Individual goal-oriented cognitive rehabilitation to improve everyday functioning for people with early-stage dementia: A multicentre randomised controlled trial (the GREAT trial)

The efficacy of cognitive stimulation, cognitive training, and cognitive rehabilitation for people living with dementia: a systematic review and meta-analysis

Cognition-oriented treatments (COTs) are a group of non-pharmacological treatments aimed at maintaining or improving cognitive functioning. Specific recommendations on the use of these interventions in people living with dementia (PLwD) are included in the Italian Guideline on the Diagnosis and Treatment of Dementia and Mild Cognitive Impairment, developed by the Italian National Institute of Health. This systematic review and meta-analysis, based on the GRADE methodology, is part of the guideline. Considered outcomes included the cognitive functions, quality of life, and functional abilities of PLwD, taking into account disease severity, modality and system of delivery, and form of the intervention. The effectiveness of these interventions on caregivers' outcomes was also assessed. Both group and individual cognitive stimulation were reported as effective in supporting cognitive functions in PLwD at any degree of severity. Individual cognitive training and group cognitive training were reported as effective in improving global cognitive functions in people with mild dementia. Cognitive rehabilitation appeared to be effective only in improving the functional abilities of people with mild dementia. Cognitive rehabilitation appeared to be the most effective in improving caregivers' outcomes, with results suggesting a reduction in care burden. The observed differences in the effectiveness of these interventions in people with different disease severity can be explained by the intrinsic characteristics of each intervention. Despite the large number of available studies, a high clinical, statistical, and methodological heterogeneity was observed. More methodologically rigorous studies are needed to clarify the effectiveness of each protocol and modality of intervention.

Exergaming for dementia and mild cognitive impairment

BACKGROUND

Dementia and mild cognitive impairment are significant contributors to disability and dependency in older adults. Current treatments for managing these conditions are limited. Exergaming, a novel technology-driven intervention combining physical exercise with cognitive tasks, is a potential therapeutic approach.

OBJECTIVES

To assess the effects of exergaming interventions on physical and cognitive outcomes, and activities of daily living, in people with dementia and mild cognitive impairment.

SEARCH METHODS

On 22 December 2023, we searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov, and the WHO (World Health Organization) meta-register the International Clinical Trials Registry Portal.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited individuals diagnosed with dementia or mild cognitive impairment (MCI). Exergaming interventions involved participants being engaged in physical activity of at least moderate intensity, and used immersive and non-immersive virtual reality (VR) technology and real-time interaction. We planned to classify comparators as inactive control group (e.g. no treatment, waiting list), active control group (e.g. standard treatment, non-specific active control), or alternative treatment (e.g. physical activity, computerised cognitive training). Outcomes were to be measured using validated instruments.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias using the Cochrane risk of bias tool RoB 2, and assessed the certainty of the evidence using GRADE. We consulted a third author if required. Where possible, we pooled outcome data using a fixed-effect or random-effects model. We expressed treatment effects as standardised mean differences (SMDs) for continuous outcomes and as risk ratios (RRs) for dichotomous outcomes, along with 95% confidence intervals (CIs). When data could not be pooled, we presented a narrative synthesis.

MAIN RESULTS

We included 11 studies published between 2014 and 2023. Six of these studies were pre-registered. Seven studies involved 308 participants with mild cognitive impairment, and five studies included 228 individuals with dementia. One of the studies presented data for both MCI and dementia separately. Most comparisons exhibited a high risk or some concerns of bias. We have only low or very low certainty about all the results presented below. Effects of exergaming interventions for people with dementia Compared to a control group Exergaming may improve global cognitive functioning at the end of treatment, but the evidence is very uncertain (SMD 1.47, 95% 1.04 to 1.90; 2 studies, 113 participants). The evidence is very uncertain about the effects of exergaming at the end of treatment on global physical functioning (SMD -0.20, 95% -0.57 to 0.17; 2 studies, 113 participants) or activities of daily living (ADL) (SMD -0.28, 95% -0.65 to 0.09; 2 studies, 113 participants). The evidence is very uncertain about adverse effects due to the small sample size and no events. Findings are based on two studies (113 participants), but data could not be pooled; both studies reported no adverse reactions linked to the intervention or control group. Compared to an alternative treatment group At the end of treatment, the evidence is very uncertain about the effects of exergaming on global physical functioning (SMD 0.14, 95% -0.30 to 0.58; 2 studies, 85 participants) or global cognitive functioning (SMD 0.11, 95% -0.33 to 0.55; 2 studies, 85 participants). For ADL, only one study was available (n = 67), which provided low-certainty evidence of little to no difference between exergaming and exercise. The evidence is very uncertain about adverse effects of exergaming compared with alternative treatment (RR 7.50, 95% CI 0.41 to 136.52; 2 studies, 2/85 participants). Effects of exergaming interventions for people with mild cognitive impairment (MCI) Compared to a control group Exergaming may improve global cognitive functioning at the end of treatment for people with MCI, but the evidence is very uncertain, (SMD 0.79, 95% 0.05 to 1.53; 2 studies, 34 participants). The evidence is very uncertain about the effects of exergaming at the end of treatment on global physical functioning (SMD 0.27, 95% -0.41 to 0.94; 2 studies, 34 participants) and ADL (SMD 0.51, 95% -0.01 to 1.03; 2 studies, 60 participants). The evidence is very uncertain about the effects of exergaming on adverse effects due to a small sample size and no events (0/14 participants). Findings are based on one study. Compared to an alternative treatment group The evidence is very uncertain about global physical functioning at the end of treatment. Only one study was included (n = 45). For global cognitive functioning, we included four studies (n = 235 participants), but due to considerable heterogeneity (I² = 96%), we could not pool results. The evidence is very uncertain about the effects of exergaming on global cognitive functioning. No study evaluated ADL outcomes. The evidence is very uncertain about adverse effects of exergaming due to the small sample size and no events (n = 123 participants). Findings are based on one study.

AUTHORS' CONCLUSIONS

Overall, the evidence is very uncertain about the effects of exergaming on global physical and cognitive functioning, and ADL. There may be an improvement in global cognitive functioning at the end of treatment for both people with dementia and people with MCI, but the evidence is very uncertain. The potential benefit is observed only when exergaming is compared with a control intervention (e.g. usual care, listening to music, health education), and not when compared with an alternative treatment with a specific effect, such as physical activity (e.g. standing and sitting exercises or cycling). The evidence is very uncertain about the effects of exergaming on adverse effects. All sessions took place in a controlled and supervised environment. Therefore, we do not know if exergaming can be safely used in a home environment, unsupervised.

The use of audio-biographical cues in dementia care: a four-year evaluation in Swiss hospitals, care, and domestic homes

Introduction

In dementia care, the integration of innovative interventions is essential to enhancing the wellbeing and quality of life of people with dementia. Among these interventions, the Music Mirror intervention has emerged as a promising tool to provide personalized audio-biographical cues aimed at soothing, motivating, and engaging people with dementia. This study examined the effects of a Music Mirror intervention on the (a) wellbeing, emotions, and behavioral and psychological symptoms of 155 individuals with dementia, (b) perceived burden, relationship quality, and gains of their informal/formal caregivers, and (c) momentary closeness, wellbeing and stress of caregivers.

Methods

This four-year study employed a quasi-experimental waiting-control group design, utilizing before-after measurements in Swiss hospitals, care homes, and domestic homes. For four 6-week intervention phases, Music Mirrors, i.e., brief written resources of acoustic material, associated with practical activities of daily life, were applied at least twice a week by the caregivers during critical moments such as staff handover. Repeated measures' analysis of variance and other tests were used to analyze the data.

Results

Individuals with dementia had a higher wellbeing after the Music Mirror use across different care situations. While the Music Mirrors were played, individuals with dementia showed more positive than negative emotions at each measurement occasion, but emotion scores did not significantly change over time. After the MM use, caregivers felt better, closer to the person with dementia, and less stressed. Caregivers also reported significant gains at the end of the intervention. However, there were no significant changes in the frequency of the behavioral and psychological symptoms of dementia, care-related burden and relationship quality over time, regardless of the treatment condition.

Discussion

By incorporating personalized audio-biographical cues into their care routines, the wellbeing of people with dementia was improved as well as it had positive momentary effects on their caregivers. The Music Mirror intervention addresses the preferences and needs of people with dementia and helps build bonds between care-recipients and caregivers. Therefore, Music Mirrors can be seen as a highly adaptive and individualized instrument to improve momentary wellbeing of people with dementia in various care situations during daily life.

Pre-implementation planning for a new personalised, dementia post-diagnostic support intervention: exploring the perspective of professional stakeholders

BACKGROUND

Only a third of people with dementia receive a diagnosis and post-diagnostic support. An eight session, manualised, modular post-diagnostic support system (New Interventions for Independence in Dementia Study (NIDUS) - family), delivered remotely by non-clinical facilitators is the first scalable intervention to improve personalised goal attainment for people with dementia. It could significantly improve care quality.

AIMS

We aimed to explore system readiness for NIDUS-family, a scalable, personalised post-diagnostic support intervention.

METHOD

We conducted semi-structured interviews with professionals from dementia care services; the Consolidated Framework for Implementation Research guided interviews and their thematic analysis.

RESULTS

From 2022 to 2023, we interviewed a purposive sample of 21 professionals from seven English National Health Service, health and social care services. We identified three themes: (1) potential value of a personalised intervention - interviewees perceived the capacity for choice and supporting person-centred care as relative advantages over existing resources; (2) compatibility and deliverability with existing systems - the NIDUS-family intervention model was perceived as compatible with service goals and clients' needs, but current service infrastructures, financing and commissioning briefs constraining resources to those at greatest need were seen as barriers to providing universal, post-diagnostic care; (3) fit with current workforce skills - the intervention model aligned well with staff development plans; delivery by non-clinically qualified staff was considered an advantage over current care options.

CONCLUSIONS

Translating evidence for scalable and effective post-diagnostic care into practice will support national policies to widen access to support and upskill support workers, but requires a greater focus on prevention in commissioning briefs and resource planning.

Intervention modalities for brain fog caused by long-COVID: systematic review of the literature

Individuals suffering from long-COVID can present with "brain fog", which is characterized by a range of cognitive impairments, such as confusion, short-term memory loss, and difficulty concentrating. To date, several potential interventions for brain fog have been considered. Notably, no systematic review has comprehensively discussed the impact of each intervention type on brain fog symptoms. We included studies on adult (aged > 18 years) individuals with proven long- COVID brain-fog symptoms from PubMed, MEDLINE, Central, Scopus, and Embase. A search limit was set for articles published between 01/2020 and 31/12/2023. We excluded studies lacking an objective assessment of brain fog symptoms and patients with preexisting neurological diseases that affected cognition before COVID-19 infection. This review provided relevant information from 17 studies. The rehabilitation studies utilized diverse approaches, leading to a range of outcomes in terms of the effectiveness of the interventions. Six studies described noninvasive brain stimulation, and all showed improvement in cognitive ability. Three studies described hyperbaric oxygen therapy, all of which showed improvements in cognitive assessment tests and brain perfusion. Two studies showed that the use of Palmitoylethanolamide and Luteolin (PEA-LUT) improved cognitive impairment. Noninvasive brain stimulation and hyperbaric oxygen therapy showed promising results in the treatment of brain fog symptoms caused by long-COVID, with improved perfusion and cortical excitability. Furthermore, both rehabilitation strategies and PEA-LUT administration have been associated with improvements in symptoms of brain fog. Future studies should explore combinations of interventions and include longer follow-up periods to assess the long-term effects of these treatments.

Rehabilitation Services for Young-Onset Dementia: Examples from High- and Low-Middle-Income Countries

The WHO Dementia Global Action Plan states that rehabilitation services for dementia are required to promote health, reduce disability, and maintain quality of life for those living with dementia. Current services, however, are scarce, particularly for people with young-onset dementia (YOD). This article, written by an international group of multidisciplinary dementia specialists, offers a three-part overview to promote the development of rehabilitation services for YOD. Firstly, we provide a synthesis of knowledge on current evidence-based rehabilitative therapies for early-onset Alzheimer's disease (EOAD), behavioural variant frontotemporal dementia (bvFTD), primary progressive aphasia (PPA), and posterior cortical atrophy (PCA). Secondly, we discuss the characteristics of rehabilitation services for YOD, providing examples across three continents for how these services can be embedded in existing settings and the different roles of the rehabilitation multidisciplinary team. Lastly, we conclude by highlighting the potential of telehealth in making rehabilitation services more accessible for people with YOD. Overall, with this paper, we aim to encourage clinical leads to begin introducing at least some rehabilitation into their services, leveraging existing resources and finding support in the collective expertise of the broader multidisciplinary dementia professional community.

Intervention of computer-assisted cognitive training combined with occupational therapy in people with mild cognitive impairment: a randomized controlled trial

Objective

Investigate the impact of combined computerized cognitive training and occupational therapy on individuals with mild cognitive impairment (MCI).

Methods

We randomly assigned 118 MCI patients into two groups: a combined intervention group (n = 37) and a control group (n = 81), the latter receiving standard nursing care. The intervention group additionally underwent 12 weeks of computerized cognitive training and occupational therapy. Blind assessors evaluated cognitive performance, anxiety, depression, and daily living activities before the intervention, post-intervention, and at a 3-month follow-up.

Results

Repeated-measures analysis of variance showed that the sMoCA scores, HAMA scores, and ADL scores of the experimental group at T2 (post-intervention) and T3 (3-month follow-up) were higher than those of the control group, and the difference was statistically significant (p < 0.001, p < 0.001, p = 0.026).

Conclusion

Computerized cognitive training combined with occupational therapy can improve patients' cognitive status, enhance their compliance with continuing care, and maintain their anxiety and self-care ability at a stable level.

Clinical trial registration

https://www.chictr.org.cn/index.html, identifier ChiCTR2200065014.

Optimizing the physical activity intervention for older adults with mild cognitive impairment: a factorial randomized trial

Background

Physical activity (PA) intervention is one of the most effective interventions to promote cognitive function of older adults with mild cognitive impairment (MCI). However, the level of PA remains low. Based on the two core interventions (X-CircuiT and health education), this study aimed to examine the effect of three implementation strategies (viz., role modeling, goal-setting, and reminding) on the PA level among older adults with MCI using the multiphase optimization strategy (MOST).

Methods

Participants were randomized into one of eight conditions in a factorial design involving three factors with two levels: (i) role modeling (on vs. off); (ii) goal-setting (on vs. off); and (iii) reminding (on vs. off). The primary outcome was PA level at 12 weeks. The secondary outcomes were cognitive function, self-efficacy, and cost-effectiveness at 12 weeks. The intention-to-treat (ITT) analysis was performed as the main analysis and the per-protocol (PP) analysis as the sensitivity analysis.

Results

A total of 107 participants were included and randomly assigned into three groups, each receiving different implementation strategies. The results of the multivariate regression analysis showed that the three implementation strategies, namely, reminding (B = 0.31, p < 0.01), role modeling (B = 0.21, p < 0.01), and goal-setting (B = 0.19, p < 0.01), could significantly improve PA level. Specifically, it was found that role modeling (B = 0.68, p = 0.03) could significantly improve cognitive function. There were no significant interactions among the three implementation strategies. Role modeling was the most cost-effective strategy, costing 93.41 RMB for one unit of PA.

Conclusions

Role modeling was likely to be the best implementation strategy. The value-based and cost-effective PA intervention package could include the core intervention (X-CircuiT and health education) and implementation strategy (role modeling).

Clinical Trial Registration

https://www.chictr.org.cn, The study was retrospectively registered on 30 June 2022 (ChiCTR2200061693).

PReventing and Approaching Crises for frail community-dwelling patients Through Innovative Care (PRACTIC): protocol for an effectiveness cluster randomised controlled trial

BACKGROUND

Demographic changes, with an increasing number and proportion of older people with multimorbidity and frailty, will put more pressure on home care services in municipalities. Frail multimorbid people receiving home care services are at high risk of developing crises, defined as critical challenges and symptoms, which demand immediate and new actions. The crises often result in adverse events, coercive measures, and acute institutionalisation. There is a lack of evidence-based interventions to prevent and resolve crises in community settings.

METHODS

This is a participatory action research design (PAR) in a 6-month cluster randomised controlled trial (RCT). The trial will be conducted in 30 municipalities, including 150 frail community-dwelling participants receiving home care services judged by the services to be at risk of developing crisis. Each municipality (cluster) will be randomised to receive either the locally adapted TIME intervention (the intervention group) or care as usual (the control group). The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) is a manual-based, multicomponent programme that includes a rigorous assessment of the crisis, one or more interdisciplinary case conferences, and the testing and evaluation of customised treatment measures. PAR in combination with an RCT will enhance adaptations of the intervention to the local context and needs. The primary outcome is as follows: difference in change between the intervention and control groups in individual goal achievement to resolve or reduce the challenges of the crises between baseline and 3 months using the PRACTIC Goal Setting Interview (PGSI). Among the secondary outcomes are the difference in change in the PGSI scale at 6 months and in neuropsychiatric symptoms (NPSs), quality of life, distress perceived by professional carers and next of kin, and institutionalisation at 3 and 6 months.

DISCUSSION

Through customised interventions that involve patients, the next of kin, the social context, and health care services, crises may be prevented and resolved. The PReventing and Approaching Crises for frail community-dwelling patients Through Innovative Care (PRACTIC) study will enhance innovation for health professionals, management, and users in the development of new knowledge and a new adapted approach towards crises.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05651659. Registered 15.12.22.

A feasibility and pilot study of a "lifelong learning" intervention for people with dementia

BACKGROUND

Developing evidence for the use of psychosocial interventions for people with dementia is a research priority. This pilot study aimed to provide variability estimates for a set of outcome measures that would inform the development of a more extensive controlled study. The larger study will seek to explore the effect of attending a lifelong learning intervention for people with dementia compared to receiving treatment as usual. This pilot and feasibility stage also analysed how data collectors and researchers evaluated the use of the outcome measures in a sample of people with mild to moderate dementia.

METHODS

Before initiating the pilot study, a participant consultation was conducted with people with dementia, who attend a lifelong learning service known as a dementia school, and their teachers. From this consultation, the research outcomes identified were the mini-mental state examination (MMSE), Quality-of-Life Alzheimer's Disease (QoL-AD), General Self-Efficacy Scale (GSE), Rosenberg self-esteem scale, and the Friendship scale. The following study was divided into two steps. In step 1, participants were people with dementia attending a dementia school (intervention group) or usual services (control group). The participants were tested at baseline and at a 6-month follow-up. Data were collected between November 2018 and July 2019. In step 2, feasibility and acceptability issues with the recruitment of participants, data collection process, and outcome measures, identified in step 1, were evaluated through a data collector focus group.

RESULTS

Fifty-five people with dementia were included in the analysis. Step 1 provided estimates of changes from baseline to follow-up, and ancillary standard deviations were supplied for all outcome measures. Step 2 provided reflections on the feasibility and acceptability of the intervention, data collection, and outcome measures. This included views on how people with dementia experience participating in a test situation.

CONCLUSIONS

This study provided estimates of change and variability in the outcome measures. Additionally, issues regarding data collection were identified and should be addressed in future studies. The project demonstrated how to support people with dementia to participate in research that is meaningful to them.

TRIAL REGISTRATION

According to national legislation, registration with a database of clinical studies was optional, as the study evaluated existing activities rather than a clinical intervention.

Self-report instruments measuring aspects of self for people living with dementia: A systematic literature review of psychosocial interventions

OBJECTIVE

A positive sense of self may be a key domain of psychological well-being for people living with dementia and therefore a legitimate target for psychosocial interventions in dementia care. Determining the effectiveness of such interventions often requires valid self-report instruments. This review aimed to investigate what aspects of self have been measured using self-report instruments in evaluating psychosocial interventions for people living with dementia and to explore the effectiveness of these interventions in terms of positive outcomes related to aspects of self.

METHOD

A systematic search of the literature using five electronic databases and one register (CENTRAL) was conducted. A narrative synthesis and methodological quality assessment was completed for the included studies.

RESULTS

A total of 24 studies were included in the review. Seven aspects of self were measured using a range of self-report instruments, many of which have not been validated for dementia. Aspects of self were; self-esteem, self-efficacy, self-compassion, self-growth, self-acceptance, self-management, and self-identity. Studies included a variety of interventions; however, the effectiveness of these interventions for these aspects of self was mixed.

CONCLUSION

There is some evidence that psychosocial interventions improve specific aspects of self in dementia but further research to improve this evidence base is needed. Future research should also investigate and confirm the validity and reliability of existing self-report instruments that aim to measure aspects of self in dementia. Limitations and implications of the review are discussed.

Healthcare interventions for older people with dementia and family caregivers in Europe: A scoping review

AIM

This study aimed to examine the extent, range and variety of research in Europe describing healthcare interventions for older people with dementia (PwD) and family caregivers.

METHODS

This was a scoping review and followed the PRISMA Scoping Review guideline. MEDLINE, CINAHL and Cochrane library databases were searched for studies published between 2010 and 2020. Studies reporting healthcare interventions in Europe for PwD over 65 years and their family caregivers were included.

RESULTS

Twenty-one studies from six European countries were included. The types of healthcare intervention identified were categorized as follows: (1) family unit intervention (interventions for both PwD and their family caregiver), (2) individual intervention (separate interventions for PwD or family caregivers) and (3) family caregiver only intervention (interventions for family caregivers only but with outcomes for both PwD and family caregivers).

CONCLUSIONS

This review provides insight into healthcare interventions for older PwD and family caregivers in Europe. More studies are needed that focus on the family as a unit of care in dementia.

Awareness and cognitive rehabilitation in Alzheimer's disease and frontotemporal dementia

INTRODUCTION

Awareness influences the evolution of neurodegenerative dementias. We gathered participants' and caregivers assessments of dependence in daily activities and we studied how each score would be related to next year participant autonomy, independently of other explicative variables.

METHOD

We retrospectively analyzed data from mildly demented participants with a clinical diagnosis of Alzheimer's disease (AD, n = 186) and frontotemporal dementia (FTD, n = 29) and their relatives. A research tool was used to assess participant dependence in 98 daily activities and associated caregiver burden. A discrepancy score between the patient's and relative's judgment was calculated to evaluate awareness of dependence in activities at baseline. This dependence scores, as well as sex, age, education, and 1 year difference in Mini-Mental State Examination were taken as possible explicative variables for dependence in activities adapted by therapists during a 1-year cognitive rehabilitation program.

RESULTS

Patients with FTD showed less awareness for daily dependence (discrepancy 20.9% vs. 11.8% in AD). Both groups benefited from cognitive rehabilitation (25% decrease in dependence) and subjective burden of relatives was decreased in both groups. In the AD group, there was a significant positive relationship between both caregiver (P < 0.001) and participant's (P < 0.02) evaluation of dependence in daily activities at inclusion and dependence of participants in adapted activities after 1 year.

DISCUSSION

Awareness of impairment in daily activities is a clinical symptom that is more important at inclusion in FTD than in AD. However, in participants with AD who, as a group, significantly benefit from a cognitive rehabilitation program, not only caregiver's but also participant's assessment of dependence at baseline is correlated to subsequent, next year greater dependence in daily activities adapted by the therapists. Although discrepant, both caregiver and participant evaluations appear to be important variables to understand the evolution and the benefit of care in participants at early stages of dementia.

The Role of Rehabilitation for Early-Stage Alzheimer's Disease and Related Dementias: Practice and Priorities

The World Health Organization describes rehabilitation as interventions that focus on addressing disability through optimizing functional ability for individuals living with various health challenges in their unique daily life contexts. Rehabilitation services are typically seeking to enhance functional capacity and health, either in concert with, or in place of pharmacologic interventions. These services typically fall into 2 categories, restorative, where the client endeavors to return to a prior level of independent function, and compensatory, where s/he may not. In the latter case, clients might receive, and be trained to use, technology aids or other external supports to enable them to engage in a safe, healthy, and meaningful day-to-day life. For some populations, however, even enhanced functional capacity can present in the form of an insidious, albeit slower decline. So, what is, or should, rehabilitation's role be in progressive neurologic conditions? Specifically, what are the policy and practice implications of rehabilitation for (not in the presence of, but for) the care of persons living with neurodegenerative conditions such as Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD)?

What are the Correlates of Hearing Aid Use for People Living With Dementia?

OBJECTIVES

To identify correlates of hearing aid use in people with dementia and age-related hearing loss.

METHODS

Bivariate and multivariate logistic regression analyses of predictor variables from 239 participants with dementia and hearing loss in the European SENSE-Cog Randomized Controlled Trial (Cyprus, England, France, Greece, and Ireland).

RESULTS

In multivariate analysis, four variables were significantly associated with hearing aid use: greater self-perceived hearing difficulties (OR 2.61 [CI 1.04-6.55]), lower hearing acuity (OR .39 [CI .2-.56]), higher cognitive ability (OR 1.19 [CI 1.08-1.31]), and country of residence. Participants in England had significantly increased odds of use compared to Cyprus (OR .36 [CI .14-.96]), France (OR .12 [CI .04-.34]) or Ireland (OR .05 [CI .01-.56]) but not Greece (OR 1.13 [CI .42-3.00]).

CONCLUSIONS

Adapting interventions to account for cognitive ability, country of residence, self-perceived hearing difficulties, and hearing acuity may support hearing aid use in people with dementia.

A psychosocial goal-setting and manualised support intervention for independence in dementia (NIDUS-Family) versus goal setting and routine care: a single-masked, phase 3, superiority, randomised controlled trial

BACKGROUND

Although national guidelines recommend that everyone with dementia receives personalised post-diagnostic support, few do. Unlike previous interventions that improved personalised outcomes in people with dementia, the NIDUS-Family intervention is fully manualised and deliverable by trained and supervised, non-clinical facilitators. We aimed to investigate the effectiveness of home-based goal setting plus NIDUS-Family in supporting the attainment of personalised goals set by people with dementia and their carers.

METHODS

We did a two-arm, single-masked, multi-site, randomised, clinical trial recruiting patient-carer dyads from community settings. We randomly assigned dyads to either home-based goal setting plus NIDUS-Family or goal setting and routine care (control). Randomisation was blocked and stratified by site (2:1; intervention to control), with allocations assigned via a remote web-based system. NIDUS-Family is tailored to goals set by dyads by selecting modules involving behavioural interventions, carer support, psychoeducation, communication and coping skills, enablement, and environmental adaptations. The intervention involved six to eight video-call or telephone sessions (or in person when COVID-19-related restrictions allowed) over 6 months, then telephone follow-ups every 2-3 months for 6 months. The primary outcome was carer-rated goal attainment scaling (GAS) score at 12 months. Analyses were done by intention to treat. This trial is registered with the ISRCTN registry, ISRCTN11425138.

FINDINGS

Between April 30, 2020, and May 9, 2021, we assessed 1083 potential dyads for eligibility, 781 (72·1%) of whom were excluded. Of 302 eligible dyads, we randomly assigned 98 (32·4%) to the control group and 204 (67·5%) to the intervention group. The mean age of participants with dementia was 79·9 years (SD 8·2), 169 (56%) were women, and 133 (44%) were men. 247 (82%) dyads completed the primary outcome, which favoured the intervention (mean GAS score at 12 months 58·7 [SD 13·0; n=163] vs 49·0 [14·1; n=84]; adjusted difference in means 10·23 [95% CI 5·75-14·71]; p<0·001). 31 (15·2%) participants in the intervention group and 14 (14·3%) in the control group experienced serious adverse events.

INTERPRETATION

To our knowledge, NIDUS-Family is the first readily scalable intervention for people with dementia and their family carers that improves attainment of personalised goals. We therefore recommend that it be implemented in health and care services.

FUNDING

UK Alzheimer's Society.

Current trends in psychotherapies and psychosocial interventions for people with dementia: a scoping review of randomized controlled trials

An outcome of dementia is a progressive decline in cognitive function. Implementing psychotherapies and psychosocial interventions is crucial for bolstering cognitive abilities, promoting independence, and elevating the quality of life for individuals with dementia. This review aims to identify current trends in psychotherapies and psychosocial interventions for people with dementia. A Scoping review was developed based on the framework proposed by Arksey and O'Malley. The literature search was conducted on electronic databases, including Scopus, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, Nursing & Allied Health Collection, and MedicLatina. Executed in June 2023, the search focused on articles published in English, Portuguese, and Spanish between 2013 and 2023. Through this search, 1409 articles were initially identified. After selecting and analyzing the reports, sixteen trials were included in this review. Eight distinct categories were identified, covering different strategies. These categories run from computerized game-based cognitive training and reminiscence therapy to compensatory and restorative strategies, memory and attention training, calculation training, dual-task training, counseling, and personalized goal attainment. The findings of this scoping review highlight the diverse landscape of psychotherapies and psychosocial interventions for people with dementia.

Designing technology to support greater participation of people living with dementia in daily and meaningful activities

Background

People living with dementia should be at the center of decision-making regarding their plans and goals for daily living and meaningful activities that help promote health and mental well-being. The human-computer interaction community has recently begun to recognize the need to design technologies where the person living with dementia is an active rather than a passive user of technology in the management of their care.

Methods

Data collection comprised semi-structured interviews and focus groups held with dyads of people with early-stage dementia (n = 5) and their informal carers (n = 4), as well as health professionals (n = 5). This article discusses findings from the thematic analysis of this qualitative data.

Results

Analysis resulted in the construction of three main themes: (1) maintaining a sense of purpose and identity, (2) learning helplessness and (3) shared decision-making and collaboration. Within each of the three main themes, related sub-themes were also constructed.

Discussion

There is a need to design technologies for persons living with dementia/carer dyads that can support collaborative care planning and engagement in meaningful activities while also balancing persons living with dementia empowerment and active engagement in self-management with carer support.

Factors that can influence neurocognitive performance: a case study in a controlled environment

This is a case study of a patient in her 50s who presents with severe malnutrition, alcohol dependence, and untreated Bipolar Affective Disorder. She was hospitalized multiple times and placed in a group home 1 year after symptom onset. Cognitive and functional improvements are observed over a 6-year period, as demonstrated by 3 comprehensive neuropsychological evaluations. Residing in a monitored and structured environment for 6 years, with stability in psychiatric medications, monitored nutrition and abstinence from alcohol are attributed to this improvement. This study provides unique evidence of the impact of balanced nutrition and improvements in psychiatric symptoms on cognition.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Management of Inherited CNS Small Vessel Diseases: The CADASIL Example: A Scientific Statement From the American Heart Association

Lacunar infarcts and vascular dementia are important phenotypic characteristics of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, the most common inherited cerebral small vessel disease. Individuals with the disease show variability in the nature and onset of symptoms and rates of progression, which are only partially explained by differences in pathogenic mutations in the NOTCH3 gene. Recognizing the disease early in its course and securing a molecular diagnosis are important clinical goals, despite the lack of proven disease-modifying treatments. The purposes of this scientific statement are to review the clinical, genetic, and imaging aspects of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, contrasting it with other inherited small vessel diseases, and to provide key prevention, management, and therapeutic considerations with the intent of reducing practice variability and encouraging production of high-quality evidence to support future treatment recommendations.

Promoting Activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED): randomised controlled trial

OBJECTIVE

To determine the effectiveness of an exercise and functional activity therapy intervention in adults with early dementia or mild cognitive impairment compared with usual care.

DESIGN

Randomised controlled trial.

SETTING

Participants' homes and communities at five sites in the United Kingdom.

PARTICIPANTS

365 adults with early dementia or mild cognitive impairment who were living at home, and family members or carers.

INTERVENTION

The intervention, Promoting activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED), was a specially designed, dementia specific, rehabilitation programme focusing on strength, balance, physical activity, and performance of activities of daily living, which was tailored and progressive and addressed risk and the psychological needs of people with dementia. Up to 50 therapy sessions were provided over 12 months. The control group received usual care plus a falls risk assessment. Procedures were adapted during the covid-19 pandemic.

MAIN OUTCOME MEASURES

The primary outcome was score on the carer (informant) reported disability assessment for dementia scale 12 months after randomisation. Secondary outcomes were self-reported activities of daily living, physical activity, quality of life, balance, functional mobility, fear of falling, frailty, cognition, mood, carer strain, service use at 12 months, and falls between months 4 and 15.

RESULTS

365 patient participants were randomised, 183 to intervention and 182 to control. The median age of participants was 80 years (range 65-95), median Montreal cognitive assessment score was 20 out of 30 (range 13-26), and 58% (n=210) were men. Intervention participants received a median of 31 therapy sessions (interquartile range 22-40) and reported completing a mean 121 minutes of PrAISED exercise each week. Primary outcome data were available for 149 intervention and 141 control participants. Scores on the disability assessment for dementia scale did not differ between groups: adjusted mean difference -1.3, 95% confidence interval -5.2 to 2.6; Cohen's d effect size -0.06, 95% confidence interval -0.26 to 0.15; P=0.51). Upper 95% confidence intervals excluded small to moderate effects on any of the range of outcome measures. Between months 4 and 15 the intervention group experienced 79 falls and the control group 200 falls (adjusted incidence rate ratio 0.78, 95% confidence interval 0.5 to 1.3; P=0.3).

CONCLUSION

The intensive PrAISED programme of exercise and functional activity training did not improve activities of daily living, physical activity, or quality of life; reduce falls; or improve any other secondary health status outcomes, despite good uptake. Future research should consider alternative approaches to maintaining ability and wellbeing in people with dementia.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN15320670.

Social connections and participation among people with mild cognitive impairment: barriers and recommendations

Objective

Social connections and participation are essential for individuals with mild cognitive impairment (MCI) to prevent the progression of cognitive decline and enhance their overall well-being. However, existing research has primarily focused on environmental barriers, overlooking personal factors and the interconnected nature of these barriers. Moreover, there is a lack of understanding regarding social connections and participation challenges specific to people with MCI in low- and middle-income countries. Therefore, this study aimed to explore the barriers that hinder social connections and participation among people with MCI in China and investigate opportunities to design appropriate supportive interventions.

Methods

Thirty-one people with MCI (13 males and 18 females; mean age = 82.74 years, SD = 7.69; mean MoCA score = 21.26, SD = 2.44) and 13 caregivers were recruited to attend focus groups. In addition, 10 therapists were interviewed using a semi-structured interview guide. Focus groups and interviews were audio-recorded, transcribed, and analyzed using a framework analysis approach.

Results

We found that the ability to build social connections among people with MCI is affected by mobility challenges, intensive grandparenting responsibilities, availability of suitable activities, and feelings of exclusion in a closed-minded community environment. Personal reasons, such as lower social efficacy, inability to find suitable social activities, and intensive family responsibilities, discourage people with MCI from social participation. The digital literacy of people with MCI depends on their motivation to learn and use digital tools; people with MCI who live in a community have a higher digital literacy than those living in care centers. The motivation to achieve digital literacy is affected by perceived benefits, costs of technology use, and social influence.

Conclusion

Multidimensional initiatives are needed to address barriers to social connections, participation, and technology adoption among individuals with MCI. This includes organizing and engaging in social activities, promoting awareness and education on the importance of social participation, and exploring technology-based interventions to improve memory and storytelling abilities. These efforts can create a supportive environment and empower individuals with MCI to participate actively in social interactions, enhancing their overall well-being.

Cognitive rehabilitation for people with mild to moderate dementia

BACKGROUND

Cognitive impairments affect functional ability in people with dementia. Cognitive rehabilitation (CR) is a personalised, solution-focused approach that aims to enable people with mild-to-moderate dementia to manage everyday activities and maintain as much independence as possible.

OBJECTIVES

To evaluate the effects of CR on everyday functioning and other outcomes for people with mild-to-moderate dementia, and on outcomes for care partners. To identify and explore factors that may be associated with the efficacy of CR.

SEARCH METHODS

We searched the Cochrane Dementia and Cognitive Improvement Group Specialised Register, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, and other clinical trial databases, and grey literature sources. The most recent search was completed on 19 October 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CR with control conditions and reporting relevant outcomes for the person with dementia and/or the care partner.

DATA COLLECTION AND ANALYSIS

We extracted relevant data from published manuscripts and contacted trial authors if necessary. Within each of the comparisons, we pooled data for each outcome of interest and conducted inverse-variance, random-effects meta-analyses. We evaluated the certainty of the evidence using GRADEpro GDT.

MAIN RESULTS

We identified six eligible RCTs published in English between 2010 and 2022, which together included 1702 participants. The mean age of participants ranged from 76 to 80 and the proportion of male participants was between 29.4% and 79.3%. Most participants, in the studies where the type of dementia was reported, had a diagnosis of Alzheimer's disease (AD; n = 1002, 58.9% of the whole sample, 81.2% of the participants for whom the specific diagnosis was reported). Risk of bias in the individual studies was relatively low. The exception was a high risk of bias in relation to blinding of participants and practitioners, which is not usually feasible with psychosocial interventions.  Our primary outcome of everyday functioning was operationalised in the included studies as goal attainment in relation to activities targeted in the intervention. For our main comparison of CR with usual care, we pooled data for goal attainment evaluated from three perspectives (self-rating of performance, informant rating of performance, and self-rating of satisfaction with performance) at end of treatment and at medium-term follow-up (3 to 12 months). We could also pool data at these time points for 20 and 19 secondary outcomes respectively. The review findings were strongly driven by one large, high-quality RCT.  We found high-certainty evidence of large positive effects of CR on all three primary outcome perspectives at the end of treatment: participant self-ratings of goal attainment (standardised mean difference (SMD) 1.46, 95% confidence interval (CI) 1.26 to 1.66; I2 = 0%; 3 RCTs, 501 participants), informant ratings of goal attainment (SMD 1.61, 95% CI 1.01 to 2.21; I2 = 41%; 3 RCTs, 476 participants), and self-ratings of satisfaction with goal attainment (SMD 1.31, 95% CI 1.09 to 1.54; I2 = 5%; 3 RCTs, 501 participants), relative to an inactive control condition. At medium-term follow-up, we found high-certainty evidence showing a large positive effect of CR on all three primary outcome perspectives: participant self-ratings of goal attainment (SMD 1.46, 95% CI 1.25 to 1.68; I2 = 0%; 2 RCTs, 432 participants), informant ratings of goal attainment (SMD 1.25, 95% CI 0.78 to 1.72; I2 = 29%; 3 RCTs, 446 participants), and self-ratings of satisfaction with goal attainment (SMD 1.19, 95% CI 0.73 to 1.66; I2 = 28%; 2 RCTs, 432 participants), relative to an inactive control condition. For participants at the end of treatment we found high-certainty evidence showing a small positive effect of CR on self-efficacy (2 RCTs, 456 participants) and immediate recall (2 RCTs, 459 participants). For participants at medium-term follow-up we found moderate-certainty evidence showing a small positive effect of CR on auditory selective attention (2 RCTs, 386 participants), and a small negative effect on general functional ability (3 RCTs, 673 participants), and we found low-certainty evidence showing a small positive effect on sustained attention (2 RCTs, 413 participants), and a small negative effect on memory (2 RCTs, 51 participants) and anxiety (3 RCTs, 455 participants).  We found moderate- and low-certainty evidence indicating that at the end of treatment CR had negligible effects on participant anxiety, quality of life, sustained attention, memory, delayed recall, and general functional ability, and at medium-term follow-up on participant self-efficacy, depression, quality of life, immediate recall, and verbal fluency. For care partners at the end of treatment we found low-certainty evidence showing a small positive effect on environmental aspects of quality of life (3 RCTs, 465 care partners), and small negative effects of CR on level of depression (2 RCTs, 32 care partners) and on psychological wellbeing (2 RCTs, 388 care partners).  For care partners at medium-term follow-up we found high-certainty evidence showing a small positive effect of CR on social aspects of quality of life (3 RCTs, 436 care partners) and moderate-certainty evidence showing a small positive effect on psychological aspects of quality of life (3 RCTs, 437 care partners). We found moderate- and low-certainty evidence at the end of treatment that CR had negligible effects on care partners' physical health, psychological and social aspects of quality of life, and stress, and at medium-term follow-up for the physical health aspect of care partners' quality of life and psychological wellbeing.

AUTHORS' CONCLUSIONS

CR is helpful in enabling people with mild or moderate dementia to improve their ability to manage the everyday activities targeted in the intervention. Confidence in these findings could be strengthened if more high-quality studies contributed to the observed effects. The available evidence suggests that CR can form a valuable part of a clinical toolkit to assist people with dementia in overcoming some of the everyday barriers imposed by cognitive and functional difficulties. Future research, including process evaluation studies, could help identify avenues to maximise CR effects and achieve wider impacts on functional ability and wellbeing.

The memory clinic and psychosocial intervention: Translating past promise into current practices

Disproportionate negative effects since the pandemic have amplified the already limited post-diagnostic support for older people with dementia. This paper summarizes an exploratory randomized controlled study of a proactive family-based intervention compared with "usual" post-diagnostic dementia care. Memory clinic practitioners collaborated with the family doctor (GP) to coordinate this. At 12-month follow-up, positive effects on mood, behavior, carer coping and maintenance of care at home were found. Current approaches to deliver post-diagnostic support in primary care may require rethinking since (i) GP workloads have increased with low numbers of GPs per head of population in parts of England; and (ii) unlike many other long-term conditions, ongoing stigma, fear and uncertainty associated with dementia adds to the huge complexity of timely care provision. There is a case for return to a "one-stop facility", with a single pathway of continuing multidisciplinary coordinated care for older people with dementia and families. Future longitudinal research could compare structured post-diagnostic psychosocial intervention coordinated by skilled practitioners in a single locality memory service "hub", against other approaches such support organized mostly within primary care. Dementia-specific instruments for outcome measurement are available for use in routine practice, and should be included in such comparative studies.

Bridging the gap: Study protocol for development of an implementation strategy for evidence-informed reablement and rehabilitation for community-dwelling people with dementia

BACKGROUND

Extensive research supports the use of goal-directed reablement and rehabilitation interventions to address a range of physical, functional, cognitive and behavioural needs of people living with dementia. Despite this, evidence-informed multidisciplinary reablement and rehabilitation interventions are not being offered in usual dementia care across Australia. An examination is needed of how best to implement reablement and rehabilitation interventions within the community-based dementia care sector.

METHODS

Drawing on implementation science, this study uses a four-phase mixed-methods retrospective and prospective approach: (1) clinical audit to evaluate current clinical practice, and through focus groups with practitioners, identify practitioner-led goals and targets for practice change; (2) Delphi survey to converge opinions from the diverse stakeholders involved in reablement in dementia, to reach national consensus around an implementation strategy; (3) hybrid pragmatic effectiveness-implementation pilot will facilitate testing of the implementation strategy in parallel with exploring effectiveness of the reablement intervention specifically within a real-world Australian community aged care context; (4) implementation capacity building.

DISCUSSION

This study will result in a freely available, nationally relevant implementation protocol, designed and tailored via input from key stakeholders over a series of iterative project activities. By testing this protocol via a pilot implementation-effectiveness study, we will generate national information about effectiveness of evidence-informed reablement programs for people living with dementia across various community aged care settings. Outcomes have potential to influence policy and drive widespread practice change, increasing access to evidence-informed reablement and rehabilitation for people living with dementia across Australia.

Proactive and Integrated Management and Empowerment in Parkinson's Disease protocol for a randomised controlled trial (PRIME-UK) to evaluate a new model of care

BACKGROUND

People living with Parkinson's disease experience progressive motor and non-motor symptoms, which negatively impact on health-related quality of life and can lead to an increased risk of hospitalisation. It is increasingly recognised that the current care models are not suitable for the needs of people with parkinsonism whose care needs evolve and change as the disease progresses. This trial aims to evaluate whether a complex and innovative model of integrated care will increase an individual's ability to achieve their personal goals, have a positive impact on health and symptom burden and be more cost-effective when compared with usual care.

METHODS

This is a single-centre, randomised controlled trial where people with parkinsonism and their informal caregivers are randomised into one of two groups: either PRIME Parkinson multi-component model of care or usual care. Adults ≥18 years with a diagnosis of parkinsonism, able to provide informed consent or the availability of a close friend or relative to act as a personal consultee if capacity to do so is absent and living in the trial geographical area are eligible. Up to three caregivers per patient can also take part, must be ≥18 years, provide informal, unpaid care and able to give informed consent. The primary outcome measure is goal attainment, as measured using the Bangor Goal Setting Interview. The duration of enrolment is 24 months. The total recruitment target is n=214, and the main analyses will be intention to treat.

DISCUSSION

This trial tests whether a novel model of care improves health and disease-related metrics including goal attainment and decreases hospitalisations whilst being more cost-effective than the current usual care. Subject to successful implementation of this intervention within one centre, the PRIME Parkinson model of care could then be evaluated within a cluster-randomised trial at multiple centres.

Implementing a home-based personalised cognitive rehabilitation intervention for people with mild-to-moderate dementia: GREAT into Practice

BACKGROUND

Evidence-based rehabilitative interventions, if widely implemented, could equip people with dementia and their families to manage life with the condition and reduce the need for health and care services. The aim of this translational study, building on evidence from the GREAT randomised controlled trial, was to develop a foundation for implementing the GREAT Cognitive Rehabilitation intervention in community-based services for people with mild-to-moderate dementia.

METHODS

Key elements of the implementation strategy were identifying and supporting managerial and clinical leadership, conducting collaborative planning and target-setting, training and supporting practitioners, and providing external facilitation. We developed implementation plans with, and trained staff in, 14 organisations. We subsequently worked closely with 11 of these, 10 National Health Service organisations and one private home care provider, to support practitioners to deliver GREAT Cognitive Rehabilitation over a 12-month period. Outcome evaluation examined the perspectives of local steering group members, practitioners and service users, and the reach, effectiveness and cost of the intervention.

RESULTS

Implementation was disrupted by the COVID-19 pandemic, but six organisations completed at least six months of intervention delivery. Forty-one practitioners, mainly occupational therapists, provided the intervention, and 54 people with dementia completed a course of GREAT Cognitive Rehabilitation. Goal attainment by people with dementia exceeded levels of improvement seen in the original trial. People with dementia, carers, practitioners and steering group members all evaluated the intervention positively, and economic analysis indicated that the intervention could be provided at modest cost. However, we identified a range of mainly organisational barriers that impeded implementation and limited the potential for sustainability.

CONCLUSIONS

GREAT Cognitive Rehabilitation benefits people with dementia, can be delivered effectively at modest cost in routine services, and is viewed positively by people with dementia, family carers and practitioners. To fully realise these benefits and achieve widespread and sustainable implementation, however, requires sufficient resources and a reorientation of service priorities towards preventive and rehabilitative approaches.

TRIAL REGISTRATION

National Institute for Health Research (NIHR) Central Portfolio Management System, registration number 38994.

Longitudinal Predictors of Informant-Rated Involvement of People with Dementia in Everyday Decision-Making: Findings from the IDEAL Program

The extent to which people with dementia are involved in everyday decision-making is unclear. We explored informant-rated involvement of people with dementia in everyday decision-making over 2 years and whether functional, behavioral, and psychological factors related to the person with dementia and the caregiver explain variability in involvement of people with dementia in everyday decision-making. We used IDEAL data for 1182 people with dementia and their caregivers. Baseline mean score on the decision-making involvement scale was 31/45; it minimally declined over time. People with dementia who were female, single, and/or whose caregiver was younger had greater involvement in everyday decision-making than those without these characteristics. Better cognition, fewer functional difficulties, fewer neuropsychiatric symptoms, less caregiver stress, and better informant-rated relationship quality were associated with higher involvement in everyday decision-making. Cognitive and functional rehabilitation, and educational resources for caregivers, could prolong involvement of people with dementia in everyday decision-making.

A person-centered approach to home and community-based services outcome measurement

In the United States, over 2.5 million people with disabilities are recipients of supports through the Center for Medicare and Medicaid Services (CMS) Home and Community-Based Services (HCBS) program. Recent decades have seen a growing focus on providing HCBS in a person-centered manner thereby supporting outcomes that are both important for and to the person. HCBS outcome measurement, however, has not kept pace with advancements in person-centered thinking as it relates to providing supports to people with disabilities. The concept of person-centered outcome measurement has been inadequately defined and is frequently misunderstood including by those in the measurement field. The authors first operationally define person-centered measurement and establish its importance within the context of HCBS and the recent CMS's Final Settings Rule. The important role that person-centered measurement has to play in quality improvement efforts in this area is then explored. A discussion is subsequently provided as to the challenges that are faced in person-centered measurement specific to the disability field. In addition to further conceptualizing and defining this form of measurement, recommendations are provided for moving the field forward.

Providing person-centred dementia care on general hospital wards

Dementia is caused by conditions that result in a progressive loss of brain function. People with dementia often have complex multimorbidity which increases their risk of admission to hospital. However, care in acute hospitals is often not adapted to patients with dementia, who have reported negative experiences of their hospital stay from admission to discharge. Person-centred care has been shown to make a positive difference to how well people with dementia cope in hospital. This article discusses how nurses working on general hospital wards can enhance the experiences of people with dementia and improve their outcomes by providing person-centred care.

Interdisciplinary Approaches to Deal with Alzheimer's Disease-From Bench to Bedside: What Feasible Options Do Already Exist Today?

Alzheimer's disease is one of the most common neurodegenerative diseases in the western population. The incidence of this disease increases with age. Rising life expectancy and the resulting increase in the ratio of elderly in the population are likely to exacerbate socioeconomic problems. Alzheimer's disease is a multifactorial disease. In addition to amyloidogenic processing leading to plaques, and tau pathology, but also other molecular causes such as oxidative stress or inflammation play a crucial role. We summarize the molecular mechanisms leading to Alzheimer's disease and which potential interventions are known to interfere with these mechanisms, focusing on nutritional approaches and physical activity but also the beneficial effects of cognition-oriented treatments with a focus on language and communication. Interestingly, recent findings also suggest a causal link between oral conditions, such as periodontitis or edentulism, and Alzheimer's disease, raising the question of whether dental intervention in Alzheimer's patients can be beneficial as well. Unfortunately, all previous single-domain interventions have been shown to have limited benefit to patients. However, the latest studies indicate that combining these efforts into multidomain approaches may have increased preventive or therapeutic potential. Therefore, as another emphasis in this review, we provide an overview of current literature dealing with studies combining the above-mentioned approaches and discuss potential advantages compared to monotherapies. Considering current literature and intervention options, we also propose a multidomain interdisciplinary approach for the treatment of Alzheimer's disease patients that synergistically links the individual approaches. In conclusion, this review highlights the need to combine different approaches in an interdisciplinary manner, to address the future challenges of Alzheimer's disease.

Methods to elicit and evaluate the attainment of patient goals in older adults: A scoping review

OBJECTIVE

This scoping review aimed to identify patient goal elicitation and evaluation methods for older adults, and to investigate which methods can be used in medication optimization interventions for nursing home residents (NHRs).

METHODS

The Arksey and O'Malley framework guided the review. A search was launched in PubMed, Embase, CINAHL, and Web of Science. Reference selection and data extraction were performed by three independent reviewers, followed by team discussions to solve discrepancies. Inductive thematic analysis was applied to synthesize the data. Included papers were reconsidered to identify methods for medication optimization interventions for NHRs.

RESULTS

Ninety-six references, encompassing 38 elicitation and 12 evaluation methods, were included. Elicitation methods differed in structure, content, and patient involvement levels. Qualitative and quantitative methods were found to assess goal attainment. Five elicitation and three evaluation methods were developed for NHRs, but none of these contained a medication-related assessment.

CONCLUSION

A variety of goal elicitation and evaluation methods for older adults was found, but none for medication optimization interventions in NHRs.

PRACTICE IMPLICATIONS

A holistic approach seems important to integrate patient goals into medication optimization interventions, not limiting goal elicitation to a medication-related assessment. Also, the choice of assessor seems important to obtain patient goals.

Dementia Early-Stage Cognitive Aids New Trial (DESCANT) of memory aids and guidance for people with dementia: randomised controlled trial

BACKGROUND

Common memory aids for people with dementia at home are recommended. However, rigorous evaluation is lacking, particularly what guidance or support is valued.

OBJECTIVE

To investigate effects of memory aids and guidance by dementia support practitioners (DSPs) for people in early-stage dementia through a pragmatic, randomised controlled trial.

METHODS

Of 469 people with mild-to-moderate dementia and their informal carers, 468 were randomised to a DSP with memory aids or to usual care plus existing dementia guide. Allocation was stratified by Trust/Health Board; time since first attendance at memory service; gender; age; and living with primary carer or not. Primary outcome was Bristol Activities of Daily Living Scale (BADLS) Score at 3 and 6 months (primary end-point). Secondary outcomes for people with dementia: quality of life (CASP-19; DEMQOL); cognition and functioning (Clinical Dementia Rating Scale; S-MMSE); capability (ICECAP-O); social networks (LSNS-R); and instrumental daily living activities (R-IDDD). Secondary outcomes for carers: psychological health (GHQ-12); sense of competence (SSCQ).

RESULTS

DSPs were successfully trained, compliance was good and welcomed by participants. Mean 6 months BADLS Score increased to 14.6 (SD: 10.4) in intervention and 12.6 (SD: 8.1) in comparator, indicative of greater dependence in the activities of daily living. Adjusted between-group difference was 0.38 (95% CI: -0.89 to 1.65, p=0.56). Though this suggests greater dependency in the intervention group the difference was not significant. No differences were found in secondary outcomes.

CONCLUSIONS

This intervention did not maintain independence in the activities of daily living with no improvement in other outcomes for people with dementia or carers.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN12591717.

Systematic Review of Factors Associated With Hearing Aid Use in People Living in the Community With Dementia and Age-related Hearing Loss

OBJECTIVES

To investigate factors that influence hearing aid use according to the Theoretical Domains Framework (TDF). The TDF is a behavioral science framework that aids understanding of factors that influence behavior.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

People living in the community with dementia and age-related hearing loss who have air conduction hearing aids.

METHODS

Systematic literature review following PRISMA guidelines. We searched for studies in 8 databases, including Ovid MEDLINE, Scopus, and OpenGrey. We undertook an interpretive data synthesis by mapping findings onto the TDF. We assessed confidence in the findings according to the GRADE-CERQual approach.

RESULTS

Twelve studies (6 quantitative, 3 qualitative, and 3 mixed methods) were included in the review. The majority of these were rated low-moderate quality. We identified 27 component constructs (facilitators, barriers, or noncorrelates of hearing aid use) nested within the 14 domains of the TDF framework. Our GRADE-CERQual confidence rating was high for 5 findings. These suggest that hearing aid use for people living in the community with dementia and hearing loss is influenced by (1) degree of hearing aid handling proficiency, (2) positive experiential consequences, (3) degree of hearing aid comfort or fit, (4) person-environment interactions, and (5) social reinforcement.

CONCLUSIONS AND IMPLICATIONS

Hearing aid interventions should adopt a multifaceted approach that optimizes the capabilities of people with dementias to handle and use hearing aids; addresses or capitalizes on their motivation; and ensures their primary support network is supportive and encouraging of hearing aid use. The findings also emphasize the need for further high-quality research that investigates optimal hearing aid use, influencing factors, and interventions that support hearing aid use.

Effects of a cognitive rehabilitation program based on mnemonic skills and memory compensatory strategies for older adults: A pilot study

BACKGROUND

With the aging of the population, the number of people with age-related memory complaints has also increased. The purpose of this study was to develop a cognitive rehabilitation program based on mnemonic skills and memory compensatory strategies (CRM) and to investigate the effects of CRM in community-dwelling older adults without dementia.

METHODS

This study was an open-label, single-arm, pilot study. We developed a CRM program comprising 8 weekly sessions. The study participants consisted of older adults with normal cognitive function and mild cognitive impairment (MCI). They were recruited from eight dementia counseling centers and one senior welfare center. To assess the effects of CRM, we administered the following tests at baseline and after completion of the program: Subjective Memory Complaints Questionnaire, the Short form of Geriatric Depression Scale, the Euro Quality of life-5 Dimension, and the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery.

RESULTS

Thirty-two participants completed the study. Among older adults with normal cognitive function, CRM showed significant improvement in verbal memory function. Among the older adults with MCI, CRM showed significant improvements in language ability, verbal recognition memory, nonverbal memory, attention, and processing speed.

CONCLUSION

CRM improved cognitive function in two distinct populations, older adults with normal cognitive function and older adults with MCI. Additionally, our preliminary findings suggest that older adults with MCI show cognitive improvement in both the trained and non-trained cognitive domains.

Differential effects from cognitive rehabilitation and high-definition tDCS in posterior cortical atrophy: A single-case experimental design

Posterior cortical atrophy (PCA) is a progressive neurodegenerative syndrome characterized by visual-perceptual deficits, which impact daily life. Recent research has focused on non-pharmacological techniques to ameliorate these deficits, with the most common being cognitive rehabilitation. The present study investigates the differential effects of high definition-transcranial direct current stimulation (HD-tDCS) and cognitive rehabilitation in a single-case experimental design with two separate experimental phases in a patient with PCA. Experimental Phase 1 consisted of 10 sessions of HD-tDCS targeting the pre-SMA/dACC and Phase 2 consisted of 10 sessions of cognitive rehabilitation. Normed and standardized scores from figure copy and recall tests served as the primary outcome measures for visuospatial processing. The participant showed no immediate or long-term changes in visuospatial measures following HD-tDCS intervention. However, cognitive rehabilitation showed immediate improvement in visuospatial memory (figure recall) and clinically significant improvement in visuospatial construction (figure copy). Visuospatial construction gains remained in the low average range in the 10-week follow-up while visuospatial memory returned to baseline. Results indicated differential effects between HD-tDCS and cognitive rehabilitation with cognitive rehabilitation showing clinically significant improvement in primary outcome measures with sustained improvement in the long-term follow-up measure. Additional research is warranted to confirm these effects.

The impact of an occupational therapy group cognitive rehabilitation program for people with dementia

INTRODUCTION

This study was conducted to examine the impact of a group cognitive rehabilitation program for people with dementia on everyday memory function and quality of life.

METHODS

Participants included in the study were community-dwelling adults with a diagnosis of dementia. The intervention was a 5-week occupational therapy lead group cognitive rehabilitation program delivered once a week for 1.5 h. Outcome measures included standardised memory tests, subjective everyday memory function and quality of life ratings. The measures were completed at baseline, post-intervention and 3-month post-intervention.

RESULTS

Outcome measures were completed with 58 participants. Statistically significant improvements in standardised memory scores were noted following the intervention. Similarly, self-rated everyday memory function and quality of life scores significantly improved following the intervention. All standardised scores and subjective ratings were maintained at 3-month follow-up.

CONCLUSION

Group-based cognitive rehabilitation programs can positively impact the quality of life and everyday memory function among people with dementia.

An intervention to promote self-management, independence and self-efficacy in people with early-stage dementia: the Journeying through Dementia RCT

BACKGROUND

There are few effective interventions for dementia.

AIM

To determine the clinical effectiveness and cost-effectiveness of an intervention to promote self-management, independence and self-efficacy in people with early-stage dementia.

OBJECTIVES

To undertake a randomised controlled trial of the Journeying through Dementia intervention compared with usual care, conduct an internal pilot testing feasibility, assess intervention delivery fidelity and undertake a qualitative exploration of participants' experiences.

DESIGN

A pragmatic two-arm individually randomised trial analysed by intention to treat.

PARTICIPANTS

A total of 480 people diagnosed with mild dementia, with capacity to make informed decisions, living in the community and not participating in other studies, and 350 supporters whom they identified, from 13 locations in England, took part.

INTERVENTION

Those randomised to the Journeying through Dementia intervention (n = 241) were invited to take part in 12 weekly facilitated groups and four one-to-one sessions delivered in the community by secondary care staff, in addition to their usual care. The control group (n = 239) received usual care. Usual care included drug treatment, needs assessment and referral to appropriate services. Usual care at each site was recorded.

MAIN OUTCOME MEASURES

The primary outcome was Dementia-Related Quality of Life score at 8 months post randomisation, with higher scores representing higher quality of life. Secondary outcomes included resource use, psychological well-being, self-management, instrumental activities of daily living and health-related quality of life.

RANDOMISATION AND BLINDING

Participants were randomised in a 1 : 1 ratio. Staff conducting outcome assessments were blinded.

DATA SOURCES

Outcome measures were administered in participants' homes at baseline and at 8 and 12 months post randomisation. Interviews were conducted with participants, participating carers and interventionalists.

RESULTS

The mean Dementia-Related Quality of Life score at 8 months was 93.3 (standard deviation 13.0) in the intervention arm (n = 191) and 91.9 (standard deviation 14.6) in the control arm (n = 197), with a difference in means of 0.9 (95% confidence interval -1.2 to 3.0; p = 0.380) after adjustment for covariates. This effect size (0.9) was less than the 4 points defined as clinically meaningful. For other outcomes, a difference was found only for Diener's Flourishing Scale (adjusted mean difference 1.2, 95% confidence interval 0.1 to 2.3), in favour of the intervention (i.e. in a positive direction). The Journeying through Dementia intervention cost £608 more than usual care (95% confidence interval £105 to £1179) and had negligible difference in quality-adjusted life-years (-0.003, 95% confidence interval -0.044 to 0.038). Therefore, the Journeying through Dementia intervention had a mean incremental cost per quality-adjusted life-year of -£202,857 (95% confidence interval -£534,733 to £483,739); however, there is considerable uncertainty around this. Assessed fidelity was good. Interviewed participants described receiving some benefit and a minority benefited greatly. However, negative aspects were also raised by a minority. Seventeen per cent of participants in the intervention arm and 15% of participants in the control arm experienced at least one serious adverse event. None of the serious adverse events were classified as related to the intervention.

LIMITATIONS

Study limitations include recruitment of an active population, delivery challenges and limitations of existing outcome measures.

CONCLUSIONS

The Journeying through Dementia programme is not clinically effective, is unlikely to be cost-effective and cannot be recommended in its existing format.

FUTURE WORK

Research should focus on the creation of new outcome measures to assess well-being in dementia and on using elements of the intervention, such as enabling enactment in the community.

TRIAL REGISTRATION

This trial is registered as ISRCTN17993825.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 24. See the NIHR Journals Library website for further project information.

The Journeying through Dementia psychosocial intervention versus usual care study: a single-blind, parallel group, phase 3 trial

BACKGROUND

There is an urgent clinical need for evidence-based psychosocial interventions for people with mild dementia. We aimed to determine the clinical benefits and cost-effectiveness of Journeying through Dementia (JtD), an intervention designed to promote wellbeing and independence in people with mild dementia.

METHODS

We did a single-blind, parallel group, individually randomised, phase 3 trial at 13 National Health Service sites across England. People with mild dementia (Mini-Mental State Examination score of ≥18) who lived in the community were eligible for inclusion. Patients were centrally randomly assigned (1:1) to receive the JtD intervention plus standard care (JtD group) or standard care only (standard care group). Randomisation was stratified by study site. The JtD intervention included 12 group and four one-to-one sessions, delivered in the community at each site. The primary endpoint was Dementia Related Quality of Life (DEMQOL) 8 months after randomisation, assessed according to the intention-to-treat principle. Only outcome assessors were masked to group assignment. A cost-effectiveness analysis reported cost per quality-adjusted life-year (QALY) from a UK NHS and social care perspective. The study is registered with ISRCTN, ISRCTN17993825.

FINDINGS

Between Nov 30, 2016, and Aug 31, 2018, 1183 patients were screened for inclusion, of whom 480 (41%) participants were randomly assigned: 241 (50%) to the JtD group and 239 (50%) to the standard care group. Intervention adherence was very good: 165 (68%) of 241 participants in the JtD group attended at least ten of the 16 sessions. Mean DEMQOL scores at 8 months were 93·3 (SD 13·0) for the JtD group and 91·9 (SD 14·6) for the control group. Difference in means was 0·9 (95% CI -1·2 to 3·0; p=0·38) after adjustment for covariates, lower than that identified as clinically meaningful. Incremental cost per QALY ranged from £88 000 to -£205 000, suggesting that JtD was not cost-effective. Unrelated serious adverse events were reported by 40 (17%) patients in the JtD group and 35 (15%) patients in the standard care group.

INTERPRETATION

In common with other studies, the JtD intervention was not proven effective. However, this complex trial successfully recruited and retained people with dementia without necessarily involving carers. Additionally, people with dementia were actively involved as participants and study advisers throughout. More research into methods of measuring small, meaningful changes in this population is needed. Questions remain regarding how services can match the complex, diverse, and individual needs of people with mild dementia, and how interventions to meet such needs can be delivered at scale.

FUNDING

UK National Institute of Health Research Health Technology Assessment Programme.

Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) in home care services: a cluster randomized feasibility trial

Background

Behavioral and psychological symptoms of dementia (BPSD) occur frequently in people with dementia and can contribute to an increased need for help and a reduced quality of life, but also predict early institutionalization. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) might be a useful personalized approach to BPSD in people with dementia. The main objective of this feasibility trial was to explore the trial design and methods along with the patients’ and the home care staff’s acceptance of the TIME intervention before developing a definitive trial. Additionally, we wanted to explore whether TIME could be appropriate for staff in home care services in their approach towards people with dementia with anxiety and depression.

Methods

This was a 18-month feasibility trial using a parallel cluster randomized controlled design. Nine municipalities from the eastern part of Norway (clusters) — 40 people with dementia and 37 of their next of kin— were randomized to the TIME intervention or to treatment as usual. In addition, qualitative data as field notes were collected and summarized.

Results

The staff in home care services experienced TIME as an appropriate method; in particular, the systematic approach to the patient’s BPSD was experienced as useful. However, the completion of the assessment phase was considered exhaustive and time-consuming, and some of the staff found it challenging to find time for the case conferences.

Conclusions

We consider that TIME, with some adjustments, could be useful for staff in home care services in cases where they face challenges in providing care and support to people with dementia. This feasibility trial indicates that we can move forward with a future definitive randomized controlled trial (RCT) to test the effect of TIME in people with dementia receiving home care services.

Trial registration

ClinicalTrial.gov identifier: SI0303150608.

A Conceptual View of Cognitive Intervention in Older Adults With and Without Cognitive Decline-A Systemic Review

Background: Dementia is the one of the most common and prominent disease in the elderly person that results in the Cognitive interventions. In this study, we aim to conceptualize the cognitive intervention for older adults with and without cognitive dysfunction and to clarify the heterogeneity existing in this literature field by determining the main variables implicated. Methods: We conducted a study analysis using previous literature highlighting the significant data reporting empirical results from cognitive intervention for healthy older adults and other seniors with different types of dementia. Each paper was reviewed in terms of compensatory cognitive training, cognitive remediation, enrichment, cognitive activation, brain training, cognitive stimulation, cognitive training, and cognitive rehabilitation. The research analysis was performed following rigorous inclusion and exclusion criteria with the purpose of collecting relevant answers to our research questions. Results: We included a total of 168 studies in our review. Our findings indicated heterogeneity regarding methods, concepts, and procedures. Additionally, the values were integrated using different information existing in this field. Conclusion: In conclusion, we highlighted that this is the first review that clarify the discrepancy of various existing definitions, methods, and procedures, as well as the overlapping information in the cognitive interventions.

Control Beliefs among People with Dementia: A Systematic Review

INTRODUCTION

Dementia diseases are still incurable, and in order to assist in living well with the disease, researchers are increasing their attention to the value of control beliefs. Control beliefs are associated with coping and psychological well-being; however, knowledge on how they relate to well-being outcomes in people with dementia is limited. This review aimed to synthesize knowledge about control beliefs in this group to guide future interventions and research.

METHOD

A systematic search of 6 databases (MEDLINE, CINAHL, PsychINFO, AgeLine, Embase, and the Cochrane Library) with broad search terms related to dementia, control, and coping was conducted. Studies that investigated people with a confirmed dementia diagnosis and that used a questionnaire to measure control beliefs quantitatively were included.

RESULTS

Eighteen studies were identified, examining self-efficacy, personal control/mastery, or locus of control. The studies varied in aim and design, with fair to good methodological quality. However, 10 studies included <50 participants with dementia, leaving findings unreliable due to low power. Participants with dementia in the mild to moderate stages were included, with average age in the seventies. Except for one validation study, the control belief questionnaires had not been validated for people with dementia.

CONCLUSION

There is a lack of knowledge about control beliefs among people with dementia, due to few and low-powered studies. Although we cannot conclude regarding control beliefs, our findings support the feasibility of quantitative research on control beliefs among people with dementia and we recommend that they be included in this type of research.

Locus of Control and Its Associations with Depressive Symptoms amongst People with Dementia

INTRODUCTION

Depression is common amongst people with dementia. This study examines whether locus of control (LoC), a perceived control construct influential in the coping process, is related to depressive symptoms in this population.

METHODS

In this prospective observational study, 257 community-dwelling older adults with a confirmed dementia diagnosis were included. At baseline, measures of depressive symptoms, LoC, cognition, independent functional ability, general health, dementia severity, and dementia disease insight were collected. At follow-up, measures of depressive symptoms and cognition were collected. Multiple linear regression using degree of depressive symptoms as measured with Montgomery-Asberg Depression Rating Scale as a dependent variable was applied to assess whether LoC was associated with depressive symptoms at baseline and follow-up while controlling for covariates.

RESULTS

LoC (p < 0.001), general health (p = 0.003), and insight (p = 0.010) were associated with severity of depressive symptoms at baseline, accounting for 28% of the variance. LoC (p = 0.025) and depressive symptoms (p < 0.001) at baseline were associated with severity of depressive symptoms at follow-up, accounting for 56.3% of the variance.

CONCLUSION

LoC was significantly associated with severity of depressive symptoms in people with dementia at baseline and at follow-up. Attention to LoC may be valuable for our understanding of depression in people with dementia, and interventions targeting depression could benefit from including a focus on internalizing perceived control. However, these findings are novel, and more research is needed.

Effects of a multicomponent intervention to slow mild cognitive impairment progression: A randomized controlled trial

BACKGROUND

Mild cognitive impairment affects 36% of people aged ≥65 years in China, around 50% of whom will develop dementia within 3 years. Early intervention can slow disease progression and delay the onset of dementia; however, whether a multicomponent intervention can decelerate the progression of mild cognitive impairment remains unknown.

OBJECTIVE

To evaluate the effects of a multicomponent intervention to slow mild cognitive impairment progression in Chinese patients.

DESIGN

Randomized controlled trial.

SETTING(S) AND PARTICIPANTS

This study was conducted in two large regional communities in Guangzhou, China. Patients aged ≥ 65 years diagnosed with mild cognitive impairment were included.

METHODS

A total of 112 eligible participants were assigned to receive either a 6-month multicomponent intervention or usual care from September 2019 until January 2021. Data were collected at the beginning of the study and at 1, 3, and 6 months thereafter. The primary outcomes were cognitive function, comprehensive physical capacity, depression, and quality of life. Analysis followed the intention-to-treat principle. A generalized estimating equation was used to determine intervention effects.

RESULTS

At baseline, clinical characteristics did not differ significantly between groups. Significant interaction effects between time and group were detected (p < 0.001), indicating that the scores of five outcomes (cognitive function, short physical performance battery, timed up and go test, quality of life, and depression) of intervention and control groups changed differently over time. Participants in the intervention group were found to have a significantly greater improvement in cognitive function, physical function, quality of life, and fewer depression symptoms compared with the control group at baseline and follow-up periods.

CONCLUSIONS

This study demonstrates the beneficial effects of a multicomponent intervention on cognitive function, physical function, depression symptoms, and quality of life in people with mild cognitive impairment in the East Asia region. The effectiveness and feasibility of this intervention program suggest that its application should be promoted in community settings to delay the progression of disease in people with mild cognitive impairment. Registration number:ChiCTR1900026042 Tweetable abstract: The multicomponent intervention improves cognitive/physical function, depression, and quality of life, slowing cognitive impairment progression.

A Randomized Controlled Trial on the Effects of a 6-Month Home-Based Physical Activity Program with Individual Goal-Setting and Volunteer Mentors on Physical Activity, Adherence, and Physical Fitness in Inactive Older Adults at Risk of Cognitive Decline: The INDIGO Study

BACKGROUND

Increasing physical activity (PA) in those who have memory concerns requires innovative approaches.

OBJECTIVE

To compare in this randomized controlled trial (RCT) the effects on PA, adherence, and fitness of two approaches to deliver a 6-month home-based PA program in older, inactive individuals at risk of cognitive decline.

METHODS

Individuals (n = 52) aged 60-85 years, inactive with mild cognitive impairment or subjective cognitive decline were recruited from the community and memory clinics. Randomization was to 6 months of 150 min/week moderate intensity PA with either: goal-setting with mentor support; or education and peer contact. A subset of participants (n = 36) continued for a further 6 months. PA, moderate and vigorous PA, and secondary outcomes, fitness, goal performance/satisfaction and self-efficacy were assessed at baseline, 6 and 12 months. Modelling of primary and secondary outcomes was conducted with linear mixed models.

RESULTS

Participants were mean age (±sd) 70.1 (6.4) years. Six-month retention was 88.5%(n = 46). No significant between-group differences were observed for PA or fitness. Post-hoc combined group data showed a significant, moderate-large effect size increase in PA with time. PA increased by a mean 1,662 (943, 2383) steps/day (95%CI) and 1,320 (603, 2037) steps/day at 6 and 12 months (p < 0.001). Median (quartiles Q1-Q3) 6 and 6-12 month combined group adherence was 88.9 (74.4-95.7)%and 84.6 (73.9-95.4)%respectively.

CONCLUSION

In this target group, no differences were detected between groups both intervention strategies were highly effective in increasing PA and fitness.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review

BACKGROUND

Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility.

METHOD

A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*.

RESULTS

We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use.

CONCLUSIONS

Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Rehabilitation in Dementia

Dementia is an eurodegenerative disorder, which causes significant disability, especially among the elderly population worldwide. The affected person shows a progressive cognitive decline, which interferes with the independence in performing the activities of daily living. Other than the cognitive domain, the patient tends to have neuropsychiatric, behavioral, sensorimotor, speech, and language-related issues. It is expected that the global burden of the disease will rise with more people entering the geriatric age group. By 2050 close, to 140 million people will be living with one or the other type of dementia. Alzheimer's disease contributes to more than 60% of cases worldwide, followed by vascular dementia. Pharmacotherapy has a limited role to play in the treatment, and at present, no drug is available, which can halt or reverse the progress of the disease. World Health Organization has mandated rehabilitation as a core recommendation in the global action plan on the public health response to dementia. Rehabilitation services are widely recognized as a practical framework to maximize independence and community participation in dementia care. The rehabilitation program is customized to achieve the desired goals, as each person has different experiences, preferences, motivations, strengths, and requirements based on type, course, and severity of the illness. It is an interdisciplinary-team approach with the involvement of several health care professionals. This article reviews the existing literature and outlines the effective rehabilitation strategies concisely in dementia care.

One-Year Change in Locus of Control among People with Dementia

INTRODUCTION

Knowledge of how perceptions of personal control change over time may provide valuable insights into how people cope with having dementia. The present study aimed to examine change in locus of control over a 12-month period in persons with dementia.

METHOD

The study included 52 participants with dementia. Locus of control was measured with the Locus of Control of Behavior Scale (LoCB), with higher scores indicating a more external locus of control, interpreted as perceiving less personal control. A ≥5% change on the LoCB was considered clinically meaningful. We recorded sociodemographic characteristics and assessed dementia severity, cognition, ability to function independently in daily activities and physical self-maintenance, depressive symptomatology, and number of prescribed medications. Analyses were performed to examine differences between those with increases (more external) or decreases (less external) in the LoCB score after 12 months and to examine associations between baseline variables and change in the LoCB score.

RESULTS

The mean LoCB score for the total sample did not change after 12 months (baseline mean 29.33 vs. follow-up mean 30.33, p = 0.553); however, 2 subgroups emerged. Using the ≥5% cutoff revealed that the LoCB score changed for 92.3% of the sample, becoming less external (lower LoCB) for 21 participants and more external (higher LoCB) for 27 participants. At baseline, the mean LoBC score was higher in the group that became less external (33.81 vs. 24.56), p = 0.006, while this was reverse at follow-up (23.57 vs. 34.41), p = 0.001. Dementia severity and dependence in physical self-maintenance increased during the 12 months in both groups. Among those becoming more external, we also found a decline in cognition (p = 0.002), an increase in dependence in daily activities (p = 0.003), an increase in the use of prescribed medication, and a decrease in depressive symptomatology (p = 0.003). The baseline LoCB score was the only variable associated with 12-month change in LoCB scores (p = 0.001).

CONCLUSION

Most participants showed a clinically meaningful change in locus of control after 12 months. Those with more signs of dementia progression reported a decrease in personal control but also a decrease in depressive symptoms. These findings are interesting for our understanding of coping but must be replicated with a larger sample.

Self-initiated management approaches in everyday occupations used by people with acquired cognitive impairment

BACKGROUND

Striving to cope with day-to-day challenges is a basic human behaviour. Self-initiated management approaches provide a resource that has yet to be discovered and systematically used in occupational therapy practice. This resource might be especially important for people with dementia who are less likely to adopt management approaches initiated by others.

AIMS/OBJECTIVES

Based on the findings of former studies on management and problem-solving actions among people with cognitive impairment, this article aims to identify and categorize the study participants' self-initiated management approaches and how these may be manifested in strategies in everyday occupations.

MATERIAL AND METHODS

The study utilized a form of meta-synthesis; an aggregated analysis, where findings from 11 studies published 2004-2020 were compared and categorized, incorporating the views of participants with dementia/mild cognitive impairment, or acquired brain injury.

RESULTS

Thirty strategies were identified and grouped into seven categories of management approaches, used in a variety of everyday occupations and situations. A majority of the strategies were found in both populations, suggesting that management approaches are more similar than different across populations with cognitive impairment.

CONCLUSIONS AND SIGNIFICANCE

Attending to the rich variation of self-initiated management approaches/strategies among persons with cognitive impairment offers possibilities for developing occupational therapy interventions.