Many people worry about how their physical and mental abilities will reduce as they grow old. Dementia caregivers also worry about their risk of getting dementia.
Ramani Sundaram, a neuroscience research scientist working at Nightingales Medical Trust, has designed and managed the “Active Ageing” program at the Nightingales Trust Bagchi Centre for Active Ageing (Bangalore). It is a holistic program that uses a multi-modal activity-based approach. It is based on the ThinkingFit study conducted in the UK, and aims to bring lifestyle modification and ensure health and happiness of the elderly, thus making ageing a positive experience. The focus is on minimizing the risk of dementia, controlling hypertension, diabetes, and depression, and preventing falls.
This interview series shares information and suggestions for persons interested in ageing well. [note] In part 1, we talked about program and its context and objectives, how participants are assessed before they join, and also listed the three components of the program. The first component, physical activity, was discussed. Below, in Part 2, we discuss the mental and social components of the program and talk about how persons who can’t leave home (like many caregivers) can adapt and use these. We also talk about the use of the program for persons mild cognitive impairment or early dementia.
Dementia Care Notes: Let’s move to the second component of your Active Ageing program, cognitive engagement (mental stimulation). What sort of mental stimulation do you include in this?
Ramani Sundaram, neuroscience research scientist: It is puzzling to see that it is general perception that body needs physical exercise to keep fit while brain fitness is not considered as important.
The brain needs mental exercise to stay active and not deteriorate.
…we work on different cognitive domains (areas) such as memory, concentration, language, perception, speed of processing, etc. Our activities are designed to be both engaging and meaningful. The idea is to make participants do cognitive activities that have positive effects on their daily functions.
In our program, we work on different cognitive domains (areas) such as memory, concentration, language, perception, speed of processing, etc. Our activities are designed to be both engaging and meaningful. The idea is to make participants do cognitive activities that have positive effects on their daily functions. These activities provide long lasting positive effects.
These cognitive areas are vast. There are many combinations that can be used to stimulate skill sets. For example, just looking at memory, we have several aspects to consider and combine, such as activities that improve visual/auditory memory, short term/immediate memory, verbal/nonverbal memory, and working memory. A well-designed program is therefore needed.
Our mental stimulation component is one hour every day, 4 to 5 days a week.
DCN: A variety of activities for one hour daily, most days a week is much more than the single daily Sudoku which many articles claim is all we need to do 🙂 Could you describe your mental stimulation session?
RS: As I mentioned earlier, many cognitive domains (areas) need to be stimulated for different kind of skill sets.
We divide our mental health routine depending on the cognitive domain. We keep selecting a focus for a week, and look at various subdomains of it during the days of that week.
A monotonous activity is not as stimulating as doing a different activity each time. One can do sudoku once in a while, but it is not very beneficial to do it every day. Novelty stimulates the brain better.
For example, in our “memory week”, we take up one subdomain of memory on each day. The subdomains can be visual/auditory memory, short term/immediate memory, verbal/nonverbal memory, and working memory. And in our “Behavioural flexibility activities week”, we would look at things like logical reasoning, decision making, speed of processing, coordination, and attention activities.
The reason behind tapping different activities each time is to do something different. A monotonous activity is not as stimulating as doing a different activity each time. One can do sudoku once in a while, but it is not very beneficial to do it every day. Novelty stimulates the brain better.
The duration of around an hour may sound too much, but if the activity is engaging, participants remain engrossed and even want more. Some activities are paper pencil based, some are Power Point based and some are sign language based. The instructor takes additional effort to make each activity more engaging.
DCN: Are these mental exercises/ activities individual or group-based?
RS: We use both modes. Most of the times our activities are group based, but we also have some individual activities.
For example, say we have a group of 15 members, we give each member a different set of unrelated 10 words. Each member has to make a story using these ten words then we divide them into 3 groups. Each group now has 5 different stories. We ask each group to combine all stories in to 1. Now we have three stories which are either enacted as mime /drama. These activities tap the creativity area and also allows members to interact with each other.
DCN: What similar approach or set of activities do you suggest for homebound persons who cannot leave home to regularly attend a program like yours?
RS: There are a set of activities that can be done at home.
One of the simplest activity is to write with a non-dominant hand (use the left hand if you are right-handed, or use the right hand if you are left-handed)…Writing activities can be further divided into mirror writing, reverse writing, and blind writing.
One of the simplest activity is to write with a non-dominant hand (use the left hand if you are right-handed, or use the right hand if you are left-handed). It is a simple, yet very effective activity. Writing activities can be further divided into mirror writing, reverse writing, and blind writing.
Another example is reading a short story and then trying to rewrite it the next day nearly the same way as it was read.
There are many more such activities. For example, one good way to improve attention is doing a “word search” game with a timer on. Another activity is making a word chain (making a new word with ending alphabet of the first word) which may be done using related words or unrelated words. Solving matchstick puzzles, making geometrical shapes with matchsticks, etc., are some other activities to start with.
DCN: Many caregivers ask us about software packages they can use — do you have any comments about them?
RS: Many software packages are available for cognitive stimulation. The activities differ depending on the package. Most of these packages are good but the issue is that there are limited types of activities in each such package. It is therefore advisable to look for packages that have more number of activities and can be upgraded or lowered as per the abilities.
We have found that unlike physical activity, when someone find mental activities challenging they tend to give up, hence it is important to select activities based on interest and speed.
Some activities are available for free in the app stores. While these are not put together as a package, they can be good as standalone activities. Examples are Hangman, Word search, Cows and Bulls, Memory Buzz etc.
DCN: How can we keep adjusting our personal program so that it remains effective as mental stimulation?
RS: Changing a routine and comfort activity might be difficult initially, but it’s beneficial as we go along.
It is not necessary to do all activities at a time. Activities can be assigned weekly. A particular week can be for computer/phone based activity while the next week can be for Sudoku, crossword etc. Sometimes, you can just juggle the routine.
The most important aspect is to find activities that are enjoyable, not just ‘useful’.
The most important aspect is to find activities that are enjoyable, not just ‘useful’. If they are enjoyable they can engage a person for long. Motivation to do them can also be improved by involving family members and friends.
DCN: How do you know if a mental stimulation routine is effective? How would a homebound person know?
RS: We do periodic assessments that help us study the effect of mental stimulation routine.
Sometimes the activities themselves work as assessment tool. Say someone is able to remember 15 items in a memory game, and after three months this participant is able to remember 25. Or someone is able to finish the same cognitive task more quickly. Many times, the participants themselves notice the improvement in their memory. They find they are better at remembering names and words, or are faster in understanding and doing things (better speed of processing).
Similarly, persons doing such mental stimulation activities at home can use tasks to assess their improvement. Take the example of a coding activity where each alphabet is given a number, say A is 1, B is 2 and so on, and the activity requires writing a small paragraph using this numeric code instead of alphabets. Suppose they are doing a coding activity in half an hour now. After a month or two, they can check how much time the activity takes. This will show if there is improvement.
It is important to understand that, unlike physical activity, improvement in mental skills is not as evident to the person or others. But the person can notice the impact through improvement in functional activities, the sort of normal activities they do regularly for themselves or others.
DCN: The third component of your program is socialization. Socializing is often difficult to achieve for someone like a caregiver who is homebound and cannot go out to meet people. Any suggestions for this?
RS: Socialization is perhaps the most important aspect of the program. Meeting different people and talking to them is highly stimulating. This can be challenging for homebound persons though it is surely important for them to socialize.
Some possibilities: Become a member in a club. It may not be possible to go most of the time, but try to start with once or twice a month. Taking part in a group activity is a good way to start. Also. though not the same as face-to-face meetings with persons, options for homebound persons include social media, phone calls, etc.
There aren’t any strict parameters to determine useful social activity; it is only about enjoying or benefiting from the group.
Our elders include introverts and extroverts. When they go out to watch a movie /picnic they all enjoy. Many may still not know each other but being in a group is a positive experience for them all.
DCN: Your program includes seniors with dementia. How have you helped seniors without dementia to understand and feel comfortable with those with dementia?
RS: We start our program by introducing all participants about the need of the program. This includes a brief session on dementia.
Our “active ageing centre and our dementia day care centre are both at the same premises. This enables our program participants to see and understand their peers with dementia. The briefing and continuous information update about dementia and its behavioural aspect also helps the participating seniors to understand their friends with dementia better. We also have get-togethers, parties, and social events that include both sets of members and thus set the stage for interactions.
We have been successful in making program participants understand that seniors with dementia can also contribute in many activities. Our program participants view dementia like any other age-related issue (diabetes, hypertension, etc.), just one where the manifestation of symptoms is different.
DCN: Dementia risk reduction is one of your objectives. Can the physical, mental, and social stimulation of a program like yours reduce the risk of dementia?
RS: Our aim is to work on the modifiable risk factors and reduce the risk of dementia.
Decades of research has shown that vascular risk factors and inactive lifestyle are associated with dementia. It remains a plausible hypothesis that mental stimulation, social engagement and physical activities have a preventive effect on age related conditions. Furthermore, activities of the sort included in our program have been associated with several outcomes like a lower death rate, better cognition, fewer illnesses, and increase in general well-being. An engaged lifestyle during the 60’s has also been associated with a longer life.
Having said that, we have to also understand that a lot more research is needed to understand dementia better. These programs are one of the ways to explore the potential for dementia prevention or achieving better quality of life as people age.
As of now there are some risk factors established for dementia, and our program works to reduce those risk factors. The ThinkingFit research study on which our program is based, has shown encouraging results in risk reduction, and we have been able to replicate similar results in a larger cohort.
DCN: Can your program benefit someone who already has mild cognitive impairment? Or someone with dementia? How is the program adapted for their participation?
…people with MCI/dementia…do many social activities with the other groups, but they do the physical and cognitive activities in this special separate group. This allows us to do the activities according to the capacity and potential of these people.
RS: The active ageing program can be very effective for people with mild cognitive impairment (MCI) and for people with dementia (early stages).
We have a separate group for people with MCI/dementia. They do many social activities with the other groups, but they do the physical and cognitive activities in this special separate group. This allows us to do the activities according to the capacity and potential of these people. In a combined session, the people with MCI/dementia tend to feel overpowered by the others. A separate group gives them a more encouraging environment.
In general, activities are made easier for them and they enjoy when they are able to complete an activity despite their limitations. As their abilities deteriorate, we adjust the activities so that they can still do and enjoy them given their current potential.
DCN: Do you have any final words for persons who want the benefits of a program like “Active Ageing” but cannot enrol for regular participation because they are homebound?
RS: Our Active Ageing program is a highly structured program driven by standard protocols and trained instructors. It may not be possible to entirely use the program at home, but some aspects of the program can definitely be adopted. Some aspects of all three components can be done at home.
…this is a lifestyle modification program and the benefits are not evident immediately. However, as people age, the benefits of the activities tend to show. The key is to start, change, and sustain the activities so that they are both meaningful and engaging.
As I explained before, even if a person is homebound and cannot attend the program at the centre regularly, the person can initially visit the centre for an assessment and guidance about what they can do safely and effectively at home. At the centre, they can understand and practice the suitable exercises under the guidance of the physiotherapist till they do them properly and safely, so that they can start doing them at home. They can also revisit the centre periodically to confirm they are doing the exercises properly and also get any new advice for using elements of our “Active Ageing” program given their situation .
Remember that this is a lifestyle modification program and the benefits are not evident immediately. However, as people age, the benefits of the activities tend to show. The key is to start, change, and sustain the activities so that they are both meaningful and engaging.
Thank you very much for this detailed explanation of your program and its underlying concepts and design, and how it benefits elders, even those with mild cognitive impairment or early dementia. It was also very useful to learn how homebound persons like many family caregivers can benefit from some of its components. Readers would definitely find it useful to age better and also reduce their dementia risk!
Ms Ramani Sundaram may be contacted by email at ramanisuba@gmail.com. The centre running active ageing programs can be reached by contacting Nightingales Medical Trust Bangalore (Phone 91 80 42426565 Email: contact@nightingaleseldercare.com).
Note: In this interview series, Ramani Sundaram shares information and suggestions based on her Active Ageing program. Before starting any exercise program, please consult your doctor as appropriate.
[This is part of the expert interviews on this site. View the list of all interviews of health care professionals and volunteers.]
Note. This is an interview of an expert/ volunteer. The views expressed and the suggestions given are those of the interviewed person, and not a recommendation being made by Dementia Care Notes. Suitability and applicability of the suggestions remain the responsibility of the reader. For professional advice suitable for your situation, please consult an appropriate professional.