Development of an integrative learning program for community dwelling old people with dementia

Objective: to develop an integrative learning program for people with dementia. Method: a methodological study was conducted using Delphi technique to develop the learning program, followed by a feasibility test. An expert panel was invited to develop the integrative learning program based on the neuroplasticity and learning framework. A feasibility test was conducted to evaluate the implementation of the program in two centers after the training of personnel who run the program. Verbatim transcripts of case conferences were coded, analyzed, and collapsed into themes and sub-themes by consensus. Results: there was no indication for content modification during the period of program implementation. Qualitatively, the participating older adults showed improvement in communications, emotions, connectedness with self and others, and well-being. Conclusion: the integrative learning program was uneventfully implemented with promising results. The program is ready for full-scale research on its efficacy in multiple centers to obtain more robust evidence.


Introduction
Caring for the elderly with dementia is a global challenge. About 5% of the world's elders (47 million) suffered from dementia and it was estimated that this will rise to 75 million in 2030 and 132 million by 2050 (1) .
In other words, there will be one new case of dementia diagnosed globally every 3 seconds. The severity of the problem can be seen by taking China as an example because it has the largest population with dementia in the world (2) . The prevalence of senile dementia (among people aged 65 or above) was rising, from 5% in 2013 to 5.56% in 2017. Taking the Chinese Mainland, Hong Kong, and Taiwan together, it was reported that the number of people aged 60 or above suffering from dementia was as high as 9.48 million in 2018 (3) . The estimated measures respectively (3) . Since China has comparatively quite high dementia prevalence rate, its huge population size will bring huge number of dementia patients with heavy burden on the community. In view of this global problem, the WHO has considered dementia as a global public health priority (4) and taken measures to help countries to contain the problem.
The number of healthy years [disability-adjusted life years (DALY)] lost is tremendous as dementia is the fifth leading cause of death globally. It was reported that about 28.8 million [95% uncertainty interval (UI) 24.5-34.0] DALYs lost were attributed to dementia (5) .
Dementia also has devastating impacts on sufferers' families and friends. Family members are often the main caregivers for people with dementia. It is an unpaid and round-the-clock job that causes not only physical and psychological exhaustion, but also a huge financial burden. It was reported that the loss of wages for being unpaid caregivers at home was forecasted to increase from $5 billion Canadian dollars in 2008 to $55 billion Canadian dollars in 2038 (6) . Besides the wage loss, there are also high intangible costs to caregivers in taking care of people with dementia as stress, fatigue, depression, and anxiety set in.
From a societal perspective, the impact of dementia on social healthcare expenditure and demand for nursing services cannot be underestimated as well. As reported, the total global expenditure on dementia treatment in 2015 was US$818 billion (7) . It was projected this will increase to US$2 trillion by 2030. Similarly, another study estimated that the annual economic losses caused by dementia in mainland China alone was 83.5-97.4 billion Yuan, and the consumption of cognitive related health services reached 51.3-59.8 billion Yuan a year (8) .
The pathogenesis of dementia is complex and scientists are still unraveling its myths from different perspectives, including physiological mechanism of the disease, neurology, behavioral performance, and other associated aspects (9)(10) . Up to now no conclusion has been reached and the most controversial debate of all is whether dementia is caused by the dysfunction of the neural circuits in the brain (11) or the malfunction of the cerebrovascular system (12) . Supporters of the dysfunction in the brain's neural circuits believe that the harmful signals of neuritic plaques and nerve fiber entanglement in certain areas of the brain cause the gradual degradation of the brain's cholinergic system, so they are more inclined to use galantamine drugs to enhance the functions of the sufferers' cholinergic system (13) . On the other hand, for those who believe it is the dysfunction in the cerebrovascular system, they believe that high homocysteine affects the blood vessel systolic reactivity of the cerebral artery which in turn leads to cognitive decline and neuro degeneration, so people are advised to take folic acid and vitamin coenzyme to reduce homocysteine levels (14) . However, the current pharmacological approach can only delay the progress of the disease. Drug therapy does not cure dementia (1,4) .
In recent decades, scientists and clinicians have been exploring various non-pharmacological treatments for dementia to reduce disability, alleviate and/or manage behavioral and mental symptoms so as to improve the quality of life of the affected people and their caregivers (2,6,15) . So far, no effective treatment has been identified (1,4) .
At present most, if not all, care models adopt a biomedical approach to manage dementia. Most dementia programs are western medicine oriented, e.g., reality orientation, reminiscence therapy, multisensory stimulation, daily life skills training, and music therapy; complementary approach such as inclusion of Chinese medicinal approach has yet to be adopted.
By taking these experiences into consideration, the team attempted to apply the concept of neuroplasticity and learning to dementia care on the premise that people have the capacity to learn new things through repeated practices. In other words, they can rebuild their capacity gradually through the process of slow stream rehabilitation.
Recent studies supported that the brain is plastic (16)(17) , which means brain cells can change their structure and functions according to the conditions required. In vivo, studies showed that the physical brain structure of mice changed through what they did in their daily experiences Wong TKS, Yang Y, Chen J, Lee CKM, Zhou Y, Jiang L, Tang Q, Chung JWY.
in enriched environments (18) . All brain cells, including those in damaged brains, have neuroplasticity (19) and especially adult neurons are capable of neurogenesis (16) .
The adult brains have huge latent plasticity and it is believed that repeated practice can lead to re-organization of the cerebral networks which can enhance functional performance through intense training (20) .
Learning is a process of acquiring skills, knowledge, attitude and values. The "learnt" experiences would mold the brain through neuroplasticity. Thus, neuroplasticity is vital to learning as new neurons are formed in the hippocampus and cerebellum of the adult brain through neurogenesis, and thus, new memories are created and older memories may be modified (21) . The brain can be rewired just by learning, thinking, and practicing. One way to achieve the change is to activate learning through goal setting and practices in a positive mindful manner in the pursuit of rewards while the brain is creating new paths (16)(17) ; and it is always desirable to have a positive environment for neuroplasticity to emerge and learning to take place, when the medial pre-frontal cortex is associated with a healthy, happy, and positive attitude which can be brought about by coming back to the present moment through mindfulness, a way to exercise the pre-frontal cortex (22)(23) . To further enhance the change, learning, an application of mindfulness, has been shown to increase the flexibility and attention in learning (24) and the learners' connectedness to the surroundings (25)(26) .
To bridge the knowledge and practice gap in current dementia care, we determined to develop an integrative learning program based on the concept of neuroplasticity and learning. It is hoped that the program will help old people with dementia manage their symptoms using a transdisciplinary approach. We can learn new things (e.g. skills, emotions and cognition) in the presence of innate neuroplasticity. The learning can be conducted in combination of group and personal contact. Group learning allows interaction and stimulation while person-centered learning accommodates individual needs. To have learning to occur, we need to repeatedly practice which optimizes our neural networks based on the neuroplasticity. Therefore, the aim of the study was to develop the integrative learning program for people with dementia.

Method
This was a methodological study in which an integrative learning program based on the neuroplasticity and learning framework was developed by an expert panel using the Delphi technique, followed by a feasibility test on its implementation using a qualitative approach. Individual interviews with the participants and thematic analysis of verbatim transcripts were carried out. Ethics approval were obtained from the Research Ethics Committee on Human Subjects of the funding agency before the commencement of the study.   Based on the outcome of the above Delphi exercise, the experts brain-stormed the contents and details of each, followed by discussions before resolutions were made by consensus. Consensus was reached for the duration of a standard 3-day protocol and 5-day protocol.

The development of the integrative learning program
The 5-day protocol was an extended version of the 3-day one, which allowed the participants to practice more in a designated time. Figure

Results
The result of the integrative learning program which was reported above for easy reference. The protocol developed from the program was closely followed by the case managers and there was no indication for change throughout the implementation period.
The demographic data showed no significant differences in gender and age between the 2 centers.
But there were statistically significant differences in educational level (p = 0.006) and duration of dementia (p = 0.001) between the 2 centers (Table 1).

Feasibility testing of the integrative learning program using a qualitative approach
The feasibility test which lasted for 6 months was  Mann-Whitney U Test was used due to small sample size; § All p-values were considered as statistically significant when p 0.05 learning. Figure 3 shows the results of the content analysis.
To ensure the trustworthiness of the analytic process, the team had invited three experienced aged care practitioners (each with at least 5 years of experience in aged care) to join in as content experts to verify the results after the subthemes were identified. They discussed the contents, subthemes and themes until they reach a consensus.

Means of expression
Gradual increase in oral expression skills, eye contact, and facial expression, and vocabulary, volume. More eye contacts and facial expressions.

Confidence in expression
Able to participate in group activities throughout the process and were happy to cooperate in all training activities.   self is reflected through their behaviors. Therefore, the key to providing good care to people with dementia is to have a shared understanding of mutually acceptable goals among the case managers, caregivers and the old people concerned. This shared understanding means everyone needs to take an active role in the program, not just the recipients of care -the old people (15) . Also, it is crucial that the case managers, caregivers and the old people have the same understanding of the old people's "self".  Given this is only a feasibility testing, the research team considered more robust and full scale evaluation of the program necessary and essential for better acceptance.
The integrative program may exemplify the contributions of nursing to meet health needs where the demand is growing using a nurse-led model of care.