Effects of Brain Stimulation in Group Activities on the Cognitive Function Improvement of the Elderly People in the Community Health Center of Bojonagara Area in Bandung Municipality

The success of development in the health sector has an impact on improving the health status and life expectancy of the people of Indonesia. Increasing life expectancy leads to an increase in the number of elderly people in Indonesia. Increasing the number of elderly population, on the one hand, is encouraging but on the other hand, it creates complex problems. Problems that are often faced by the elderly over time occur due to a process of decline that has an impact on changes in the structure and function of organs including the brain. These conditions have an impact on decreasing brain cell function which results in impaired cognitive function in the elderly. The aging affecting cognitive impairment will cause the elderly to have impairment in carrying out daily activities so that they will depend on others and eventually, their quality of life decreases. One of the efforts to resolve such issue is by maintaining and improving cognitive ability through brain stimulation. Optimum brain stimulation is combining physical, mental, social and spiritual stimulation into one activity. This research aims at finding out the “Effects of Brain Stimulation in Group Activities on the Cognitive Function Improvement of the Elderly People in the Community Health Center of Bojonagara Area in Bandung Municipality”. Quasi-experimental design is used in this research with Pre Post test control group design approach. Samples used are 36 people for intervention group and 36 people for control group. The sample is taken using purposive sampling technique. The intervention of brain stimulation is provided 3 times a week for 7 weeks. Brain stimulation is provided through brain gym, relaxation and dhikr. Data are analyzed using Wilcoxon and Mann Whitney. The research result indicates the effects of brain stimulation in group activity on cognitive function of the elderly people (p value 0.001). How to cite this paper: Meilianingsih, L. and Husni, A. (2019) Effects of Brain Stimulation in Group Activities on the Cognitive Function Improvement of the Elderly People in the Community Health Center of Bojonagara Area in Bandung Municipality. Open Journal of Nursing, 9, 891-900. https://doi.org/10.4236/ojn.2019.98066 Received: July 9, 2019 Accepted: August 20, 2019 Published: August 23, 2019 Copyright © 2019 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access L. Meilianingsih, A. Husni DOI: 10.4236/ojn.2019.98066 892 Open Journal of Nursing Therefore, it is suggested that the head of the community health center and the lead of elderly health programs apply brain stimulation as structured activity for elderly intelligent health in the working area of the Community Health Center.


Introduction
Indonesia is the third Asian country with the largest population of elderly people. In 2010, the total elderly people in West Java were 2,880,548 lives [1]. In 2005, there were 500,000 people suffering from dementia in Indonesia and in 2007, there were 2500 people suffering from dementia in West Java [2]. The aging affecting cognitive impairment will cause the elderly to have impairment in carrying out daily activities so that they will depend on others and eventually, their quality of life decreases. On the one hand, the increasing number of elderly populations is encouraging, however, on the other hand, it creates complex issues. The complexity of issues faced by the elderly people is a challenge to improve their health and welfare in accordance with the health development goals.
As time goes by, issues often faced by the elderly are caused by the process of decline that has an impact on changes in the structure and function of organs including the brain [3]. Changes in brain and nerve cells can interfere with the memory of the elderly. During the degenerative process of the brain, there will be changes in cognitive function, namely difficulties in recalling, reduced ability to make decisions and slower actions.
The aging process which affects cognitive impairment will cause the elderly to experience disruption in carrying out daily activities so that they become dependent and they need to be assisted by others to carry out all activities and eventually, the quality of life of the elderly decreases. Unfortunately, aging cannot be stopped. It is a natural process that occurs in all humans. Aging cannot be stopped but can be slowed down. One of the efforts to resolve such issue is by maintaining and improving cognitive ability through brain stimulation [3]. Therefore, it is necessary to make efforts to maintain and improve cognitive abilities by increasing brain stimulation. Optimum brain stimulation is combining physical, mental, social and spiritual stimulation into one activity [4] [5] [6] [7].
Changes in brain and nerve cells can interfere with the memory of the elderly [8] [9]. During the degenerative process of the brain, there will be changes in cognitive function, namely difficulties in recalling, reduced ability to make decisions and slower actions [10].
In order to identify the cognitive function in the elderly, Mini-Mental State Examination (MMSE) questionnaire can be used [3] [11] [12].

Study Design
Brain stimulation in group activities can improve cognitive function of the elderly in the Community Health Center of Bojonegara Area in Bandung Municipality.

Population and Sample
This research used Quasi-Experimental design, pretest-posttest control group design. The number of samples is taken by using a large sample formula for hypothesis testing difference 2 on average with a standard deviation (σ) of 3.5, the average before treatment in the previous study 17.11 (μ1), and the average after treatment at Previous research was 20.05 (μ2) [13] so that the sample size for this study was 33 people, plus the anticipation of a dropout 10% was as many as  Univariate analysis is carried out to find out the cognitive function of the elderly before and after the intervention. Bivariate analysis is carried out using Wilcoxon signed-rank to see the difference of each proportion and Mann Whitney U to compare the difference between the intervention and control groups.

Research Procedure
Preliminary cognitive data collection was carried out using the MMSE instrument. It was carried out in the intervention group and control group. The data were collected approximately in 15 -20 minutes. In the intervention group, brain stimulation intervention was carried out with researchers, students and cadres as facilitators. Brain stimulation was carried out for 7 weeks and 3 times a week (it was carried out two times with facilitators and one time independently) in order to carry out brain stimulation activities including brain gym (physical activity) for 30 minutes, breathing relaxation and dhikr (mental and spiritual activities) for 15 minutes. To ensure the participation of respondents in these activities is used the participation observation form in each activity. Subsequently, final measurement of cognitive function was carried out to the intervention and control groups.

Results
Before looking at the results of the study, we need to know the demographic data from the research respondents, as follows Table 1: The cognitive abilities of the elderly before and after brain stimulation are likely to be different because brain stimulation is a factor that can affect the cognitive abilities of the elderly. For more details can be seen in the following: Based on Table 3, cognitive function in the intervention group following   and null hypothesis is rejected which mean there is a difference in the cognitive function of the intervention group and the control group.

Discussion
The result of Wilcoxon test from pre-and post-brain stimulation on the intervention group indicates p value 0.00 < α (0.05), null hypothesis is rejected which means there is an effect of brain stimulation in group activities on cognitive function. This research is also in line with the research conducted by Widayani which explains that there is an effect of brain stimulation on the improvement of cognitive function (p value 0.00) [14]. A similar research was also conducted by Kusharyadi with the result of p value 0.001 [15]. Hall CB, the more brain stimulation activity carried out may reduce the risk of memory loss by 30% -50% [5].
The result of analysis of the initial and final measurement in the control group indicates p value 0.066 > α (0.05). Null hypothesis is accepted which means there is no effect of brain stimulation in the group activity on the cognitive function. Meanwhile, intelligence health program for the elderly including brain stimulation activity had not been carried out. Cognitive function of the elderly will decrease if no action is taken or brain stimulation is not carried out [17].
In the measurement prior to the treatment/initial treatment there was no dif- terpreted that the brain stimulation is significant or has effect on the cognitive function of the elderly.
In the intervention group, prior to the brain stimulation treatment, mean or average score of the cognitive function was 25.56 of the maximum score of 30.
This condition indicates that the cognitive function prior to the intervention has been good but not optimal. Meanwhile the minimum score was 19. However, after treatment was provided to the intervention group in the form of brain stimulation in group activities, there was a change in the Mean score to be 29.06 and the minimum score became 22. It indicates increase in the cognitive function. The change or increase in scores obtained following the treatment was 3.5.
Brain stimulation carried out is brain gym, relaxation, dhikr and involvement of the elderly in group activities. Optimal brain stimulation is carried out by combing physical mental, social and spiritual stimulation into one activity [4] [5] [6] [7]. Brain stimulation activities for the elderly carried out in group may help the involvement process of the elderly in activities aiming at improving cognitive function [5].
In this research, brain stimulation was provided structurally for seven weeks.
Brain stimulation will affect the cognitive function if it is carried out structurally within seven weeks or more and it is carried out for 45 minutes, three times a week [7] [11]. Based on several corresponding researches, brain vitality gym can improve cognitive function with p value 0.05 [18]. Similar research was also carried out by Eko Susilo with the result of p value 0.000 [13]. Movement in the brain vitality gym can provide stimulus which can improve the cognitive ability (alertness, concentration, speed, perception, learning, memory, problem solving and creativity). In addition, the brain vitality gym improves balance and harmonization between emotional-logic control, optimizes performance function of five senses, maintains flexibility and improves memory [19]. Regular exercise can increase protein in the brain called Brain Derived Neurotrophic Factor (BDNF) [5]. BDNF protein plays an important role in keeping nerve cells fit and healthy. There have been many researches concerning the role of BDNF in memory function. The low level of BDNF may lead to dementia. Physical exercise reduces dementia by 35% [20].
In this research, brain stimulation was also provided through mental activity, namely relaxation. Mental stimulation can improve or maintain the cognitive function of the elderly. Mental stimulation carried out continuously can improve the relationship between brain cells, so that there is a reserve of cognitive function for the elderly which can inhibit the decline in cognitive function. Several researches have shown that mental activities can reduce stress and improve cognitive function. Severe and chronic stress can shrink the hippocampus which causes Alzheimer [6]. Relaxation is one of mental activities which can increase calmness, reduce stress and anxiety [21]. One of the types of relaxation is breathing relaxation. Deep and gentle breathing causes blood circulation to be filled with oxygen, cleanse metabolism and clearer thinking process [21]. The  [22].
Spiritual activity in the form of dhikr is also the treatment provided in this research. Spiritual activity can give the meaning of life, self-worth and life expectancy for the elderly, so as to stimulate their cognitive function. Research on 3050 elderly people carried out by Hill indicated that those who attend religious events regularly tend to experience cognitive decline slower than those who do not actively involve in religious activities [23]. Solemn prayer, dhikr can train the elderly to concentrate/focus their attention on new things. Dhikr is one of the efforts to get closer to Allah by remembering Him. Dhikr process by pronouncing tawhid and istighfar sentence will increase the disposal of CO 2 in lungs and lead to mental tranquility and relaxation [24]. The result of research conducted by Widuri and Subandi indicates that dhikr therapy had significant effect on reducing stress level (p value 0.004) [25].
In this research, brain stimulation was provided in group activity. Active participation in social activities and interaction with other people can help to stimulate the cognitive function and slowing down the occurrence of dementia [4] [5]. Maintenance and coaching of various social relations, as well as active participation in social activities can prevent cognitive decrease in the elderly.
Result of research carried out by Riyanto indicated that the elderly participating in social activities such as Quran recitation, or meetings in the community less than one time a week had risk 1788 times greater to have poor cognitive function compared to those having social activities more than or equal to one time a week [26].

Conclusions
There was an effect of brain stimulation in group activities on cognitive function of the intervention group with p value 0.000. Meanwhile, in the control group there was no difference in the initial and final measurement with p value 0.066.
In the measurement prior to the initial treatment/measurement, there was no difference in cognitive function in the intervention group and the control group with p value 0.317. However, in the measurement following the final treatment/measurement, there were significant differences in cognitive function of the intervention group and control group (p value 0.001). The average score of cognitive function of the elderly prior to the treatment in the intervention group was 25.56 and following the treatment, there was an increase of 3.5, and the average score became 29.06. Meanwhile, the cognitive function of the initial measurement in the control group had an average score of 26.36 and in the final measurement, there was a decrease in the average score to be 26.11.
The result of this research shows that brain stimulation can improve the cognitive function of the elderly. Therefore, the person in charge of elderly health programs and implementing nurses in the community health center can apply brain stimulation in the structured activities of elderly intelligence health in the