Empty-nest elderly: mahjong and Chinese square dance for improving the cognitive function in the community

A couple of studies^11,12 have reported that empty nesters experience loneliness after their children leave, but the participants in both studies were midlife women. Jakobsson and Hallberg¹³ indicated that loneliness and fear are universal among aging people. Fahrenberg¹² termed the depression and isolation found among empty nesters the “empty nest syndrome”.

Depression is one of the most frequent mental disorders among aging people, and it severely impairs their lives. The risk factors include female sex, widowhood or single life, low socioeconomic status, bereavement, stressful life events, poor social support, prior depression, comorbidities, disability, cognitive deterioration, and vascular factors.^14,15 Depression comes ninth behind prolific killers when ranked by disability and death combined in the world.¹⁶

Reitz and Mayeux¹⁷ showed that the global prevalence of dementia is as high as 24 million, and it has been predicted to quadruple by the year 2050. Aging is one of the risk factors for dementia and Alzheimer’s disease. The incidence and prevalence increase with age, almost doubling every 5 years after the age of 60 years.¹⁸ The initial no-symptoms preclinical phase of Alzheimer’s disease is followed by a period wherein cognitive impairment, but no functional impairment, is present (mild cognitive impairment).¹⁹ Among aging Malays, the prevalence of any cognitive impairment has been reported to be 25.5%.²⁰

Chinese empty nesters are vulnerable to many common cognitive problems as are empty nesters worldwide. Gao et al.²¹ showed that empty nesters’ ability of self-care was worse than and the physical and mental scores were lower than the non-empty nester. Lyu et al.²² showed that the empty nester was statistically low in vitality, emotional role, and mental health. Liu and Guo²³ indicated that the empty nester was vulnerable to mental problems and was prone to have low level of life satisfaction.

Feng et al.²⁴ noted that the high prevalence of geriatric depression among Uyghur elderly in Xinjiang is serious: 10.61% among the elderly experienced depression. Female sex, low income, low education level, chronic diseases, experienced adverse events during the past 2 years, and the lack of ability to take self-care are the risk factors.²⁴ Ma et al.²⁵ indicated that empty nesters show a higher prevalence of depressive symptoms. Su et al.²⁶ showed that the empty nester in the rural area has more depression and less objective support than an urban empty nester. Tong et al.²⁷ indicated that in Shanghai, >30% of the elderly reported a mild or above-mild level of depression. Participants with low income, less favorable housing conditions, and loneliness showed more depressive symptoms. Wang et al.²⁸ reported that elderly adults with depression, loneliness, and cognitive impairment, as well as females and people living alone or in rural areas, were at risk for anxiety disorder. The prevalence of depressive symptoms was 74.46% among empty nesters in the rural area of Yongzhou City, and the depressive symptoms showed association with negative coping style, support utilization, religious beliefs, economic status, marital status, and subjective support.²⁹ Zhai et al.³ revealed that it is natural for empty nesters who are male, ≥70 years old, and retired, as well as those with low level of education, to exhibit depression. Zhang et al.³⁰ reported that in the economically depressed area of Hunan Province, elderly persons’ education, income, and social support showed significantly more effects in predicting subjective well-being.

Cheng et al.³¹ indicated that loneliness is obvious in the empty nester and that depressive symptoms constitute the stronger risk factor. Liu and Guo³² reported that the empty nester has a higher level of loneliness. Social support and income are negatively associated, whereas the education level and being single are positively associated. Wu et al.³³ revealed that 80.94% of the empty nesters in Anhui rural area had moderate-to-high levels of loneliness.

Chan et al.³⁴ indicated that the number of people with dementia and Alzheimer’s disease has been increasing fast in the past few years in China. The number of elderly with dementia was 3.68 million in 1990, 5.62 million in 2000, and 9.19 million in 2010. And the number for those with Alzheimer’s disease was 1.93 million in 1990, 3.71 million in 2000, and 5.69 million in 2010. Dong et al.³⁵ reported that in the period 1980–2004, Alzheimer’s disease and vascular dementia were the major forms of dementia in China. Moreover, the risk factors for Alzheimer’s disease are gender, education level, occupation, and age. Hua and Jin³⁶ indicated that the quality of life of the immediate family members of senile dementia patients is relatively low. China’s empty nesters need better care, especially those in rural areas.³⁷

The video game experts possess higher speeds and better visual short-term memory, switch more quickly, and mentally rotate objects more efficiently.³⁸ Hardy et al.³⁹ indicated that the participants who were trained through mental activities had more significant improvement in terms of the speed of processing, short-term memory, working memory, problem solving, fluid reasoning assessments, and cognitive function. Spiritual activity may benefit the elderly adults’ cognitive function.⁴⁰ Digital games are used to enhance the cognitive function.⁴¹ Mental training can strengthen plasticity in the brain and psychological function, in addition to increasing control over the distribution of limited brain resources.⁴²

Fox⁴³ revealed that exercise is effective in depression, has a positive influence on physical self-perceptions and self-esteem, and has a moderate anxiety-reducing effect. Health promotion behaviors change the quality of life and overall functioning among Korean community-dwelling aging people, and the inclusion of exercise in health promotion behaviors is essential.⁴⁴ A meta-analysis indicated that fitness has momentous but selective benefits on cognitive function.¹⁹

Dance – as a form of physical activity – helps release emotional expression, allows for creativity, and decreases stress, depression, and loneliness. Moreover, it helps the older brain to form new interconnections and to work faster, in addition to increasing the improvement of memory, attention, and the ability to multitask and plan.⁴⁵ Dancing can improve physical fitness and mental health, develop social skills, and provide entertainment during aging.⁴⁶ Dance can prevent Alzheimer’s disease and other forms of dementia in the elderly. Participants who engaged in reading, dancing, and playing board games and a musical instrument at least 11 times per month reduced their risk of dementia by 63%.⁴⁷

Klusmann et al.⁴⁸ reported that exercise and computer class have equivalent beneficial effects on cognitive fitness and might delay cognitive decline in healthy elderly women. Exercise enhances cognitive vitality across the life span through reduction of disease risk and improvement in the molecular and cellular structure and function of the brain.⁴⁹ Mental exercise is hypothesized to offer personal benefits to the cognitive function, the benefits becoming higher with increased age.⁵⁰

Mahjong is a psychological game that originated in China during the period of the Qing dynasty, and it involves four people. It is very popular in China, even worldwide. The main population playing mahjong in China is made up of the old adults. Mahjong is easy to learn but is also a profoundly mentally demanding game. Mahjong requires the player to calculate the composite scores, remember others’ moves, and build up one’s own strategy during the play. Mahjong does not require professional supervision and can be implemented as widely as space allows at a given time.

Mahjong can affect the cognitive function of people with dementia, even after withdrawal for a month. Once an initial threshold is attained, the benefits of mahjong appear to be long-lasting. It also can be a potentially benefit for communities in terms of expenditure when mahjong is used in daily routine care.⁵ Mahjong can preserve functioning or delay decline in specific cognitive domains, even in those with significant cognitive impairment.⁶ One study showed that playing mahjong can enhance short-term memory, attention, and logical reasoning capability in the middle-aged and elderly populations. Playing mahjong yields superior benefits over time.⁷

Chinese square dance is an exercise routine performed to music in squares, parks, and other public places. Dancing originating in China has been recorded during the reign of Emperor Yao. There are >8000 kinds of Chinese square dances, and they come in a variety of levels of difficulty. It is very popular with middle-aged and old-aged women. On August 6, 2016, 1000 women gathered to dance at the Xian Yang Unity Square in Shaanxi Province, Xianyang City, for the World Fitness day.

One related article showed that Chinese square dance could effectively reduce the depression levels of women in the perimenopausal stage.⁸ Chinese square dance can promote cognitive function and relieve depression and anxiety in old adults.⁹