By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
• This randomized, controlled trial involved 56 Nanchong City, China, nursing home residents with a baseline knowledge of mahjong (but no recent playing history) and a diagnosis of mild cognitive impairment.
• Randomized into two groups, half of the participants played one hour/game of mahjong three times daily for 12 weeks. The remaining participants served as a control group.
• Three measures of cognitive functioning, the Montreal Cognitive Assessment – Beijing, the Shape Trail Test, and the Functional Activities Questionnaire, were administered to the group at study start, at six weeks, and after 12 weeks.
• All scores showed significant improvement over the 12 weeks in the intervention group with P < 0.001.
SYNOPSIS: This randomized, controlled trial notes improvement in measures of executive functioning, such as organization and planning, in elderly Chinese participants with mild cognitive impairment who were selected to play mahjong three times weekly for 12 weeks.
SOURCE: Zhang H, Peng Y, Li C, et al. Playing Mahjong for 12 weeks improved executive function in elderly people with mild cognitive impairment: A study of implications for TBI-induced cognitive deficits. Front Neurol 2020;11:178.
Mild cognitive impairment (MCI) refers to a cognitive state, often associated with aging, where a patient demonstrates objective evidence of memory deficits without clear functional impairment. Often conceptualized as a stage between normal aging and dementia, MCI is estimated to occur in 10% to 20% of the population aged at least 65 years. Executive function, mediated by the prefrontal cortex and responsible for planning, working memory, and organization, seems particularly vulnerable in patients with MCI.1
Research into this condition has identified several subtypes of MCI and clarified that about 10% of patients with MCI will develop Alzheimer’s disease annually.2 Cognitive fitness activities in patients with MCI have shown an association with delaying or avoiding progression to a more severe form of neurodegenerative
disease.1,2 Zhang et al thus designed a randomized, controlled trial involving the mentally challenging game mahjong and patients with MCI.
Mahjong is a four-player game developed in China more than 2,000 years ago. Spreading to the rest of the world during the 20th century, it remains most popular today among the elderly in China. Playing this tile and dice game requires planning, strategy, memorization of patterns, attention, and focus. There is a gambling element to the game as well.3
Fifty-six patients aged 65 years and older, residents of a local nursing home in Nanchong City, China, were accepted as study participants and randomized into either a control (activity as usual) or mahjong group. All had a diagnosis of MCI and were familiar with playing Mahjong, although they were not current players. Exclusion criteria included both psychiatric and neurologic diagnosis. The intervention arm (mahjong players) played in groups of four persons for one hour, three times weekly at a consistent time, for 12 weeks.
Three scales, described below, measuring cognitive and functional status were administered to the group at the start of the study, at week 6, and at the 12-week conclusion of the study.
- The Montreal Cognitive Assessment-Beijing (MoCA-B) is a screening test for cognitive impairment with scores ranging from 0 to 30 (each correct answer is one point).4
- The Shape Trail Test (STT) measures visual attention and the ability to shift attention.5
- The Functional Activities Questionnaire (FAQ) is a self-reported measure of the instrumental activities of daily living, such as managing finances and cooking meals. Scores in 10 areas range from 0, representing no impairment, to 3, representing severe impairment.6
A comparison between the MoCA-B scores head-to-head between the two arms does not show statistical separation during the study. However, the MoCA-B (scores from 0 to 30 with higher scores representative of less impairment) showed significant improvement from baseline to 12 weeks in the mahjong group and did not significantly change in the control group during this time. (See Tables 1 and 2.)
Looking at the STT (scores reflect time and errors, thus higher scores reflect greater impairment), again, comparing the scores between the two arms of the study reveals no significant difference after 12 weeks. However, in a pattern similar to the results of the MoCA-B test, there is a continual reduction over the 12 weeks in STT scores of the mahjong group, while there is no such reduction in the control group. (See Tables 3 and 4.)
The FAQ scores (higher scores reflect greater degree of functional impairment) decreased continuously and with statistical significance in the mahjong group during the 12 weeks. As opposed to the other measures, the FAQ scores in the mahjong group also showed statistical separation from the control group starting at the six-week mark. (See Tables 5 and 6.)
Zhang et al revealed that patients with MCI directed to play Mahjong three times weekly over 12 weeks showed statistically significant improvement in three different scales measuring executive functioning. The control arm of this study did not demonstrate significant improvement over this time. This is not the first investigation looking at mahjong and cognition. There have been several studies in this area measuring the association of this game with memory and attention in general, but none specifically measuring executive functioning. This study brings further clarity and additional information to this field.
Originally defined in the 1980s as “… the ability to maintain an appropriate problem-solving set for attainment of a future goal,” our conceptualization of executive functioning has broadened to include five general domains. These are:
- fluency or the ability to generate more than one solution to a problem;
- working memory;
- inhibition (of other impulses and distraction while working on a task); and
- set shifting (the ability to shift attention as needed).7
It is interesting and impressive that 12 weeks of playing mahjong was associated with measurements of improvement in these areas. The concept of neural plasticity may have some relevance here; further studies may elucidate the specific mechanisms involved. In some ways, this study brings up more questions than answers. For example, a clear understanding of cause and effect is not established. Comparing mahjong to a “usual activity” control group is a good first step, but leaves knowledge gaps. There is separation between the mahjong and control arms when measuring with the FAQ, but not with the STT or MoCA-B. A better understanding of this relationship could help interpret and apply results.
An active intervention group playing an alternative type of strategy game or having a different focus, such as physical activity, could yield more definitive and clinically relevant results. Additionally, larger numbers of participants and longer follow-up could help generate confidence in generalizing recommendations. However, even with limitations, this study may have particular relevance in our current era of COVID-19. As the result of a vulnerable population, many nursing homes have understandably restricted visitors from the community and reduced internal activities and social gatherings.
When considering the health effect of such policies, the primary care provider (PCP) may want to reflect on the findings from this study. It is unclear whether the social interactions provided as a “side effect” of meeting three times weekly with a group of peers, the gameplay itself, or a combination of factors were instrumental in improvements in cognition. Regardless of the mechanism, it does appear that regular interaction with gameplay in a small group over three months was associated with an improvement in executive functioning.
When working with elderly patients and their caregivers, the clinical relevance is clear: social and mental stimulation have a potential role in improving executive functioning. It is well within the realm of the PCP to assist patients while caregivers and/or the facility balance the risks and benefits of such interactions.
- Sachdev PS, Lipnicki DM, Kochan NA, et al. The prevalence of mild cognitive impairment in diverse geographical and ethnocultural regions: The COSMIC collaboration. PLoS One 2015;10:e0142388.
- Mancioppi G, Fiorini L, Timpano Sportiello M, Cavallo F. Novel technological solutions for assessment, treatment, and assistance in mild cognitive impairment. Front Neuroinform 2019;13:58.
- Kwan L. Mahjong: A brief history of the game. Published Oct. 10, 2014. Roundhouse. http://roundhouse.ca/mahjong-a-brief-history-of-the-game/
- Nasreddine Z. Montreal Cognitive Assessment (MoCA). Updated July 2020. Mapi Research Trust. https://eprovide.mapi-trust.org/instruments/montreal-cognitive-assessment
- Zhao Q, Guo Q, Li F, et al. The Shape Trail Test: Application of a new variant of the trail making test. PLoS One 2013;8:e57333.
- Teng E, Becker BW, Woo E, et al. Utility of the functional activities questionnaire for distinguishing mild cognitive impairment from very mild Alzheimer disease. Alzheimer Dis Assoc Disord 2010;24:348-353.
- Boonstra AM, Oosterlaan J, Sergeant JA, Buitelaar JK. Executive functioning in adult ADHD: A meta-analytic review. Psychological Medicine. 2005. http://hdl.handle.net/1765/10172