Effects of Cognitive Training on Cognition and Quality of Life of Older Persons with Dementia

Efficacy of Nonpharmacological Interventions in Cognitive Impairment: Systematic Review And Network Meta-Analysis

INTRODUCTION

There is currently no known cure for cognitive impairment, which highlights the need to explore other ways of managing this condition. This topic has recently become an area of active research. However, the availability of nonpharmacological options poses a challenge when trying to determine the best treatment for improving cognitive function.

METHODS

We conducted a systematic review and a Bayesian network meta-analysis to compare the effects of nonpharmacological interventions on global cognition in patients with mild cognitive impairment and dementia. The nonpharmacological interventions were classified as aerobic exercise, strength exercise, multicomponent physical exercise, other physical exercises, tai chi, mind-body exercises, traditional cognitive rehabilitation, computer-based cognitive rehabilitation, occupational therapy, music therapy, physical-cognitive rehabilitation, and reminiscence therapy.

RESULTS

Physical-cognitive rehabilitation emerged as the most effective nonpharmacological intervention for enhancing global cognition in patients with unspecified cognitive impairment and dementia, whereas occupational therapy focused on dual-task interventions was found to be the most effective nonpharmacological intervention for mild cognitive impairment.

CONCLUSION

These results underscore the importance of adopting a dual approach to managing cognitive impairment, integrating both cognitive and physical rehabilitation within the same intervention.

Impact of discontinuing non-pharmacological interventions on cognitive impairment in dementia patients by COVID-19 lockdown. A pilot observational, longitudinal, retrospective study carried out in an adult day center in Spain during the COVID-19 pandemic

Background

The lockdown imposed during the COVID-19 pandemic led to social isolation and prevented patients with dementia from receiving a suite of non-pharmacological interventions (NPIs) that prevent cognitive decline. This discontinuation of NPIs could substantially affect the mental health status of people with dementia in social care settings, such as adult day care centers (ADCs).

Propose

The study aimed to evaluate the effects of the COVID-19 lockdown on mental health and cognitive impairment in patients with dementia who could not attend their usual ADCs and did not receive our NPIs, based on World Health Organization (WHO) Guidelines.

Methods

Observational, longitudinal, retrospective study carried out in an adult day center in Spain and reported it in accordance with the Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement. Cognitive status was assessed using the Mini-Mental State Examination (MMSE) in 80 patients attending the ADC of the "Leonese Association of Dementia Patients" (León, Spain), who had been evaluated with this instrument before the COVID-19 lockdown.

Results

We observed a 0.4-point decrease in MMSE score/month (IQR = 1.4) during lockdown versus a 0.1-point decrease/month (IQR = 0.3) before this period (p = 0.038). Notably, this translated to >10-point decreases in MMSE score/year in 33.8% of participants during lockdown versus 5.5% earlier (p < 0.001). No statistically significant associations (p < 0.05) were found between the individual characteristics of the caregivers and the occurrence of the event.

Conclusion

The reported declines in MMSE scores reveal a significant acceleration of cognitive decline during the period of inactivity. This could suggest that our NPIs, focused on slowing cognitive decline, are beneficial and, therefore, necessary in patients with dementia.

The multifactorial nature of healthy brain ageing: Brain changes, functional decline and protective factors

As the global population faces a progressive shift towards a higher median age, understanding the mechanisms underlying healthy brain ageing has become of paramount importance for the preservation of cognitive abilities. The first part of the present review aims to provide a comprehensive look at the anatomical changes the healthy brain endures with advanced age, while also summarizing up to date findings on modifiable risk factors to support a healthy ageing process. Subsequently, we describe the typical cognitive profile displayed by healthy older adults, conceptualizing the well-established age-related decline as an impairment of four main cognitive factors and relating them to their neural substrate previously described; different cognitive trajectories displayed by typical Alzheimer's Disease patients and successful agers with a high cognitive reserve are discussed. Finally, potential effective interventions and protective strategies to promote cognitive reserve and defer cognitive decline are reviewed and proposed.

Unifying framework for cognitive training interventions in brain aging

Cognitive training is a promising tool for slowing or preventing cognitive decline in older adults at-risk for dementia. Its success, however, has been limited by a lack of evidence showing that it reliably causes broad training effects: improvements in cognition across a range of domains that lead to real-world benefits. Here, we propose a framework for enhancing the effect of cognitive training interventions in brain aging. The focus is on (A) developing cognitive training task paradigms that are informed by population-level cognitive characteristics and pathophysiology, and (B) personalizing how these sets are presented to participants during training via feedback loops that aim to optimize "mismatch" between participant capacity and training demands using both adaptation and random variability. In this way, cognitive training can better alter whole-brain topology in a manner that supports broad training effects in the context of brain aging.

The Effect of Music-Based Intervention on General Cognitive and Executive Functions, and Episodic Memory in People with Mild Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials

Background: Music-based intervention has been used as first-line non-pharmacological treatment to improve cognitive function for people with mild cognitive impairment (MCI) or dementia in clinical practice. However, evidence regarding the effect of music-based intervention on general cognitive function as well as subdomains of cognitive functions in these individuals is scarce. Objective: To evaluate the efficacy of music-based interventions on a wide range of cognitive functions in people with MCI or dementia. Method: We searched the effect of various music therapies using randomized controlled trials on cognitive function using several databases. Studies based on any type of dementia or MCI were combined. The effects of music-based intervention on each cognitive function were pooled by meta-analysis. Results: A total of 19 studies involving n = 1024 participants (mean age ranged from 60 to 87 years old) were included. We found statistically significant improvements in MMSE (general cognitive function), the Frontal Assessment Battery (executive function), and the Auditory Verbal Learning Test (episodic memory). Conclusions: This study provides positive evidence to support music-based interventions for improving a wide range of cognitive functions in older adults with MCI and dementia. Therefore, we recommend increased use of music in people’s homes, day care centers and nursing homes. This study was registered with PROSPERO, number 250383.

Study design and protocol of a low to high intensity computer-based cognitive training at home in supplement to standard care in patients with AD

INTRODUCTION

Recent studies on cognitive training in patients with Alzheimer's disease (AD) showed positive long-term effects on cognition and daily living, suggesting remote computer-based programmes to increase training sessions while reducing patient's travelling. The aim of this study is to examine short-term and long-term benefits of computer-based cognitive training at home in patients with mild to moderate AD, as a complement to the training in speech and language therapists' (SLT) offices. The secondary purpose is to study training frequency required to obtain noticeable effects.

METHODS AND ANALYSES

This is a national multicentre study, conducted in SLT offices. The patients follow training in one of three conditions: once a week in SLT office only (regular condition) and once a week in SLT office plus one or three times per week at home. The trainings' content in SLT office and at home is identical. For all three groups near and far transfer will be compared with evaluate training frequency's effect. Our primary outcome is executive and working memory scores in experimental tasks, and the secondary is neuropsychological tests and questionnaires' scores. Linear models' analyses are considered for all measures with a random intercept for patients and another for per practice. The fixed effects will be: three modality groups and time, repeated measures, (T0-pretraining, T1-post-training, T2-long-term follow-up) and the interaction pairs.

ETHICS AND DISSEMINATION

The study got ethics approval of the national ethical committee CPP Sud Méditerranée III (No 2019-A00458-49) and of the National Commission for Information Technology and Liberties (No 919217). Informed consent is obtained from each participant. Results will be disseminated in oral communications or posters in international conferences and published in scientific journals.

TRIAL REGISTRATION NUMBER

NCT04010175.

A Randomized Clinical Trial on the Impact of Individually Targeted Computerized Cognitive Training on Quality of Life Indicators in Adults With HIV-Associated Neurocognitive Disorder in the Southeastern United States

ABSTRACT

HIV-associated neurocognitive disorder (HAND) is experienced by 30% to 50% of people living with HIV (PLWH), potentially affecting their quality of life (QoL). In the Training on Purpose Study, we investigated whether targeted cognitive training can improve QoL in PLWH with HAND. Using a two-group experimental design, we randomized 109 adults with HAND to either (a) the Individualized-Targeted Cognitive Training group or (b) a no-contact control group. Those in the training group were assigned 10 hr of cognitive training per two selected cognitive domains (20 hr total) for which impairment was observed. Overall, two patterns emerged. First, significant improvements in measures of everyday cognitive complaints, depression, and mental health were consistently observed after the completion of many cognitive training protocols. Second, immediate and delayed spatial learning and memory training resulted in more significant indicators of QoL improvements compared with the other cognitive domain trainings. The findings suggest that some types of cognitive training may have advantages over others in improving aspects of QoL.

Clinical trials in older people

Randomised controlled trials (RCTs) usually provide the best evidence for treatments and management. Historically, older people have often been excluded from clinical medication trials due to age, multimorbidity and disabilities. The situation is improving, but still the external validity of many trials may be questioned. Individuals participating in trials are generally less complex than many patients seen in geriatric clinics.

Recruitment and retention of older participants are particular challenges in clinical trials. Multiple channels are needed for successful recruitment, and especially individuals experiencing frailty, multimorbidity and disabilities require support to participate. Cognitive decline is common, and often proxies are needed to sign informed consent forms. Older people may fall ill or become tired during the trial, and therefore, special support and empathic study personnel are necessary for the successful retention of participants.

Besides the risk of participants dropping out, several other pitfalls may result in underestimating or overestimating the intervention effects. In nonpharmacological trials, imperfect blinding is often unavoidable. Interventions must be designed intensively and be long enough to reveal differences between the intervention and control groups, as control participants must still receive the best normal care available. Outcome measures should be relevant to older people, sensitive to change and targeted to the specific population in the trial. Missing values in measurements are common and should be accounted for when designing the trial.

Despite the obstacles, RCTs in geriatrics must be promoted. Reliable evidence is needed for the successful treatment, management and care of older people.

Exploring outcome measures with cognitive stimulation therapies and how these relate to the experiences of people with dementia: A narrative literature review

A narrative literature review was undertaken to consider the outcome measures used in research on cognitive stimulation therapy (CST), cognitive training (CT) and cognitive stimulation (CS) interventions. This review extends findings from previous reviews by including a broad range of study methodologies, both qualitative and quantitative, and explored whether participant experiences of taking part in the research are discussed. A database search identified 1261 articles matching the search criteria, with 29 included in this review. Studies tended to use the manualised CST model, with 11 other models identified. Randomised control trials were chosen as the most used method to explore impact. Across the studies, 65 different outcome measures were used with people with dementia, and only four studies used a qualitative approach. Little information is provided on the assessment process in terms of time taken, assessor, or of the experience of the person with dementia. There is heterogeneity of measures used, within and across domains, and number, and agreement or consistency of measures would provide greater comparability across CS studies. Gaps in reporting were noted on the detail of the assessment process and the experience of people with dementia taking part in this research.

Exploring Factors Associated With Successful Nonpharmacological Interventions for People With Dementia

Background and purpose

Methods

Results

Conclusions

Monetary value of informal caregiving in dementia from a societal perspective

BACKGROUND

Dementia is a condition which results in a high cost of care, a significant proportion of which is the cost associated with informal care. In previous studies, informal caregiving has been challenging to assess due to difficulties in estimating the true time spent on caregiving work and how to value caregivers' time. The aim of this study was to compare the costs of dementia among patients living alone and among those living with a caregiver to show the monetary value of informal caregiving from a societal perspective.

METHODS

Data from our four dementia trials using the same measures were combined, allowing the inclusion of 604 participants. Participants were followed up for 2 years or until death for their use of health and social services. Use of all services was retrieved from medical/social records. We also included the costs of lost productivity of those caregivers who were not retired.

RESULTS

The total mean cost of services and lost productivity was €22,068/person-year (pyrs). Participants living alone had a mean cost of €45,156/pyrs, whereas those living with a spouse had a mean cost of €16,416/pyrs (mean cost ratio 2.99, 95% confidence interval 2.64-3.39). Participants living alone and having <15 Mini-Mental State Examination points had higher costs than people with dementia in institutional care.

CONCLUSIONS

Detailed data of service use and characteristics of people with dementia showed that from a societal perspective, living alone is a very strong determinant of service use in dementia. Informal caregivers do invaluable work for society.

Promoting Successful Cognitive Aging: A Ten-Year Update

A decade has passed since we published a comprehensive review in this journal addressing the topic of promoting successful cognitive aging, making this a good time to take stock of the field. Because there have been limited large-scale, randomized controlled trials, especially following individuals from middle age to late life, some experts have questioned whether recommendations can be legitimately offered about reducing the risk of cognitive decline and dementia. Despite uncertainties, clinicians often need to at least make provisional recommendations to patients based on the highest quality data available. Converging lines of evidence from epidemiological/cohort studies, animal/basic science studies, human proof-of-concept studies, and human intervention studies can provide guidance, highlighting strategies for enhancing cognitive reserve and preventing loss of cognitive capacity. Many of the suggestions made in 2010 have been supported by additional research. Importantly, there is a growing consensus among major health organizations about recommendations to mitigate cognitive decline and promote healthy cognitive aging. Regular physical activity and treatment of cardiovascular risk factors have been supported by all of these organizations. Most organizations have also embraced cognitively stimulating activities, a heart-healthy diet, smoking cessation, and countering metabolic syndrome. Other behaviors like regular social engagement, limiting alcohol use, stress management, getting adequate sleep, avoiding anticholinergic medications, addressing sensory deficits, and protecting the brain against physical and toxic damage also have been endorsed, although less consistently. In this update, we review the evidence for each of these recommendations and offer practical advice about behavior-change techniques to help patients adopt brain-healthy behaviors.

Person-Centered Care in Persons Living with Dementia: A Systematic Review and Meta-Analysis

Background and Objectives

The concept of person-centered care has been utilized/adapted to various interventions to enhance health-related outcomes and ensure the quality of care delivered to persons living with dementia. A few systematic reviews have been conducted on the use of person-centered interventions in the context of dementia care, but to date, none have analyzed intervention effect by intervention type and target outcome. This study aimed to review person-centered interventions used in the context of dementia care and examine their effectiveness.

Research Design and Methods

A systematic review and meta-analysis were conducted. We searched through 5 databases for randomized controlled trials that utilized person-centered interventions in persons living with dementia from 1998 to 2019. Study quality was assessed using the National Institute for Health and Clinical Excellence checklist. The outcomes of interest for the meta-analysis were behavioral and psychological symptoms in dementia (BPSD) and cognitive function assessed immediately after the baseline measurement.

Results

In total, 36 studies were systematically reviewed. Intervention types were reminiscence, music, and cognitive therapies, and multisensory stimulation. Thirty studies were included in the meta-analysis. Results showed a moderate effect size for overall intervention, a small one for music therapy, and a moderate one for reminiscence therapy on BPSD and cognitive function.

Discussion and Implications

Generally speaking, person-centered interventions showed immediate intervention effects on reducing BPSD and improving cognitive function, although the effect size and significance of each outcome differed by intervention type. Thus, health care providers should consider person-centered interventions as a vital element in dementia care.

Factors associated with institutionalization among home-dwelling patients of Urgent Geriatric Outpatient Clinic: a 3-year follow-up study

Aim

To examine the effect of predictive factors on institutionalization among home-dwelling patients of Urgent Geriatric Outpatient Clinic during a 3-year follow-up.

Findings

The rates of institutionalization and mortality were 29.9% and 46.1%, respectively. The use of home care, dementia, higher age and falls during the previous 12 months significantly predicted institutionalization during the follow-up.

Message

Cognitive and/or functional impairment mainly predicted institutionalization among older patients of UrGeriC having health problems and acute difficulties in managing at home.

Purpose

To examine the effect of predictive factors on institutionalization among older patients.

Methods

The participants were older (aged 75 years or older) home-dwelling citizens evaluated at Urgent Geriatric Outpatient Clinic (UrGeriC) for the first time between the 1st of September 2013 and the 1st of September 2014 (n = 1300). They were followed up for institutionalization for 3 years. Death was used as a competing risk in Cox regression analyses.

Results

The mean age of the participants was 85.1 years (standard deviation [SD] 5.5, range 75–103 years), and 74% were female. The rates of institutionalization and mortality were 29.9% and 46.1%, respectively. The mean age for institutionalization was 86.1 (SD 5.6) years. According to multivariate Cox regression analyses, the use of home care (hazard ratio 2.43, 95% confidence interval 1.80–3.27, p < 0.001), dementia (2.38, 1.90–2.99, p < 0.001), higher age (≥ 95 vs. 75–84; 1.65, 1.03–2.62, p = 0.036), and falls during the previous 12 months (≥ 2 vs. no falls; 1.54, 1.10–2.16, p = 0.012) significantly predicted institutionalization during the 3-year follow-up.

Conclusion

Cognitive and/or functional impairment mainly predicted institutionalization among older patients of UrGeriC having health problems and acute difficulties in managing at home.

Neuropsychological outcome of cognitive training in mild to moderate dementia: A randomized controlled trial

Effectiveness of a 12-week cognitive training (CT) programme for community-dwelling patients with dementia was evaluated on various cognitive functions (attention, memory, executive functions and reasoning) and psychological well-being (PWB). A single-blind randomized controlled trial was conducted in adult day care centres in Helsinki, Finland. Participants (N = 147) were older individuals with mild to moderate dementia living at home and attending day care (mean age 83 years, 72% female, 63% at mild stage of dementia). The intervention group (n = 76) received systematic CT for 45 min twice a week while the control group (n = 71) attended day care as usual. The cognitive and psychological outcomes were measured at baseline, and followed up at 3 and 9 months. No differences between the two groups in changes of any of the cognitive functions, or PWB over time were found. We observed a positive trend at 3 months in the change for PWB favouring the intervention group, but no significant interaction effect was found (p = .079; d = -0.31). Thus, systematic CT appears to have no effect on neuropsychological outcomes of cognitive functioning and PWB in older adults who already have dementia.

The factors associated with subjective cognitive decline and cognitive function among older adults

AIMS

To explore the risk factors for subjective cognitive decline and cognitive function among older adults in South Korea.

DESIGN

This study employed a descriptive cross-sectional design.

METHODS

A convenience sample of 182 patients was recruited from a senior welfare center in Seoul. The mean age of the participants was 78.4 years (SD 5.91). Among them, 64.3% were women. The data were collected by a trained research assistant using structured questionnaires from September 2016-February 2017. Demographic characteristics, comorbidities, depression, physical and cognitive activity levels, instrumental activities of daily living, subjective cognitive decline, and cognitive function were assessed. Student's t tests, chi-square tests, and hierarchical multiple regression analyses were used for statistical analyses.

RESULTS

The findings revealed that 37.4% of the participants were not cognitively intact. Depression, perceived health status, and cognitive function were significantly associated with subjective cognitive decline (F = 7.10, p < .001, adjusted R²  = 25.3). Age, educational level, perceived health status, and subjective cognitive decline were significantly related to cognitive function (F = 20.98, p < .001, adjusted R²  = 47.0). After controlling for these variables, cognitive activity was significantly and independently related to cognitive function.

CONCLUSION

The results suggest that for the maintenance of cognitive function, cognitive activity should be encouraged. In addition, older adults who complain of subjective cognitive decline and have risk factors such as depression need therapeutic interventions to prevent actual decrease of cognitive function.

IMPACT

The present findings advance prior knowledge by considering variables such as physical and cognitive activity levels to provide novel evidence that can be used to develop interventions for community-dwelling older adults. Thus, to be effective, nursing interventions must seek to improve cognitive function through intellectual stimulation.

Cognitive training for people with mild to moderate dementia

BACKGROUND

Cognitive impairment, a defining feature of dementia, plays an important role in the compromised functional independence that characterises the condition. Cognitive training (CT) is an approach that uses guided practice on structured tasks with the direct aim of improving or maintaining cognitive abilities.

OBJECTIVES

• To assess effects of CT on cognitive and non-cognitive outcomes for people with mild to moderate dementia and their caregivers.• To compare effects of CT with those of other non-pharmacological interventions, including cognitive stimulation or rehabilitation, for people with mild to moderate dementia and their caregivers.• To identify and explore factors related to intervention and trial design that may be associated with the efficacy of CT for people with mild to moderate dementia and their caregivers.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group Specialised Register, on 5 July 2018. ALOIS contains records of clinical trials identified through monthly searches of several major healthcare databases and numerous trial registries and grey literature sources. In addition to this, we searched MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov, and the World Health Organization's trials portal, ICTRP, to ensure that searches were comprehensive and up-to-date.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that described interventions for people with mild to moderate dementia and compared CT versus a control or alternative intervention.

DATA COLLECTION AND ANALYSIS

We extracted relevant data from published manuscripts and through contact with trial authors if required. We assessed risk of bias using the Cochrane 'Risk of bias' tool. We divided comparison conditions into active or passive control conditions and alternative treatments. We used a large number of measures and data to evaluate 19 outcomes at end of treatment, as well as 16 outcomes at follow-up in the medium term; we pooled this information in meta-analyses. We calculated pooled estimates of treatment effect using a random-effects model, and we estimated statistical heterogeneity using a standard Chi² statistic. We graded the evidence using GradePro.

MAIN RESULTS

The 33 included trials were published between 1988 and 2018 and were conducted in 12 countries; most were unregistered, parallel-group, single-site RCTs, with samples ranging from 12 to 653 participants. Interventions were between two and 104 weeks long. We classified most experimental interventions as 'straight CT', but we classified some as 'augmented CT', and about two-thirds as multi-domain interventions. Researchers investigated 18 passive and 13 active control conditions, along with 15 alternative treatment conditions, including occupational therapy, mindfulness, reminiscence therapy, and others.The methodological quality of studies varied, but we rated nearly all studies as having high or unclear risk of selection bias due to lack of allocation concealment, and high or unclear risk of performance bias due to lack of blinding of participants and personnel.We used data from 32 studies in the meta-analysis of at least one outcome. Relative to a control condition, we found moderate-quality evidence showing a small to moderate effect of CT on our first primary outcome, composite measure of global cognition at end of treatment (standardised mean difference (SMD) 0.42, 95% confidence interval (CI) 0.23 to 0.62), and high-quality evidence showing a moderate effect on the secondary outcome of verbal semantic fluency (SMD 0.52, 95% CI 0.23 to 0.81) at end of treatment, with these gains retained in the medium term (3 to 12 months post treatment). In relation to many other outcomes, including our second primary outcome of clinical disease severity in the medium term, the quality of evidence was very low, so we were unable to determine whether CT was associated with any meaningful gains.When compared with an alternative treatment, we found that CT may have little to no effect on our first primary outcome of global cognition at end of treatment (SMD 0.21, 95% CI -0.23 to 0.64), but the quality of evidence was low. No evidence was available to assess our second primary outcome of clinical disease severity in the medium term. We found moderate-quality evidence showing that CT was associated with improved mood of the caregiver at end of treatment, but this was based on a single trial. The quality of evidence in relation to many other outcomes at end of treatment and in the medium term was too low for us to determine whether CT was associated with any gains, but we are moderately confident that CT did not lead to any gains in mood, behavioural and psychological symptoms, or capacity to perform activities of daily living.

AUTHORS' CONCLUSIONS

Relative to a control intervention, but not to a variety of alternative treatments, CT is probably associated with small to moderate positive effects on global cognition and verbal semantic fluency at end of treatment, and these benefits appear to be maintained in the medium term. Our certainty in relation to many of these findings is low or very low. Future studies should take stronger measures to mitigate well-established risks of bias, and should provide long-term follow-up to improve our understanding of the extent to which observed gains are retained. Future trials should also focus on direct comparison of CT versus alternative treatments rather than passive or active control conditions.