Effects on Language and Verbal Fluency of a Cognitive Stimulation Program in Older Adults: Randomized Controlled Trial

Round 1

Reviewer 1 Report

Calatayud et al. present an article that studies the effect of cognitive simulation program n language and verbal fluency in older adults. Addressing the following points can help sharpen the manuscript:

1.     Line 13-15 and line 70-72 are repetitive.

2.     In Figure 1, several data points from follow-up 1 and 2, analysis seem to be excluded from analysis. Explain why.

3.     Figure 2 needs be formatted for clarity. It is not clear as to which exercises belong to which level.

4.     Table 1 needs to be formatted to align all the values.

5.     In Line 295, it should be F = 7.633.

6.     In Table 4, explain e.t. and other columns as well.

7.     In Table 4, there is typo in group and CVA.

8.     In Table 4, what is edad?

9.     Grammatical errors, typos and punctuations should be thoroughly checked for in the entire manuscript.

10.  Tables should be formatted well and decimal values should be checked for absence of ,

Author Response

We would like to thank the editor for the feedback and recommendations. We have revised the paper according to the recommendations of the editor and reviewers.

Thank you very much for the reviewer's comments and suggestions, which have served to improve the manuscript. Please, see below for a point-by-point description of the changes made in the manuscript in response to them. We also enclose a revised manuscript with the changes made with change control. We appreciate these positive comments.

1. Line 13-15 and line 70-72 are repetitive.

Answer: We appreciate the reviewer's comment. To avoid repetitive paragraphs we have modified the first paragraph of the abstract.

The efficacy of cognitive stimulation programs for the elderly is sufficiently documented. However, there is a lack of studies that have addressed the effectiveness of language stimulation programs by cognitive levels in this population.

2. In Figure 1, several data points from follow-up 1 and 2, analysis seem to be excluded from analysis. Explain why.

Answer: Figure 1 had a formatting error that has been corrected.

3. Figure 2 needs be formatted for clarity. It is not clear as to which exercises belong to which level.

Answer: We appreciate the reviewer's comment, we have tried to simplify the table so that it is understood what type of language activities were performed at each level according to MEC-35.

4. Table 1 needs to be formatted to align all the values.

Answer: Thanks for the appreciation, the alignment has been modified.

5. In Line 295, it should be F = 7.633.

Answer: Sorry for the typo. Type error in line 295 (F = 7.633) has been fixed.

6. In Table 4, explain e.t. and other columns as well.

Answer: Thank you for your appreciation. Abbreviations and their meaning have been indicated in the table legend.

e.t.: standard error of the estimate; R2: R square (coefficient of determination); CVA: Cerebrovascular accident; B: Beta

7. In Table 4, there is typo in group and CVA.

8. In Table 4, what is edad?

Answer points 7 and 8: Thank you very much for locating both typos. The translation errors in table 4 have been corrected.

9. Grammatical errors, typos and punctuations should be thoroughly checked for in the entire manuscript.

Answer: Thanks for the appreciation. Grammatical errors, typos and punctuations have been checked for in the entire manuscript.

10. Tables should be formatted well and decimal values should be checked for absence of ,

Answer: Thank you for the appreciation. The commas have been checked in all tables and have been changed to points.

Finally, also the manuscript has been corrected by a native English speaking editor, who has corrected several typos and improved writing (please, see revised text). 

Reviewer 2 Report

The article is interesting and the authors did a good effort to present the results comprehensively. But still requires minor changes. See my specific comments given below;

1. Add the section “Statement of the Study” and states the study objective clearly

2. How did the authors choose Primary Care Centre in the city of Zaragoza (Spain?) for conducting research? Elaborate it

3. What were the inclusion criteria? Clearly write it for general readers

4. Discussion section is too long. Make it more precise

5. Conclusion section is very short and doesn’t reflect the main theme of the study. Revise the conclusion

6. What are the limitations of the study? Add it

7. What are the implications of the study? Add it

8. What’s the future scope of the study? Add it

Author Response

We would like to thank the editor for the feedback and recommendations. We have revised the paper according to the recommendations of the editor and reviewers.

Thank you very much for the editor's comments and suggestions, which have served to improve the manuscript. Please, see below for a point-by-point description of the changes made in the manuscript in response to them. We also enclose a revised manuscript with the changes made with change control. We appreciate these positive comments.

1. Add the section "Statement of the Study" and states the study objective clearly.

Answer: thank you for your comment, we have added this section at the end of the introduction and clarified the objective.

The aim of this study was to analyze, through a randomized clinical trial, the effects produced on language and verbal fluency over time, with a cognitive stimulation program by cognitive levels and with specific language activities, in older adults with SMC living in the community.

2. How did the authors choose Primary Care Centre in the city of Zaragoza (Spain?) for conducting research? Elaborate it

Answer: We appreciate the reviewer's comment, and proceed to explain in detail the reasons for the choice of this center.

The reasons for choosing a primary care health center were firstly the fact that in Spain the figure of the Occupational Therapy professional is not yet included in the public health services, and somehow it was a pilot experience in our city (Zaragoza- northeastern Spain). This fact conditioned the choice of the specific health center San José Norte-Centro, since it did not have adequate facilities to carry out the intervention phase, we looked for a collaborating entity close to this center (Foundation La Caridad, which is mentioned in the paper), which worked in common with this center, and which facilitated mobility within the same neighborhood of the participants.

On the other hand, this is a working-class neighborhood with medium-level socio-economic characteristics, coinciding with other neighborhoods adjacent to the city center; therefore, the results could be extrapolated to other centers in the city.

At the time of the study, the foundation (which served the areas of children and youth, senior citizens and social inclusion) worked with 68.45% of the elderly. In the health center, of the total population served, those over 65 years of age represent 22.77% in San José Centro and 26.67% in San José Norte.

Some details have been transferred to the paper to aid understanding:

This has been added in the material and methods section, 2.1-Design and participants section.

The reasons for choosing a primary care health center were firstly the fact that in Spain the figure of the Occupational Therapy professional is not yet included in the public health services, and somehow it was a pilot experience in our city (Zaragoza- northeastern Spain).

This has been added in the methodology section under intervention:

This foundation was close to the health center, which facilitated the participants' access to it and had the appropriate facilities to carry out the intervention program (which the health center lacked).

3. What were the inclusion criteria? Clearly write it for general readers

Answer: As indicated by the reviewer, we have clarified the inclusion and exclusion criteria for a better understanding by the reader.

Inclusion and exclusion criteria

Individuals aged 65 years or older, scoring 24 points or more on the MEC-35 (validated Spanish version of the Mini-Mental State Examination (MMSE) [21] and presenting subjective memory complaints were included. We excluded individuals who had received cognitive stimulation in the last year (to avoid possible biases), those who were institutionalized, and those who presented functional (<60 points on the Barthel index and 3 or less points on Lawton), psychological (more than 6 points on the abbreviated Goldberg anxiety scale and 12 points or more on the Yesavage depression questionnaire) and major sensory (blindness and deafness) problems, as well as neuropsychiatric disorders. These exclusion criteria were taken into account in the face of physical, functional, psychological or sensory impossibility to attend or adequately carry out the intervention sessions.

4. Discussion section is too long. Make it more precise

Answer: In accordance with the reviewer's comment, we have summarized and clarified the discussion section.

5. Conclusion section is very short and doesn't reflect the main theme of the study. Revise the conclusion

Answer: We have revised the conclusion to focus on the specific results of our study.

This study has shown that comprehensive cognitive stimulation in older people with SMC, with a work methodology by cognitive levels, and which takes into account previous work aspects, improves overall cognitive performance, in addition to improving language proficiency and verbal fluency.

In addition, aspects such as educational level, verbal fluency and mental occupation are positively related as predictors of linguistic competence, which should be taken into account to treat the most vulnerable older people.

6. What are the limitations of the study? Add it

Answer: Study limitations have been added.

7. What are the implications of the study? Add it

Answer: Implications of the study have been added.

8. What’s the future scope of the study? Add it

Answer: Added future scope.

Also the manuscript has been corrected by a native English speaking editor, who has corrected several typos and improved writing (please, see revised text).