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Introduction
Alzheimer is a brain disturbance that often has a chronic and progressive course. This disease alters a person’s mental abilities, personality, and behavior [1]. Memory and daily activities are frequently impaired in Alzheimer patients [2]. Patients frequently forget recent events, frequently ask questions, have communication and social interaction problems, lose awareness of place and time, and suffer from decreased motivation, depression, and anxiety [3]. Alzheimer patients cannot live alone, make individual decisions, or carry out daily tasks [4].
Alzheimer disease is the most prevalent and well-known kind of dementia, specified by the unjustified destruction of neurons and cerebral cortex atrophy [5]. Following these changes, there is a progressive loss of recent memory, cognitive disturbance, and mood changes [6]. After heart disease, cancer, chronic respiratory diseases, and stroke, Alzheimer is the fifth leading cause of death in the elderly [7, 8].
Alzheimer has two neuropathological characteristics, one of which is the accumulation of beta-amyloid peptide plaques on the exterior of neurons, produced by the degradation of the amyloid precursor protein [9]. The formation of neurofibrillary tangles within neurons, caused by hyperphosphorylation of the tau protein and observed in the hippocampus and other cortical regions, is another characteristic of Alzheimer disease [10]. Beta-amyloid is regarded as a potent poison for mitochondria, which leads to functional disorders in mitochondria, the production of free radicals, and the eventual destruction of neurons [11]. Slowly, the disorder in the brain’s cognitive functions manifests with the onset of the disease. Two cognitive functions exist in the human brain, namely executive functions which regulate and control a person’s thinking and performance, and non-law functions [12].
As the disease progresses, the subjects gradually lose their sense of independence, fail to achieve their goals, and have severe social interaction problems [13]. Depression, anxiety, aggression, a decrease in self-confidence, a lack of satisfaction, and a sense of inadequacy are all symptoms of these issues [14]. As a result, the patient’s quality of life reduces. The quality of life comprises a state of well-being defined by a multidimensional concept of health in physical, mental, spiritual, social, and economic aspects [15]. Despite these damages and problems, the human brain has complex and dynamic functional characteristics and aims to control the severity of the disease’s destruction as much as possible [16]. Educational interventions play an essential role in the improvements mentioned above. Researchers have provided non-pharmacological methods, such as cognitive-based rehabilitation, to help Alzheimer patients in addition to drug treatments by examining the positive impact of external stimuli on neurons [17]. This specific treatment program consists of targeted and planned activities for cognitive stimulation in patients with mild to moderately advanced dementia [18].
The subjects’ brains are malleable, changing in response to learning, practice, and environmental stimuli [19]. When brain damage occurs or when parts of the cells are lost as a result of Alzheimer, the human brain can maintain its optimum level of function by changing the neural structure and forming new connections in the remaining parts [20]. In addition, following an injury, the human brain can respond to external stimuli (cognitive rehabilitation programs, sports, music, etc.). Stimulation of the brain aids in maintaining the nervous system’s functioning by forcing the brain to respond to stimuli, thus maintaining its neural connections [21]. The impacts of these stimuli on the brain structure increase in synapses, new neuronal sprouting, an increase in the parameters involved in brain nerve tissue growth, and a decrease in cell death [22].
Considering the increase in the population of the elderly with Alzheimer, it is necessary to investigate methods for treating and preventing this disease. Also, drug treatments could be more effective or insufficient in some stages; in the long run, when the disease develops resistance, they lose their effectiveness. Drugs are associated with side effects and impose high costs on patients due to the disruption of the hormonal balance. Consequently, cognitive rehabilitation protocols are important. The current study aims to investigate the effect of cognitive rehabilitation on the memory improvement of Alzheimer patients.

Materials and Methods
This research used a semi-experimental design with a pre-test and post-test design. The statistical population in Baghdad City, Iraq in 2021 included 60 patients with Alzheimer, divided into an experimental (n=30) and a control group (n=30). The patient’s cognitive abilities were assessed before the intervention (pre-test), immediately after the intervention (post-test), and 2 months after the intervention (follow-up). The experimental group had twenty-eight 45-min sessions of training based on the Montessori method (2 sessions per week) [23].
The inclusion criteria were confirming the presence of Alzheimer in the participants, memory and attention disorders diagnosed by the neurologist, having a Glasgow coma table state of consciousness of 13 to 15 (patients who were conscious and awake or at least in the phase of confusion), not receiving similar therapeutic interventions, and having minimal literacy [24]. The exclusion criteria were mental retardation, major depression, and other severe psychiatric disorders, the presence of a brain white matter lesion, brain atrophy (despite the absence of previous symptoms), alcohol and drug addiction, hearing loss, a lack of speech, a disturbance in the state of consciousness, sensory and motor disorders, and a lack of cognitive impairment other than Alzheimer. Before beginning the research, the objectives and general process were presented to all participants. Then, with the cooperation of the patient’s families, a written consent letter to participate in the research was obtained. After the follow-up stage, the desired educational intervention was presented to the control group of patients.
The everyday memory questionnaire [20] was used to collect data in the present study. This tool is one of the most commonly used memory rehabilitation questionnaires. The EMQ comprises 28 statements that assess repetition inadequacy and memory weaknesses in faces, places, actions, speech, reading, writing, and learning new tasks. Answers are scored based on a 9-point Likert scale ranging from 1 (never in the last six months) to 9 (more than once daily). Higher scores indicate a worsening of everyday memory function. Scores between 28 and 58 indicate good memory, scores between 59 and 116 indicate medium memory and scores greater than 116 indicate poor memory status. The reliability and validity of the EMQ have been confirmed in several research. In the current study, the reliability and validity were 0.84 and 0.78, respectively. In this study, reliability was checked using the Cronbach α method, and content validity was checked using the opinions of professors of the University of Baghdad’s College of Medicine.
The intervention sessions for the experimental group consisted of twenty-eight 45-min sessions of training based on the Montessori method (2 sessions per week). Table 1 shows the educational content of the sessions.

A pre-test stage was held using EMQ in both groups before the start of the first session in the experimental group. The post-test stage was held after the completion of all sessions, and a follow-up stage was held two months later.
After data collection, the descriptive level of analysis was performed on the research data (frequency, mean, etc.). The data were analyzed via the SPSS software, version 19, utilizing the independent t-test and repeated measures analysis of variance (ANOVA). The Kolmogorov-Smirnov test was utilized to evaluate the research hypothesis, and the Bonferroni post hoc test was employed to compare the data over time. The results have a significance level of <0.05.

Results
The findings of the demographic characteristics of the patients are provided in Table 2.

According to Table 2, 26(43.3%) were male and 34(56.7%) were female. In the experimental group, the mean age was 81.76±8.54 years and the mean age was 79.62±7.83 years in the control group. Most participants were >75 years (61.7%) and had secondary education (86.7%). Also, the marital status of the participants was almost the same. In addition, the independent t-test showed no statistically significant difference for both groups’ demographic characteristics (P>0.05). The comparison of the two groups’ pre-test, post-test, and follow-up mean EMQ values are provided in Table 3.

According to Table 3, the experimental group’s post-test and follow-up EMQ scores decreased significantly. In contrast, the results of all three stages in the control group remained nearly identical. In addition, the independent t-test examined the significance of the difference between the results of each stage for the two groups. The results demonstrated no significant difference in the scores of both groups during the pre-test stage (P>0.05); however, the difference was significant during the post-test and follow-up phases (P<0.001).
In the current study, the impact of cognitive rehabilitation on the memory improvement of Alzheimer disease patients was examined. Before testing the hypothesis, the Kolmogorov-smirnov test was utilized to examine the normality of the scores for EMQ variables. In this test, the goodness of fit was not statistically significant and the scores had a large difference from the normal distribution (z=0.143 in the pre-test stage; z=0.161 in the post-test phase; z=0.187 in the follow-up stage). Therefore, the repeated measures ANOVA assumption is not violated. The findings of repeated measures ANOVA are shown in Table 4.

According to Table 4, the significance of the stage effect indicates a significant difference between the two groups mean values in the post-test and follow-up stages (P<0.001). In addition, the significance of the phases and the experimental group indicates that the mean values of this group are significantly lower than the values of the control group during the post-test and follow-up stages (P<0.05). Given the application of the independent variable (cognitive rehabilitation intervention), there was a significant difference in the value of the dependent variable (everyday memory) between both groups. 
Subsequently, the Bonferroni post hoc test was conducted to compare time, and the results indicated a significant difference in the values of the pre-test stage with the post-test and follow-up phases (P<0.001). In contrast, no significant difference was observed between the post-test scores and with follow-up stages (P>0.05).

Discussion
The current research aimed to evaluate the impact of cognitive rehabilitation on the memory improvement of Alzheimer patients. These results demonstrated the effect of cognitive rehabilitation on Alzheimer patients’ everyday memory. Consequently, everyday memory has significantly increased compared to the control group. The current study’s results are consistent with the findings of other studies [25, 26, 27].
In the current study, dementia treatment planning based on the Montessori method demonstrated significant positive impacts on the cognitive abilities of Alzheimer patients. The positive impact of the method is because of its general philosophy, which is based on the same ideas and principles and is designed and explained in the same way. Accordingly, every human being is treated with respect and emphasizes their choices, abilities, and strengths, and the subjects can find their place in society and develop self-efficacy and self-esteem [28]. This method focuses the content of the executive sessions on the 5 human senses and attempts to stimulate the desired sense and force an appropriate response. The effectiveness of this intervention is summarized by its content, method of execution, and participation of the appropriate individuals. Following the fundamental principles of the Montessori method, treatment planning for dementia includes activities that emphasize the senses. The activities are designed to be as appealing as possible to the individual. The individual is invited to participate and has the freedom to choose, and their desires and interests are prioritized.
In the intervention method used in the current study, the implementation of activities focuses on skills and abilities, the pace of activities is adjusted based on the individual’s condition, and visual cues, signs, or patterns are employed. Although the individual is given small responsibilities, they begin with simple tasks, complex activities are broken down into smaller steps, and the individual’s enjoyment of the activity is evaluated. This method emphasizes that there is no right or wrong, and only the Alzheimer patient’s motivation and participation matter; therefore, the therapist can work on cognitive, social, and executive aspects through training, repetition, guidance, and the execution of activities to improve the cognitive performance of individuals with Alzheimer and achieve positive results [29]. The current study’s findings can be explained using the theory of neuroplasticity, or neural flexibility of the brain. Recent research has shown that different brain areas can change significantly even in adulthood. Making structural changes over time; thus, changes in related functions is what flexibility entails. This process can be observed at different levels and scales, ranging from microscopic changes in neurons to more extensive scale changes, such as cortex routing and remapping in response to brain damage. On the other hand, cortical remapping occurs on a much larger scale early in brain development [30]. Additionally, behavior, environmental stimuli, thoughts, and emotions can cause neural flexibility via the activity-dependent flexibility process, which is critical and necessary in developing healthy people [31].
One limitation of the current research is that only Alzheimer patients in Baghdad participated. Consequently, the findings cannot be generalized to other regions and nations. In addition, patients’ memory status has not been compared to their memory status before Alzheimer disease. To conduct future studies, it is suggested that alternative methods and protocols be used to assess Alzheimer patients’ everyday memory. It is also suggested that the current study’s methodology be used to evaluate other brain diseases.

Conclusion
The present study demonstrated that cognitive rehabilitation interventions effectively reduce cognitive deficits in the elderly; therefore, by using it as an independent treatment method or in conjunction with existing treatments, it can be utilized to reduce Alzheimer-related disorders in the elderly, even in individuals who appear to lack the ability to learn, regular or irregular practice and repetition lead to learning, as demonstrated by the findings. Therefore, the necessity of cognitive rehabilitation for Alzheimer patients is emphasized more than ever before, and experts are instructed to implement it.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of the University of Baghdad’s College of Medicine.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We hereby express our gratitude to the Student Research Committee of the University of Baghdad College of Medicine who helped us in conducting this research.


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