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

Yue Zhng, Mrci A. Petrini,b,*

aSchool of Health Science, Wuhan University, Wuhan, Hubei, 430071, China

bChiang Mai University, Chiang Mai, Thailand

Abstract: Objective: The elderly population has proliferated worldwide. The empty-nest family pattern has become predominant among the aging people, and they are more vulnerable to the development of cognitive disorders. However, there is no standardized service in the community nursing care that includes procedures on how to improve the cognitive function of the elderly. Meanwhile, the booming number of empty-nest elderly stimulates the community nurses to assume the responsibility for their care. All of these bring more difficulties and opportunities for community nurses who are dedicated to the prevention of geriatric cognitive disorders.Methods: The authors reviewed the literature related to “empty-nest elderly”, “cognitive function”, “mahjong”, and “Chinese square dance” in the Elsevier, Web of Science (WOS), China National Knowledge Infrastructure (CNKI), Springer and PubMed databases. The study illustrates the utility possibility of an efficient and straightforward method for improving the cognitive function among the elderly in the context of community nursing care in China and even in the rest of the world.Results: Mental and physical activity contributes to cognitive fitness and may be beneficial in delaying cognitive decline. Mental activities, such as playing mahjong, and physical activities, such as the Chinese square dance, are common Chinese activities. Both of them can affect cognitive function in some way.Conclusions: China is experiencing one of its most severe aging problems. Community health personnel and related professionals may consider using mahjong and Chinese square dance to promote psychological health in empty-nest elderly individuals in the community.

Keywords: empty-nest elderly · cognitive function · mahjong · Chinese square dance

1. Introduction

In 2016, the United States Census Bureau reported that the elderly population will rise by 55 million in the ensuing 2 years and account for 8.5% of the total population. The number of people aged 65 years and older will increase by about 236 million in the next 9 years, and it will almost double to 1.6 billion globally from 2025 to 2050, while the total population will increase just 34%.1

The elderly population has grown rapidly worldwide,and the aging problem has become serious. China is experiencing one of its most severe aging problems. The United States Census Bureau represented the elderly population in 2015 as 10.1% of the total population; this figure will increase to 17.2% in 2030 and 26.7% in 2050 in China. By 2050, the elderly population in China (348.8 million) will be more than the combined total populations of Japan, Egypt, Germany, and Australia (345.6 million).1

Gratton and Gutmann2indicated that the percentage of empty-nest married men aged 60 years and older living with their wife increased from 19% to 78% between 1880 and 2000 in the United States. Empty nest families have been becoming the main pattern among aging people.3Liet al.4reported that the number of empty-nest elderly families will reach 90% of the total number of families in China. Many studies exploring empty nesters' cognitive condition in China have shown that this kind of population is more vulnerable to depression, loneliness, dementia, Alzheimer's disease, and other mental syndromes.Some of the studies indicated that the rural area is more vulnerable. Some studies have reported that psychological and physical activity contributes to cognitive fitness and may be beneficial in delaying cognitive decline.

In China, mental activities such as mahjong and physical activities such as Chinese square dance are the most common activities. However, there has been little previous research into mahjong and Chinese square dance.Researchers5-7have reported that mahjong can affect the cognitive function of people with dementia and can preserve the functioning or delay the decline in certain cognitive domains, even in those people with significant cognitive impairment. Researchers8,9showed that Chinese square dance can promote cognitive function in middleaged females, in addition to relieving depression and anxiety in old adults. Many studies indicated that dancing could improve physical fitness, mental health, and creativity; help develop social skills and provide entertainment well during aging; release emotional expression; and decrease stress,depression, loneliness, and dementia. Cultural dance can increase the physical activity and health.10

Therefore, investigating whether mahjong and Chinese square dance improve the cognitive function in community empty-nest elderly or not is appropriate. The study is significant in the context of understanding the needs of elderly adults in ways that can contribute to a public policy aimed at improving the cognitive function of the empty nester, enabling China to handle the challenges rapidly and cost-effectively in population aging.

2. Cognitive condition of the empty-nest elderly

2.1. Cognitive condition of the empty-nest elderly worldwide

A couple of studies11,12have reported that empty nesters experience loneliness after their children leave, but the participants in both studies were midlife women.Jakobsson and Hallberg13indicated that loneliness and fear are universal among aging people. Fahrenberg12termed the depression and isolationfound 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.14,15Depression comes ninth behind prolific killers when ranked by disability and death combined in the world.16

Reitz and Mayeux17showed 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.18The 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).19Among aging Malays, the prevalence of any cognitive impairment has been reported to be 25.5%.20

2.2. Cognitive condition of the empty-nest elderly in China

Chinese empty nesters are vulnerable to many common cognitive problems as are empty nesters worldwide. Gao et al.21showed 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.22showed that the empty nester was statistically low in vitality, emotional role, and mental health. Liu and Guo23indicated that the empty nester was vulnerable to mental problems and was prone to have low level of life satisfaction.

Feng et al.24noted 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.24Ma et al.25indicated that empty nesters show a higher prevalence of depressive symptoms. Su et al.26showed that the empty nester in the rural area has more depression and less objective support than an urban empty nester. Tong et al.27indicated 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.28reported 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.29Zhaiet al.3revealed 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.30reported 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.31indicated that loneliness is obvious in the empty nester and that depressive symptoms constitute the stronger risk factor. Liu and Guo32reported 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.33revealed that 80.94% of the empty nesters in Anhui rural area had moderate-to-high levels of loneliness.

Chan et al.34indicated 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.35reported 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 Jin36indicated 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

3. Benefits of mental and physical activities in the aging population

3.1. Mental activities

The video game experts possess higher speeds and better visual short-term memory, switch more quickly, and mentally rotate objects more efficiently.38Hardy et al.39indicated 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.40Digital games are used to enhance the cognitive function.41Mental training can strengthen plasticity in the brain and psychological function, in addition to increasing control over the distribution of limited brain resources.42

3.2. Physical activities

Fox43revealed 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 communitydwelling aging people, and the inclusion of exercise in health promotion behaviors is essential.44A 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.45Dancing can improve physical fitness and mental health, develop social skills, and provide entertainment during aging.46Dance 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

3.3. Mental and physical activities

Klusmann et al.48reported 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.49Mentalexercise is hypothesized to offer personal benefits to the cognitive function, the benefits becoming higher with increased age.50

4. Reasons for applying mahjong and Chinese square dance

4.1. Reasons for applying mahjong as a mental activity

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.5Mahjong can preserve functioning or delay decline in specific cognitive domains,even in those with significant cognitive impairment.6One study showed that playing mahjong can enhance shortterm memory, attention, and logical reasoning capability in the middle-aged and elderly populations. Playing mahjong yields superior benefits over time.7

4.2. Reasons for applying Chinese square dance as a physical activity

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.8Chinese square dance can promote cognitive function and relieve depression and anxiety in old adults.9

5. Conclusions

The aging problem has become increasingly serious.Empty-nest elderly is the main pattern of old adults.Mental and physical activity can change their mental syndrome (depression, loneliness, dementia, Alzheimer's disease, and so on). Mahjong and Chinese square dance seem to open a method for community nurse care. Further research is needed to develop these tools to cater to the needs of empty-nest elderly and community nurses. Thus, the cognitive function of the elderly population will be more easily promoted. Community health personnel and related professionals may consider mahjong and Chinese square dance to promote psychological health in empty-nest elderly individuals in a community.

Conflicts of interest

All contributing authors declare no conflicts of interest.