I Have Decided to Read Out Loud for the Rest of My Life! Cognitive Health and the StrongerMemory Program

Risk Factors and Prevention

Despite uncontrollable risk factors such as age and genetic markers, emerging evidence indicates that heart and brain health are crucial in reducing the risk of ADRD (Alzheimer’s Association, 2023). For older people who are seeking to lower the risk of memory decline, a diverse approach to overall health and well-being has demonstrated positive effects on cognition. Maintaining physical, social, emotional, and cognitive health is essential for the well-being of older adults (Arai et al., 2011; Zhang et al., 2022). These factors, along with other markers like education level, significantly impact cognition and memory decline (Cabeza et al., 2018; Lövdén et al., 2020; Nyberg et al., 2020).

Interventions

While there is no cure for ADRD, both pharmacological and nonpharmacological interventions have been developed to help individuals manage the symptoms associated with cognitive impairment. There is a growing need for evidence-based nonpharmacological cognitive interventions to help healthy older adults maintain brain health. Recent studies on nonpharmacological interventions aimed at preventing memory decline and improving cognition have been encouraging. These studies have shown improvement in various memory performance tasks, such as working memory and recognition (Reijnders et al., 2013).

Working memory, which involves how the brain stores and processes information in the moment is linked to many cognitive functions including problem-solving and reasoning (Studer-Luethi et al., 2023; Zinke et al., 2014). In some studies, participants who completed working memory training tasks, showed significant improvements in all domains of working memory [verbal, visuospatial, and executive control] (Berry et al., 2010; Zinke et al., 2014).

Cognitive Training

Cognitive training is another activity for improving cognition and maintaining brain health in older adults. Cognitive training exercises, which help maintain current brain functioning, are beneficial for sustaining cognitive functioning in healthy older adults (Ballesteros et al., 2018; Chiu et al., 2017; McEwen et al., 2018; Studer-Luethi et al., 2023; Yang et al., 2022). Despite the benefits of cognitive training, some studies have shown that completing cognitive exercises can lead to frustration and anxiety in individuals with memory challenges (Maki et al., 2014).

Multidomain Interventions

Multidomain nonpharmacological interventions, which target a variety of health and cognitive domains such as nutrition, exercise, brain health, and socialization, have proven successful. Studies combining physical exercise with cognitive training have shown significant improvement in cognition (Anderson & Grossberg, 2014; Lee et al., 2023; McEwen et al., 2018). One notable study, the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), used a multidomain intervention exploring diet, exercise, cognitive training, and vascular risk monitoring over 2 years. Compared to the control group, cognition in participants in the treatment group experienced significant cognitive benefits and reported a higher quality of life after the intervention (Ngandu et al., 2015). With over 1,000 participants, this study provides strong evidence for a diverse approach to preventing cognitive decline prevention in older adults, emphasizing the exploration of multiple nonpharmacological interventions simultaneously.

Importance in Social Work

The use of nonpharmacological interventions is essential in social work and other professions as the older population continues to grow. Previous studies on nonpharmacological practices for older adults with cognitive challenges demonstrate that these interventions are the most cost-efficient while still providing positive outcomes (Stewart et al., 2017). The efficacy of nonpharmacological interventions is integral to the field, offering valid tools that older adults can use independently with minimal to no associated costs (Stewart et al., 2017; Vance et al., 2010). In the study conducted by Stewart and colleagues (2017), the use of cognitive stimulation therapy (CST), a nonpharmacological psychosocial group intervention for individuals living with dementia, resulted in increased cognitive functioning and higher rates of observed joy and excitement in participants. This intervention is highly accessible to helping professionals who can learn the techniques and use them with older adults and their care partners. Implementing and sustaining effective nonpharmacological interventions is crucial to the field providing readily attenable interventions for older adults and their caregivers.

Cognitive Activities

Specific cognitive activities have been shown to be effective in maintaining brain health and preventing memory decline in older adults. Completing math problems is a common cognitive training activity and evidence indicates a positive relationship with cognitive performance in several studies (Buschert et al., 2011; Kawashima et al., 2005; Kulason et al., 2018; Li et al., 2019). One study found that participants who completed math problems combined with reading experienced improved cognition, and the results remained consistent after 6 months (Kawashima et al., 2005). Reading, as its own intervention, is also a powerful cognitive-stimulating exercise. Many researchers have found that reading, whether alone or combined with other cognitive exercises, aids in cognitive performance (Chang et al., 2021; Forrin & MacLeod, 2018; Josephsson et al., 1993; Kulason et al., 2018). In addition, writing as a cognitive exercise has shown to help with cognition and memory both in healthy older adults and individuals with mild cognitive impairment (MCI; de Medeiros et al., 2007; Iizuka et al., 2019; Kwok et al., 2011).

Impact on Quality of Life

The impact of cognitive decline affects all aspects of an older adult’s life. It can generate feelings of agitation and stress leading to social withdrawal. Cognitive interventions have been shown to reduce agitation and promote more alert responses in older adults (Latchem & Greenhalgh, 2014). In addition, mood generally improves among older adults who complete cognitive interventions (Buschert et al., 2011; Chandler et al., 2019). After performing cognitive exercises, older adults report greater satisfaction with their memory and less worry over instances of forgetfulness (Kaci Fairchild & Scogin, 2010). These effects demonstrate that cognitive training and memory decline prevention techniques are important not only for maintaining brain health but also for enhancing mood and overall quality of life in older adults.

Current Study

Studying the motivations and experiences of older adults participating in these programs is crucial. This study uses focus groups to explore the motivations and experiences of older adults involved in the StrongerMemory brain health program including their interest in incorporating the brain health exercises into their daily routines indefinitely.

Recruitment

All individuals who participated in the StrongerMemory research study (N = 102) were eligible to participate in the focus groups. Participants were from a local continuing care retirement community or a senior village anywhere in the country participating in the village movement (an aging in place model of living for older adults) where members had agreed to participate in the StrongerMemory program. A member of the research team sent email invitations to individuals who had completed or were near the end of the 12-week period of the research protocol. Focus group sessions were scheduled and conducted either in person at a continuing care retirement community or over Zoom. A total of 30 participants took part in the focus groups.

Data Analysis

The research team was comprised of two faculty, eight student research assistants, and a postdoctoral fellow. An inductive method of discovery using grounded theory techniques including open and thematic coding, constant comparative analyses, memoing, and theme generation was used to analyze the data. A total of 132 codes emerged from the data during the open-coding process. Through a rigorous data analysis process, five main themes and two subthemes emerged with corresponding codes (some codes were eliminated due to redundancy in meaning) (see Appendix B).

Dedoose, a web-based qualitative and mixed-methods data analysis tool, was used for the qualitative analysis of the focus group interviews (Dedoose Version 9.0.107, 2023). The research team uploaded the transcribed interviews and imported the finalized codebook with definitions in Dedoose. Two members of the research team analyzed each of the six transcripts and developed initial codes. A third research team member went through the same transcripts, formulating their own set of codes. After this process was completed, the research team came together to determine the final codes. The final codes were linked to transcript excerpts in Dedoose and then defined based on the focus group data. Constant comparative analysis is the process of comparing codes for similarity and differences. Three research members worked on this process which involved deleting codes that were redundant and categorizing the remaining codes with the emerging themes (Appendix B).

The research team met weekly to discuss and compare the emerging themes. The main points of the discussion were recorded as memos in Dedoose. This process led to the emergence of five themes and two subthemes, each with a set of associated codes.

Motivating

An overarching theme that emerged from the focus group interviews was motivating. The codes that encompass the theme of motivating and all the themes are presented in Appendix B. External and internal motivations of participants to (a) join the StrongerMemory program and (b) to continue with the StrongerMemory program upon completion of the research protocol are subthemes that further define motivating. External motivation was reflected mostly in continuing the StrongerMemory program rather than joining the program. External motivation for joining the program, as expressed by one participant, was the desire to engage in a hobby activity like playing bridge, that required memory capacity. Another external motivation that emerged was the presence of participants’ family history of Alzheimer’s disease. Factors related to external motivation for continuing the program included: approval from others; group/community; incentives; understanding of the research behind the program; and the desire to contribute to research which could benefit others. For example, one participant expressed that the approval of a medical professional strengthened the motivation of the participant to continue the program: “. . . in an annual physical with my primary care physician, I told her, I was involved in this program, and she was pleased and thought that was a great idea.” Internal motivation is also divided into (a) joining the program and (b) continuing the program exercises.

Properties related to internal motivation for joining the program include noticing memory decline; preventing memory decline; a sentiment of “why not”; worrying about memory decline (in present and in future). For example, participants described cognitive challenges they were experiencing such as forgetting names, forgetting why they went into a room, forgetting faces, short-term memory issues, not being able to express themselves as they used to, noticing their memory getting worse, remembering words, and having difficulty expressing deep thoughts:

What motivated me was I was realizing I wasn’t remembering names. That was the biggest thing. There was a woman I had worked with, knew her kids, worked with her, had her as a student, the whole thing, and I was trying to pull up her name and I could not.

The primary factor related to internal motivation for keeping up with the program was self-improvement. The hope for improvement and the worry about memory decline overlap with motivation for joining the program. “. . . I was much more focused on how it would affect me personally and that is what I focused on.”

Appreciating

The second theme that emerged from the focus groups was appreciating. This theme is defined by the several ways participants enjoyed and valued their experiences with the StrongerMemory program. Subthemes included how participants (a) deepened their outcomes and enjoyment through the specific exercises instructed by the program and (b) found meaning and enjoyment outside the parameters of the program by connecting with others. Deepening outcomes and enjoyment through the StrongerMemory program include the ways that participants enjoyed the meaning they made from completing the StrongerMemory exercises, especially through writing. One participant described enjoying the writing prompts because of the opportunity to reflect:

Well, it’s certainly brought up memories, things I had not thought about in years and years, and people I had not thought about, and I think that that’s one thing I really liked about those questions. So many of them took you back to your childhood . . .

Finding meaning and enjoyment outside of the program includes the ways participants connected with others in their StrongerMemory practice groups and beyond. For example, enjoying support from others such as reading with a partner, became a regular way that participants accomplished their StrongerMemory exercises. The accountability of reading together or checking in with each other to see if they completed the exercises helped participants stick with the program. One participant commented that: “I really liked reading with a friend. It was a very pleasant thing to do. We finished a book!”

Taxing

When discussing the StrongerMemory program, another theme that emerged among participants was taxing. Taxing referred to both (a) the content of the program and (b) the ability with which participants were able to complete the 12-week program. This theme was conceptualized through the following codes: disliking, scheduling, managing time, lacking, interpreting, challenging, and procrastinating. When it came to the content of the program, the intent was to have the tasks completed daily, with 10 minutes of each activity. However, participants shared that there were mental, physical, and motivational struggles that came with completing the program. Comments from participants included:

It’s just been so difficult for me, trying to put my words onto paper.

I was too meticulous and before I knew it my 10 minutes were up.

Discomfort reading aloud to myself

Irritated throat when reading out loud and eyes hurt from reading on the page.

I mean one of the things we disliked about most was reading the problems out loud after we did the problem, so we really wondered was that very important because that led to a lot of frustration.

Committing

Committing was conceptualized from a set of codes that are grounded in the data. The codes that encompass committing included forming habits, sticking to it, supporting, needing community, continuing, and growing. Committing is grounded in the different ways participants found their own reasons for continuing the StrongerMemory program during the research protocol and after the research protocol was complete. For example, many of the participants discussed how forming habits around completing the program every day helped them to stick with the exercises for all 12-weeks. The participants mostly discussed how having a schedule to complete the exercises helped to keep them on track during the research protocol. One participant said: “I do it in the morning. I usually have breakfast and spend the next hour or so reading the paper. And I do that, and I usually then just do the math at the same time.” Like this participant, many others expressed that completing the exercises at a particular time of day helped them to keep up with the program. While the time of day varied for many, the act of embedding the program into their schedules did help several participants stay on track.

Another way participants spoke on their commitment to the program was through the community aspect of their weekly StrongerMemory meetings. Participants shared how important it was to have others around them as a level of support during the 12-week program. One participant commented:

The biggest reality has been how close we have become. And how we’re rooting for each other in every way, not just memory wise and we just meet for that half hour, but it’s really important, and some of us are slackers like me. And our leader, the leader in the group I’m in, in the mid-week she sends us something funny to remind us to do StrongerMemory. You know, she sends us an email and I’m usually, I always do that next.

This was a common sentiment within the focus groups, with many different participants indicating that they had others within their weekly groups that helped give them general encouragement to keep up with the program. Having a group of people to rely on and encourage their improvement kept this participant, as well as others who had similar sentiments, engaged in the StrongerMemory Program. Many participants expressed that they would choose to continue the program, even if they do not do it as often or just focus on specific exercises. One participant said: “Let’s face it, my problems aren’t going to go away. So, next semester, we’ll be doing it again.” Another participant expressed, “I feel that as far as continuing, I will probably do this forever.”

Enhancing

The final theme that emerged was enhancing. Enhancing includes ways in which participants adapted the program to fit their needs and suggestions on how to improve the program. There were a variety of ways in which participants adapted the exercises, in particular the math exercises and writing exercises. When it came to writing prompts some participants preferred to personalize the topics and when it came to math exercises, some participants found a way to reuse the math sheets by using plastic covers and markers, to avoid running out of printed math sheets:

One thing helpful about the math, is that, for me, it’s good to start with something that’s very easy, you know, it kind of gets you in a rhythm. So I usually start out by erasing the previous numbers that I had. Of course I’ve gone all through the sheets, now I’m going through it either the second or third time that I’m erasing. I do four pages, and erase four pages, and then write them in. And then do the answers.

Participants had a wider choice when it came to reading. For example, some enjoyed reading the Bible, while others enjoyed reading the newspaper. Others used tools such as charts and calendars to schedule time to complete exercises. Some used stopwatches to time their math exercises, others took notes in cursive.

Participants formed groups which served as motivators to complete the exercises but also as a source of support and a source of fun and positivity. For example, during the COVID-19 pandemic, the weekly meetings served as a social activity, which alleviated feelings of isolation and depression:

The one thing that I found that was very positive for me was that we met once a week and um, as a group to talk about the challenges and what types of rewards we were receiving and that by far was one of the greatest things for me, the fact that we met and visit with each other once a week.

Some participants offered their opinion on how to enhance the research by suggesting areas of focus. For example, a suggestion was made to determine the average time it took participants to notice an improvement. Another suggestion was to partner with the medical community working on mental health to uncover any insights into brain functioning. It is important to note that most participants held advanced degrees, and this may have prompted them to provide advice on research and data collection, as well as inquire into the background of the StrongerMemory program.