The Effectiveness of Computer-Based Cognitive Rehabilitation on the Rumination in Older Adult with Death Anxiety Living in Nursing Homes

Old age, as a sensitive stage of human evolution, brings unique characteristics and conditions. Rumination is one of the most common mental health issues among older adults, which can be improved with appropriate interventions. Therefore, this research aimed to examine the effectiveness of computer-based cognitive rehabilitation (CBCR) on rumination in older adults with death anxiety living in nursing homes. The research method was quasi-experimental with pretest-posttest-control group design. The statistical population included older adults residing in nursing homes in Ardabil, Iran in 2023, among whom, 30 individuals (aged 60 to 80 years) were selected using convenience sampling method and based on the study inclusion criteria, and assigned to an experimental group (15 individuals) and a control group (15 individuals). The experimental group received twelve 45-minute sessions of CBCR collected by the researcher, while the control group received no intervention. The questionnaires used in this research included Templer's Death Anxiety Scale for older adults and Nolen-Hoeksema and Morrow’s Rumination Questionnaire. Data were analyzed using univariate analysis of covariance (ANCOVA) in SPSS-26 software. The findings indicated that CBCR has a positive effect on rumination in older adults (P<0.001). These results indicate that CBCR can be considered useful for addressing rumination in older adults due to its ease of use and the variety of tasks it includes. Therefore, CBCR can be used as an effective method to reduce rumination in older adults living in nursing homes.
EXTENDED ABSTRACT
 
Introduction
Statistical estimates indicate that in the next 30 years, the percentage of older population in Iran will reach approximately 26% of the total population. Compared to other age groups, older adults are more affected by social and psychological issues. In this context, anxiety about the stressful and unknown event of death leads to intrusive and harmful rumination among older adults. Among the treatments developed for older adults, cognitive therapies have proven effective. However, although various cognitive therapies have been studied, there has been little research on the effectiveness of computer-based cognitive rehabilitation (CBCR) on rumination in older adults. This method deals with cognitive biases, introducing new information processing methods to change the interpretative biases related to rumination. While there is a research gap in this field, it is also important to note that individuals with deficiencies in information processing are prone to cognitive errors. Providing cognitive rehabilitation interventions for such individuals aims to uncover cognitive distortions that fuel rumination and negative affect, encouraging individuals to identify and alter irrational ruminations and misinterpretations of events. Therefore, considering the research literature gaps in this field, the present study aimed to examine the effectiveness of CBCR on improving rumination among older adults with death anxiety.
Method
The present research was an applied study in terms of its goal and a quasi-experimental study in terms of its method and nature of data collection, employing a pretest-posttest design with a control group. The statistical population included all older adults aged 60 and above with death anxiety residing in nursing homes in Ardabil, Iran in 2023, among whom 30 individuals were selected based on their scores in the Death Anxiety and Rumination questionnaires and their willingness to participate, using convenience sampling method. The sample size was calculated based on Delavar’s (2017) recommendation of selecting 15 individuals for each group in experimental methods. Inclusion criteria were (1) residing in nursing homes, (2) age above 60, (3) commitment to session activities (completing session assignments), and (4) willingness to participate. Exclusion criteria were (1) incomplete questionnaire responses (more than 20% of unanswered items) and (2) discharge from the nursing homes. Participants completed the Templer’s Death Anxiety Scale and the Nolen-Hoeksema and Morrow’s Rumination Questionnaire. The intervention protocol implemented in this study included CBCR which involved video games and podcasts, collected by the researcher, and conducted in twelve 45-minute sessions, on Saturdays, Mondays, and Wednesdays over four weeks. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential statistics (independent t-test with assumption checking) in SPSS software version 26.
Results
Before conducting data analysis, it was determined that the distribution of scores was normal (P>0.05), and the assumption of similar variances was met in the experimental and control groups (P>0.05). Besides, the assumption of equality of the met covariance matrices of the dependent variable in the groups was fulfilled (P<0.05). During the data analysis, descriptive statistics showed the mean scores of ruminations in the control group and pre-test were 53.866, in the control group and post-test were 52.600, in the experimental group and pre-test were 53.666, and in the experimental group and post-test were 41.400. The standard deviations for rumination in the control group and pre-test were 5.578, in the control group and post-test were 6.103, in the experimental group and pre-test were 4.099, and in the experimental group and post-test were 3.737. The mean score of rumination in the experimental group decreased in the post-test compared to the pre-test. The significance of these differences requires inferential analysis, but it is noteworthy that the Shapiro-Wilk statistics for the control and experimental groups in the pre-test and post-test stages of the rumination variable were not significant. To examine the inferential statistics, as shown in Table 1, there is a significant difference between the experimental and control groups in terms of rumination. In other words, CBCR significantly reduced rumination in the experimental group (mean score of 41.400) compared to the control group (mean score of 52.600). The effect size is -3.03, indicating a large effect in the experimental group compared to the control group. The negative value signifies that the experimental group had lower rumination scores. In other words, CBCR was effective on the rumination variable.
Conclusion
The results showed that the education program based on the PERMA model effectively improved rumination in older adults. The analysis of the first hypothesis demonstrated that the education program has a substantial impact on rumination, suggesting that this intervention can have long-term effects on older adults’ perceptions and psychological health. By emphasizing aspects of well-being, the PERMA model may potentially buffer older adult population against poor mental health by enhancing subjective happiness and mental well-being.
The PERMA model-based education program helps older adults discover meaning and purpose in their lives, enabling them to establish positive social relationships, promoting social integration, and receiving social support. Through the use of this education program, older adults are equipped to solve problems, find suitable solutions, and attain psychological satisfaction. Furthermore, the education program aids older adults in facing life’s challenges, establishing positive relationships, and achieving their goals.
Ethical Consideration
Ethical Code
This study was conducted independently and with the necessary permissions from the Research Deputy of Mohaghegh Ardabili University andthe General Directorate of Welfare of Ardabil County.
Financial Support
This study received no financial support.
Authors’ Contributions
F.G: Conceptualization, Methodology, Writing – Original Draft, Project Administration; H.Q: Software, Validation, Formal Analysis, Data Curation, Visualization; A.SH: Writing – Review & Editing, Supervision
Conflict of Interest
The author had no conflicts of interest.
Acknowledgments
The authors would like to thank the Research Deputy of Mohaghegh Ardabili University and the officials of the General Directorate of Welfare of Ardabil County for their moral support and cooperation in conducting this research. They also extend their gratitude to participants who patiently responded to the questionnaires and attended the therapy sessions.
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