INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriatr. Psychiatry 2008; 23: 8594.

Published online 25 May 2007 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/gps.1846

A randomized, two-year study of the efficacy of

cognitive intervention on elderly people: the Donostia
Longitudinal Study
Cristina Buiza 1, Igone Etxeberria 1, Nerea Galdona 1, Mara Feliciana Gonzalez 1,
Enrique Arriola 1, Adolfo Lopez de Munain 2, Elena Urdaneta 1 and Jose Javier Yanguas 1*
1
Department of Research and Development, Matia Gerontological Institute Foundation, Donostia, Spain
2
Department of Neurology, Hospital Donostia, Donostia, Spain

SUMMARY
Background Research on non-pharmacological therapies (cognitive rehabilitation) in old age has been very limited,
and most has not considered the effect of interventions of this type over extended periods of time.
Objective To investigate a new cognitive therapy in a randomized study with elderly people who did not suffer cognitive
impairment.
Methods The efficacy of this therapy was evaluated by means of post-hoc analysis of 238 people using biomedical,
cognitive, behavioural, quality of life (QoL), subjective memory, and affective assessments.
Results Scores for learning potential and different types of memory (working memory, immediate memory, logic memory)
for the treatment group improved significantly relative to the untreated controls.
Conclusions The most significant finding in this study was that learning potential continued at enhanced levels in trained
subjects over an intervention period lasting two years, thereby increasing rehabilitation potential and contributing to
successful ageing. Copyright # 2007 John Wiley & Sons, Ltd.

key words Donostia Longitudinal Study (DLS); learning potential; cognitive intervention; multidisciplinary assessment

INTRODUCTION understanding of the changes taking place in the

The rising population of older people is a fact of
21st century life. Today, senior citizens make up 16% of
the total population, and this percentage is expected to
climb to 27% in 2010 (Eurostat, 2004). This growing
population means growing demand for specialized,
multidisciplinary attention appropriate to the circum-
stances of the elderly.
Looking at the pattern of human cognition during
normal ageing, cross-over studies have shown
differential associations between specific cognitive
functions and the underlying neural basis susceptible
to degeneration (Fotenos et al., 2005). For this reason,
longitudinal studies are needed to provide a better
*Correspondence to: Dr J. Javier Yanguas, INGEMA, Usandizaga 6,
20002, San Sebastian, Gipuzkoa, Spain.
E-mail: jyanguas@fmatia.net
Copyright # 2007 John Wiley & Sons, Ltd.
individual patterns of specific cognitive functions
(Newman et al., 2005).
A review of the literature on the status of cognitive
functions in persons over 65 suggests that even though
neuroanatomical and neurochemical changes occur in
the brain in the elderly, cognitive functioning stays at
tolerable levels during normal ageing (Jonides et al.,
2000; Mell et al., 2005).
Studies into memory complaints have suggested
that complaints of this kind in the elderly are ass-
ociated with current cognitive performance and are
not a predictor of the development of dementia
(Flicker et al., 1993). Subjective complaints concern-
ing memory tend to be related more to personality
traits and with depression than to dementia (Capella,
2005).
However, cognitive functioning is closely related
to the cognitive reserve, meaning the scope for
Received 6 March 2006
Accepted 15 August 2006
86 c. buiza
positive cognitive change, also called learning potent-
ial. Learning potential can be defined as a subjects
capacity to improve his or her cognitive yield
subsequent to training (Zhu, 2005). In other words,
individual variability after training is a basis for
predicting the cognitive potential. Indeed, as Baltes
et al. (1995) has observed, a subjects learning
potential or cognitive reserve can be used to predict
the likelihood of his developing dementia. Learning
potential could be a measure of an individuals reserve
capacity and as such a good indicator of successful
ageing (Fernandez-Ballesteros et al., 2005).
Numerous studies have demonstrated the important
role played by cognitive training in averting age-
associated memory alterations. Therefore, it is likely
that brain plasticity is distinctly possible in the elderly
(Kopytova et al., 2004). The ACTIVE (Advanced
Cognitive Training for Independent and Vital Elderly)
group has published a longitudinal study on cognitive
training and older people (Ball et al., 2002). Their
results showed that cognitive interventions helped
older people to improve their cognitive yield (episodic
memory, reasoning, and processing speed) over
two years.
Rapp et al. (2002) carried out a randomized clinical
trial to test the efficacy of a cognitive and behavioural
treatment designed to improve memory execution and
participants attitudes toward their own memory
performance. The results indicated that the exper-
imental group had significantly better performance
and short-term memory evaluations than the controls
at the end of the treatment period and over a 6-month
follow-up period.
These studies show the difference between cogni-
tive rehabilitation and cognitive stimulation. Some
studies concluded that cognitive rehabilitation is not
related with improvement of cognitive function in
patients with dementia (Clare et al., 2005). On the
other hand, frequent participation in cognitively
stimulating activities is associated with reduced risk
of AD (Wilson et al., 2002).
Still, very few studies have maintained follow-up
for more protracted periods and/or have employed
sufficiently large samples to enable their findings to
be viewed with confidence, and hence the results must
be considered with caution (Selwood et al., 2005).
However, recent pharmacological studies are very
short time to study the Alzheimer onset development
(Cummings et al., 2005).
For all these reasons, the Donostia Longitudinal
Study (DLS) was designed to determine the benefits of
cognitive intervention in a large sample of subjects
divided into three separate GDS (Global Deterioration
Copyright # 2007 John Wiley & Sons, Ltd.
ET AL.
Scale) groupings, namely, GDS 12, GDS 34, and
GDS 56 (Reisberg et al., 1982). The present paper
considers only the portion of the investigation that
dealt with the GDS 12 group, i.e. elderly people with
undamaged memories.
The principal DLS objective was to study the
effectiveness of non-pharmacological cognitive inter-
vention in older people who either exhibited no
cognitive deterioration or expressed AAMI (Age
Associated Memory Impairment), effectiveness being
measured as objective improvement in the scores for
the cognitive functions tested, both after treatment and
without treatment.
The purpose was to investigate whether benefits to
cognition and quality of life resulted from or were
maintained by participating in 180 weekly sessions
(2 years of follow-up) after the initial programme,
compared with a control group and a experimental
group number 2, both likewise drawn from partici-
pants in the initial programme.
METHODS
Subjects
Patients were selected from a variety of settings
in order to obtain a broad range of people. All
of the participants were recruited from the comm-
unity the Guipuzcoa region in Spain. Sample socio-
demographic characteristics are summarized in
Table 1.
Written informed consent or witnessed oral consent
to participate in the programme and to obtain a
serum sample was obtained from each patient
before the beginning of the study. The requirements
for inclusion in the study were to be over 65 years
of age without cognitive impairment or with standard
criteria of AAMI (Age Associated Memory Impair-
ment; Crook et al., 1986). It requires a complaint of
memory impairment, a score on a memory test one
standard deviation below the mean performance of
healthy young adults, adequate intellectual function-
ing, absence of dementia, and absence of diseases that
may cause memory impairment. The main causes of
exclusion from the study were: (a) any degenerative
neurological disorder other than AD (Parkinsons
disease, epilepsy, progressive supranuclear paraly-
sis, subdural bruise or other injury, convulsive
disorders, multiple sclerosis, etc.); (b) severe psycho-
tic traits, depression, agitation or behavioural pro-
blems that might prevent successful completion of
the programme; (c) a history of alcohol or sub-
stance abuse; (d) schizophrenia; (e) systemic disease
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DOI: 10.1002/gps
 donostia longitudinal study
Table 1. Demographic by group at baseline
Group Number of participants
Experimental group number 1 85
Experimental group number 2 68
Control 85
Total 238
estimated as being likely to yield a life expectancy of
less than one year.
Design
The DLS employed a quasi-experimental, double-
blind design that included different treatment con-
ditions, namely, an experimental group number 1, an
experimental group number 2, and a control group.
The total sample (n 238) was then divided into the
three treatment groupings (experimental group num-
ber 1, experimental group number 2, control). Final
group sizes were 85 subjects in the experimental group
number 1, 68 in the experimental group number 2, and
85 in the control group.
After the baseline evaluation, the randomisation
agency randomly assigned each subject to one of the
three conditions described. Randomisation was
stratified by the participants age, gender and
cardiovascular risk.
Programme
The DLS lasted two years, during which time each
patient underwent six evaluations, an initial assess-
ment followed by another every 6 months. The
intervention grew out of a theoretical model developed
by the authors based on Braak and Braaks model of
Alzheimers staging (Braak and Braak, 1991, 1994,
1997), which recognizes the existence of pathological
anatomical correlates that affect different areas of the
brain at the various stages of Alzheimers disease
(AD), with a specific disease course.
In view of this models basis in the current research,
several steps were designed and implemented to
enhance the interventions ability.
The intervention was directed at all cognitive
functions, especially those considered essential to
maintaining subjects independence and quality of
life. Memory loss is one of the main concerns of
Copyright # 2007 John Wiley & Sons, Ltd.
87
Gender Mean age
29% males 73.28 (SD: 6.53)
71% females
30% males 70.18 (SD: 5.58)
70% females
26% males 73.14 (SD: 7.24)
74% females
27% males 74.43 (SD: 8.31)
73% females
elderly people and can produce feelings of anxiety and
depression (Verhaeghen et al., 2000). In addition to
cognitive functions, issues relating to well-being
were also addressed in the experimental group number
1, e.g. individuals health self-care, social skills,
problem-solving, relaxation, self-esteem, feeding,
physical activity, music-therapy, laught-therapy, cul-
tural aspects (association, volunteering, gastronomy),
liking, daily living (how to act in case of domestics
accidents pets, how to act in case of medical
emergencies) spa-therapy, etc.
Training addressed the cognitive functions of
attention and orientation (special, temporal, and per-
sonal), memory (immediate execution memory, recent
logic execution memory, recent word list memory,
short-term memory, working memory, learning poten-
tial), language (designation, repetition, oral compre-
hension, written comprehension, written language,
reading), visuoconstructive ability, executive func-
tions (phonetic fluency, semantic fluency, abstraction,
categorization, planning, bimanual coordination, pre-
motor functioning), visomanual coordination (speed
and execution) and praxia (ideational and ideomotor).
The neuropsychologist avoided the use of any
exercise that could have similarity with test assess-
ment scales.
Intervention programme content was structured so
as to be both weekly and monthly. In the experimental
group number 1, weekly cognitive function training
sessions were designed to reinforce the functions
concerned (Figure 1). At the same time, in addition to
the weekly cognitive training, each month there was
one weekly session dealing with issues relating to
well-being. The intervention was similar in the
experimental group number 2 in terms of session
length and frequency, venue, monitors, and the
number of subjects in each group. The final content
was the same in both the experimental group number 1
and experimental group number 2, but in the latter
group the content was unstructured and did not follow
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88
any organized schedule. Lastly, the control group
underwent the same evaluations as the subjects in the
other two groups but did not experience training of any
kind and simply carried on with their lives as before.
Training in the number 1 and number 2 exper-
imental groups took place in a group context. Session
frequency was twice weekly and session length was
one hour and a half. There were a total of 180 sessions
during the 2 years of intervention.
Measurement of neuropsychological assessment
Over the course of this study six assessments were
carried out per subject. Of these, four followed an
established protocol set out in Table 2, and two were
control assessments using the ADAS-COG test.
Table 2. Biomedical and neuropsychological assessment protocol
Assessment Variable
Family and personal antecedents
Medical exploration
Cognitive deteriorate of vascular origin
Basic activities of daily living
Instrumental activities of daily living
Temporal, spatial and personal orientation
Attention
Working memory
Inmediate execution memory
Logic memory
Recent word list memory
Short term memory
Learning potential
-Designation language
Repetition language
Audit compression
Written compression
Written language
Reading language
Visuo-constructive ability
Planning
Bimanual coordination
Pre-motor function
Visomanual coordination speed
Visomanual coordination execution
Phonetic fluency
Semantic fluency
Abstraction
Categorization
ICPR
IMPR
Copyright # 2007 John Wiley & Sons, Ltd.
c. buiza ET AL.
First, a multicomponent assessment (biomedical,
neuropsychological, affective, and personality) was
performed by an interdisciplinary team made up of a
neurologist, four neuropsychologists, a geriatrist,
and a social worker, all suitably experienced and
specifically trained for this study. The assessment was
approved by the Matia Foundation Ethics Committee.
Only the neuropsychological evaluations are being
considered and presented here.
Statistical methods
Statistical analysis was carried out using the SPSS
program, version 12.0 using a level of significance
of less than 0.05. Values are the mean and the
standard deviation. The Kruskal-Wallis test was
Tests Reference
Medical interview
Hachinski Scale Hachinski et al., 1975
Barthel index Mahoney and Barthel, 1965
Lawton scale Lawton and Brody, 1969
Information and orientation Wechsler, 1987
of WMS-R
Direct and inverse digits Wechsler, 1987
of WMS-R
Logic memory of WMS-R Wechsler, 1987
Auditory Verbal Learning Rey, 1964
Test (AVLT)
-Boston vocabulary test Goodglass and Kaplan, 1996
Boston Diagnostic Aphasia Goodglass and Kaplan, 1996
Examination (BDAE)
WAIS-III (BLOCKS) Wechsler, 1999
Clock drawing (order and copy) Goodglass and Kaplan, 1983
Motor sequences of Luria Manga and Ramos, 2001
Trail Making Test, part A Army Individual Test Battery, 1944
Manga y Ramos, 2001
FAS Benton and Hamsher, 1989
Proverbs
Similarities of WAIS-III Wechsler, 1999
Motor sequences of Luria Manga and Ramos, 2001
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DOI: 10.1002/gps
 donostia longitudinal study
Cerebral changes
associated with normal
aging.
-NFT (neurofibrillar tangles)
in entorrinal region,
-Volume decrease in
subcortical areas
Suitable activities.
-Implicit and explicit learning,
-free recall and recognition,
-verbal and visual memory,
-remote and autobiographic
memory (thought tasks like
narration of passed events,
memory of last dates),
-semantic memory (to guess
personages)
Figure 1. Example of the training of semantic memory.
used to establish differences within each group over
time.
RESULTS
The mean and the standard deviation (SD) values for
each of the three groups are presented in Table 3 and in
Figures 2 and 3.
Memory
Immediate memory (IMEME). There was a statisti-
cally significant improvement ( p < 0.001) in the
experimental group number 1 which was more distinct
in year two than in year one (mean starting score:
18.66
7.50, mean score at year one: 18.94
7.55,
mean score at year two: 21.75
7.81). In the other two
groups there was no change after one year of
intervention, although there was a tendency towards
improvement after two years.
Recent logic execution memory (RELEM). All three
groups improved significantly ( p < 0.03) after two
years of intervention. The mean scores for the
experimental group number 1 were: mean starting
score: 14.17
7.19, mean score at year one: 14.59

7.42, and mean score at year two: 17.37
8.65. The
mean scores for the experimental group number 2
were: mean starting score: 13.84
7.68, mean score at
year one: 16.78
6.11, and mean score at year two:
Copyright # 2007 John Wiley & Sons, Ltd.
89
Clinical.
Remote,
autobiographical and
semantic memory are
maintained.
Neuropsychological correlate
underlies.
-Medial structures of temporal lobe
(hypothalamus: temporal back cortex;
amygdale: affective components of
the memory; adjacent cortical areas
to the hippocampus: entorrinal cortex,
perirrinal and parahyppocampus),
-Structures of front basal brain (septal
area and Broca band diagonal)
-Medial thalamus
18.19
7.68. Finally, the mean scores for the control
group were: mean starting score: 12.45
7.04, mean
score at year one: 14.28
7.80, and mean score at year
two: 16.21
8.43.
Short term memory (STM). A large decrease was
observed in all three groups, although the decreases
were statistically significant only for the experimental
group number 1 ( p < 0.001) and the control group
( p < 0.01).
Working memory (WM). The scores for all the groups
increased both at one year and at two years, but the
increase was only statistically significant ( p < 0.003)
in the experimental group number 1 at year two (mean
starting score: 3.45
1.54, mean score at year one:
4.07
1.40, and mean score at year two: 4.06
1.63)
(Figure 2).
Learning potential
The results show an improvement in the scores for the
experimental group number 1 with respect to the
starting score both at year one (mean starting score:
5.18
2.48, mean score at year one: 5.87
2.26) and
at year two (mean starting score: 5.18
2.48, mean
score at year two: 5.85
2.56). The increase after two
years of training was statistically significant ( p <
0.044). In the other two groups there was no
improvement in the scores for this function (Figure 3).
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90 c. buiza ET AL.

Table 3. Means (and standard deviations) for the three groups on each measure, at the three assessment phases

Variable Experimental Experimental Control group

group number 1 group 2

Biannual IMEME 21.75 (7.5)*** 22.22 (7.55) 21 (7.61)

Annual IMEME 18.94 (6.62) 20.53 (6.02) 18.22 (6.72)
Initial IMEME 18.66 (6.32) 18.74 (7.51) 17.65 (6.68)
Biannual RELEM 17.37 (8.65)*** 18.19 (7.68)** 16.21 (8.43)**
Annual RELEM 14.59 (7.42) 16.78 (6.11) 14.28 (7.80)
Initial RELEM 14.17 (7.19) 13.84 (7.39) 12.45 (7.04)
Biannual STM 4.1 (2.32)*** 4.37 (2.11) 3.47 (1.70)**
Annual STM 3.43 (1.64) 3.78 (1.80) 3.32 (1.86)
Initial STM 5.71 (3.06) 5.21 (2.37) 4.88 (2.98)
Biannual VICOS 132.16 (65.70)*** 177.04 (211.28)** 132.07 (59.01)**
Annual VICOS 110.02 (57.78) 147.28 (74.19) 122.38 (67.95)
Initial VICOS 89.73 (75.02) 110.89 (60.80) 107.57 (66.64)
Biannual VICOC 1.15 (2.02) 1.00 (1.96) 1.88 (3.6)
Annual VICOC 0.58 (1.54) 1.56 (3.41) 1.08 (2.51)
Initial VICOC 0.79 (1.48) 1.37 (2.44) 0.84 (1.91)
Biannual PFLE 27.26 (11.47)* 22.74 (9.05) 24.07 (10.64)
Annual PFLE 26.07 (12.98) 20.75 (7.34) 22.32 (9.53)
Initial PFLE 23.58 (9.98) 20.21 (8.61) 22.06 (9.48)
Biannual ABSTRAC 3.88 (1.60) 3.22 (1.21)** 2.84 (1.96)**
Annual ABSTRAC 3.82 (1.91) 3.78 (1.99) 3.60 (2.01)
Initial ABSTRAC 4.34 (1.75) 4.26 (1.76) 4.12 (1.88)
Biannual ICPR 4.9 (0.37)* 4.85 (0.45) 4.88 (0.39)
Annual ICPR 4.98 (0) 5 (0) 4.96 (0.28)
Initial ICPR 4.98 (0.20) 5 (0) 4.96 (0.24)
Biannual IMPR 47.06 (2.21)** 47.26 (1.58) 47.72 (1.03)
Annual IMPR 47.76 (1.11) 47.88 (0.70) 47.92 (0.56)
Initial IMPR 47.90 (0.72) 47.89 (0.64) 47.70 (1.62)

ABSTRAC Abstraction; ICPR ideational praxias; IMEME immediate execution memory; IMPR ideomotor praxias; PFLE pho-
phonetic fluency execution; RELEM recent logic execution memory; STM short term memory; VICOS visomanual coordination
speed; VICOC visomanual coordination execution.
*p < 0.05.
**p < 0.01.
***p < 0.001 with respect to initial measure.

4,2
**
4

3,8
Experimental 1
3,6 Experimental 2
Control
3,4

3,2

3
Initial Annual Biannual
Figure 2. Change in Working Memory over time.

Copyright # 2007 John Wiley & Sons, Ltd. Int. J. Geriatr. Psychiatry 2008; 23: 8594.
DOI: 10.1002/gps
 donostia longitudinal study
Control
Experimental 2
Experimental 1
4,5 5 5,5
Figure 3. Change in learning potential over time.
Visomanual coordination
Speed (VICOS)i. All three groups experienced a
decline in the first year, and in the second year the
decline grew larger and became statistically signifi-
cant in the three groups (experimental group number
1: p < 0.001, experimental group number 2: p < 0.007,
control: p < 0.003).
Motor execution (VICOC). The scores for all
participants held steady in both years one and two
of the intervention, except for a small but statistically
significant ( p < 0.028) decrease in the control group at
year two (mean starting score: 0.84
0.11, mean
score at year one: 1.08
0.51, mean score at year two:
1.88
0.6).
Executive functions
Phonetic fluency (PFLE). This function improved in
all three groups at the end of the study period,
slightly in the experimental group number 2 and
control groups and substantially and significan-
tly ( p < 0.029) in the experimental group number 1
(mean starting score: 23.58
9.98, mean score at
year one: 26.07
12.98, mean score at year two:
27.26
11.47).
Capacity for abstraction (ABSTRAC). The scores for
all the groups worsened considerably over the
first year of the study. In the experimental group
number 1 the mean starting score was 4.34
1.75,
while the mean score at year one was 3.82
1.91. In
the experimental group number 2 the mean starting
score was 4.26
1.76, and the mean score at year one
Copyright # 2007 John Wiley & Sons, Ltd.
91
Biennial
Annual
Initial
*
6 6,5
was 3.78
1.99. Lastly, in the control group the mean
starting score was 4.12
1.88, and the mean score at
year one was 2.84
1.96. However, at the end of year
two the experimental group number 1 had regained the
lost ground, whereas the experimental group number
2 (mean starting score: 4.26
1.76, mean score at year
two: 3.22
1.21) and the control group (mean starting
score: 4.12
1.88, mean score at year two: 2.84

1.96) underwent statistically significant declines ( p <
0.002 and p < 0.007, respectively).
Praxia
Praxia remained constant in the three groups over the
2 years the intervention lasted, statistically significant
( p < 0.004) results being achieved only in the
experimental group number 1 after year 2.
DISCUSSION
This cognitive intervention grew out of a theoretical
model developed by the authors based on Braak and
Braaks model of Alzheimers staging which recog-
nizes the existence of pathological anatomical
correlates that affect different areas of the brain at
the various stages of AD.
Memory
The scores for the memory functions assessed
(IMEME, RELEM, and learning potential) improved
in all the groups during the 2 years of follow-up. The
findings can in some measure be attributed to
methodological issues attaching to the tests employed,
with a repetition factor that affects test scores having
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92 c. buiza
been described in the literature (Dikmen et al., 1999).
Since the same tests were administered at each
assessment, the subjects could have benefited from
learning about the test content or the assessment
procedure, thereby enhancing execution. Neverthe-
less, it should be noted that the improvement was in all
cases highest in the experimental group number 1, thus
reflecting the effect of intervention in addition to
possible learning through repetition of the tests.
Short-term memory losses consistent with normal
ageing (Baddeley, 1986; Craik, 1991) and biological
processes taking place at this time of life (Korol and
Gold, 1998) were recorded in all the groups. Generally
speaking, short-term memory tends to decline over a
persons lifetime. Normal scores for adults are 7
2
items, dropping to 5
2 items in the elderly not
affected by brain disorders. These age-related memory
deficits have been documented in formal laboratory
tests (Light, 1991; Kausler, 1994; Small et al., 1999).
Moreover, short-term memory decreases inexorably
with age, and training capable of offsetting these
losses is difficult. Avila et al. (2004) reported similar
results for memory in a Brazilian population.
While initially, then, it might seem that this study
corroborates the findings of previous studies without
contributing important new data, it is important to
realize that this is a mistaken impression, because
most previous studies have been cross-over studies
whose results need to be validated by longitudinal
studies (Delgado and Llorca, 2004), like the Donostia
Longitudinal Study discussed here.
Working memory improved in all three groups at
both year 1 and year 2. These results, too, can at
least partly be explained by issues relating to the
methodology and assessment tools (Lezak, 1995).
Still, it is important to underline the positive effect
exerted by the intervention programme in the
experimental group number 1. The same results have
been obtained by other workers (Veltmeyer et al.,
2005), who reported specific impairment in the
operation of working memory systems that guide
ongoing, planned behaviour and facilitate the acqui-
sition and retention of new memories.
Learning potential
In recent years it has been suggested that learning
potential (also called cognitive plasticity or rehabilita-
tion potential) may be a good predictor of the course of
cognitive impairment and dementia (Baltes and Willis,
1982). The consensus of opinion holds that learning
potential continues throughout a persons entire
lifetime. For this reason, in the intervention pro-
Copyright # 2007 John Wiley & Sons, Ltd.
ET AL.
gramme considered in this study training focused
heavily on this function. Results showed improve-
ments in the experimental group number 1 both at year
one and at year two, the latter improvement being
statistically significant ( p < 0.044). In the other two
groups, this function remained unchanged. These results
are an extremely important finding in ageing research,
since the purpose of trying to improve the cognitive
reserve is to make up for possible losses in abilities both
during the ageing process and in potential degenerative
disorders (Fernandez-Ballesteros et al., 2005).
Visomanual coordination
Visomanual coordination decreased in the three
groups in year one and underwent a still larger and,
moreover, statistically significant decline in year 2. As
has been found for manual dexterity (Francis and
Spirduso, 2000), these results can be ascribed to
slower execution times in the elderly as they age (Van
Gorp et al., 1990; Yan, 2000). The 2-year intervention
programme proved to be unable to halt the decline,
highlighting the need for a more specific intervention
design for this function.
Based on all the foregoing, it can be concluded that
cognitive interventions, at least those built around
structured sessions which last for a sufficient length
of time, are effective for elderly persons who have
not suffered cognitive impairment. This is borne out
by the fact that the scores of the some cognitive
functions for which training was provided improved or
held steady in those subjects who completed the
intervention programme considered here. These results
suggest that with intervention these subjects were able
to tap into their cognitive reserve. A recent study
has proven that persons in GDS stage 2 show a pre- Mild
Cognitive Impairment (Reisberg et al., 2005).
Cappa et al. (2005) studied the effectiveness of
non-pharmacological treatments in improving older
peoples memory in the framework of the recommen-
dations of the European Federation of Neurological
Societies (EFNS), and they concluded that memory
improved significantly following cognitive training.
The SIMA Project for maintaining and supporting
independent living in old age (Oswald et al., 1996)
tested different interventions offering competence train-
ing, memory training, psychomotor training, com-
bined psychomotor and competence training, and
combined memory and psychomotor training. The
results demonstrated that memory and competence
training were the interventions that resulted in
the greatest improvement in the ability of older
people to lead independent lives.
Int. J. Geriatr. Psychiatry 2008; 23: 8594.
DOI: 10.1002/gps
 donostia longitudinal study
KEY POINTS
 The experimental group number 1 exhibited
significant gains in immediate memory, short-
term memory, and working memory.
 Learning potential increased for those partici-
pants who received cognitive therapy in both
years of the study, whereas in the other two
groups learning potential stayed flat.
 Cognitive therapy may act to prevent or
postpone cognitive decline in patients at GDS
levels 12 at risk for dementia.
Limitations
The first limitation observed in this study concerns the
assessment tools employed themselves. Despite being
the tools recommended in the scientific literature, in
some cases their discriminating ability is poor, mainly
on account of limited effectiveness and a failure to
offer multiple versions. In the EADC (European
Alzheimers Disease Consortium) survey, Ramirez
et al. (2005) mentioned the importance of harmoniza-
tion of the tests used to evaluate cognitive deteriora-
tion. The second limitation was that because there
were a number of intervention groups, they obviously
could not all be led by the same person, the best
situation methodologically to achieve optimally
uniform results in the intervention. Steps were taken
to minimize the effect of multiple group leaders by
having all monitors take a preparatory course in which
they were trained in standard working procedures.
However, the authors realize that there can be
considerable differences between monitors and that
course satisfaction and the results achieved by the
different groups may depend on monitor input. Lastly,
the authors also realize that a experimental group
number 2 intervention wholly devoid of any cognitive
training at all would have been best and might
have yielded different results, but by the same
token the subjects continued participation depended
on offering meaningful course content as part of the
intervention programme. Offering only routine,
repetitive activities would in all likelihood have led
most of the participants to drop out of the study.
ACKNOWLEDGEMENTS
This study was made possible through the assistance
of IMSERSO (Institute of Migrations and Social
Services, specially Mara Teresa Sancho Castiello).
This study was awarded in 2005 with Premio Obra
Copyright # 2007 John Wiley & Sons, Ltd.
93
Social Caja Madrid a la mejor investigacion social.
The authors also thank all those patients and their
relatives, monitors, Matia Foundation nursing homes,
social services, municipal arts centres, Navarran
Medical Service (OSASUNBIDEA), Fundacion La
Caixa, parish churches, that contributed to this
study.
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