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Taiebine M. Neurocognitive Stimulation of Moroccan Bilingual Patient with Alzheimer’s Disease: A Case Study. Avicenna J Neuro Psycho Physiology 2024; 11 (1) :7-11
URL: http://ajnpp.umsha.ac.ir/article-1-475-en.html
URL: http://ajnpp.umsha.ac.ir/article-1-475-en.html
Euro-Mediterranean University of Fez (UEMF), Fès, Morocco , m.taiebine@ueuromed.org
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Figure 1. Cerebral magnetic resonance imaging sagittal cut showing a left hippocampal atrophy
Table 1. Summary of neuropsychological assessments
Fig 2. Geopolitical map drawn by the patient in October 2017
Fig 3. Geopolitical map drawn by the patient in January 2019
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Background
The World Alzheimer's Report [1] emphasizes the importance of Cognitive Stimulation Therapy (CST) for individuals with dementia at an early stage. The CST has been developed in the United Kingdom and found to improve cognitive function and quality of life in individuals with dementia [1]. However, for countries whose primary language is not English, such as Morocco, adaptation and translation of the therapy may be necessary. This study aimed to reflect on the standard administration of non-pharmacological interventions for individuals with mild-to-moderate dementia using an individualized program.
There are various non-pharmacological interventions available to enhance the psychological, physical, and cognitive well-being of patients with Alzheimer's disease (AD). For example, reminiscence therapy [2] and multi-sensory stimulation [3] have been used to improve general functioning in daily life. Additionally, coupling Cognitive Stimulation Therapy with Montessori-Based Dementia may enhance cognitive functions [4].
Moreover, cognitive training and rehabilitation are the primary therapeutic approaches used for individuals with early-stage AD. While there is limited evidence due to methodological biases and a lack of randomized controlled trials, single-case designs and small-group studies [5] provide cautiously positive outcomes [6]. These approaches may enhance specific cognitive processes, such as attention, executive function, and memory. One study found that memory training in patients with AD resulted in a significant improvement in their abilities [7].
The AD often presents with psycho-emotional disorders in addition to cognitive disorders. Non-pharmacological interventions, such as music therapy, have been the subject of increasing research. In this regard, the daycare center for Alzheimer's patients in Rabat, Morocco, offers singing and cooking therapy workshops. The singing workshop is held bimonthly and lasts for 90 min. It incorporates choral singing, both with and without musical instruments, and features songs from the Moroccan and Arabic musical repertoires. Studies have indicated that music therapy can help patients cope with negative emotions [8], improve feelings of well-being [9], and reduce anxiety, depression, and irritability [10]. Additionally, music therapy has been found to help reduce social isolation [11].
Finally, Chan et al. [12] developed a 10-session group-based mindfulness program tailored for individuals with mild-to-moderate dementia to manage psychological distress with support from caregivers. The program was found to significantly increase the quality of life of these patients. The manual presented here is designed to be administered flexibly to promote the personhood of participants and is intended for use by therapists with experience in practicing mindfulness meditation.
Case Presentation
This study was carried out between October 2017 and 2019, and aimed to report the case of T. A., who presented with mild to moderate AD. He was 74 years old, 100% right-handed, married, father of three children, agricultural engineer specializing in horticulture. The patient practiced oil painting and participated in various artistic exhibitions 10 years ago.
The patient's neurological examination results were normal; however, brain magnetic resonance imaging revealed hippocampal atrophy (figure 1). A neuropsycho-logical assessment revealed that the patient had experienced difficulties with memory and language since 2011, which had impeded communication with others. The patient showed an overall cognitive decline, with dominant memory impairment (Mini-Mental State Examination: 23/30 in 2017 vs. 15/30 in 2019)(table1). Despite these cognitive challenges, the patient continued to drive his car and engage in 30 min of physical activity each day.
The patient was enrolled in an individualized cognitive stimulation therapy (iCST) program according to clinical guidelines [2,13]. This therapy involved a 30-minute one-to-one bilingual French-Arabic session three times a week for 25 weeks. The themes addressed childhood, food, current affairs, faces/scenes, word associations, creativity, object categorization, orientation, money usage, number games, word games, and team games. The program activities included structured cognitive stimulation through themed activities (current affairs and associated word number games) tailored to the needs and preferences of patients. The usual format of the session followed this pattern: 5 min dedicated to time and space orientation, followed by a discussion of current affairs and a focus on the main activity for 20 min. The spouse of the patient was also involved in the provision of home-based stimulation using a diary and activities from the activity workbook.
There are various non-pharmacological interventions available to enhance the psychological, physical, and cognitive well-being of patients with Alzheimer's disease (AD). For example, reminiscence therapy [2] and multi-sensory stimulation [3] have been used to improve general functioning in daily life. Additionally, coupling Cognitive Stimulation Therapy with Montessori-Based Dementia may enhance cognitive functions [4].
Moreover, cognitive training and rehabilitation are the primary therapeutic approaches used for individuals with early-stage AD. While there is limited evidence due to methodological biases and a lack of randomized controlled trials, single-case designs and small-group studies [5] provide cautiously positive outcomes [6]. These approaches may enhance specific cognitive processes, such as attention, executive function, and memory. One study found that memory training in patients with AD resulted in a significant improvement in their abilities [7].
The AD often presents with psycho-emotional disorders in addition to cognitive disorders. Non-pharmacological interventions, such as music therapy, have been the subject of increasing research. In this regard, the daycare center for Alzheimer's patients in Rabat, Morocco, offers singing and cooking therapy workshops. The singing workshop is held bimonthly and lasts for 90 min. It incorporates choral singing, both with and without musical instruments, and features songs from the Moroccan and Arabic musical repertoires. Studies have indicated that music therapy can help patients cope with negative emotions [8], improve feelings of well-being [9], and reduce anxiety, depression, and irritability [10]. Additionally, music therapy has been found to help reduce social isolation [11].
Finally, Chan et al. [12] developed a 10-session group-based mindfulness program tailored for individuals with mild-to-moderate dementia to manage psychological distress with support from caregivers. The program was found to significantly increase the quality of life of these patients. The manual presented here is designed to be administered flexibly to promote the personhood of participants and is intended for use by therapists with experience in practicing mindfulness meditation.
Case Presentation
This study was carried out between October 2017 and 2019, and aimed to report the case of T. A., who presented with mild to moderate AD. He was 74 years old, 100% right-handed, married, father of three children, agricultural engineer specializing in horticulture. The patient practiced oil painting and participated in various artistic exhibitions 10 years ago.
The patient's neurological examination results were normal; however, brain magnetic resonance imaging revealed hippocampal atrophy (figure 1). A neuropsycho-logical assessment revealed that the patient had experienced difficulties with memory and language since 2011, which had impeded communication with others. The patient showed an overall cognitive decline, with dominant memory impairment (Mini-Mental State Examination: 23/30 in 2017 vs. 15/30 in 2019)(table1). Despite these cognitive challenges, the patient continued to drive his car and engage in 30 min of physical activity each day.
The patient was enrolled in an individualized cognitive stimulation therapy (iCST) program according to clinical guidelines [2,13]. This therapy involved a 30-minute one-to-one bilingual French-Arabic session three times a week for 25 weeks. The themes addressed childhood, food, current affairs, faces/scenes, word associations, creativity, object categorization, orientation, money usage, number games, word games, and team games. The program activities included structured cognitive stimulation through themed activities (current affairs and associated word number games) tailored to the needs and preferences of patients. The usual format of the session followed this pattern: 5 min dedicated to time and space orientation, followed by a discussion of current affairs and a focus on the main activity for 20 min. The spouse of the patient was also involved in the provision of home-based stimulation using a diary and activities from the activity workbook.
Figure 1. Cerebral magnetic resonance imaging sagittal cut showing a left hippocampal atrophy
The patient demonstrated significant improvement in spoken language and mood as a result of iCST; however, his memory was impaired, as evidenced by his Mini-Mental State Examination and Memory Impairment Screen scores during the follow-up assessment (table 1). In particular, iCST sessions involved discussion of a wide range of news with the patient about TV soap operas or political shows they were following. As the patient had exceptional visuospatial and constructional abilities, multiple sessions were conducted in which a geopolitical map was used to test their knowledge of agriculture in different countries while they practiced their former occupation (figure 2 & 3). Additionally, the patient was asked to draw a map at home and then draw it from memory as a technique to engage them positively in iCST. This was later coupled with reminiscence therapy, in which the patient was guided through life experiences and encouraged to evaluate them.
Table 1. Summary of neuropsychological assessments
| Tests | Assessment in December 2017 | Assessment in January 2019 |
| Mini-Mental State Examination [14] | Total score: 23/30 Orientation: 7/10 Registration: 3/3 Attention et calculation: 5/5 Recall: 0/3 Language: 7/7 Praxis: 1/1 |
Total score: 15/30 Orientation: 5/10 Registration: 3/3 Attention et calculation: 1/5 Recall: 0/3 Language: 5/7 Praxis: 1/1 |
| Trail making test [15] | TMT A: 1 Error/1 min and 20 sec TMT B: 6 Errors/3 min and 31 sec |
TMT A: 1 Error/2 min and 11 sec TMT B failed |
| Clock drawing test [16] | 7/10 | 2/10 |
| Categorical and literal verbal fluency [16] | Letter fluency: 13 (3 intrusions) Semantic category fluency:
|
Letter fluency: 4 (3 intrusions) Semantic category fluency:
|
| Digit span task [16] | Digit span forwards: 4 Digit span backwards: 3 |
Digit span forwards: 4 Digit span backwards: 3 |
| Face-name associative recognition test [17] | Total score: 12/34 | Total score: 7/34 |
| Hayling test [18] | Part A: 14/15 Part B: 15/15 |
Part A: 8/15 Part B: 3/15 |
| Instrumental activities of daily living | 8/8 | 8/8 |
| Starkstein apathy scale [19] | 14/42 | 12/42 |
Fig 2. Geopolitical map drawn by the patient in October 2017
Fig 3. Geopolitical map drawn by the patient in January 2019
Discussion
When adapting CST for use in different cultures, it is important to involve relevant stakeholders, such as participants and family caregivers, community health workers, mental healthcare staff, and other older people with knowledge of historical, cultural, and religious issues. Furthermore, an extensive cultural adaptation and translation of the CST into Arabic is necessary. Future research should focus on the establishment of the effectiveness of CST for dementia patients with AD in Morocco across various settings. Despite a lack of evidence regarding the impact of iCST on cognitive function or quality of life of people with dementia [2], participation in iCST may improve the quality of the relationship between patients and their caregivers if the protocol follows a structured rationale in terms of thematic sessions.
Wilson et al. [20] suggested that remaining mentally active throughout life may support brain health and possibly reduce the risk of AD and other dementias. Besides, remaining socially and mentally active may help build cognitive reserves but the exact mechanism by which this may occur is unknown. Further research is needed to better understand how social and cognitive engagement may affect biological processes to reduce risk.
Hall et al. [21] explored the neuropsychological underpinning as well as the effects of CST on specific cognitive domains. They found that memory, comprehension of syntax, and orientation seem to be the cognitive areas most affected by the CST. They explained this finding by the induced language-based nature of the CST, which might improve neural pathways responsible for processing such cognitive processes. However, Liu et al. [22] stipulated that CST as a person-centered therapy may enhance these cognitive processes, especially in people with higher brain/cognitive reserve. The CST group maintained the total brain volume/total intracranial volume, compared to the control group. Increased resting-state functional connectivity in the default mode network (DMN) in the posterior cingulate cortex and bilateral parietal cortex nodes was observed in the CST, compared to the control group. The authors correlated the potential role of the DMN in episodic memory retrieval with metacognitive processes.
Finally, in the aftermath of the COVID-19 pandemic [23], utilizing the e-mental health framework in dementia care [24] appears to be essential in the transition from traditional face-to-face interventions to online or hybrid formats. However, there are current challenges that lead to digital inequities in the implementation of CST in the post-COVID era, particularly in low-income countries. These challenges include lower mental abilities, IT illiteracy, and limited access to the internet.
As the COVID-19 pandemic is expected to be a long-lasting issue, there is a pressing need to deliver CST services for dementia that can overcome geographic barriers, connect people from different backgrounds, reduce transportation time and costs, and provide access to those with mobility and health issues that prevent them from attending groups. In light of these circumstances, the authors of CST and iCST have developed an online platform to promote cognitive and mental well-being in individuals with dementia [25,26].
The iSupport [27] is a self-help online program developed by the World Health Organization that provides training for caregivers of AD patients. This web-based intervention is an example of a cross-cultural tool that needs to be translated and adapted in different languages and cultures, especially in non-European languages, such as Arabic or Persian. The same approach could be applied to remote cognitive stimulation therapy [28]. Therefore, technological advances should be made accessible worldwide through equity and digital inclusion using cross-cultural responsive guidelines in remote cognitive stimulation interventions for patients with AD and their caregivers [29].
Conclusions
Patient T. A. was diagnosed with late-stage 1 mild to moderate AD in 2011, characterized by memory disorders confirmed by neurological, neuro-psychological, and neuroradiological examinations. He was enrolled in the iCST program, which resulted in a slight improvement in mood; however, memory and language were still impaired, as indicated by neuropsychological testing. This later highlighted some aspects of CST application and its benefits in the case of T.A.; however, further research is needed using a larger dataset and comparing the cohort to age-matched and healthy controls to validate the impact on cognition and quality of life.
A specific adaptation of CST in Arabic is necessary [27], taking into account the socio-linguistic and socio-cultural profile of the Moroccan Arabic language (diglossia), cultural legacy and heritage (Moroccan crafts, games, and musical folklore), level of literacy (illiterate vs. educated), and social economic status (occupation, quality of life, well-being, and opportunities for lifelong stimulation).
Compliance with ethical guidelines
This research does not have the ethics code. However, all ethical principles were considered in this article. The participants were informed about the purpose of the research and its therapeutic stages; they were also assured about the confidentiality of their information. Furthermore, they were allowed to leave the study whenever they wish.
Acknowledgments
Special thanks go to the patient and his spouse, without whose patience and help it would be impossible to carry out this study.
Authorsʼ contributions
MT developed the original idea, wrote and revised the manuscript. He also assessed and treated the patient.
Funding/Support
None.
Conflicts of Interest
The author declared no conflict of interest.
References
When adapting CST for use in different cultures, it is important to involve relevant stakeholders, such as participants and family caregivers, community health workers, mental healthcare staff, and other older people with knowledge of historical, cultural, and religious issues. Furthermore, an extensive cultural adaptation and translation of the CST into Arabic is necessary. Future research should focus on the establishment of the effectiveness of CST for dementia patients with AD in Morocco across various settings. Despite a lack of evidence regarding the impact of iCST on cognitive function or quality of life of people with dementia [2], participation in iCST may improve the quality of the relationship between patients and their caregivers if the protocol follows a structured rationale in terms of thematic sessions.
Wilson et al. [20] suggested that remaining mentally active throughout life may support brain health and possibly reduce the risk of AD and other dementias. Besides, remaining socially and mentally active may help build cognitive reserves but the exact mechanism by which this may occur is unknown. Further research is needed to better understand how social and cognitive engagement may affect biological processes to reduce risk.
Hall et al. [21] explored the neuropsychological underpinning as well as the effects of CST on specific cognitive domains. They found that memory, comprehension of syntax, and orientation seem to be the cognitive areas most affected by the CST. They explained this finding by the induced language-based nature of the CST, which might improve neural pathways responsible for processing such cognitive processes. However, Liu et al. [22] stipulated that CST as a person-centered therapy may enhance these cognitive processes, especially in people with higher brain/cognitive reserve. The CST group maintained the total brain volume/total intracranial volume, compared to the control group. Increased resting-state functional connectivity in the default mode network (DMN) in the posterior cingulate cortex and bilateral parietal cortex nodes was observed in the CST, compared to the control group. The authors correlated the potential role of the DMN in episodic memory retrieval with metacognitive processes.
Finally, in the aftermath of the COVID-19 pandemic [23], utilizing the e-mental health framework in dementia care [24] appears to be essential in the transition from traditional face-to-face interventions to online or hybrid formats. However, there are current challenges that lead to digital inequities in the implementation of CST in the post-COVID era, particularly in low-income countries. These challenges include lower mental abilities, IT illiteracy, and limited access to the internet.
As the COVID-19 pandemic is expected to be a long-lasting issue, there is a pressing need to deliver CST services for dementia that can overcome geographic barriers, connect people from different backgrounds, reduce transportation time and costs, and provide access to those with mobility and health issues that prevent them from attending groups. In light of these circumstances, the authors of CST and iCST have developed an online platform to promote cognitive and mental well-being in individuals with dementia [25,26].
The iSupport [27] is a self-help online program developed by the World Health Organization that provides training for caregivers of AD patients. This web-based intervention is an example of a cross-cultural tool that needs to be translated and adapted in different languages and cultures, especially in non-European languages, such as Arabic or Persian. The same approach could be applied to remote cognitive stimulation therapy [28]. Therefore, technological advances should be made accessible worldwide through equity and digital inclusion using cross-cultural responsive guidelines in remote cognitive stimulation interventions for patients with AD and their caregivers [29].
Conclusions
Patient T. A. was diagnosed with late-stage 1 mild to moderate AD in 2011, characterized by memory disorders confirmed by neurological, neuro-psychological, and neuroradiological examinations. He was enrolled in the iCST program, which resulted in a slight improvement in mood; however, memory and language were still impaired, as indicated by neuropsychological testing. This later highlighted some aspects of CST application and its benefits in the case of T.A.; however, further research is needed using a larger dataset and comparing the cohort to age-matched and healthy controls to validate the impact on cognition and quality of life.
A specific adaptation of CST in Arabic is necessary [27], taking into account the socio-linguistic and socio-cultural profile of the Moroccan Arabic language (diglossia), cultural legacy and heritage (Moroccan crafts, games, and musical folklore), level of literacy (illiterate vs. educated), and social economic status (occupation, quality of life, well-being, and opportunities for lifelong stimulation).
Compliance with ethical guidelines
This research does not have the ethics code. However, all ethical principles were considered in this article. The participants were informed about the purpose of the research and its therapeutic stages; they were also assured about the confidentiality of their information. Furthermore, they were allowed to leave the study whenever they wish.
Acknowledgments
Special thanks go to the patient and his spouse, without whose patience and help it would be impossible to carry out this study.
Authorsʼ contributions
MT developed the original idea, wrote and revised the manuscript. He also assessed and treated the patient.
Funding/Support
None.
Conflicts of Interest
The author declared no conflict of interest.
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Article Type: Case Report |
Subject:
Aging
Received: 2024/01/8 | Accepted: 2024/06/4 | Published: 2024/06/10
Received: 2024/01/8 | Accepted: 2024/06/4 | Published: 2024/06/10
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