**5. Intervention in cognitive aging**

Broadly speaking, research on cognitive aging shows a gradual decline scenario, which may or may not be normative, and is associated with age and previously identified risk factors. The progression from normality to pathology is a concern in the health sciences field due to the negative implications that mild cognitive impairment and dementia have on people's lives.

This is why gerontology has focused on the study of nonpharmacological intervention techniques that promote the improvement or maintenance of cognitive functioning at a level that allows people to lead a functional and disability-free life associated with cognitive pathologies. The main conceptual basis for nonpharmacological intervention on cognitive functioning in aging focuses mainly on the concepts of brain plasticity, brain reserve, and cognitive reserve.

Under the concept of brain plasticity [74], in the last 25 years, evidence has been presented to support the idea that the brain is far more flexible in structure and function than it was previously believed. Brain plasticity refers to the extraordinary ability of the brain to modify its own structure and function following changes within the body or in the external environment. Although it is stronger during childhood, it remains the fundamental and significant lifelong property of the brain during aging. Brain plasticity is implicated in learning abilities and plays a fundamental role in degenerative brain disorders. Recent research suggests that the pathology of the Alzheimer's disease, for example, is associated with the loss of plasticity.

The brain reserve is related to neurobiological aspects and it has a more passive approach, since it refers to the size and number of neurons that a person has after a brain injury.

Finally, the cognitive reserve has been defined as the adaptation of the brain to an injury situation using pre-existing cognitive processing resources or compensation resources through the activation of neural networks [75]. The cognitive reserve allows better tolerance of the effects of the disease associated with dementia, supporting a greater amount of neuropathologies before reaching the symptoms of the disease. The cognitive reserve influences the manifestation of the symptoms of cognitive impairment and, at least partially, in its development toward dementia [76]. People with MCI and low reserves show a steeper decline early in the process of deterioration, compared to the high level of reserve this marked deterioration would have at the end of the process, due to the protective role of this reserve [77].

dementia, raising the level of "intellectual reserve." Regarding this, a systematic review of the literature on the relationship between education and dementia in the last 25 years concluded that lower education was associated with an increased risk of dementia in many but not all studies. Education associated with the risk of dementia showed different results according to the population, and the years of education did not uniformly reduce the risk of dementia. It seems that a more consistent relationship with dementia occurred when the years of education reflected cognitive ability, suggesting that the effect of education on the risk of dementia can

In addition to this, occupations performed during lifetime that did not require complex cognitive processes or stimulants seem to be associated with an increased risk of dementia. For example, when studying a group of nuns (average 54 years of age), a strong association was found between low educational and occupational levels with dementia. The risk of dementia increased in those participants with poor education, without professional training and who had never been in charge of a leadership position. These findings support the hypothesis of the benefits of having a cognitive reserve capacity against the consequences of brain diseases [72]. In this sense, it was reported that university preparation represented a lower risk of dementia among five categories, where illiterates showed the highest proportion of individu-

als with dementia, while the lowest proportion was found in university students [73].

Broadly speaking, research on cognitive aging shows a gradual decline scenario, which may or may not be normative, and is associated with age and previously identified risk factors. The progression from normality to pathology is a concern in the health sciences field due to the negative implications that mild cognitive impairment and dementia have on people's lives. This is why gerontology has focused on the study of nonpharmacological intervention techniques that promote the improvement or maintenance of cognitive functioning at a level that allows people to lead a functional and disability-free life associated with cognitive pathologies. The main conceptual basis for nonpharmacological intervention on cognitive functioning in aging focuses mainly on the concepts of brain plasticity, brain reserve, and cognitive reserve. Under the concept of brain plasticity [74], in the last 25 years, evidence has been presented to support the idea that the brain is far more flexible in structure and function than it was previously believed. Brain plasticity refers to the extraordinary ability of the brain to modify its own structure and function following changes within the body or in the external environment. Although it is stronger during childhood, it remains the fundamental and significant lifelong property of the brain during aging. Brain plasticity is implicated in learning abilities and plays a fundamental role in degenerative brain disorders. Recent research suggests that the pathology of the Alzheimer's disease, for example, is associated with the loss of

The brain reserve is related to neurobiological aspects and it has a more passive approach,

since it refers to the size and number of neurons that a person has after a brain injury.

be better assessed in the context of a life development model [71].

**5. Intervention in cognitive aging**

plasticity.

154 Gerontology

The intervention for the optimization of cognitive functions is based on these concepts to implement nonpharmacological treatments, in order to overcome the challenges of cognitive changes associated with aging, prevent pathologies such as MCI and dementia, and, finally, if it is necessary, alleviate their effects.

According to the British Psychological Society [78], there are a variety of nonpharmacological treatments and interventions which can help people to maintain good mental health, especially after diagnosis of MCI or dementia. Psychosocial interventions can help the diagnosis of dementia, reducing stress and improving mood (such as anxiety or depression), improving and maintaining cognitive functioning, and promoting quality of life in general. Specifically, treatments for improving and maintaining cognitive functioning in aging are Cognitive Training, Cognitive Stimulation Therapy, and Cognitive Rehabilitation that have significant differences in terms of their purpose, target population, duration, and management.

The Cognitive Training, also called Brain Training, involves specific aspects of memory and other cognitive skills. Since it is not personally tailored, regular pastimes such as crosswords, Sudoku, games, or exercises on a computer would also count as cognitive training. Cognitive training is for anyone who wants to keep his brain active and enjoys brain training games and puzzles, including people living with dementia. Exercises are designed to train specific functions, such as memory of words, logic and reasoning, attention, problem solving, and mathematics. Training could be a regular activity done continuously and can be self-administered [78].

Cognitive Stimulation Therapy (CST) is a group therapy that is used to help strengthen personal communications skills, thinking, and memory. CST groups run for a limited number of sessions (usually 12–14, one or two per week). As a complement, the maintenance cognitive stimulation therapy (MCST) groups continue indefinitely and aim to maintain the benefits that CST groups provide. CST and MCST are suitable for people with diagnosis of mild cognitive impairment or dementia in mild-to-moderate stages. A typical CST session lasts for 1 hour and may involve games, singing, applying reminiscence therapies, sharing stories, discussing current events, practicing arts, and making crafts. CST has shown to be beneficial for cognition and quality of life, and it is also cost-effective. Additionally, if CST is followed by MCST, it offers a significant improvement in cognitive function providing long-term benefits [79].

On the other side, cognitive rehabilitation is an approach to manage the impact that dementiarelated difficulties, such as problems with thinking and memory, can have on everyday life. It is recommended for people who have early-onset dementia. Cognitive rehabilitation is not about curing or reducing dementia-related difficulties with thinking and memory, instead it is about learning ways of compensating these difficulties or managing them better. Many cognitive rehabilitation programs could involve families and careers. Usually, it is implemented by gerontologists, occupational therapists, clinical psychologists or clinical neuropsychologists [78]. Cognitive rehabilitation mainly focuses on identifying and addressing individual needs and goals, which may require strategies for taking in new information or compensatory methods such as memory aids, and has provided preliminary indications of its potential benefits in improving activities of daily living in people with mild Alzheimer's disease [80].

Any kind of cognitive intervention should be based on a previous diagnosis, including two types of assessment. The first should be a screening (usually with the Mini-Mental State Examination), and the second is an in-depth evaluation (with standardized tests in the sociocultural context, according to age and schooling) of the performance of the individual in different cognitive tasks. From the diagnosis results if the person shows a "normal" or intact performance, meaning that he preserves his cognitive functions as expected to his age and schooling in their context; or it presents a significantly inferior performance that can be classified as slight cognitive impairment and in case of suspected dementia. This previous evaluation is needed to take the decision of whether an intervention is necessary and what kind is required, what aspects should be developed on and what capacities should be promoted [81].

The objectives of intervention programs based on training and/or cognitive stimulation are generally set out in terms of "improving, maintaining, strengthening, and restoring." While in programs based on cognitive rehabilitation, the objectives are defined in terms of "compensate."

Once the type and purpose of the treatment have been selected, during the planning of the cognitive intervention, basic methodological aspects must be considered, in order to systematize the steps involved in the process. These guidelines include [82]: (1) Systematic organization of the session and its activities, (2) progression, starting with easy and continue with difficult activities, (3) intensity, with a suitable and adapted rhythm, (4) logic and sense, with meaning and actual sequence, (5) the activities should be interesting, (6) motivation, curiosity, and desire to learn, (7) the activities should be gratifying, (8) personal and emotional involvement, the elements of the process should have a pleasant and emotional sense, (9) the elements of the process should promote the interpersonal relationships of people with their environment.

As a basic guideline during the intervention work, it is recommended to maintain a routine through a structured session, in this sense, as part of the training and/or cognitive stimulation a session scheme is proposed. It includes the following elements, not necessarily in this order:

Mnemonic strategies are used for improving memory processes and with it ensuring that important information is available when needed in our daily lives. Memory strategies can be distinguished according to their origin, whether they are external or internal. The first involves using aids that are outside our body to help us remember things, while internal strategies are mental activities that engage the person in remembering information [31] (**Table 3**). Both types of strategies are effective ways of learning and retaining information and are widely used as part of training and cognitive stimulation programs in the aging

**Table 3.** Mnemonic strategies and techniques that can be used as part of training and cognitive stimulation

On the other hand, interventions based on cognitive rehabilitation, designed for people with mild to severe dementia, should be highly personalized to fulfill the requirements regarding both to the potential and deterioration of the person, so it is difficult to design sessions with rigid schemes. However, this does not imply that the work should not be systematized. In a review of interventions targeting people with Alzheimer's disease or related dementia, a diversity in the types of interventions was found which consisted mainly of memory training,

reminiscence therapy, validation therapy, and life review techniques [83].

**Strategies Technique Definition and examples**

Internal Organization/categorization It consists of establishing categories of data or information

location in the kitchen)

Visualization Based on the ability to recreate visual mental images.

Mental associations Relate items that want to be remembered (e.g., associate the

Mental hooks Associate elements linked to the imagination and location,

Story technique Organize a story with data from a list of items or events that

Mental maps It involves creating a panoramic view of a situation in order

remind me of an activity)

Itinerary method It is about making mental associations of an image in a

house)

External Memory aids These are aids located in the context or near the person's

the mind

grouping it based on their common characteristics. (e.g., grocery lists according to the type of food, color,

Cognitive Aging

157

http://dx.doi.org/10.5772/intechopen.71551

(Ex: visually imagine a photo or movie where all the elements that want to be remembered are found)

which can mentally link data that can be easily located in

want to be remembered (e.g., to create a story that includes

specific place. To achieve this, a mental journey or an itinerary should be made, setting in certain places the elements to remember (e.g., in the different rooms of the

environment. In this situation a person or object promotes the memory (e.g., change the ring from one finger to another, carrying a schedule, diary, calendar, etc. Ask a person to

name of a person with a physical characteristic)

the planned activities during the day)

to remember both general and specific data

process.

programs.



is about learning ways of compensating these difficulties or managing them better. Many cognitive rehabilitation programs could involve families and careers. Usually, it is implemented by gerontologists, occupational therapists, clinical psychologists or clinical neuropsychologists [78]. Cognitive rehabilitation mainly focuses on identifying and addressing individual needs and goals, which may require strategies for taking in new information or compensatory methods such as memory aids, and has provided preliminary indications of its potential benefits in improving activities of daily living in people with mild Alzheimer's disease [80]. Any kind of cognitive intervention should be based on a previous diagnosis, including two types of assessment. The first should be a screening (usually with the Mini-Mental State Examination), and the second is an in-depth evaluation (with standardized tests in the sociocultural context, according to age and schooling) of the performance of the individual in different cognitive tasks. From the diagnosis results if the person shows a "normal" or intact performance, meaning that he preserves his cognitive functions as expected to his age and schooling in their context; or it presents a significantly inferior performance that can be classified as slight cognitive impairment and in case of suspected dementia. This previous evaluation is needed to take the decision of whether an intervention is necessary and what kind is required, what aspects should be developed on and what capacities should be promoted [81]. The objectives of intervention programs based on training and/or cognitive stimulation are generally set out in terms of "improving, maintaining, strengthening, and restoring." While in programs based on cognitive rehabilitation, the objectives are defined in terms of "compensate." Once the type and purpose of the treatment have been selected, during the planning of the cognitive intervention, basic methodological aspects must be considered, in order to systematize the steps involved in the process. These guidelines include [82]: (1) Systematic organization of the session and its activities, (2) progression, starting with easy and continue with difficult activities, (3) intensity, with a suitable and adapted rhythm, (4) logic and sense, with meaning and actual sequence, (5) the activities should be interesting, (6) motivation, curiosity, and desire to learn, (7) the activities should be gratifying, (8) personal and emotional involvement, the elements of the process should have a pleasant and emotional sense, (9) the elements of the process should promote the interpersonal relationships of people with their environment. As a basic guideline during the intervention work, it is recommended to maintain a routine through a structured session, in this sense, as part of the training and/or cognitive stimulation a session scheme is proposed. It includes the following elements, not necessarily in this order:

**1.** Orientation to reality (personal, spatial and temporal) [81].

**4.** Psycho-educational technique, knowledge and theoretical information promote the im-

**5.** Practical training in the use of mnemonic strategies adapted to the needs of the person

**6.** Feedback and closure. Always ask: How does this help me in everyday life?

**2.** Attention/concentration technique.

provement of the perception of memory.

**3.** Relaxation technique.

156 Gerontology

(see **Table 3**).

**Table 3.** Mnemonic strategies and techniques that can be used as part of training and cognitive stimulation programs.

Mnemonic strategies are used for improving memory processes and with it ensuring that important information is available when needed in our daily lives. Memory strategies can be distinguished according to their origin, whether they are external or internal. The first involves using aids that are outside our body to help us remember things, while internal strategies are mental activities that engage the person in remembering information [31] (**Table 3**). Both types of strategies are effective ways of learning and retaining information and are widely used as part of training and cognitive stimulation programs in the aging process.

On the other hand, interventions based on cognitive rehabilitation, designed for people with mild to severe dementia, should be highly personalized to fulfill the requirements regarding both to the potential and deterioration of the person, so it is difficult to design sessions with rigid schemes. However, this does not imply that the work should not be systematized. In a review of interventions targeting people with Alzheimer's disease or related dementia, a diversity in the types of interventions was found which consisted mainly of memory training, reminiscence therapy, validation therapy, and life review techniques [83].
