Cognitive problems of Iranian elderly with mild cognitive impairment: A qualitative study for developing a cognitive rehabilitation package

Preserving the cognitive ability of the elderly is a common issue of concern among researchers and health policymakers (1). Mild cognitive impairment (MCI) is a concerning condition indicating an elderly person's cognitive abilities are less than expected (3-5). Researchers interested in aging research strive to prevent the progression of cognitive problems as much as possible by identifying the cognitive problems of the MCI elderly as early as possible or, if this goal is not met, to compensate for their cognitive problems by developing rehabilitation packages (11). Evidently, cognitive rehabilitation packages cannot be provided without first understanding the cognitive problems of the elderly with MCI (15). According to the previous studies, the majority of those studies conducted for developing cognitive rehabilitation packages for the elderly have used the results of quantitative studies as the basis for choosing cognitive tasks (6, 11, 14, 16-19); this is even though in these studies, the actual view of the elderly themselves, or people who know them well, has never been asked. The current study used a qualitative research method to identify the cognitive problems of the Iranian elderly with mild cognitive impairment (MCI) to address these limitations. Besides, the results can be used to develop a cognitive rehabilitation package for the Iranian elderly with MCI.

The current study was a qualitative thematic analysis study that followed the method proposed by Braun and Clarke (27). The statistical population consisted of all Iranian elderly with MCI. The study sample included 14 elderly subjects with MCI diagnoses, seven relatives of elderly MCI patients (informants), and five specialists in providing mental health services to the elderly (Two psychiatrists, two psychologists, and one nurse), for a total of 26 subjects. The subjects were all Kerman city residents, and the study occurred between the summer and fall of 2021. Data Saturation was used to determine the adequacy of the sample size. The NUCOG test and a semi-structured in-depth interview were used as research tools (28). Guba and Lincoln's four recommended criteria (i.e., Credibility, Dependability, Confirmability, and Transformability) were used to assess the trustworthiness of the research data (31).
The data analysis process was carried out in six comprehensive steps:

Familiarization with the data,
Generation of initial codes,
Search for themes,
Review of the identified themes,
Definition and naming of themes,
Production of the final report.

As Figure 1 illustrates, the cognitive problems of the Iranian MCI elderly fall into two broad categories: Main problems and side problems. The main cognitive problems include four themes a) memory problems, b) attention problems, c) executive function problems, and d) language problems. Besides the main problems, another theme under the title of anxious mood has also been extracted (side problems).

Figure 1. Final thematic map related to the cognitive problems of the Iranian MCI elderly

A more in-depth investigation revealed that the theme of memory problems in the Iranian elderly is more of an episodic memory type; this means that their most common type of forgetfulness is related to forgetfulness in daily affairs. In terms of attention, they have problems in all four general areas of attention, i.e., shifting attention, selective attention, sustained attention, and divided attention. The theme of executive function problems in Iranian MCI elderly was so diverse that it included problems in all three general areas of executive functions, i.e., cognitive flexibility, inhibitory control, and working memory. In addition, the theme of linguistic problems in the Iranian MCI elderly manifested in difficulty finding words. Furthermore, Iranian elderly with MCI demonstrated a high level of emotional and mood problems, prompting the extraction of another theme from the data under the heading of anxious mood theme.

The current study's findings are consistent with previous research that has shown that the MCI elderly have problems with memory (6-8), attention (6-8), executive functions (7-9), and language (7, 8). An intriguing finding from the current study was that the problems of the Iranian elderly were significantly more prominent in some aspects of a cognitive domain than in others. For example, in the field of memory, the problems of the Iranian elderly were mainly of the episodic variety (and not other types of memory such as procedural, semantic, and the like). Similarly, regarding language, the Iranian MCI elderly had more difficulty finding words than other problems (such as Neologism, understanding, and the like). As a result, relying on such findings is critical for developing rehabilitation packages for the Iranian MCI elderly. Another intriguing finding was that, while the study was designed to identify cognitive problems in the elderly with MCI, the majority of subjects raised issues related to mood and emotional aspects of their lives due to the MCI disorder. This prompted the researchers to propose another theme; i.e., anxious mood; something more than the cognitive problems that the current study focused on (the main problems). Indeed, it appears that cognitive rehabilitation programs tailored to the Iranian elderly should include tasks that address both their primary (cognitive) issues, as well as their secondary issues (anxious mood).
Ethical Considerations
Compliance with ethical guidelines
The ethical principles included in this study were the subjects' arbitrary participation in the research, adherence to confidentiality principles, and informed consent. Additionally, the study was approved by the Research Ethics Committee of the University of Isfahan (Approval ID: IR.UI.REC.1400.49).
Authors' contributions
This article is part of Mohammad Ghaderi Rammazi's PhD dissertation at the University of Isfahan (IranDoc tracking code: 1617543). All authors participated in the ideation, writing, editing, and preparation of the article's final version.
Funding
This research was funded with the support of the Cognitive Science and Technologies Council (CSTC; tracking code: 10567).

Acknowledgments
The authors with this express their gratitude to all the participants and people who facilitated the implementation of this research in any way.
Conflicts of interest
This article contains no conflicts of interest.