Effect of a structured course involving goal management training in older adults: A randomised controlled trial

Abstract

Objective

The objective of this study was to investigate the effects of a structured 6-week neuropsychological course on the executive functioning of older adults with cognitive complaints.

Methods

A randomised controlled design was used involving 69 community dwelling individuals aged 55 years and older. Both objective and subjective measures were included to assess executive functioning. General linear model with repeated measures analysis of variance was used to examine the intervention effects.

Results

After the intervention, the participants in the intervention group were significantly less annoyed by their cognitive failures, were better able to manage their executive failures and reported less anxiety symptoms than those in the waiting list control group.

Conclusion

These findings indicate that a combination of psycho-education and training has the potential to change the attitude of older individuals towards their cognitive functioning.

Practice implications

Because this training focussed on cognitive functions that are among the first to decline in older adults and the subjective evaluation of the people after training was quite favourable, the proposed intervention may be considered a valuable contribution to cognitive interventions for older adults.

Introduction

Most cognitive functions decline with age. Working memory functions less well [1], inhibitory mechanisms become less efficient [2], [3], and performance in dual task situations is reduced [4]. Working memory, inhibition, and shifting between two tasks are frequently seen as aspects of executive functioning [5]. This is important because executive functioning is a basic condition for everyday functioning of older adults and poor executive functioning may be a threat to independent living and successful aging [6], [7], [8]. For example, older people may experience difficulties in planning their leisure time activities, managing their finances, coping with novel situations, or learning to deal with new strategies and procedures, such as using computers, Internet services, cellular phones and other electronic devices. All these activities require that the proper goal is selected and maintained in memory while the task is executed. In addition, when performing such complex tasks, it is important to be able to divide a task into simpler tasks and to set priorities for the execution of subordinate goals [9], [10]. Although many older adults experience difficulties with planning activities, the effect of behavioural interventions to improve these cognitive functions in older adults has not been a focus of much research. Most interventions for older individuals directed at improving cognitive functioning, also called neuropsychological interventions, focus on memory functioning and recently also memory self-efficacy [11], [12]. It is therefore a challenging opportunity to examine whether older individuals benefit from an intervention directed at executive functions, notably organization and planning of activities in daily life.

The intervention protocol of goal management training (GMT) [13], was originally developed to teach patients with brain injury a strategy to improve their ability to plan activities and to structure intentions. The GMT was based on the theoretical framework of disorganization of behaviour [9], [14]. This theory states that any line of activity requires a list of goals or task requirements that are used to create a structure of actions or mental operations by which these goals are achieved. In performing a task, the current state of affairs and the goal state are compared, and appropriate actions or mental operations are selected in order to reduce any mismatch. This process continues until there is no mismatch between the current state and the goal state. Given that the number of actions that can actually be performed at any one time is limited, it is important to inhibit irrelevant actions that will not contribute to a particular goal. The GMT contains several stages that are based on this notion. First, participants have to be aware of the current state of affairs (“stop”). Then the appropriate goals have to be selected (“what do I have to do?”), and if needed goals have to be partitioned into subordinate goals (“split”). In the final stage (“checking”), the outcome of the selected actions is compared with the goals to be achieved.

The GMT has been evaluated in 30 patients with mild to severe brain injury, who were randomly assigned to groups who received GMT or motor skill training. Participants who followed the GMT showed significant gains on everyday paper-and-pencil tasks designed to mimic tasks that are problematic for patients with problems in executive functioning [15]. The problems and topics used in the original GMT are also applicable to older adults without clear cut brain dysfunction or psychopathology, because older adults show reduced performance on executive functioning tasks, which may impact their daily life functioning. We developed a dedicated structured course based on the GMT for use in older adults. The adapted course consists of 12 sessions (two sessions per week). Apart from the original GMT, psycho-education was added to the adapted intervention in order to provide information to the participant about cognitive functioning in general and the mechanism behind failures in daily life in particular. The adapted intervention was tested according to a randomised waiting list control design [16], [17], [18]. The success of this intervention was evaluated in terms of its effectiveness in (1) reducing complaints and cognitive failures, (2) reducing mood related complaints and (3) in improving objective cognitive functioning. The effectiveness of the intervention was evaluated on cognitive complaints and failures, because the focus of the intervention is on real life activities that emphasize complaints and problems experienced by the participants. Furthermore, there is much evidence available that subjective evaluation of cognitive functioning does not always predict objective test performance [19], [20], [21]. Therefore, we evaluated the effectiveness of the intervention both on self-reported problems and cognitive test performance. It is important to investigate anxiety symptoms and mood, because these emotional states may influence or be influenced by cognitive complaints and subjective attitudes toward cognitive functioning. This is in line with a controlled intervention study that indicated that an experimental neuropsychological intervention program significantly reduced mood-related complaints [22]. During the course, participants practised activities encountered in real life with emphasis on the complaints and problems experienced by the participants. We therefore expected that the training would have most impact on complaints and cognitive failures participants experienced.