With its fast-aging population, HK is finding ways to slow the onset of dementia among over a million elderly people. Wang Yuke reports.

Ting Hing, with trembling hands, picked the toy cars from a box and set them in order on a grid, as the instructions in his handbook told him. He's 86. Three years ago, he was diagnosed with dementia after a fall that put him in hospital.

Brain workouts delay the onset of dementia. They lead to more years of "quality living for senior citizens", says Timothy Kwok Chi-yui, director of the Jockey Club Centre for Positive Ageing.

Ting was having fun. His fingers were too frail to grasp the toy cars, often requiring several attempts to pick them up. At times, he fixated blankly on the handbook of instructions, as if his mind had drifted. Still, he got through to "level 40".

His wife Chan Kit-yee, 72, said his condition deteriorated quickly after he was diagnosed. He slept most of the day, didn't have a clue where he was. He was weak on his right side, said little and wept for no apparent reason.

Hong Kong, with one of the most rapidly ageing populations in the world, is applying every means to slow the decline of cognitive faculties in older people, says Kwok, professor of Medicine and Therapeutics at Chinese University of Hong Kong (CUHK). Dementia is his principal area of study.

The toy library, for older people suffering mild dementia, opened last month, as a joint project of the Hong Kong Lutheran Social Service and the Jockey Club Centre for Positive Ageing. It works in partnership with day care centers for the elderly.

There are more than 1,000 toys. Seniors can borrow them, or play with them on site. Play fosters better memory, improves motor skills, creativity, logical thinking, visual and spatial perception and helps people to focus their thoughts.

The toy library has branches all over the city. One is on the ground floor of the building where Ting lives.

He wasn't very interested in the place at first. He was shy of women other than his wife and fidgeted when they were around.

Ting had no education and worked all his life in kitchens. "He seldom read or wrote, and had few friends," said his wife. He was full of energy until a short time before he got sick, then he started appearing detached, aloof, and always tired.

A Magnetic Resonance Imaging scan revealed he'd probably had several small strokes, even before the fall put him over the edge. "He complained about numbness of his limbs," Chan recalled. "But we didn't take it seriously."

Dementia has several causes. The most common is Alzheimer's disease, accounting for nearly two-thirds of dementia cases. Another 29 percent are afflicted with vascular dementia, caused by multiple strokes. It also comes from brain tumors, head injuries, brain cell abnormalities and drug and alcohol abuse.

About one in 10 people in Hong Kong over the age of 65 have dementia to some degree. About 30 percent over 80 have it. That's alarming in the population projections released by the Census and Statistics Department last year. There were 1.1 million people over 65 in 2015. Less than 50 years from now, there will be 3.3 million. Close to a million of them will be over 80.

"Playing games worked (for him)," Chan said.

Studies show that people who stay mentally active are more resistant to dementia. For them, the onset of dementia comes much later in life, if at all, said Kwok.

Ting's favorite games are jigsaw puzzles and card matching game dealing with pairing cards or matching them in groups.

At first, Ting couldn't play a full game. He'd get distracted. Now he has no trouble playing all the way through and Chan says he's recovered some of his faculties.

Use it or lose it

Mentally active people have a better "cognitive reserve", says Kwok. That's the faculty that maintains the ability of the brain to work around the effects of brain cell damage, and keep the brain functioning normally. There are billions of neurons sending information to the brain. Problems arise when they are damaged.

Connections between neurons, through which we make sense of the world, are made through experience. Without stimulation, the neurons scatter independently, and then go rogue, explains Kwok. Connections can also be broken if a person has a skill, but doesn't use it for a long time, the same as unused muscles atrophy. Brain cells do die off anyway, as part of the ageing process.

"People who always challenge their minds and constantly are exposed to new information have an immense number of neuronal connections. Some connections may be disrupted as neurons degrade, but (in a healthy person), other connections will take over, to keep the brain functioning normally," says Kwok.

The cognitive reserve keeps the brain resilient and adaptable. People with large reserves develop cognitive difficulties much later than people who are mentally stagnant and don't have the amount of neuron connections to compensate for brain cell damage, says Adrian Wong, a research assistant professor at CUHK. His expertise is stroke and clinical neurosciences.

Today, Ting has moved on to more systematic rehabilitation in a program at a seniors' day care center. Chan has to pay for the service but it puts Ting in a class with nine other dementia sufferers, who play computer-based games.

"He often tells me after class what questions he answered correctly and how his classmates applauded him," laughed Chan. She noted that Ting has overcome much of his shyness with women.

He speaks normally now and betrays no sign of his disability in public. He is no longer expressionless, but is able to respond appropriately during day-to-day encounters.

Chan completed primary school. She used to do hotel cleaning and watch parts assembling. She attributes her brain and physical agility to her previous working and educational background. "Some of those games were hard even for me. It took a lot of brain work to sort things out." She learns Putonghua on Mondays, watches spy dramas, travels and hangs out with friends to keep her mind active.

People from mentally demanding occupations appear substantially insulated from the memory loss that precedes Alzheimer's disease. The findings are drawn from a published study in 2008 led by Swiss scientist Valentina Garibotto.

Sharpening the mind

Fung, 82, has cared for his wife for the last 10 years. That's about the time she was diagnosed with dementia. She was illiterate. Her only real interest was Majhong. Other than that, she did simple housework.

Once a capable housewife, Fung said, his wife started turning odd in her late fifties - like putting the rice cooker on the stove, over a flame. She could never find anything that wasn't in plain sight and there were visits from the police after she'd left restaurants without paying.

When it dawned on Fung that things were not right, it was already too late. Without intervention to slow the decline of her mental faculties, she had lapsed into dementia, he recalled, with surprising haste.

She would go out, get lost, and security staff or a cop would have to bring her home. She was completely dependent. Fung fed her, bathed her and turned her over in bed.

Finally he put her in a nursing home. "She has difficulty swallowing, recognizes nobody but me, and screams and cries because she wants to speak but can't."

Playing games is one of the best ways to keep the brain sharp, remarks Kwok. The best approach, he said, is to introduce games that emphasize variety - because there is such a broad range of cognitive domains. Different types of games are effective for different mental faculties.

Computer games get much credit for putting the brakes on cognitive decline. Skeptics worry, however, that whatever may be learned from the games doesn't transfer to daily living.

Kwok agrees on that basis that games present no social interaction. "The group setting" is vital, he says. Groups create opportunities for interpersonal communication and the sharing of emotional experience. He believes a social element in training would help dementia patients in everyday life.

Advocates remain unwavering in the belief that computer-based cognitive training is best. Professor Wong cited a study by Johns Hopkins University and Harvard Medical School. It showed video games improve cognitive functions of older adults better than classic cognitive training.

Software-based cognitive games are provided at service centers for the elderly. Not many people use them, though, says Karen Chow, assistant director of service at Lutheran Social Service. She believes elderly people seem more confident playing tactile toys. "But we shouldn't turn away from computer-based cognitive training programs. They might be unpopular with the current older population, but may be welcomed by those in their 50s and 60s who are more tech-savvy," Chow said.

Spouse and family caregivers of dementia patients are believed to be more prone to dementia, highlights professor Kwok. There is a combination of factors. Their spouse or caregiver may see a bleak outlook and become incapable of making the mental adjustment. Caregivers suffer stress. It's possible the onset of dementia in one partner was set off by a shared, unhealthy lifestyle.

Kwok and his team have been working on a 10-year study aiming to establish the level of risk to the spouses of dementia patients.

The latest data awaits analysis, Kwok told China Daily. He said he expects a report by the end of this year - but from their preliminary evaluation, he believes spouses are at great risk of dementia.

Contact the writer at jenny@chinadailyhk.com

Ting Hing (right) has recovered some of his faculties as the result of persistent brain exercise with his wife's support.  Elderly people with mild and moderate cognitive decline give it a try at various brain games in Toy Library. Photos by wang Yuke / China Daily

(HK Edition 05/26/2016 page10)