20 >.000 0.12 18           >.000
Verbal Fluency (Animals) 0.7 20 >.000 2.2 18          >.000
df* AD : 2, 20;  p >.000 for AD;    p >.000 for AD;       p >.000 for Non Demented


Applying the ANOVA of repeated measures within the experimental AD group we observed main effects of the training program for the 3 time-phases F (1, 10) =167.0, p = .000. Specifically, 3 months after the intervention, the experimental AD group showed statistically significant improvement in naming performance p = .000 from the baseline condition, as well as 6 months after the end of the training program p = .000 (table, 6).

For the control AD group the ANOVA of repeated measures indicated statistically significant difference in naming performance for the 3 time phases F (1, 10) = 503.0, p = .000. Specifically, 3 months after the baseline condition we observed no statistically significant difference in naming performance p > .05, as well as between the third and sixth month p > .05. However, we observed statistically significant difference in naming performance after 6 months from the baseline condition p = .013 (table, 6).  

We also observed main effects of the training program for the experimental non demented aging F (1, 9) = 39.2, p = .000. There was statistically significant improvement 3 months after the training program p = .000 and statistically significant decline from the third to the sixth month p = .002. However, the naming performance continued to be better than the baseline condition 6 months after the end of the training program p = .001 (table, 6).  

In contrast, the control non demented aging group indicated no statistically significant difference during the 3 temporal phases F (1, 9) = 3.88, p = .04 (table, 6). The diagram no 1 shows the naming performance during the baseline and follow up conditions.

Table 6. Mean and SD in naming performance in the 3 phases of performance. 
GROUPS Baseline 3 months Follow up 6 months Follow up
Μean        SD Μean       SD  Μean          SD 
AD  CONTROL 103           11.8 101           12.9    97              9.7
AD  EXPERIMENTAL  101           15.4    169           13.3 156              9.4
NON DEM. CONTROL 172           13.2  172           15.0 168            12.6
NON DEM. EXPERIMENTAL 157           22.5 191             9.0 185.7         10.8


Figure 1  Naming Performance of the 4 groups in baseline condition and
               after 6 months of the end of the intervention program
Figure1 


In order to investigate the generalization of the effects on untrained naming items (table, 7) after 6 months of the end of the program we tested the 4 groups on  untrained items of the trained categories (60 items). Performing the analysis of Tukey we observed moderate statistically significant differences between the AD groups p= .026 with better results for the experimental AD group. We also observed statistically significant difference between the 2 experimental groups p = .000. The experimental non demented aging group achieved better performance than the experimental AD group p=.000.


 
Table 7.  Naming Performance on untrained items
Subjects Performance on Untrained Items
  EXP. GROUP* CONT.GROUP^
MEAN  S.D MEAN S.D
AD 35.0       6.2 27.9      5.6
NON DEM# 57.2       4.6 55.2      6.3
         *EXP. GROUP=EXPERIMENTAL GROUP            ^CONT.GROUP=CONTROL GROUP                 #NON DEM=NON DEMENTED

Neuropsychological and psycholinguistic assessment 6 months after the baseline condition 
Between groups

In order to test the hypothesis regarding the transfer of training effects on non trained cognitive abilities we applied the t-test for matched groups between the baseline and retest scores after 6 months of the end of the training program. We observed statistically significant differences between the 2 AD groups to the following neuropsychological tests: the MMSE F (1, 20) = 66.7, p = .000, the CAMCOG F (1, 20) = 45.5, p = .000,  the time of responding in CAMCOG  F (1, 20) = 5.15, p = .034; the BNT in no cue, semantic and phonological cue condition F (1, 20) = 14.2, p = .001, F (1, 20) = 19.3, p = .000, F (1, 20) = 15.8, p = .001 respectively and the  responding time of BNT F (1, 20) = 16.2, p = .001; the Pyramids and Palm Trees and the time of responding in the PPT F (1, 20) = 36.6, p = .000, F (1, 20) = 14, p = .001 respectively; the Wisconsin and marginally the responding time of Wisconsin F (1, 20) = 45.2, p = .000, F (1, 20) = 4.5, p = .047, respectively.

According to the memory function assessed by the RBMT subtests we observed statistically significant differences between the AD groups in the subtests of the direct and indirect recall of the story F (1, 20) = 17.0, p = .001, F (1, 20) = 13.8, p = .001 respectively, and the direct and indirect recall of route F (1, 20) = 24.5, p = .000, F (1, 20) = 16.6, p = .001 respectively.
According to the psycholinguist tests the AD groups performed statistically significant differences to the following ones: the matching of picture-sentence  PALPA 56 F (1, 20) = 14.8, p = .001 and the responding time of the PALPA 56 F (1, 20) = 23.0, p = .000; the matching of picture- sentences with propositions PALPA 59 F (1, 20) = 22.4, p = .000; the time of responding of the Synonyms PALPA 50 F (1, 20) = 13.5, p = .001; the subtest of PALPA 51a F (1, 20) = 5.4, p = .03; the Animals (BDAE) F (1, 20) = 130.8, p = .000; the Comprehension of Comprehension of Oral spelling (BDAE) F(1, 20) = 19.5, p = .000 and the Reading Comprehension of sentences  and paragraphs (BDAE) F (1, 20) = 13.0, p = .002.

We didn’t observe statistically significant differences between the 2 non demented aging groups in neither neuropsychological nor psycholinguistic test (p>.05).

Within groups
The next step was to investigate the neuropsychological and psycholinguistic performance within subjects after 11 months from the baseline condition. The ANOVA of repeated measures indicated statistically significant differences for the experimental AD group in the following neuropsychological tests: the MMSE F (1, 10) = 74.1, p = .000, the CAMCOG F (1, 10) = 81.5, p = .000, the responding time of CAMCOG F (1, 10) = 30.3, p = .000; the BNT with no cue, semantic and phonological cue condition and the responding time of  the BNT F (1, 10) = 30.8, p = .000, F (1, 10) = 43.0, p = .000, F (1, 10) = 42.8, p = .000 respectively; the PPT and the time responding of the PPT F (1, 10) = 72.4, p = .000, F (1, 10) = 11.0, p = .000 respectively, and the Wisconsin F (1, 10) = 190.0, p = .000.

According to memory function the experimental AD group performed statistically significant differences to the following subtests of the Rivermead: the direct  recall F (1, 10) = 9.8, p = .012  and indirect recall of the story F (1, 10) = 702.0, p = .008, the direct recall F (1, 10) = 6.3, p = .000  and indirect recall of a certain route in the space  F (1, 10) = 4.5, p = .031,  the indirect recall of a message F (1, 10) = 1, p = .026 and the remind of recall of a personal object F (1, 10) = 0.3, p = .002 (table 8). According to the psycholinguistic tests the experimental AD group indicated statistically significant differences to the following ones: the Matching of picture – sentence PALPA 56 F (1, 10) = 50.6, p = .000, the responding time of PALPA 56 F (1, 10) = 9.6, p = .011,  the Matching of picture – sentence preposition PALPA 59 F (1, 10) = 31.6, p = .000, the Written narrative of the BDAE F (1, 10) = 49.2, p = .000 and the Comprehension of Oral spelling of the BDAE F (1, 10) = 150.8, p = .000 (table, 9).

For the control AD group the ANOVA of repeated measures analysis (baseline vs 6 month follow up) indicated statistically significant differences to the following neuropsychological tests: the MMSE F (1,10) = 36.8, p = .000, the CAMCOG F (1,10) = 9.7, p = .011,  the responding time of WISCONSIN F (1,10) = 5.9, p = .035. Though in the psycholinguistic tests the control AD group indicated statistically significant differences just in the subtest of the Matching picture – sentence PALPA 56 F (1,10) = 6.92, p = .025 (table 8 and 9).

Applying the same statistical procedure  (ANOVA repeated measures 11 months from the baseline) for the  experimental non demented aging group we observed statistically significant differences for the following neuropsychological tests: the MMSE F (1, 9) = 49.8, p = .000, the CAMCOG F (1, 9) = 50.8, p = .000, the responding time  of the CAMCOG F (1, 9) = 28.5, p = .000; the BNT  no cue, semantic and phonological cue condition F (1, 9) = 72.9, p = .000, F (1, 9) = 40.9, p = .000, F (1, 9) = 36.0, p = .000,  the responding time of the BNT F (1, 9) = 13.9, p = .005,; the PPT F (1, 9) = 7.5, p = .023, the responding time of  the PPT, F (1, 9) = 18.6, p = .002;, the Wisconsin F (1, 9) = 34.0, p = .000 and the responding time of the Wisconsin, F (1, 9) = 11.2, p = .009 (table 8 and 9). The experimental non demented group indicated also statistically significant differences to the direct and indirect recall of the story of the Rivermead F (1, 9) = 9.8, p = .012,  F (1, 9) = 10.8, p = .009 respectively (table, 8). According to the psycholinguistic tests the experimental non demented group indicated statistically significant differences to the following subtests: the Matching of pictures-sentences PALPA 56 F (1, 9)= 8.4, p = .018, the Matching of pictures-sentences prepositions PALPA 59 F (1, 9) = .89, p = .005, the Judgment of Synonyms  PALPA50 F (1, 9) = 10.5, p = .010 and the Comprehension of Oral spelling (BDAE)  F (1, 9) = 11.1, p = .009. However, they performed no statistically significant difference to the subtests of the Synonyms (Concert-Abstract) (PALPA 51a & b), the Written narrative (BDAE), the Reading of sentences and paragraphs (BDAE), the Animals (p>.050) (table, 9).

The control non demented aging group indicated no statistically significant differences in any neuropsychological nor psycholinguistic tests (p>.05).
 

  Table 8. Retests in Neuropsychological tests 6 months after the end of the program

  AD NON DEMENTED
NEURO
PSYCHOLOGICAL 
TESTS NO EXERCISE EXERCISE NO EXERCISE EXERCISE
MEAN SD MEAN SD      ΜEAN SD ΜEAN SD
MMSE 21.5    1.9 27.2     1.2 27.8     1.8 28.9     1.0
CAMCOG 72.3    7.9 90.0     3.6 90.4     7.9 93.8     6.7
CAMCOG- time 44.5    5.2 38.2     7.7 40.6   19.0  31.3     3.2
BNT no cue 33.0    6.2 43.9     7.3 43.3     6.0 47.9     6.5
BNT semantic cue 35.4    6.2 46.7     5.9 44.2     6.2 49.5     5.6
BNT-phonological cue 40.5    8.8 52.3     4.3 51.7     3.9 54.4     3.9
BNT time 19.5    6.0 10.4     4.6 12.0     3.3   9.1     2.6
PPT 45.5    1.8 49.7     1.5 49.6     1.3 50.6     1.7
PPTtime 14.0    3.4   8.8     3.0 13.2   13.2   6.5     3.6
Immediate Recall of Story (RMBT)   7.0    3.6  12.7    2.8 14.8     2.7  16.4    3.0
Indirect Recall of Story (RΒΜΤ)   6.3    3.7 11.6     3.0 14.4     2.7  16.2    3.0
Route (RΒΜΤ)   3.4     0.7   4.8     0.6   5.0     0.0   5.0     0.0
Indirect Route (RΒΜΤ)   3.4     0.7   4.5     0.7   5.0     0.0   5.0     0.0
Appointmet (RΒΜΤ)   1.0     1.0   1.4     0.7   1.0     0.0   1.3     0.5
Face Recognition (RΒΜΤ)   4.0     0.9   4.6     0.9   5.0     0.0   5.0     0.0
Object (RΒΜΤ)   1.2      1.0   1.5     0.5   1.2     0.4   1.1     0.3
Face-Name (RΒΜΤ)  0.4      0.4   0.6     0.4   1.0     0.0   0.95   0.1
Message (RΒΜΤ)  0.8      0.4   1.0     0.0   1.0     0.0   1.0     0.0
Indirect Message (RΒΜΤ)  0.4      0.7   0.7     0.5   1.0     0.0   1.0     0.0
Wisconcin  1.7      1.1   3.7     1.7   4.1     1.7   4.0     1.6
Wisconcin time 17        4.8 12.7     9.9 10.0     5.3   8.5     3.2

 

Table 9. Retest of the psycholinguistic assessment 6 months after the end of the program

PSYCHO  LINGUISTIC  AD  
TESTS
  EXPERIM. CONTROL EXPERIM. CONTROL
ΜEAN SD ΜEAN SD ΜEAN SD ΜEAN SD
Matching picture-sentence PALPA 52.8     1.5 47.0      4.7 54.4    3.3         53.4    1.5
TIME 1 17.7     2.9 30.9   8.6 14.3    4.8        18.7    8.1
Matching picture- Prepositions PALPA 20.5     1.5 16.9   1.9 21.0    1.9           20.6   2.4
TIME2   7.3     2.5 10.0     5.5   6.7    2.7             7.4   3.3
Synonyms CONCRETE  PALPA 13.6     2.9 11.0     2.3 14.3    1.3          13.4    2.0
Synonyms ABSTRACT 13.0     2.5 11.0     2.8  15.0   1.4        15.5    0.5
TIME3 6.8       2.8 10.0     4.5    4.4   2.4            6.0   3.0
Judgment of Synonyms PALPA 53.4   12.9 41.5   19.2   58.2  1.5          52.7  14.2
TIME 4   6.7     3.6 12.0    3.3    4.0    1.5            6.8    4.0
Narrative Written BDAE   4.9     0.2 4.5    1.9    5.0    0.0            4.9    0.3
Auditory Syllabication BDAE   6.5     1.0 4.3    1.3    7.2    0.8            6.3    1.4
Reading  Comprehension BDAE   8.2     0.6 6.6   1.3    8.3    1.6            8.7    0.9
Verbal Fluency-Animals 20.7     2.0 11.5  1.7  18.9    3.4          19.8    3.0


Discussion

Recent literature indicates that there is a long debate regarding the effectiveness of cognitive training in AD patients. Our results are consistent with the findings of studies suggested that cognitive training can have long term and small generalization effects in the first stages of AD when examiners use systematically (3 times per week) an individual dual cognitive support program at least for 4 months.

Applying the repeated measures ANOVA, 3 and 6 months after the training program we observed that both the experimental groups (AD-Non Demented) improved their naming performance and maintained it at least for 11 months from the baseline condition comparing to the control groups. So we confirmed the first hypotheses that our cognitive training program reduced the naming deficits for a considerable time (at least 6 months after the end of the program) as in the study of Piccolini, Amadio, Spazzafumo, Moroni, & Freddi, 1992. Other studies suggest that there are some rehabilitative techniques with positive effects on the learning capacity for demented elderly (Yesavage, & Jacob, 1984; Hill, Sheikh, & Yesavage,1987; Yesavage, Sheikh, & Friedman,1990) lasted at least for 6 months (Sheikh,  Hill, & Yesavage,1986) and retrograde the decline associated with old age. In our opinion the observed naming improvement in our study is due to the deep learning effects achieved during encoding and recall procedure as suggested from the literature too. Additionally, the techniques of the connecting of the new trained knowledge with the old intact one under the examiner’s assistance and the errorless learning condition had significant role too. The training and relearning of the specific characteristics between the same category objects helped the reorganisation of the intact and faded information in semantic memory and the errorless learning condition strengthened its consolidation. We can’t prove if the trained coding techniques were applied consciously or not to untrained matrix, e.g., the direct or indirect story/route recall of the RBMT, as the experimental AD group showed statistically significant improvement 11 months from the baseline condition, or if it was practise effect. This needs further investigation.

The control AD group indicated statistically significant decline in naming performance for the 3 time phases. Specifically, there was no statistically significant naming decline 3 months after the baseline condition though there was moderate statistically significant decline in naming performance 6 months from the baseline. This may means that the vocabulary is reducing slowly in mild dementia.

The experimental non demented aging group although performed better than the experimental AD one, their naming performance declined to the sixth month too. This slight deduction was concerned the less familiar everyday objects and indicates that the everyday living is an essential factor of advanced learning. In contrast, the control non demented aging group showed no statistically significant difference in naming performance during the 3 temporal phases. So our results are in congruence with the references that the vocabulary remains intact until the 7th decade (Obler & Albert,1984) independently of culture. Our study also found a small generalization effect to untrained objects of the trained categories, as the experimental groups showed significant naming improvement than the control ones. We suppose that the training program and the home exercises helped them to strengthen the relearned information and to reorganize their semantic memory.

Besides the improvement of naming ability, the training program improved other untrained cognitive functions and abilities six months after the end of it. The experimental AD group improved the functions of the semantic and episodic memory and the attention. They seemed to transfer the trained memory strategies from the visuosemantic matrix (pictures of everyday objects) to oral-semantic no trained matrix (direct- indirect story recall) which means that the modality of the stimuli is not so crucial factor as the trained strategies. We suppose that the errorless learning condition, the extended repetition of the stimuli and the deep learning improved the global cognitive state of the AD and specifically the performance of episodic and working memory (Comprehension of Oral spelling of the BDAE). This may happened as the participants have to find associations and links per 4 items in order to recall a hidden item after a few minutes delay and were practiced to use coding and restore strategies. The participants also took advantage of the phonological cues in the BNT and showed an improved shifting ability from one rule to another and from one category to another, as indicated by the Wisconsin. The training program additionally enhanced other language abilities of the experimental AD group as the psycholinguistic tests indicated. These included matching ability, synonym judgement, verbal fluency and reading comprehension ability. This improvement could be explained by the fact that deep learning is achieved by the application of these abilities (judgement and comprehension of differences of similar objects and extended rehearse).  

According to the performance we observed no statistically significant differences between the 2 non demented groups in neither neuropsychological nor psycholinguistic test. This could be mean that there is  no or not considerable cognitive or language decline during 11 months for non demented elderly.

According to the performance within groups we observed that the experimental AD group indicated statistically significant differences in cognitive functions and linguistic abilities 11 months from the baseline condition. They achieved a better performance in global cognitive state (ΜΜSE), semantic memory (PPT), naming ability (BNT), attention (Wisconsin), store and recall ability (RΒΜΤ),  the responding time  and the digit span of working memory. This may means that the experimental AD group used trained memory strategies in a conscious or unconscious way in direct or indirect recall of information and the results of this training can be seen even in prospective memory (recall of personal object), an untrained function. They also improved other language abilities as matching, critical judgment and narrative writing. This improvement perhaps can be explained as a result of the deep learning too, as we practised them in the coding phase during the intervention program.

The control AD group indicated statistically significant cognitive decline, a slower speed of information processing, and a matching ability deficit 7 months from the baseline condition considering the performance in the MMSE, the CAMCOG, the Wisconsin responding time and the Matching picture-sentences (PALPA 56). Matching ability in a complex material task presupposes intact function of a couple of functions and processing, as  keeping and processing information in the digit span of working memory, an intact buffer of working memory; good reading comprehension ability; intact mechanism of coding and decoding of information; good organization of semantic memory; good working of the mechanisms of searching and finding information in mental lexicon; intact judgment ability in order to find the differences between similar pictures. Summarizing, the experimental AD group was improved in general cognitive performance and episodic memory as they used better strategies of encoding and recalling information reducing their omissions or mistakes six months after the end of the training program.

The experimental non demented aging group indicated statistically significant improvements in many neuropsychological tests too. This means that the same training program had about similar impacts to the experimental groups. Besides the naming ability this group improved the semantic memory (PPT), the attention (WISCONSIN), the speed of information processing (time) and the episodic memory (direct and indirect recall of the Rivermed story). The training program produced no improvement to other language abilities which means that the same program activated different cognitive and language abilities in a non demented brain. So we suggest that the non demented people need a more high level and demanded memory training program in order to be improved to the same abilities, as the experimental AD group did.

The control non demented group didn’t show statistically significant differences in neither neuropsy-chological nor psycholinguistic tests. This could be mean that during 7 months there is no obvious cognitive and/or language decline for non demented elderly people.

Our conclusions are that mild AD patients can achieve reorganization of intact and relearned faded information using trained memory strategies based on deep learning. Memory strategies helped the interconnection of faded semantic information and the association between the meaning, the function, the characteristics and the lexical labels of the items. They maintained the relearned information at least for 11 months from the baseline condition without feedback or notable decline in naming ability. They also transferred these strategies to other cognitive and language abilities (e.g., general cognitive state, attention). So our results agree with the conclusion of the meta analysis study of Sitzer, et al., 2006 that cognitive training programs in mild Alzheimer’s disease achieves medium effect sizes for learning, memory, executive functioning and general cognitive state. However, there is still the problem if the patients transfer the learned strategies and skills to everyday life which is among the criteria for cognitive intervention success. The intact semantic memory seems to be presupposition in order to achieve naming and general cognitive improvement as other researchers suggested in the past (Ellis & Young, 1988).   However, among the factors which ensure a successful intervention are the motivations of the patients, the willingness of improvement and the using of everyday stimuli. In this way we can encourage the patient to transfer the trained information to actual life conditions. A friendly and supportive environment is also needed so that the patient feels comfortable and maintains effort through all the phases of the training program.

According to the question if every non constructed training program or with psychotherapeutic role could have a similar effect, there are many studies that they indicated no improvement (Goldstein et al., 1982; Goldwasser, Averbach, & Harkins, 1987;  Wallis, Boldwin, & Higginbotham, 1983). The answer is similar for the claim that the experimental groups may be helped because of the psychologist’s presentation. Tarraga, et al., 2006 showed that the Alzheimer’s group participated to a psychotherapeu-tic program of social skills or the control AD group showed no improvement. Some of psychosocial methods are more appropriate or with insufficient indications for the reduction of depression, aggression or apathy in Alzheimer disease under specific circumstances (Verkaik, van Weert, & Francke, 2005). Similarly, Talassi, et al., , 2007 suggest that only a rehabilitation cognitive program which provides a punctual cognitive stimulation has significant effects. According to the pharmacological treatment, our results are in congruence with that of Bottino, Carvalho, Alvarez, Avilia,  Zukauskas, Bustamente  et al., 2005 and Cipriani, Bianchetti, & Trabucchi et al., 2006 for the cognitive improvement of mild AD patients associated with inhibitors of acetylocholinesterase and a cognitive training program. However, it would be helpful to have an additional control and experimental group without pharmacological treatment. We also conclude that there are flexible boarders between cognitive functions as while the clinicians are trying to train a cognitive deficit, they improve others indirectly interconnected abilities.

Furthermore, the question remains if the patients and their relatives are aware of this cognitive improvement and if the training has effects on the activities of daily living and social skills. These are questions to be pursued in future research. Even though, we agree with the opinion of Piccolini, et al., 1992 that it is an illusion to think that patients with irreversible cognitive deficits can recuperate, performing any kind of rehabilitative therapy. Though, we could train their caregivers on individualized cognitive training programs fitted to their patients’ cognitive deficits in order to retrograde the progression of AD and minimize the cost of a cognitive training program.



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APPENDIX



For example: Look at the picture with the furniture:
Find and tell the differences between the 4 furniture (e.g., use, function, visual characteristics, place for setting). We do the same procedure too for the next tree pictures and then we hinted a moderate difficult for Greek reality item (e.g., armchair, pepper, steak, tea-pot) from each picture. Then we asked the participant to recall the hinted item having in front of him the rest of the each picture.  If he/she could not recall it we gave semantic information used during the encode phase and if the participant couldn’t find it again we gave the first syllable of this furniture.    

Example of home exercises:
   1. Find other 5 at least not trained furniture
   2. Find other 5 at least not trained green vegetables
   3. Find other 5 at least non trained foods with meat
   4. Find other 5 at least not trained cookware.





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