The Effects of a Nonpharmacological Intervention Practice for Older Adults with Mild Cognitive Impairment and Their Family Caregivers in China

ABSTRACT

Mild cognitive impairment (MCI) marks a critical phase in the progression to dementia. In our study, social workers utilized the Multicomponent Nonpharmacological Intervention Approach (MCNIA) to aid MCI participants (N = 52) and their caregivers, dividing into intervention and control groups. The intervention group underwent an additional regimen of non-pharmacological therapies besides pharmacological treatment. Our findings highlighted that: 1) MCNIA significantly enhanced cognitive and daily living abilities in the intervention group; 2) Caregivers experienced reduced burdens and improved social support; 3) Correlation analyses involving biomarkers indicated that MCNIA was particularly effective in alleviating depression in those with slightly more severe cognitive impairment.

KEYWORDS:

• Mild cognitive impairment
• MCNIA
• care burden

Introduction

With the accelerating demographic shift of aging pace in China, cognitive impairment ranks among the top 10 contributors to chronic disease-related mortality in older adults, with a rising number of affected individuals (Qin, 2015). Mild Cognitive Impairment (MCI), recognized as a transitional stage between normal cognitive function and dementia, presents an opportune period for preventive intervention (S. W. Li, 2006; Patterson, 2018). Non-pharmacological interventions, gaining widespread recognition for their advantages of a low risk profile and ease of implementation, are becoming prominent in various interventions (Stewart et al., 2017).

Scholars exploring non-pharmacological interventions for cognitive impairment have shown promising results. Greenaway et al. (2013) demonstrated that systematic training for MCI participants, focusing on memory support systems, effectively decelerates memory decline and enhances daily life functioning. Buschert et al. (2011) implemented a six-month collective intervention, including memory stimulation, psychomotor recognition, and social interventions, resulting in significant improvements in overall cognitive function. The latest report from The Lancet Commission emphasizes the potential benefits of diverse non-pharmacological interventions, such as cognitive training, physical exercise, and other activities, in mitigating neurological symptoms for individuals with dementia (Livingston et al., 2020).

Numerous emerging therapies and their practical applications have shown the effects of non-pharmacological interventions in ameliorating mild cognitive impairment, by blending aspects of medicine, psychology, and art (Author et al., 2022). Music therapy can be categorized into two forms based on the mode of intervention, namely receptive music therapy and active music therapy (Zheng et al., 2003Yin, Gao & Ouyang, 2018). Creative story therapy, emphasizing a person-centered approach, involves crafting stories by guiding elderly individuals to observe images and employ their imaginations. Facilitators prompt seniors with questions about time, place, characters, events, causes, processes, and outcomes to stimulate their creativity (Teng & Cheng, 2021). Reminiscence therapy utilizes memory aids like photo albums, old objects, music, and, increasingly, electronic media such as videos and photos. These aids serve to trigger reminiscences and evoke positive memories (L. Bai & Yu, 2019). Touch therapy involves physical contact with the patient’s body, triggering the release of enkephalin and endorphins in the brain, which counteract cortisol, thereby reducing pain and anxiety. This therapeutic approach fosters mental and physical relaxation, promoting symptom relief (Cai & Zhang, 2015; Zhao & Zhang, 2017).

Additionally, there is a growing trend of incorporating modern technology and culture into non-pharmacological interventions in China. These innovative approaches include pet therapy and robot pet therapy (M. Y. Li, 2016), virtual reality technology therapy (Mu et al., 2018), and phototherapy (L. Wang et al., 2019). China has also integrated traditional Chinese medicine with cultural characteristics to develop non-pharmacological interventions for cognitive impairment. Examples include cluster needling at scalp points (Sa et al., 2019) and emotional zone acupuncture (M. Zhang et al., 2019).

However, intervention studies for MCI normally focus on single or combined therapies, and to the best of our knowledge there is little exploration of the effects of the Multidimensional Non-Pharmacological Intervention Model (MCNIA) for MCI participants. On the other hand, the effects of therapies are generally measured using scales, and there is a lack of corresponding objective indicators for verification. Given the favorable results observed in our pilot studies, we have chosen to investigate the efficacy of MCNIA (Multi-Component Non-Pharmacological Intervention Approach). This approach primarily integrates music intervention, touch therapy, creative story therapy, reminiscence therapy, cognitive training, and various other therapeutic modalities. Additionally, we have incorporated non-pharmacological intervention tools such as finger exercises, Schulte formulas, and mindfulness meditation. To provide objective measures of progress, biomarkers have been introduced as control variables.

Moreover, owing to the unique nature of cognitive impairment, individuals with Mild Cognitive Impairment (MCI) are deeply intertwined with their families, relying on caregivers for daily assistance (Author et al., 2023). This dependency on caregivers can, to some extent, heighten the burden placed on these caregivers. The physiological and psychological challenges experienced by caregivers due to this burden can, in turn, impact the quality of life of the individuals with cognitive impairment and potentially hasten the progression of the disease (Koca et al., 2017). Hence, when investigating individuals with MCI, it is imperative to include caregivers in non-pharmacological interventions, transitioning from individual-focused interventions to comprehensive family and group interventions, thus enhancing the overall efficacy of the interventions.

Currently, research on caregiver burden primarily revolves around identifying influencing factors and examining the current state of caregiver burden, as well as the multifaceted factors influencing it. Studies have revealed that various factors, including gender (Park et al., 2015), access to external support resources (Chappell et al., 2015), levels of social support (Bastawrous et al., 2015), economic status, cultural background, and personal attributes (Pudelewicz et al., 2019), can all contribute to caregiver burden. In efforts to alleviate caregiver burden, Chinese scholars have explored potential intervention approaches such as family dignity intervention (X. Bai et al., 2020), health education (L. Li, 2009), and coping skills intervention (Yang et al., 2013), among others.

However, it is crucial to recognize that the primary source of caregiver burden stems from the cognitive impairment of the care recipient. Should the care recipient’s condition remain unimproved, caregiver burden will continue to accumulate and intensify. The physical exhaustion and emotional distress exhibited by caregivers due to this burden can, in a cyclical manner, affect the quality of life of the individuals they are caring for (Livingston et al., 2020), potentially hastening the progression of their cognitive impairment. Consequently, there is a compelling need to incorporate both MCI participants and caregivers into the intervention approach, with an exploration of the impact of integrated social work interventions on the well-being of both parties.

Built on the foundation of evidence-based practice, this study endeavors to scrutinize the impact of MCNIA on both individuals with MCI and their caregivers. The unique design of this study places MCI participants as direct recipients of the intervention, while caregivers assume an indirect role. All caregivers of the intervention group observed the intervention process and learned the treatment skills from social workers. We assumed that the entire procedure would serve as a healing process for MCI participants, and an empowering process for their caregivers. Consequently, the primary objectives of this investigation are twofold: 1) the effect of MCNIA on MCI participants, aims to enhance the cognitive, physiological, and social support; 2) whether interventions tailored for MCI participants can effectively alleviate the caregiving burden, enhance caregivers’ self-efficacy, and expand their social support networks.

Methodology

Participants

This study was collaboratively conducted in partnership with the neurology department of a prominent hospital in Shanghai, China. The memory clinic’s participant database was employed to identify MCI participants meeting the specified criteria. Recruitment efforts were carried out through outpatient unit interactions, phone outreach, and promotional activities within WeChat (Chinese instant messaging and social media app) groups.

Based on the examination of the Mini Mental State Examination (MMSE) score (21–27) and the Montreal Cognitive Assessment (MOCA) score (16–25) together with diagnosis descriptions by doctors, a total of 154 MCI participants were initially identified. After excluding those individuals who could not participate in the intervention for various reasons (See Figure 1), the final recruitment comprised 52 MCI participants. These participants were stratified into the intervention group (27 participants) and the control group (25 participants). Notably, each MCI participant was accompanied by a family member throughout the intervention process. In the study’s pretest and posttest phases, 39 participants successfully completed both assessments, with 20 individuals in the intervention group and 19 in the control group. This represented an overall attrition rate of 25%.

Figure 1. Sampling and intervention process.

Research design

Utilizing a quasi-experimental research design, MCI participants and their family members were categorized into either intervention or control groups based on their preferences. Both the intervention and control groups received standard medication treatment and health guidance from a lead neurologist. In addition, the intervention group underwent multidimensional non-pharmacological interventions. This inclusive approach encompassed not only MCI participants but also their accompanying caregivers, who actively participated in the non-pharmacological interventions. Consequently, caregivers belonging to the control group were categorized into a separate caregivers’ control group. Data collection and analysis were conducted both before and after the intervention, encompassing MCI participants and their caregivers in both the intervention and control groups.

Intervention approach

The MCNIA practice approach embraces a multi-faceted non-pharmacological intervention model, centering on the amalgamation of music therapy, touch therapy, creative storytelling therapy, reminiscence therapy, cognitive training, and other therapeutic modalities. This core intervention strategy is augmented by the inclusion of non-pharmacological tools like finger exercises, Schulte puzzles, and mindfulness meditation, culminating in the creation of an eight-session comprehensive intervention plan.

These intervention approaches were selected on the basis of empirical research, and they were formulated by considering the feasibility of implementing social work interventions according to the evidence from the research team’s pilot study. First, the acceptances from the participants were evaluated, and the implementation sequence followed a progression from basic to more complex, from simple to challenging, and was determined in alignment with the natural sequence of stimulation to human nerves. Second, the objective was to assess whether these protocols are easily transferrable by other people or can be readily disseminated. The intervention steps have been attached as an Appendix.

The researchers implemented a 2-month, 8-week multi-dimensional non-pharmacological intervention for the paralleled intervention groups from May 2022 to October 2022, with a frequency of once a week. The intervention group was divided into three groups of 9 people, each based on participant preferences, and the interventions were carried out on Monday afternoons from 2:00 pm to 3:00 pm, Tuesday afternoons from 2:00 pm to 3:00 pm, and Thursday mornings from 9:30 am to 10:30 am. The control group received regular medical care as usual.

Data collection

Questionnaire surveys were collected from all participants at baseline and after the intervention for both participants and caregivers. In addition to cognitive decline, individuals with cognitive impairment often experience a reduction in their ability to perform self-care tasks, negative mood (Karkou & Meekums, 2017), diminished sleep quality, and impaired social functioning. These adverse effects tend to worsen as cognitive impairment progresses, as noted in the research conducted by Y. Wang et al. (2022). Hence, beyond evaluating the cognitive status of MCI participants, the study’s broader objectives encompass the assessment of their daily living capabilities, sleep patterns, psychological well-being, and levels of social support through the application of diverse assessment instruments. The Activities of Daily Living (ADL) scale was employed to gauge functional abilities, while the Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality. To assess depressive symptoms, the Geriatric Depression Scale (GDS) was administered, and the Social Support Rating Scale (SSRS) was utilized to measure the level of social support available to participants.

In parallel, caregivers of the MCI participants provided demographic and socioeconomic information through a self-designed questionnaire. Additionally, their caregiver burden was assessed using the Caregiver Burden Inventory (CBI). Furthermore, the Social Support Rating Scale (SSRS) and the General Self-Efficacy Scale (GSES) were employed to gauge the levels of social support and general self-efficacy among caregivers. These comprehensive assessments contribute to a holistic understanding of the impact and effects of the intervention on both MCI participants and their caregivers.

The scale questionnaire assessments were administered by two experienced and trained social workers who always promptly addressed and clarified any inquiries from participants or their family members, in order to avoid misunderstandings. Subsequent to the questionnaire completion, thorough checks were carried out to promptly rectify any missing or inaccurate responses.

Instruments

A self-administered questionnaire was utilized to gather general demographic information and measures of relevant variables.

Scales for MCI participants

Mini-Mental State Examination (MMSE) & Montreal Cognitive Assessment (MoCA)

The cognitive functioning of MCI patients was evaluated using the MMSE and MoCA scales (Folstein et al., 1975). Each scale comprises 30 questions, with one point assigned for compliant responses and no points for non-compliant responses, out of a total of 30 points. Higher scores on the MMSE (Cronbach’s α = .813) and MoCA (Cronbach’s α = .826) indicate better cognitive functioning. A score of < 27 on the MMSE and < 26 on the MoCA is indicative of memory impairment (Arevalo-Rodriguez et al., 2015; Chand et al., 2022).

Activity of Daily Living Scale (ADL)

Developed by Lawton in 1969, the ADL scale (Cronbach’s α = .759)assesses the ability of elderly individuals to live independently daily. A score of ≤ 26 is considered essentially normal, while a score of > 26 suggests varying degrees of decline in daily functioning. A higher score indicates a more pronounced decline in the ability to perform daily living tasks (Lawton & Brody, 1969).

Pittsburgh Sleep Quality Index (PSQI)

Compiled by Buysse, the PSQI scale (Cronbach’s α = .896) consists of 19 items in 7 dimensions, scored on a 4-point scale. A higher total score indicates poorer sleep quality. With a cutoff score of 7, PSQI ≤ 7 signifies good sleep quality, while PSQI > 7 indicates poor sleep quality (Jia et al., 2019).

Geriatric Depression Scale (GDS)

Developed by Brank et al. in (1982), the GDS (Cronbach’s α = .830) screens for depression in old age. Comprising 30 items, a higher score indicates a higher level of depression (Wongpakaran et al., 2019).

Social Support Rating Scale (SSRS)

In this study, the version prepared by Xiao Shuiyuan in 1986 was employed (Cronbach’s α = .825). With 10 entries divided into three dimensions and a four-level scale, a higher score reflects a better degree of social support (Xiao, 1994).

Scales for MCI Participants’ Caregivers

Caregiver Burden Inventory (CBI)

Scored on a 5-point scale, the CBI (Cronbach’s α = .782) comprises 24 entries assessing the burden of care imposed by MCI patients. A lower score indicates a greater burden of care (H. Z. Zhang et al., 2008).

General Self-Efficacy Scale (GSES)

Originally developed in 1981 by German psychologists Ralf et al., the GSES was later improved and reduced to 10 items. Using a 4-point scale, higher scores on the GSES (Cronbach’s α = .866) indicate greater self-efficacy (Schwarzer et al., 1995).

Social Support Rating Scale (SSRS)

Same as above (Cronbach’s α = .825).

Data analysis

The study employed independent samples t-tests and chi-square tests to compare baseline indicators between the MCI intervention group, their caregivers, and the control group. This was done to ensure the two groups were similar and comparable before the intervention. Table 1 below presents the baseline information of MCI participants. Additionally, independent sample t-tests were utilized to assess intergroup differences, including changes in scale scores between the control and intervention groups, as well as variations in biomarkers within the intervention group. To confirm pre- and posttest changes, paired sample t-tests were conducted. We summarize the pre- and posttest analysis results of both MCI participants and caregivers in Table 3, while the results of intergroup differences assessment for MCI participants and caregivers are presented in Table 4.

Table 1. MCI patients’ baseline information.

Category	Intervention group	Control group	t/χ^2	p
	(n = 20)	(n = 19)
Age	72.20 ± 6.23	74.58 ± 7.88	−1.049^a	0.126
Gender
M	7 (35%)	9 (47%)	0.616^b	0.433
F	13 (65%)	10 (53%)
Education
PriSch	2 (10%)	3 (16%)	0.743^b	0.267
JunSch	6 (30%)	4 (21%)
VocTra	6 (30%)	7 (37%)
College	6 (30%)	5 (26%)
MMSE	24.50 ± 2.50	25.42 ± 2.46	−1.159^a	0.704
MoCA	18.60 ± 2.60	19.53 ± 3.01	−1.030^a	0.633
ADL	16.65 ± 2.11	15.42 ± 2.01	1.827^a	0.883
GDS	12.25 ± 5.31	8.00 ± 6.48	2.245^a	0.445
PSQI	6.20 ± 4.73	6.67 ± 4.51	−0.310^a	0.873
SSRS	33.20 ± 6.48	33.95 ± 8.01	−0.320^a	0.609

Note: Subscript “a” represents independent samples t-test, and subscript “b” represents chi-square test. Continuous variables are expressed as mean ± standard deviation, while categorical variables are expressed as frequency (percentage). The significance level α is 0.05, and when p < .05, the difference is considered significant.

Results

Results show that all p-values were > .05, indicating no significant differences between the two groups at baseline, and the two groups were comparable. Table 2 presents the details.

Table 2. MCI Caregivers’ baseline information.

Category	Intervention group	Control group	t/χ^2	p
	(n = 18)	(n = 19)
Age	67.17 ± 11.56	59.63 ± 12.76	1.880^a	0.406
Gender
M	9 (50%)	9 (47%)	0.026^b	0.873
F	9 (50%)	10 (53%)
Marital Sta
Married	17 (94%)	17 (89%)	0.307^b	0.580
Single	1 (6%)	2 (11%)
Employment
Working	3 (17%)	9 (47%)	3.976^b	0.079
Retired	15 (83%)	10 (53%)
Edu level
PriSch	1 (5.5%)	0 (0%)	4.116^b	0.533
JunSch	5 (28%)	4 (21%)
VocTra	7 (39%)	6 (32%)
College	5 (26.5%)	9 (47%)
Self-reported health
Not well	1 (5.5%)	0 (0%)	1.456^b	0.692
Acceptable	10 (56%)	13 (68%)
Good	6 (33%)	5 (26%)
Very good	1 (5.5%)	1 (6%)
Monthly income
3000–3999 RMB	0 (0%)	3 (16%)	3.642^b	0.162
4000–4999 RMB	4 (22%)	2 (11%)
5000 RMB+	14 (78%)	14 (73%)
CBI	65.17 ± 12.05	51.26 ± 12.11	1.924^a	0.121
SSRS	34.44 ± 8.73	37.89 ± 7.20	−1.315^a	0.521
GSES	24.33 ± 5.19	23.63 ± 6.53	0.361^a	0.411

Subscript “a” represents independent samples t-test, and subscript “b” represents chi-square test.

Both independent samples t-test and chi-square test were performed separately to the analysis. The results in Table 2 show that all p-values were greater than .05, indicating no significant differences in baseline data between the MCI participant caregiver intervention group and the control group.

The intervention effect of MCNIA for MCI participants

The intervention effect of MCNIA on MCI participants was assessed through paired-sample t-tests, conducted on the pre- and post-intervention scores for each indicator within both the intervention group and the control group. In the intervention group, statistically significant changes were observed in the MMSE score (p < .01), MoCA score (p < .001), ADL score (p < .001), and GDS score (p < .001) as presented in Table 3. These findings indicate a significant enhancement in cognitive and daily living abilities, coupled with a reduction in depression levels. Conversely, there were no notable alterations in PSQI scores or SSRS scores in the intervention group, nor in any of the respective index scores within the control group.

Table 3. Paired sample T-test among intervention group and control group.

		Intervention Group(n = 20)			Control Group(n = 19)
Variable	Test	Mean ± SD	t	p	Mean ± SD	t	p
MMSE^P	Pre-test	24.50 ± 2.50	−3.36	0.003**	25.42 ± 2.46	1.661	0.114
	Post-test	26.05 ± 1.73			24.42 ± 3.29
MoCA^P	Pre-test	18.60 ± 2.60	−3.94	0.001***	19.53 ± 3.01	−1.507	0.149
	Post-test	21.00 ± 3.15			20.58 ± 4.86
ADL^P	Pre-test	16.65 ± 2.11	5.548	0.000***	15.42 ± 2.09	0.924	0.368
	Post-test	14.70 ± 3.12			15.05 ± 2.30
GDS^P	Pre-test	12.25 ± 5.31	3.847	0.001***	8.00 ± 4.68	1.343	0.196
	Post-test	9.70 ± 3.63			5.95 ± 3.46
PSQI^P	Pre-test	6.20 ± 4.73	1.287	0.241	6.67 ± 4.51	0.790	0.440
	Post-test	5.30 ± 3.54			5.94 ± 4.01
SSRS^P	Pre-test	33.20 ± 6.48	−1.03	0.316	33.95 ± 3.08	0.637	0.532
	Post-test	34.25 ± 6.06			33.37 ± 6.91
CBI^C	Pre-test	65.17 ± 12.05	−4.919	0.000***	51.26 ± 12.11	1.073	0.297
	Post-test	78.11 ± 10.52			47.84 ± 12.65
SSRS^C	Pre-test	34.44 ± 8.73	−3.598	0.002**	37.89 ± 7.20	−0.922	0.369
	Post-test	39.00 ± 5.91			39.00 ± 6.88
GSES^C	Pre-test	24.33 ± 5.19	−3.621	0.002**	23.63 ± 6.53	−1.940	0.068
	Post-test	28.11 ± 5.09			27.89 ± 5.33

Note: *p＜0.05 **p＜0.01，***p＜0.001^P participant，^Ccaregiver.

To further analyze the disparities in changes across index scores between the intervention group and the control group, an independent sample t-test was conducted. The between-group differences in the changes of MMSE (p < .01), MoCA (p < .001), ADL (p < .001), and GDS (p < .05), as shown in Table 4, are significant, indicating that MCNIA had a significant effect on the differences in MMSE, MoCA, ADL, and GDS scores between the intervention and control groups.

Table 4. Changes between intervention group and control group.

	Intervention Group	Control Group
Variable	(n = 20)	(n = 19)	t	p
ΔMMSE^P	1.55 ± 2.52	−1.68 ± 3.73	3.19	0.003**
ΔMoCA^P	2.5 ± 2.97	−0.89 ± 3.12	3.48	0.001***
ΔADL^P	−1.95 ± 1.57	1.42 ± 2.69	−4.80	0.000***
ΔGDS^P	−2.55 ± 2.96	0.79 ± 4.68	−2.67	0.011*
ΔPSQI^P	−0.9 ± 3.12	−1.53 ± 4.41	0.51	0.611
ΔSSRS^P	0.95 ± 3.41	−0.74 ± 3.39	1.55	0.130
ΔCBI^C	12.94 ± 11.16	1.72 ± 5.67	3.80	0.001***
ΔSSRS^C	4.56 ± 5.37	0.56 ± 3.11	2.73	0.010**
ΔGSES^C	3.78 ± 4.42	5.06 ± 9.19	−0.53	0.599

^Pparticipant，^Ccaregiver.

The intervention effect of MCNIA for caregivers of MCI participants

Meanwhile, paired-sample t-tests were conducted on the pre- and posttests for both the intervention and control groups of caregivers, and the results are presented in Table 3. The changes in CBI scores (p < .001), SSRS scores (p < .01), and GSES scores (p < .01) within the intervention group were all found to be statistically significant. Subsequently, an independent sample t-test was performed to analyze the changes in CBI, SSRS, and GSES scores for both the intervention and control groups, and the results are outlined in Table 4. Significantly, there were notable differences in the changes of CBI scores (p < .001) and SSRS scores (p < .05), indicating statistical significance. Conversely, there was no significant difference in the change of GSES between the intervention and control groups (p > .05).

Analysis of the biomarker with the effect of MCNIA for MCI participants

Biomarkers are objective indicators of disease situations. In order to evaluate the effects of the MNCIA on MCI groups more accurately, the research team used blood samples of the 20 MCI participants to conduct analyses with the scale measurements. To ensure a balanced and comparable distribution of MCI participants who received the intervention, and to investigate the correlation between biomarkers and the score changes observed in MCI participants following the intervention, the median scores of MMSE and MoCA were used to divide the analysis groups. Participants below or equal to the median were grouped as intervention group 1 (n = 10), while participants above the median were designated as intervention group 2 (n = 10). Independent sample t-tests were performed for various indicators, including MMSE, MoCA, GDS, as well as Aβ42, Aβ40, Aβ/Aβ40, Tau, p-Tau, and NFL, for both intervention groups 1 and 2.

The results reveal a significant correlation within the intervention groups in the independent sample t-test for MoCA and GDS, whereas no significant correlations were observed for the other indicators, as outlined below. In the independent sample t-tests of MoCA and Aβ42, Aβ40, Aβ42/Aβ40, Tau, p-Tau, and NFL, the mean values of Aβ42, Aβ40, p-Tau, and NFL (p > .05) in intervention group 1 exhibited no significant differences when compared to intervention group 2. However, significant differences were observed in the mean values of Aβ42/Aβ40 (p < .05) and Tau (p < .01).

Similarly, in the independent sample t-tests of GDS with Aβ42, Aβ40, Aβ/Aβ40, Tau, p-Tau, and NFL, no significant differences were identified between intervention group 1 and group 2 in terms of the mean values of Aβ42, Aβ42/Aβ40, Tau, p-Tau, and NFL (p > .05), as illustrated in Table 5. However, a significant correlation was observed in the mean value of Aβ40 (p < .01), signifying a notable association between cerebrospinal fluid Aβ40 content and changes in GDS among MCI group members who underwent the same non-pharmacological intervention.

Table 5. Independent sample T-test of MoCA/GDS and Aβ42、Aβ40、Aβ42/Aβ40、Tau、P-Tau、NFL.

	Intervention G1	Intervention G2
Biomarkers	(n = 10)	(n = 10)	t	p
Aβ42^M	11.24 ± 2.56	11.87 ± 2.42	−0.522	0.762
Aβ40^M	271.22 ± 51.05	253.13 ± 110.64	0.442	0.057
Aβ42/Aβ40^M	0.043 ± 0.014	0.065 ± 0.058	0.939	0.049*
Tau^M	0.98 ± 0.07	0.75 ± 0.46	1.465	0.001**
p-Tau^M	2.11 ± 1.96	1.38 ± 1.51	0.858	0.253
NFL^M	27.38 ± 10.40	29.05 ± 12.01	−0.345	0.674
Aβ42^G	12.01 ± 2.11	11.01 ± 2.79	0.805	0.636
Aβ40^G	280.43 ± 33.91	244.58 ± 116.35	0.837	0.003**
Aβ42/Aβ40^G	0.043 ± 0.008	0.065 ± 0.059	−1.042	0.094
Tau^G	0.92 ± 0.21	0.75 ± 0.31	1.312	0.442
p-Tau^G	1.77 ± 1.97	2.11 ± 1.64	−0.376	0.723
NFL^G	28.28 ± 10.25	29.72 ± 12.25	−0.254	0.584

M: Group divided by median score of MoCA;G: Group divided by median score of GDS.

To delve deeper into this topic, under similar non-pharmacological interventions, we found significant correlations between the Aβ42/Aβ40 ratio and the Tau protein content in cerebrospinal fluid with cognitive changes in MCI group members. Specifically, a higher Aβ42/Aβ40 ratio and lower Tau protein levels were strongly associated with improved cognitive abilities in these individuals. Those individuals who demonstrated better cognitive improvement exhibited higher Aβ42/Aβ40 ratios and lower Tau protein levels.

Furthermore, it is noteworthy that as the Aβ42/Aβ40 ratio decreases, the severity of MCI tends to increase (Mizoi et al., 2014). Likewise, as the level of Tau protein increases, the severity of MCI also tends to escalate (Chen & Zhang, 2014). In the case of intervention group 2, the Aβ42/Aβ40 ratio and Tau protein levels were 0.022 and 0.23 lower than those in group 1, respectively, indicating that MCI’s overall severity in group 2 was less pronounced than that in group 1. Consequently, we can reasonably conclude that non-pharmacological interventions have a more pronounced effect on improving cognitive abilities in group members with relatively less severe conditions.

Additionally, group members who showed greater improvements in depressive mood exhibited higher levels of Aβ40 in their cerebrospinal fluid. Moreover, a lower Aβ40 level corresponded to a milder degree of MCI, while higher GDS (Geriatric Depression Scale) scores indicated more severe depressive symptoms among the elderly. The mean Aβ40 value in intervention group 1 was higher than that in group 2, suggesting that MCI was more severe in group 1. Conversely, the mean change in GDS was smaller in group 1, indicating that the intervention was more effective in alleviating depressive symptoms in this group. Consequently, it can be further inferred that under the same level of non-pharmacological intervention, the improvement in depressive symptoms is more pronounced among group members with a much higher degree of MCI.

Findings and conclusions

To summarize the research output, first, the multi-component non-pharmacological intervention program employed in this study effectively enhanced cognitive function and daily living abilities while reducing depression levels among MCI participants. Second, the multi-component non-pharmacological intervention program in this study effectively alleviated caregiver burden among MCI group members, and improved their social support levels. However, it remains inconclusive whether the non-pharmacological intervention significantly impacted the self-efficacy of the caregivers of MCI group members. Third, under identical intervention conditions, changes in the MoCA scores of MCI group participants were influenced by the Aβ42/Aβ40 and Tau protein levels in their cerebrospinal fluid. Additionally, MCI group participants who experienced greater improvements in depressive mood exhibited higher levels of Aβ40 in their cerebrospinal fluid. These findings illustrated that Multicomponent Non-Pharmacological Interventions (MNCIA) effectively enhanced cognitive and daily living abilities while alleviating depression levels in individuals with MCI. Additionally, for caregivers of MCI participants, non-pharmacological interventions contributed to reducing caregiving burdens and augmenting social support levels. Furthermore, the analysis of biomarker ratios among MCI participants revealed that non-pharmacological interventions had a more significant impact on improving cognitive abilities in participants with mild MCI symptoms, whereas they were more effective in ameliorating depressive moods among participants with severe MCI.

MNCIA integrates a range of therapies, including music therapy, cognitive training, reminiscence therapy, creative story therapy, and touch therapy, in a sequential and comprehensive intervention program. The effects of this program have been validated through practical implementation, offering both theoretical significance and practical value. Moreover, the incorporation of biomarkers as objective indicators within the field of non-pharmacological interventions compensates for measurement errors arising from regional and educational differences in assessments such as MMSE and MoCA, as well as mitigates the limitations of assessment tools characterized by the “ceiling effect.” Through independent sample t-tests, the predictive capacity of biomarkers such as Aβ40, Aβ42/Aβ40, and Tau proteins in gauging the improvement of MCI participants under the same level of intervention has been established, thus advancing the body of research evidence in this area.

Limitations and implications

This study, however, does have certain limitations that warrant consideration. First, resource constraints restricted the inclusion of a small sample size of individuals with Mild Cognitive Impairment (MCI). Moreover, all participants were drawn exclusively from the database of the same neurology department within a single hospital. Consequently, the generalizability and efficacy of the multi-dimensional non-pharmacological intervention program for a broader MCI population need further exploration. Additionally, due to the limited sample size, it was not feasible to conduct correlation and regression analyses to assess the potential relationships between changes observed in participants before and after the intervention and caregiver burden. In future research endeavors, expanding the sample size could facilitate the continuation of non-pharmacological interventions, enabling a deeper investigation into the impacts of such interventions on both MCI participants and their caregivers. Furthermore, this expanded sample size in future studies would allow for the exploration of potential connections between changes in MCI participants and caregiver burden, thus providing valuable insights into the broader implications of non-pharmacological interventions in this context.

To conclude, the study benefits the participants, the caregivers, and the social work practice. For participants with mild cognitive impairment (MCI), non-pharmacological interventions provide opportunities for social interaction. Through good communication with peer group members, the social support network of MCI participants is expanded, and their level of social support is improved. At the same time, various interventions in group activities can enhance the emotional connection between group members and caregivers, thus improving their cognitive functions. Weekly intervention activities also serve as motivation for group members to engage in outdoor activities, which can help improve their spatial orientation and daily life functions.

For caregivers, non-pharmacological group activities alleviate caregiving burdens by enhancing various abilities of MCI participants. Engaging with other caregivers within the group facilitates the formation of a caregiver alliance, allowing for the sharing of caregiving stress and the acquisition of comprehensive caregiving knowledge. This exchange contributes to an increased level of social support and an enriched overall caregiving experience. Social workers, serving as professional leaders of the group, play a crucial role in promptly identifying emotional issues among group members. They employ professional social work methods to provide individual interventions that address anxiety, depression, and other emotions, ultimately reducing depression levels among the participants.

The study also bears significance for the field of gerontological social work research and practice. The structured MCNIA program underscores the paramount importance of adopting a holistic approach to dementia care. Both medical and social work practitioners can glean valuable insights from this program, encouraging the exploration of similar multimodal interventions that not only target cognitive function, but also attend to emotional and psychological well-being. The incorporation of group activities and facilitated sharing sessions within the MCNIA program brings into focus the potential advantages of group-based interventions. These interventions serve as \approaches to foster a sense of community and diminish feelings of isolation among participants and their caregiving partners. Additionally, geriatric social workers play a pivotal role in supporting and training caregivers, stressing the significance of maintaining an enriching and emotionally nurturing home environment. This emphasis on caregiver support is instrumental in prolonging a more positive caregiving relationship, and enhancing the overall quality of care provided.

Furthermore, this research is distinguished from other studies on MCI because it implemented a localized intervention approach, MCNIA, and demonstrated its efficacy. In addition, the study included blood biomarkers as a control criterion to assess participants’ cognitive status in social work practice. Analyzing scale scores in conjunction with blood sample data allowed for a more solid measurement of cognitive functional status. The investigation into the correlation of biomarkers among group members with the effects of non-pharmacological interventions represents a significant advancement in evidence for non-pharmacological intervention studies.

Nevertheless, to the best of our knowledge, research on caregivers of MCI groups in China predominantly centers on influencing factors on caregiver burden, with few practical studies conducting interventions for both groups. Inclusion of caregivers in the practical interventions as a simultaneous intervention group not only ensured the efficacy of the interventions for MCI participants, but also demonstrated that participatory interventions effectively alleviated caregivers’ burden of care. The present research provides a valuable case study with the potential for supporting subsequent related intervention research.

Ethics declarations

This study has been approved by the ethics review board of the collaborating hospital, Hospital C (Reference Number: 2019SL001). Prior to the start of the study, informed consent forms were signed by the participants, with their acknowledgment of the research content and risks, and the confidentiality of their personal data. All personal information of the participants was anonymous in the data analysis.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research is supported by the Non-profit Central Research Institute Fund of the Chinese Academy of Medical Sciences (Grant No. 2021-JKCS-026); Science and Technology Innovation Action Plan of Shanghai Science and Technology Commission (Grant No. 23Y11906600)and Innovative clinical research project of Shanghai Changzheng Hospital (Grant No. 2023YJBF-PY13).

Appendix

Table

Session	Theme	Content
Session 1	“Starting on the Memory Journey”	1) Self-introduction 2) Public education on cognitive impairments 3) “Chinese Whispers” game 4) Healthy finger exercises 5) Sharing achievements and expectations; Group agreement
Session 2	“Knowing the Brain”	1) Review of homework; “Number Clap” game 2) Training in time and location orientation abilities 3) Attention training: reciting numbers forward and backward 4) Schultz table training 5) Sharing achievements and setting homework
Session 3	“Music for You, Better Living”	1) Review of homework; “Raining Cats and Dogs” game 2) Music therapy introduction 3) Storytelling and drawing with music 4) Sharing achievements and setting homework
Session 4	“Gaining from the Brain”	1) Review of homework; “Snap the ‘7’” game 2) Association memory method 3) Sharing achievements; Distribution of association memory cards; Setting homework
Session 5	“Hands and Brain Together”	1) Review of homework 2) Instant memory training 3) Find the differences in pictures 4) Touch therapy 5) Meditation 6) Sharing achievements; Sharing touch therapy audio; Setting homework
Session 6	“Creative Life”	1) Review of homework 2) Speak out colors when seeing words 3) Creative storytelling therapy 4) Sharing achievements; Setting homework
Session 7	“Strengthening friendship”	1) Review of homework 2) “Three Gardens” game 3) Nostalgia therapy 4) Sharing achievements; Setting homework
Session 8	“Moving Forward on the Memory Journey”	1) Review of homework 2) “You Draw, I Guess” game 3) Recap of all eight sessions 4) “We’re Graduating:” Playing the group activities review video 5) Distribution of compiled non-pharmacological intervention manual