Age and Ageing 1994;23:1 95-1 99

Dementia in Elderly Patients:

Can the 3R Mental Stimulation
Programme improve Mental Status?
K. KOH, R. RAY, J. LEE, A. NAIR, T. HO, P. C. ANG

Summary
The aim of this study was to determine whether the 3R mental stimulation programme can improve the mental

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status score (MSS) of a group of patients with dementia attending a day care centre. Fifteen patients with
dementia attending a day care centre were exposed to the 3R stimulation programme over eight weeks while 15
controls were not. All patients from both groups were subjected to pre- and post-exposure questionnaires
modified from the Mental Status Questionnaire of Kahn et al. A mental status score (MSS) was thus calculated
on both occasions.
All patients in the exposed group showed an improved mental status score, with the mean 'pre-exposure' and
'post-exposure' scores of 4.4 and 7.3, respectively (p < 0.001; paired t test). In contrast, the mental status scores
of 12 control patients had deteriorated and mean 'pre-exposure' and 'post-exposure' scores were 4.1 and 3.4,
respectively (p<0.05; paired t test). Using multiple covariance analysis, the adjusted 'post-exposure' mean
mental status score was 7.1 for the exposed and 3.6 for the controlled group (p < 0.001).
The 3R programme appears to be effective for short-term mental stimulation of demented elderly people.

Introduction Materials and Methods

Degenerative mental disorders have become important
health problems in countries with ageing populations
[1]. Community-based studies have estimated that one
in five of the elderly population suffers from some
mental disorder. Of these, 60% are likely to have
dementia with one in ten requiring care in nursing
homes and three in ten in long-stay psychiatric wards
[2]. Enormous financial and manpower resources are
thus consumed.
In maintaining the independence of elderly people
within the community, much depends on delaying the
progressive degeneration of their mental state. Many
short-term mental stimulation programmes have
reported achieving some improvement in the mental
state of demented elderly individuals [3-6]. Most of
these however, are based on one method of mental
stimulation for example, reminiscence or reality orien-
tation. Few have used a combination of techniques.
This project was undertaken to build on existing
evidence by producing a carefully analysed account as to
whether short-term mental stimulation can benefit
demented elderly patients within the community. Three
different elements of mental stimulation namely remin-
iscence, reality orientation and remotivation were
incorporated into the 3R programme where the main
objective was to improve the cognitive functions of a
person diagnosed with primary degenerative dementia
(PDD).
The study sample: This 1991 community-based study involved
elderly patients with primary degenerative dementia (PDD)
attending day care at a Senior Citizens' Health Care Centre
(SCHCC) in Singapore. This centre provides supervised
rehabilitation and day care for patients by therapists and
nursing staff. Only patients with a mental status score (MSS)
of 6 and below, indicative of some degenerative mental
dysfunction, were eligible for the study. Each eligible subject
was assessed by the doctor and staff nurse of the SCHCC and
the diagnosis confirmed by a psychiatrist with an interest in
geriatric disorders.
Those excluded were below 55 years of age, or were noisy,
violent or irrational, on medication such as sedatives and
tranquillizers, known to have marked impairment of vision or
hearing, severely incontinent or insufficiently mobile, i.e.
unable to walk 50 yards to the room where the sessions were
held.
There were 30 eligible subjects among the patients receiving
day care at the SCHCC. Of these, the first 1 5 eligible names on
the centre's patient register were provided with the 3R
programme and are hereafter referred to as the 'exposed
group'. The next 15 eligible patients comprised the 'control
group' and were not exposed to a systematic programme of
mental stimulation.
The 3R Programme: The 3R mental stimulation programme
incorporated the basic elements of reminiscence, reality
orientation and remotivation. Reminiscence is the technique
of using past events and related objects to stimulate memory
through recollection. Reality orientation is the technique of
stimulating the elderly demented patient for time, place,
 K. KOH ET AL.

persons and situations to which they can relate. Remotivation Table I. Mental state score (MSS) as assessed by the Modified
is the testing and stimulation of the individual's intellectual Mental State Questionnaire for patients in the exposed and
and cognitive characteristics through discussion, thought and control groups
thought deduction. These techniques were designed for small
group therapy sessions. Exposed (n = 15) Control (n = 1 5)
Over an 8-week period, the exposed group were required to
attend weekly sessions each with a specific topic for discussion. Mean (SD) Range Mean (SD) Range
These included money, hobbies, pets, water, clocks, fruit,
festivals and transport. During each session, the five basic Pre-exposure 4.4(1.4) 2-6 4.1(1.7) 1-6
steps for remotivation recommended by Janssen and Giberson Post-exposure 7.3(1.9) 3-10 3.4(1.8) 0-7
[7] were followed. These had been modified to incorporate
elements of reminiscence and reality orientation (see Apper>- Change + 2.9* (1.3) 1-6 -0.7 b (1.2) -3-1
dix I). /
The goal of each of the eight weekly sessions was to ' p < 0.001 by paired t test; b p < 0.05 by paired t test.
stimulate the visual, tactile, olfactory and gustatory senses of
group members using a variety of objects such as photographs, This was accomplished with multiple covariance analysis [14,
food, flowers and household objects. Hearing was stimulated 15]. For easy interpretation, post-exposure MSS rather than
with voices and music [8]. the 'change in MSS' was used as the dependent variable in the
All patients recruited into the 3R programme were exposed covariance analysis. Indeed the two approaches (using post-

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to the same team of doctors and nurses who had undergone exposure score vs. using change in score as dependent variable)
special training on conducting the sessions and the assess- are algebraically identical [11, 13, 14].
ments. Before entry, patients and their carers were also briefed
on the overall programme objectives in order to encourage full
participation and attendance. No other measures were taken to Results
ensure carers were taught the 3R programme and any mental
The age of the patients ranged from 55 to 85 years
stimulation received at home was uncontrolled.
(mean = 71.9; standard deviation = 9.6) in the exposed
Mental status scores: A modified version of the Mental Status
Questionnaire (MSQ) of Kahn et al. [9] was used as a simple group and from 64 to 86 (mean = 74.1; standard devia-
instrument to assess mental status. Simplicity was a prerequi- tion =6.8) in the control group. There were four men
site for this evaluation as testing older patients' mental status and 11 women in each group.
could prove to be difficult with failing health, failing sensory The baseline and post-exposure MSS scores for the
organs and increasing psychological deficits [10]. As the exposed and control groups are shown in Table I. All 15
modified MSQ was simple to administer, it could easily be patients in the exposed group showed some improve-
used repeatedly for post-programme reassessment and at ment in the MSS score, with the mean baseline and
longer intervals. post-exposure score of 4.4 and 7.3, respectively. The
Pre-exposure or baseline mental status scores (MSS) were mean difference of +2.9 is statistically significant
initially assessed from all 30 patients using the modified
Mental Status Questionaire (MSQ) (see Appendix II). Eight
(p < 0.001). In contrast, 12 of the 15 patients in the
weeks later, post-exposure MSS were similarly obtained from control group showed a deterioration in the MSS score,
the 15 exposed and 15 control subjects. The MSS score can with the mean baseline and post-exposure score of 4.1
range from 0 (0 out of 10 correct answers to the MSQ) to 10. A and 3.4, respectively. The mean difference of —0.7 is
patient with 7 to 10 (10 is maximum) correct answers was also statistically significant (p < 0.05).
considered 'normal', 4 to 6 as 'mild impairment', 2 or 3 as
'moderately advanced impairment', and 0 or 1 as 'severe
mental dysfunction'. 8 _
Statistical Analysis: The primary goal of the statistical
analysis was to compare the change in mental state score 7 _
to
(MSS) between the exposed patients (those given the 3R to
programme over the 8-week period) and the control patients 6 -
(those who were not given the 3R programme over the same o
u 5 _
period).
Preliminarily, the post-exposed MSS was compared with
the baseline MSS separately for the exposed and control group a 4 -
t/5
by the paired t test. This was followed by comparing the IS
C
Ti
change in MSS (post-exposure MSS minus baseline MSS)
between the exposed and controlled groups using the t test by ^ 2
considering the 'change' as the dependent variable. It has been
shown, however, that the t test on 'change' is not a valid 1 _
procedure because a 'change' in any biological variable is
0
potentially confounded by its baseline value [11, 12], a
Pre-exposure Post-exposure Post-exposure
phenomenon referred to as 'regression towards the mean' [13,
14]. Since the change in MSS is potentially confounded by
(Observed) (Adjustedf
baseline MSS, it is more valid to compare the change in MSS Figure. Mean and 95% confidence interval of mental state
between the exposed and control groups statistically adjusting score (MSS) in exposed and control groups/Statistically
for the imbalance of the baseline MSS in the two compared adjusted for pre-exposure MSS, sex and age by multiple
groups and other potential confounders such as sex and age. covariance analysis. See text for explanation.
 THE 3R MENTAL STIMULATION PROGRAMME
Table II. Change in mental state from pre-exposure to post-
exposure Mental State Scores (MSS) for patients in the
exposed (n = 15) and control groups (n = 15)
Post-exposure
Exposed group Control group
Pre-
exposure N MI MAI SD N MI MAI
N 0 0 0 0 0 0 0
MI + 10 2 0 0 0 5 -5
MAI 0 +2 1 0 0 0 2 —1
SD 0 0 0 0 0 0 0 2
N = normal; MI = mild impairment; MAI = moderately
advanced impairment; SD = Severe mental dysfunction. See
text for explanation on the classification of these categories
based on the MSS scores.
Table II compares the change in mental state from
pre-exposed to post-exposed between the exposed and
control groups. Three of the 15 patients in the exposed
group showed no change in mental state and 12 patients
showed improvement. In contrast, nine patients in the
control group showed no change in mental state and six
had deteriorated during the 8-week interval.
The Figure displays the mean pre-exposure and post-
exposure MSS scores and their 95% confidence interval
for the exposed and control groups. Both the observed
and statistically adjusted post-exposure mean MSS
scores are shown (the 'adjusted' mean scores were
statistically corrected for differences in pre-exposure
MSS score, sex and age between the two compared
groups by analysis of covariance [15]). There is neither
statistical nor material difference in baseline scores
between the exposed and control groups.
At the end of 8 weeks, a rise in the mean MSS in the
exposed group and a fall in the mean MSS in the control
group was observed. Although the adjusted difference in
MSS was smaller than the observed difference, both
were statistically significant (p < 0.05) because their
95% confidence intervals did not overlap. The 3R
programme had brought an improvement in the mean
mental state score (MSS) of the exposed group whereas
a lower mean MSS of the control group was observed
over the same period.
Discussion
In this study the 3R mental stimulation programme was
used as a short-term (2 month) means of stimulating
memory in patients with a mental status score (MSS) of
6 and lower. This interval was arbitrarily chosen in
order to minimize drop-outs arising from illness requir-
ing hospitalization, for example.
Programme participants could have been positively
affected by staff congeniality in an encouraging
ambiance and the opportunity for repeated interaction
with others receiving day care. Before the start of the
programme, all staff involved had been given similar
training by a psychiatrist to ensure standardization of
the mental stimulation and assessment methods. The
dedication of these trained staff providing constant
reinforcement during the sessions could also have
contributed to the final outcome [8, 16, 17]. Another
factor which could have affected outcome is the learning
effect imparted from the pre-assessment questionnaire.
The precise effect of these factors however was not
SD
quantifiable because of their subjectiveness.
The mean baseline MSSs for the exposed and control
0 groups were 4.4 and 4.1, respectively. As these values
0 could potentially confound the results, statistical adjust-
ments were made using multiple covariance analysis.
Two other potential confounders, sex and age were also
included in the adjustment.
At the programme's end, a rise in the mean MSS in
the exposed group and a fall in the mean MSS in the
control group were observed. Although the adjusted
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difference was smaller than the observed difference for
the mean post-exposure MSS of both groups as seen in
the Figure, both these differences were statistically
significant (p < 0.05) because their 95% confidence
intervals did not overlap. One can thus infer that the 3R
programme had brought an improvement in the mean
mental state score (MSS) of the exposed group over that
of the control group.
Although the observations made suggest that the 3R
programme does improve the short-term mental scores
of the exposed group, the overall benefit in improving
mental status is still debatable. This is because the
criterion of change used, i.e. MSS function, is a
reiteration of the information and orientation material
which are repeatedly reinforced throughout the pro-
gramme. Moreover, the simplicity and brevity of the
MSS used did not enable the assessment of changes in
other areas of cognition which may have taken place.
Before the start of the programme, those selected for
the exposed group and their carers were given a briefing
to encourage participation. Carers, however, were not
actively encouraged to continue the reinforcement of the
3R programme at home. They were also not expected to
report any behaviour changes which might have
occurred at home as patients were evaluated only on the
basis of their post-exposure mental status scores. As
evaluation of the home behaviour of the exposed group
and their carers was not carried out, the authors were
unable to confirm Greene's finding that parallel changes
in the patients' behaviour at home occur after consistent
and systematic reality orientation [18].
Besides continued carer reinforcement at home, other
factors which could affect the long-term effectiveness of
the 3R method of mental stimulation were the diagnos-
tic accuracy of the patient's condition, health care
provider compliance, patient compliance, efficacy and
coverage [19-21]. These factors should therefore be
considered in future studies on long-term mental stimu-
lation of demented patients.
Continued follow-up and long-term validation of the
3R programme was not possible as most of the pro-
gramme participants had been discharged to their carers
or to alternative day care centres whenever they were
 K KOH ET AL.
assessed by staff to have attained their optimal level of
rehabilitation. This is because the SCHCC has a waiting
list of those awaiting rehabilitation and day care and
therefore cannot keep patients long term.
The community-based 3R mental stimulation pro-
gramme is inexpensive and suited to small groups under
the charge of day care staff who need not undergo
intensive training to conduct the programme. It pro-
vides an enjoyable pastime for elderly participants and
we recommend that day care centres consider this form
of mental stimulation for inclusion in their patients'
daily routine.
Acknowledgements
The authors thank Dr T. Yoong, Medical Director, Depart-
ment of Health Services for the Elderly, the Ministry of Health
and staff nurses A. Sultana, S. W. Tan, H. Kaur, H. C. Lim,
T. De Cruz and F. C. Ow for their help. They would also like
to acknowledge the help of Dr Y. H. Koh of the Training and
Health Education Department in planning the protocol used.
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Appendix I. The 3R mental stimulation programme
Step 1: Creating a climate of acceptance (5 minutes)
During each session the group leader, a specially trained nurse,
would begin by introducing each of the group members. She
would greet each member by name and in doing so reinforce
their identity to other group members. She would also
orientate members to the time and place where the session is
being held with the use of a clock or calendar.
Step 2: Interest in the topic for discussion (15 minutes)
The leader would introduce a topic to be discussed and
simultaneously stimulate the past memory of group members
(reminiscence). She would enquire about present and personal
interests in turn (reality orientation), stimulate a discussion
on this and encourage the other members to participate
(remotivation) in the conversation.
Step 3: Sharing in the world we live in (15 minutes)
The leader would choose an object for circulation among
group members. This stimulates the senses of group members
using objects such as pictures, old photographs, flowers, food,
clothing items or household appliances. They would then be
encouraged to talk about their own experience with the object
in their hands.
Step 4: Climate of appreciation (20 minutes)
Group members were also asked to recall their previous
working experiences, hobbies or pastimes. The leader may
encourage them to sing or read poems and old magazine/
newspaper articles to stimulate recall.
Step 5: Conclusion (5 minutes)
At the end of each session, group members were told what to
anticipate for their next meeting. They were then given a date,
topic, time, place and were encouraged to think about the
intended topic for discussion. They were then personally
thanked by name for coming so as to reinforce their own
identity.
 THE 3R MENTAL STIMULATION PROGRAMME 199

Appendix II: The Modified Mental Status Question- Authors' addresses

naire used in Senior Citizens' Health Care Centre K. Koh, J. Lee
Name: NRIC No.: Department of Community Occupational and Family
Medicine,
Correct Incorrect National University Hospital,
1. Where are we now? D
Lower Kent Ridge Road,
a Singapore 0511
2. What month is it? • D
3. What day of the month is it? D a R. Ray
4. What year is it? D • Community Health Services,
5. How old are you? D D
A. Nair, T. Ho
6. Where were you born? D •
7. Who is the Prime Minister of Department of Health Services for the Elderly,
Singapore • D
Ministry of Health, Singapore
8. How many children have you? • a
9. What is your address? • D P. C. Ang
10. Reverse counting 10 to 0 D • Mount Elizabeth Hospital, Singapore
Total Score: DD (min: 0, max: 10) Received in revised form 10 August 1993

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