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Successful culturally-adapted and multifaceted cognitive training

Jiranan Griffiths, PhD1, Lakkana Thaikruea, M.D., Cert of FETP, M.S., PhD2, Peeraya Munkhetvit, PhD1, Adisak Kittisares, MD, FRC3, Pairada Varnado, MSc4, Nahathai Wongpakaran, MD, FRCPsychT4
1Department of Occupational Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Thailand
2Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Thailand
3Neurology Clinic, Sriphat Medical Center, Faculty of Medicine, Chiang Mai University, Thailand
4Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Thailand

Key Highlights:

  • Cognitive training is necessary for delaying cognitive decline in mild neurocognitive disorder (mild NCD).
  • Multifaceted cognitive training is useful for improving cognitive function in patients with mild NCD.
  • Culturally-adapted and multifaceted cognitive training is well accepted and effective for community dwelling older persons with mild NCD.

Mild neurocognitive disorder (NCD), as defined by DSM-5, is a transitional stage between normal cognition and major NCD. Mild NCD can be found in one or more domains of cognition with a minimal effect on everyday functional activities. While there currently are no disease-modifying agents available, non-pharmacologic interventions like exercise and cognitive training have been proven to delay the progression of cognitive deterioration.

According to updated practice guidelines by the American Academy of Neurology (Petersen et al., 2018), various studies have shown that exercise for a period of at least six months is a promising intervention that can delay the progression of cognitive impairment in mild NCD, while studies on cognitive training have been inconclusive.

The Asia-pacific region contains the majority of the world’s population, and accessibility to treatment for managing and delaying the progression of mild NCD is limited. The availability of cognitive training services is uncommon in most Asia-pacific communities as most interventions are developed and implemented in western countries. Some tools are expensive or difficult to use for elderly in the rural areas of this region. We, therefore, aimed to conduct research among elderly Thai individuals with mild NCD. The study was conducted in a rural community in northern Thailand where there was a high prevalence of mild NCD and a lack of equipment and healthcare professionals. Required materials that could be easily obtained in the community were culturally adapted for the protocol, and it was thought that culturally-adapted tools could help reduce stigma among older adults. The aim was to promote strategies for increasing adherence and encourage positive attitudes in caring for patients with mild NCD. This article reports on a novel, culturally-adapted intervention that combines physical activity and multifaceted cognitive training for patients with mild NCD living in a rural community. The research was part of a doctoral dissertation by Dr. Griffiths when she was working on her PhD in the Department of Community Medicine at Chiang Mai University. She was interested in working on Mild Cognitive Impairment (MCI) and mild NCD in older people in a rural community in Chiang Mai Province.

The research was divided into two phases: the first phase was identifying the prevalence of MCI in elderly Thai individuals living in rural areas and identifying risk factors associated with MCI. The evaluation and diagnosis of MCI was comprehensive and included assessment of cognition using MoCA-B (Julayanont et al., 2015), a comprehensive interview with application of Albert’s diagnostic criteria for MCI, past medical history, psychiatric history, and review of medications or substances (Albert et al., 2011). The study population was large with 1,096 participants, most of whom were farmers, and the results showed a high prevalence of MCI (71.4%) in the rural community (Griffiths, Thaikruea, Wongpakaran, & Munkhetvit, 2020).

In phase two, we designed an interventional program for those older adults diagnosed with mild NCD by a geriatric psychiatrist or a neurologist using DSM-5. The program combined physical activity and multifaceted cognitive training. For physical activity, locally available instruments that could be easily obtained and were inexpensive (i.e., bamboo sticks) were used as a medium for participants to move along with the rhythm of music. The multifaceted cognitive training included a variety of techniques such as cognitive training, cognitive stimulation, memory strategies, table-top activities, and psychomotor recreation. Meaningful and productive activities related to their daily lives were also included and the activities were in a group-based setting. A randomized control trial was used with 70 mild NCD participants (35 controls and 35 in the intervention group) to test the effectiveness of the intervention. The program included 24 sessions over the course of three months. The interventional group had significant improvement in cognitive function, attention, memory and executive function compared to the control group, which were promising findings. Another benefit of using local materials was that attendance remained high with 93% at the end of the program. The participants had positive feedback and enjoyed the interventional program (Griffiths, Thaikruea, Wongpakaran, Munkhetvit, et al., 2020).

We hope that our findings will be useful which could be implemented in similar communities. The findings of this research provide insight into the prevalence of undetected MCI in this rural community, and show the successful implementation of an intervention for mild NCD that was well-received in the community.


  1. Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C., . . . Phelps, C. H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement, 7(3), 270-279. doi:10.1016/j.jalz.2011.03.008
  2. Griffiths, J., Thaikruea, L., Wongpakaran, N., & Munkhetvit, P. (2020). Prevalence of Mild Cognitive Impairment in Rural Thai Older People, Associated Risk Factors and their Cognitive Characteristics. Dement Geriatr Cogn Dis Extra, 10(1), 38-45. doi:10.1159/000506279
  3. Griffiths, J., Thaikruea, L., Wongpakaran, N., Munkhetvit, P., Kittisares, A., & Varnado, P. (2020). Effects of Combined Physical Movement Activity and Multifaceted Cognitive Training in Older People with Mild Neurocognitive Disorder in a Rural Community: A Randomized Control Trial. Dement Geriatr Cogn Disord, 49(2), 194-201. doi:10.1159/000507922
  4. Julayanont, P., Tangwongchai, S., Hemrungrojn, S., Tunvirachaisakul, C., Phanthumchinda, K., Hongsawat, J., . . . Nasreddine, Z. S. (2015). The Montreal Cognitive Assessment-Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low-Educated Elderly Adults. Journal of the American Geriatrics Society, 63(12), 2550-2554. doi:10.1111/jgs.13820
  5. Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S. D., Ganguli, M., Gloss, D., . . . Rae-Grant, A. (2018). Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 90(3), 126-135. doi:10.1212/WNL.0000000000004826

Ms. Varnado, a clinical psychologist; Prof. Wongpakaran, a geriatric psychiatrist; Prof. Thaikruea, a physician and an epidemiologist; Asst. Prof. Griffiths and Asst. Prof. Munkhetvit, occupational therapists; and Dr. Kittisares, a neurologist.

Excerpted from the IPA Bulletin, Volume 38, Number 1.


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