1. Background

Owing to the rapid aging of society, there is an increasing interest in reduced cognitive function in older adults. Cognition refers to high-level brain functioning that involves the recognition, distinction, and resolution of a variety of external stimuli. Cognitive function consists of memory, visual-motor integration, judgment, execution, attention, orientation, language skills, and so on. Memory, the ability to restore and recall information such as words, faces, and events [1], and visual-motor integration, the ability to integrate physical movement with sensory information from visual perception [2], are most susceptible to changes at the early stage of cognitive decline [3, 4]. Decline in memory and visual-motor integration causes various problems in performing almost all activities of daily living, such as saying words and names in conversation, remembering a phone number or a promise, finding things, writing and drawing, or changing positions. Older adults experiencing these problems fear the loss of cognitive function, perceive it as a serious health threat, and seek ways to slow or prevent the decline [5]. However, memory skills continuously decrease with age [6], leading older adults to lose self-confidence in their memory [7], which can finally lead to depression and may affect their quality of life [8].

Memory training is the most common and traditional approach for improving the cognitive function of older adults. Traditional memory training consists of and focuses only on teaching specific memory strategies for the effective encoding, consolidation, and retrieval, according to the information processing perspective. However, such interventions do not deal with the other influencing factors related to the memory of older adults. Among them, memory belief is the most feasible aspect for memory interventions [5]. Memory self-efficacy is one's self-efficacy beliefs pertaining to memory performances [9]. Self-efficacy is the belief in one's own ability to successfully accomplish something. It is a theory by itself, but it is also a construct of social cognitive theory. According to self-efficacy theory, verbal persuasion, mastery experiences, vicarious experiences, and somatic and emotional states affect our self-efficacy and, therefore, our behavior [10]. High self-efficacy motivates individuals to perform a desirable behavior and to increase efforts to achieve the expectations [11]. Actually, memory self-efficacy modulates brain activities during intentional encoding for memory executives. People with high memory self-efficacy seem to be more actively engaged [12], more efficiently conduct memory performance by relying on their memory executives [13], and perform better on memory tasks [12]. However, older adults tend to underestimate their memory and have lower memory self-efficacy owing to the memory decline they experience in their everyday affairs [7]. Low memory self-efficacy further decreases memory performance [12]. If specific training strategies based on self-efficacy theory are thoroughly integrated into a program [6], memory performance in even older adults can be improved by increasing memory self-efficacy [12].

Depression is another considerable aspect of memory programs for older adults. Because depressive older adults have more trouble engaging in a program owing to the emotional distress or exhaustion they experience, they rarely complete the program, which can influence its effectiveness [14]. Previous studies have demonstrated the necessity of affectional approaches in memory programs for older adults based on the results that depression is negatively related to memory [15] and self-efficacy in older adults [8, 15]. Multifactorial programs that include aspects related to older adults' memory, such as self-efficacy, can improve not only cognition but also depression [16]. Further, alleviation of depression by itself increases self-efficacy and makes them engage in more positive behaviors [8].

Visual-motor integration as well as memory is essential to promote the cognitive function of older adults. Visual-motor integration is particularly necessary for maintaining an optimal quality of life because it coordinates and executes physical activities along with visual perception and commands from the central nervous system for daily living activities such as eating, walking, and writing [4]. The concept of visual-motor integration was originally developed to distinguish learning difficulties in children's cognitive development and to improve their academic achievement and adaptation in school. It has been applied in recent studies to detect and ascertain cognitive decline in older adults [4, 17] because those with cognitive decline frequently show a decline in visual-motor integration at the initial stage [3, 4]. For intact visual-motor integration, various and extended brain areas must be used to recognize visual stimuli and to plan and execute movements. The occipital, parietal, and temporal lobes help to distinguish and recognize visual stimuli; the frontal lobe facilitates the integration of sensory information and planning of appropriate acts; and the basal nuclei and cerebellum modulate muscle movements [1]. This means that visual-motor integration training can stimulate all brain regions to improve neuroplasticity, and thus improve performance on daily living activities. Therefore, visualmotor integration training can be one of the most effective methods to enhance the cognitive functioning of older adults and it is important to examine the effectiveness of including visual-motor integration in intervention for preventing cognitive decline in older adults.

To sum up, memory and visual-motor integration training can be the most efficient and necessary approach to stimulate neuroplasticity in older adults. In addition, memory self-efficacy is a crucial element to improve memory [12] and alleviate depression in older adults [8]. Although several previous studies [6, 12, 18] demonstrate the effect of memory training based on self-efficacy, they focus only on memory training. However, evidence [14, 19] shows that no significant effect on memory also exists. Furthermore, no previous study has verified the effect of visual-motor integration training in older adults, though it is one of the most sensitive areas that demand prompt intervention. Therefore, it is important to demonstrate whether a memory and visual-motor integration program based on self-efficacy theory is effective for memory self-efficacy, memory, visual-motor integration, and depression in older adults. The present study is the first trial to integrate self-efficacy theory into traditional memory training and to include visual-motor integration training. In this context, this study was planned to test the effects of a memory and visual-motor integration program based on self-efficacy as a new and efficient method for increasing cognitive function in older adults.

2. Purpose

The purpose of this study was to test the effects of a memory and visual-motor integration program based on self-efficacy theory on older adults' memory self-efficacy, memory, visualmotor integration, and depression.

3. Hypotheses

Hypothesis 1. Memory self-efficacy will significantly increase in the experimental group members who participate in a memory and visual-motor integration program based on self-efficacy theory for older adults, as compared with that in the control group members.

Hypothesis 2. Memory will significantly increase in the experimental group members as compared with that in the control group members.

Hypothesis 3. Visual-motor integration will significantly increase in the experimental group members as compared with that in the control group members.

Hypothesis 4. Depression will significantly decrease in the experimental group members as compared with that in the control group members.

1. Design

A non-equivalent control group pre-test–post-test quasi-experimental design was implemented to verify the effects of a memory and visual-motor integration program based on the self-efficacy for older adults

2. Participants

The number of participants was calculated using the G-power 3.1.7 program with the following conditions: a significance level of α at .05, a power of .80, and an effect size of 0.73 in an independent t-test. The effect size was verified by the study on memory training for older adults by Verhaeghen et al. [20]. In the present study, the number of participants calculated for each group was 31. Considering the dropout rate of 13% observed in the study by Han et al. [21] that included a group cognitive enhancement program for older adults, 35 participants were recruited in each group.

The inclusion criteria were being aged 65 years or older, not being diagnosed with cognitive impairment or dementia, being able to function independently in daily life without difficulty, and being able to understand and follow the program without communication difficulties resulting from visual and hearing problems. The exclusion criteria were having a severe disease requiring chemotherapy or radiation therapy and having received a diagnosis of a mental disorder or taking medication for severe depression, schizophrenia, or other psychiatric problems.

To recruit participants for this study, the researcher visited senior centers and elderly welfare facilities located in D or G city, Korea, and explained the study purpose and procedures to the manager and facility users. The researcher and five research assistants assessed whether the applicants who wished to participate in this study met the inclusion and exclusion criteria, and they implemented the Mini Mental State Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) assessment packet (MMSE-KC). The MMSE-KC score was considered to indicate cognitive impairment when the participant fell below the 5th percentile in the norm table categorized by age, gender, a nd educational level [22]. Based on these findings, the final participants for this study were selected.

3. Instruments

4. Memory and visual-motor integration program for older adults based on self-efficacy theory

A memory and visual-motor integration program was implemented for the older adults in each senior center or welfare facility allocated to the experimental group. The successful memory training implemented by West et al. [6] consisted of 6 2-hour sessions for 6 weeks. A multifactorial cognitive progam including physical activities was conducted twice a week in the study by Sun [16]. Additionally, it had to be considered that older adults could have difficulties with long program running time, which might affect the results [19]. Therefore, the memory and visual-motor integration program implemented in the present study consisted of twelve 90-minute sessions conducted twice a week over 6 weeks. The program was based on self-efficacy theory of Bandura [11] and focused on building memory self-efficacy, proposed by the memory training of West et al. [6], and the visual-motor integration program proposed by Yeo [2]. The program was validated by 2 nursing professors, who had experience of intervention studies for older adults, and 1 doctor of medicine who majored in exercise and medical physiology, and the program was subsequently modified and refined. The program details are shown in Table 1.

Table 1
Overall Procedures of the Memory and Visual-Motor Integration Program Based on Self-Efficacy Theory

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1) Application of self-efficacy sources

Bandura proposed that there were 4 sources of self-efficacy: enactive mastery, vicarious experience, verbal persuasion, and physiological and affective states. Therefore, to increase memory self-efficacy in the present study, these 4 sources were incorporated in all elements of the program (Table 2).

Table 2
Strategies of the Visual-Motor Integration and Memory Training Program Using Sources of Self-Efficacy

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For enactive mastery, all participants were assigned classroom tasks and homework that gradually increased in difficulty, including memory games, drawing lines as directed, rhythmic hand gestures, and so on. The personal level of the participants was considered to facilitate successful performance. The professionals reviewed the entire program, and detailed tasks and homework were supplemented and modified according to the level of the participants.

To foster vicarious experiences, participants had opportunities to observe their peers' successful practice before their own, and they talked with each other about beneficial strategies to achieve success.

Verbal persuasion consisted of 12 sessions that incorporated instruction, didactic persuasion, and personal coaching. The educational contents covered changes in memory function with aging, neuroplasticity, information processing and memory strategies, visual-motor integration training, and the effectiveness of the training. They focused on correctly understanding the changes in cognitive function in the normal aging process and learning specific methods to enhance cognitive function. In addition, participants had opportunities to recognize their positive changes in a supportive and encouraging environment, emphasizing on their potential memory ability, and they were provided with positive feedback for their tasks and homework.

For emotional relaxation, program facilitators provided participants with a supportive environment in which they could complete their tasks without competing and rushing. Moreover, they could discuss their memory problems with peers and ascertain that everyone has similar cognitive problems. Additionally, recreational activities, singing together, and 5 minutes of deep-breathing meditation were conducted to reduce their anxiety.

5. Data collection

Data for this study were collected at 4 senior centers and 2 elderly welfare facilities located at D or G city from July 14 to October 14, 2014. The researcher visited several senior centers and elderly welfare facilities and explained the study purpose and procedures to the manager and facility users. The researcher also ensured that the facility users did not already participate in any cognitive enhancement program. Among them, 6 organizations provided informed consent, and participants who belonged to the organizations were recruited. Four senior centers and 2 elderly welfare facilities had a similar socioeconomic level. Therefore, 2 senior centers and 1 elderly welfare facility were assigned to the experimental or control groups, respectively.

After eliminating 2 persons with dementia and 3 with hearing difficulties among 79 applicants wanting to participate in this study, 74 participants who satisfied the inclusion and exclusion criteria were selected.

In the experimental group, 39 participants participated at the beginning. Two individuals did not complete the pre-test, and 7 dropped out from the program due to moving, personal schedules, and so on. Thus, 30 participants participated until the post-test.

In the control group, 35 participants participated at the beginning. Thirty-two participated after eliminating 1 person who did not complete the pre-test and 2 who did not take part in the post-test. A final total of 62 participants, 30 in the experimental group and 32 in the control group, participated in this study for a participation rate of 83.7%.

6. Study procedures

To verify the effects of the memory and visual-motor integration program based on self-efficacy theory for older adults, the following procedures were carried out in the present study.

7. Ethical considerations

To protect the rights of the participants, this study was conducted after receiving approval from the K University Institutional Review Board (IRB No. 2014-0048). Each participant signed a written consent form after receiving an explanation of the study goals, data collection, and confidentiality procedures. They received information that the data collection process could be stopped at any time without penalty. After the post-test data collection, the control group was provided with the same educational booklets given to the experimental group, including daily homework tasks and information to enhance memory

8. Data analysis

Data were analyzed to verify the hypothesis, using the SPSS (PASW Statistics) WIN 18.0 program as follows. Descriptive statistics were conducted with mean, standard deviation, medians, and interquartile range, and normality distributions were verified with the Kolmogorov-Smirnov test. Homogeneity with reference to general characteristics and outcome variables at baseline and differences in the pre-test and post-test scores between the experimental and control groups were examined with chi-square test, independent t-test, and Mann-Whitney U test.

1. Homogeneity test for the general characteristics of the experimental and control groups

General characteristics of the participants, including age, gender, educational level, marital status, whether they lived alone, economic status, subjective health status, drinking, smoking, regular exercise, disease, memory, and instrumental activities of daily living, were investigated, and the homogeneity between the experimental and control groups was examined. The homogeneity test did not indicate any significant differences. Therefore, the experimental and control groups were considered homogeneous at baseline (Table 3).

Table 3
Homogeneity Test of Baseline Characteristics Between Groups (N=62)

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2. Homogeneity of baseline outcome variables between groups

Homogeneity of baseline outcome variables between the experimental and control groups was examined before applying the program. The homogeneity test did not reveal any significant differences in the baseline outcome variables. Thus, the experimental and control groups were homogeneous in terms of their memory self-efficacy, memory, visual-motor integration, and depression scores at baseline (Table 4).

Table 4
Homogeneity Test of Outcome Variables Between Groups at Baseline (N=62)

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3. Hypothesis verification

Before hypothesis verification, post-test and post–pre differences of each group were evaluated in terms of the normality with Kolmogorov-Smirnov test. In the post-test, memory self-efficacy and memory of each group and visual-motor integration of the control group were satisfied with the normality assumption (the range of D: 0.07~0.14, p>.05), but visual-motor integration of the experimental group and depression of each group were not satisfied with that (the range of D: 0.18~0.19, p<.05). In the normality test of post–pre differences, memory self-efficacy was satisfied with the normality assumption in both experimental (D=0.11, p=.200) and control groups (D=0.13, p=.182), but memory (Exp., D=0.12, p=.200; Cont., D=0.20, p=.002), visual-motor integration (Exp., D=0.13, p=.183; Cont., D=0.18, p=.014), and depression (Exp., D=0.13, p=.200; Cont., D=0.20, p=.002) were not satisfied with that. According to the results for normality, an independent t-test for the effect of memory self-efficacy and a Mann-Whitney U test for the effect of the other outcome variables were conducted.

1) Hypothesis 1

Memory self-efficacy significantly increased in the experimental group members who participated in the memory and visual-motor integration program based on self-efficacy theory for older adults as compared with that in the control group (t=2.20, p=.031). Hypothesis 1 was therefore supported (Table 5).

Table 5
Effects of MVPS on Memory Self-Efficacy, Memory, Visual-Motor Integration, and Depression (N=62)

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