Reconstructing Learning and Leisure Activity Interventions for People with Dementia— Preserving Core Active Ingredients While Reducing Cognitive and Implementation Burden

1. Introduction

1.1. Redefining “Learning and Leisure Activities” in Dementia

Cognitive stimulation, learning, and leisure activities do not “cure” dementia; however, they play an important role in suppressing progression-accelerating factors such as disengagement, apathy, and social withdrawal (Robert et al., 2009). Apathy is one of the most prevalent core symptoms of dementia and, while overlapping with depression, can be clinically distinguished as reduced activity and goal-directed behavior (Robert et al., 2009). Reviews of non-pharmacological interventions suggest that individualized therapeutic activities may alleviate apathy (Brodaty & Burns, 2012).

This positioning of learning and leisure activities in dementia—not as disease-modifying interventions but as foundational interventions to suppress progression-accelerating factors—is schematically illustrated in Figure 1.

1.2. Limitations of Conventional Cognitive Training and Learning Interventions

Many learning programs are designed on the implicit assumptions of:

(i)

comprehension and memory;

(ii)

accurate task performance;

(iii)

continuous self-management; and

(iv)

tolerance for evaluation.

In dementia, these assumptions often break down early, resulting in interventions that are theoretically valid but difficult to implement. This mismatch creates failure experiences that reinforce apathy and refusal, leading to a vicious cycle.

2. Constraints in Learning and Leisure Activity Interventions

2.1. Cognitive Constraints: Difficulties in Comprehension, Memory, and Self-Regulation

Understanding task meaning, retaining procedures, making choices among multiple options, and self-evaluation rely heavily on executive function and attention, which are easily compromised in dementia.

2.2. Emotional Constraints: Failure Experiences Trigger BPSD

Learning that emphasizes “mistakes” or “inability” can induce anxiety, anger, and refusal, ultimately promoting withdrawal from activities.

2.3. Implementation Constraints: Care Burden and Daily Care Pathways

Interventions that require extensive preparation, long durations, specialized tools, or relocation are less likely to be sustained.

3. Distinguishing Active Ingredients from Excessive Burden

3.1. Core Active Ingredients

Integrating the literature with implementation realities, the effective elements of learning and leisure activities can be summarized as follows:

• Maintenance of engagement: Prevents fixation of disengagement and apathy
• Securing successful experiences (achievement/pleasure): Preserves reward systems and self-efficacy
• Addition of social context (interpersonal elements when feasible): Simultaneously promotes stimulation, arousal, and emotional stability
• Minimal repeatable units: Even short activities that can be performed “every day”

Cognitive Stimulation Therapy (CST) has been shown to improve cognitive function, quality of life, and depression in people with mild to moderate dementia (Desai et al., 2024). This paper does not deny the effectiveness of CST itself; rather, it emphasizes that in home care and later stages of dementia, the key is to translate the active ingredients (active engagement, successful experiences, and social context) into minimal daily units. Figure 2 reorganizes these core ingredients into a minimal model compatible with dementia care realities.

3.2. Excessive Implementation Burdens to Be Removed

• Evaluation of correct answers or achievement levels (test-like formats)
• Requiring motivation or sustained willingness from the person
• Complex rules or tasks requiring memory
• Decision-making burdens caused by offering multiple choices
• Obligatory recording, scoring, or reflection

4. Dementia-Adaptive Minimal Model of Learning and Leisure Activities

4.1. Minimal Component ①: 10–20 Minutes per Day of “Meaningful Activity” (Including Leisure)

The 10–20-minute duration does not represent an optimal dose, but rather the minimum amount that can realistically be sustained daily.

Examples (fixed according to individual preferences):

• Leisure: coloring, origami, gardening, partial sewing tasks, arranging a shogi board, simple musical instruments, singing
• Roles: assisting with meal setup, folding towels, sorting, wiping, arranging
• Language: reading aloud, short read-aloud sessions, reminiscence using old photographs
• Sensory: keeping rhythm, hand and finger movements (focus on process rather than completion)

4.2. Minimal Component ②: Difficulty Set to Ensure Successful Experiences (“Leaning Toward Can-Do”)

• Early termination is acceptable; completion is not required
• Demonstrate and perform together rather than explaining verbally
• Do not correct mistakes; do not evaluate outcomes based on product quality

4.3. Minimal Component ③: Interpersonal Elements When Possible (One-to-One Is Sufficient)

Social isolation and reduced social relationships are associated with cognitive decline (Kuiper et al., 2015). Therefore, rather than group participation, doing activities together one-to-one should be prioritized.

4.4. Minimal Component ④: Removal of Evaluation and Self-Management Demands (Shifting Responsibility to the Environment)

Instead of relying on the person’s effort or self-management, caregivers and the environment should create pathways that allow activities to begin naturally with minimal steps.

5. Implementation Protocol (Summary)

• Frequency: Daily (short duration)
• Format: Same time, same place, same tools (predictability)
• Leader: Caregiver-led (does not assume user initiative)
• Recording: Simple ○/× check only (no evaluation)

6. Implications for Research, Practice, and Policy

The implementation-adaptive model proposed here differs fundamentally from conventional learning interventions in its assumed cognitive demands. This contrast is illustrated in Figure 3. The novelty of this paper lies not in proposing new cognitive training, but in redefining learning and leisure activities as control mechanisms for progression-accelerating factors and reconstructing them into an implementable minimal unit. Evaluation metrics should extend beyond cognitive test improvements to include apathy, depression, BPSD, daytime activity, ADL decline, caregiver burden, and hospitalization or institutionalization—outcomes directly linked to societal costs (Brodaty & Burns, 2012).

7. Conclusion

Learning and leisure activity support for people with dementia should be reconstructed not as “brain-training interventions,” but as foundational interventions to prevent disengagement, apathy, and social withdrawal. By preserving core active ingredients—engagement, successful experiences, and social context—while removing evaluation, judgment, and self-management demands, a model that functions in home and care settings can be established.