Physical and cognitive stimulation in Alzheimer Disease. the GAIA Project: a pilot study

Carer Involvement in Rehabilitation for People Living With Dementia: A Systematic Review

AIMS

To examine the role and impact of carer involvement in rehabilitation for community-dwelling individuals with dementia, focusing on cognitive stimulation therapy, cognitive rehabilitation, cognitive training, cognitive behavioural therapy, and exercise.

DESIGN

A systematic review and synthesis without meta-analysis.

DATA SOURCES

Five electronic databases, reference lists, and citations were searched (2017-2024), targeting primary research that reported results concerning one or more of those five focused rehabilitation interventions for people with dementia and their carers.

METHODS

Results were synthesised using narrative approaches. The Cochrane Risk of Bias Tool and the Mixed Methods Appraisal Tool were used to appraise the quality of included studies.

RESULTS

Forty-one studies (12 main trials, 22 pilot studies, and 7 sub-studies) were included. While the patterns between carer involvement level and types of rehabilitation were observed, their relationship to intervention effectiveness was unclear. High carer involvement in cognitive stimulation therapy and exercise was associated with improved cognition and quality of life for people with dementia and better health-related quality of life for carers. Pilot studies showed mixed but generally positive trends, with increased depressive symptoms in carers needing further investigation. Qualitative findings highlighted social interaction and improved caregiving knowledge as key enablers to positive experiences, whereas lack of motivation was the main barrier to rehabilitation engagement.

CONCLUSION

This review identified several patterns between the level of carer involvement and intervention types. However, the mechanism underlying different involvement levels and rehabilitation success remains unclear. More rigorous research is needed to determine the relationship between carer involvement and the effects of rehabilitation interventions on supporting the independence of people with dementia.

IMPACT

This review enhanced the understanding of carers' roles and impacts in supporting dementia rehabilitation and possible links to optimal health outcomes.

REPORTING METHOD

Synthesis Without Meta-analysis (SWiM) reporting guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient/public contribution.

The effect of cognitive stimulation therapy (CST) on apathy, loneliness, anxiety and activities of daily living in older people with Alzheimer's disease: randomized control study

OBJECTIVES

This study was conducted to determine the effect of Cognitive Stimulation Therapy (CST) on apathy, loneliness, anxiety, and activities of daily living of individuals with Alzheimer's disease.

METHOD

The study was conducted in a daily care center between January 2023 and January 2024 in a randomized control study. A total of 52 people, 26 intervention and 26 control groups, were enrolled in the study and formed the sample of the study. Demographic Information Form, Apathy Evaluation Scale (AES-C), Geriatric Anxiety Scale (GAS), UCLA Loneliness Scale Short Form (UCLA-SF), and Functional Impairment in Dementia Scale (DAD) were used in the study.

RESULTS

After the intervention, it was found that the intervention group's levels of apathy, loneliness and anxiety were significantly reduced compared to the control group. In the intra-group comparisons, it was found that there was a significant difference between the pre-test and post-test scores of the AES-C, UCLA-SF, GAS of the individuals in the intervention group after the application of CST, and between the pre-test and pre-test scores of the DAD (p < 0.05).

CONCLUSION

CST was found to be effective in reducing apathy, loneliness and anxiety levels and increasing daily living activities in older people with Alzheimer's disease.

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.

A meta-analysis of the efficacy of physical exercise interventions on activities of daily living in patients with Alzheimer's disease

Objective

This study aimed to systematically review published randomized controlled trials on the effects of physical exercise on activities of daily living (ADL) in Alzheimer's patients through meta-analysis, thereby synthesizing existing evidence to provide scientific intervention recommendations for exercise prescriptions in Alzheimer's patients.

Methods

Based on strict literature inclusion and exclusion criteria, a systematic search was conducted in databases including PubMed and Web of Science from their inception to July 1, 2024. The Cochrane risk assessment tool was used to evaluate the design of randomized controlled trials. Studies reporting on physical exercise interventions for ADL in Alzheimer's patients were systematically identified. Subgroup analyses and meta-regression were performed to explore sources of heterogeneity.

Results

Nineteen articles, for analysis, providing 27 randomized controlled trials (RCTs). A random-effects model was used to calculate the effect size and 95% confidence interval for each independent study, and meta-analysis was performed using Stata 16.0 and RevMan 5.4 software. The results showed that physical exercise might significantly improve ADL in Alzheimer's patients (SMD = 0.33, 95% CI: 0.12-0.54, I 2 = 81.7%). Sensitivity analysis confirmed the robustness of the results (p > 0.05). Egger's test did not reveal significant publication bias (p = 0.145). Samples were divided into different subgroups based on intervention content, duration, frequency, and session length. Subgroup analysis based on intervention characteristics showed that resistance training or aerobic exercise (SMD = 0.83, 95% CI: 0.60-1.05), long-term interventions (>6 months, SMD = 0.31, 95% CI: 0.13-0.49), medium-frequency interventions (4-5 times per week, SMD=0.39, 95% CI: 0.23-0.55), and short-duration training ( ≤ 30 min, SMD = 0.96, 95% CI: 0.71-1.21) might be most effective in enhancing ADL in Alzheimer's patients. These improvements were not only statistically significant but also had substantial impact in clinical practice.

Conclusion

Resistance training or aerobic exercise lasting more than 6 months, 4-5 times per week, and lasting no more than 30 min per session may be most effective in improving ADLs in patients with Alzheimer's disease.

Comparison of the effect of online physical exercise and computerized cognitive stimulation in patients with Alzheimer's disease during the Covid-19 pandemic

INTRODUCTION

To investigate the effect of physical exercise alone and in combination with cognitive stimulation on cognition, physical function, and quality of life in patients with Alzheimer's Disease (PwAD).

METHODS

The study was a randomized controlled, single-blinded trial with pre-and post-treatment and follow-up assessments conducted at the private hospital and home environment in PwAD. Seventy-five (N = 75) participants diagnosed with AD were enrolled, but sixty (N = 60) participants (mean age 77.8 years, standard deviation (SD) 6.7) were randomized as physical exercise group (PEG) (n = 20), physical exercise and cognitive stimulation group (PE + CSG) (n = 20) and control group (CG) (n = 20). Participants in PEG and PE + CSG performed an online supervised physical exercise program (SPEP) given biweekly for 12 weeks. Additionally, the cognitive stimulation (CS) program was offered for at least three or five days for 12 weeks for PE + CSG. No treatment was given for the CG. The primary outcome measures were cognition, balance, functional mobility (FM), upper extremity muscle strength (UEMS) and lower extremity muscle strength (LEMS), and quality of life (QoL). Furthermore, depression, basic activities of daily living (BADL) and instrumental activities of daily living (IADL) were measured secondarily.

RESULTS

PE + CSG demonstrated significant improvement in cognition, balance, FM, UEMS, IADL and reduction in depression compared to the CG (p < 0.05). Besides, participants in the PE + CSG had statistically superior QoL and IADL than the PEG (p < 0.05).

CONCLUSIONS

The addition of CS to the SPEP was a safe and effective method to gain statistically significant improvements in cognition, balance, FM, UEMS, IADL, and reduction in depression in PwAD.

Long-term cognitive training enhances fluid cognition and brain connectivity in individuals with MCI

Amnestic mild cognitive impairment (aMCI) is a risk factor for Alzheimer's disease (AD). Multi-domain cognitive training (CT) may slow cognitive decline and delay AD onset. However, most work involves short interventions, targeting single cognitive domains or lacking active controls. We conducted a single-blind randomized controlled trial to investigate the effect of a 6-month, multi-domain CT on Fluid Cognition, functional connectivity in memory and executive functioning networks (primary outcomes), and white matter microstructural properties (secondary outcome) in aMCI. Sixty participants were randomly assigned to either a multi-domain CT or crossword training (CW) group, and thirty-four participants completed the intervention. We found a significant group-by-time interaction in Fluid Cognition (p = 0.007, F (1,28) = 8.26, Cohen's d = 0.38, 95% confidence interval [CI]: 2.45-14.4), with 90% of CT patients showing post-intervention improvements (p < 0.01, Cohen's d = 0.7). The CT group also showed better post-intervention Fluid Cognition than healthy controls (HCs, N = 45, p = 0.045). Functional connectivity analyses showed a significant group-by-time interaction (Cohen's d ≥ 0.8) in the dorsolateral prefrontal cortex (DLPFC) and inferior parietal cortex (IPC) networks. Specifically, CT displayed post-intervention increases whereas CW displayed decreases in functional connectivity. Moreover, increased connectivity strength between the left DLPFC and medial PFC was associated with improved Fluid Cognition. At a microstructural level, we observed a decline in fiber density (FD) for both groups, but the CT group declined less steeply (1.3 vs. 2%). The slower decline in FD for the CT group in several tracts, including the cingulum-hippocampus tract, was associated with better working memory. Finally, we identified regions in cognitive control and memory networks for which baseline functional connectivity and microstructural properties were associated with changes in Fluid Cognition. Long-term, multi-domain CT improves cognitive functioning and functional connectivity and delays structural brain decline in aMCI (ClinicalTrials.gov number: NCT03883308).

Evidence mapping and quality assessment of systematic reviews on exercise intervention for Alzheimer's disease

BACKGROUND

A significant body of literature suggests that exercise can reverse cognitive impairment and ameliorate somatic function in patients with Alzheimer's disease (AD). Systematic reviews (SRs), a common approach of evidence-based medicine, concentrate on a specific issue of a research area. The objective of this work is to provide an overview of existing evidence on the effects of exercise intervention in AD patients and report related health outcomes by reviewing SRs.

METHODS

SRs on exercise intervention in AD patients were retrieved from the PubMed, the Cochrane Library, CBMdisc, Scopus, Web of Science, Embase (via Ovid), China National Knowledge Infrastructure, and WanFang databases from the time of inception to February 2023. The quality of the SRs was evaluated utilizing the A Measurement Tool to Assess Systematic Review 2 (AMSTAR 2) checklist. The results were reported according to the population-intervention-comparison-outcome (PICO) framework and the corresponding evidence mapping was illustrated in tables and bubble plots.

RESULTS

A total of 26 SRs met the eligibility criteria. In terms of methodological quality, 10 SRs were rated as "critically low", 13 SRs were rated as "low", and 3 SRs were rated as "moderate". Exercise was found to exert a beneficial effect on cognitive function, functional independence, physical function, and neuropsychiatric symptoms in patients with AD.

CONCLUSION

Exercise intervention benefits AD patients mainly by improving cognitive function, physical function, functional independence, and neuropsychiatric symptoms. However, due to the low-to-moderate methodology of most SRs included in this analysis, further investigations are required to support our current findings.

The effect of physical exercise intervention on the ability of daily living in patients with Alzheimer's dementia: a meta-analysis

Objective

To systematically evaluate the effect of physical exercise intervention on the activities of daily living (ADL) on patients with Alzheimer's dementia (AD) and explore the optimal exercise scheme.

Methods

PubMed, EMBASE, the Cochrane Library, Web of Science, and Science Direct databases were searched from 1987 to December 2023 to collect randomized controlled trials (RCTs). Two investigators independently screened the literature and extracted data according to the inclusion and exclusion criteria. The quality of the included studies was evaluated using Cochrane Review Manager 5.3. And STATA 16.0 was used for performing the meta-analysis.

Results

Fifteen randomized controlled trials were included. The results of the meta-analysis showed that physical exercise had a positive effect on the improvement of ADL in patients with AD [standardized mean difference (SMD) = 0.312, 95% confidence interval (CI 0.039-0.585), P = 0.02], and the difference was statistically significant. The results of subgroup analysis showed that anaerobic exercises such as strength and balance training with a medium cycle of 12-16 weeks and lasting 30-45 min each time were more ideal for the improvement of basic daily living ability of AD patients.

Conclusion

Physical exercise can effectively improve activities of daily living in patients with Alzheimer's dementia and it may be a potential non-drug treatment for AD patients.

Enhancing Minds in Motion® as a virtual program delivery model for people living with dementia and their care partners

The Alzheimer Society of Ontario's Minds in Motion (MiM) program improves physical function and well-being of people living with dementia (PLWD) and their care partners (CP) (Regan et al., 2019). With the COVID-19 pandemic, there was an urgent need to transition to a virtual MiM that was similarly safe and effective. The purpose of this mixed methods study is to describe the standardized, virtual MiM and evaluate its acceptability, and impact on quality of life, and physical and cognitive activity of participants. Survey of ad hoc virtual MiM practices and a literature review informed the design of the standardized MiM program: 8 weeks of weekly 90-minute sessions that included 45-minutes of physical activity and 45-minutes of cognitive stimulation in each session. Participants completed a standardized, virtual MiM at one of 6 participating Alzheimer Societies in Ontario, as well as assessments of quality of life, physical and cognitive activity, and program satisfaction pre- and post-program. In all, 111 PLWD and 90 CP participated in the evaluation (average age of 74.6±9.4 years, 61.2% had a college/university degree or greater, 80.6% were married, 48.6% of PLWD and 75.6% of CP were women). No adverse events occurred. MiM participants rated the program highly (average score of 4.5/5). PLWD reported improved quality of life post-MiM (p = <0.01). Altogether, participants reported increased physical activity levels (p = <0.01) and cognitive activity levels (p = <0.01). The virtual MiM program is acceptable, safe, and effective at improving quality of life, cognitive and physical activity levels for PLWD, and cognitive and physical activity levels among CP.

Effect of physio-cognitive dual-task training on cognition in pre-ageing and older adults with neurocognitive disorders: A meta-analysis and meta-regression of randomized controlled trial

Declines in cognitive performance, such as those seen in neurocognitive disorders (NCDs) are often associated with ageing. Both physical activity and cognitive training are common interventional strategies that can mitigate the decline in cognitive and physical performance. This review aims to (1) to evaluate the effects of Physio-Cognitive Dual-task Training (PCDT) intervention on cognition, physical performance, activities of daily living (ADL) and health-related quality of life (HRQoL) in pre-ageing and older adults with neurocognitive disorders, (2) explore the effects of covariates on intervention outcomes. A systematic search was conducted in eight databases. Cochrane's Risk of Bias Tool version 1 and GRADE criteria were used to assess risk of bias and certainty of evidence, respectively. Meta-analysis and meta-regression analyses were conducted using R software. Twenty-six randomized controlled trials involving 1,949 pre-ageing and older adults with NCDs were included in the meta-analysis. PCDT interventions had small-to-medium effect size on all cognition outcomes (g = 0.40-0.52) and instrumental ADL (g == 0.42), and a large effect size on HRQoL (g = 0.72). The quality of evidence was rated moderate to low for the outcome measures in pre-ageing and older adults with NCDs. These findings highlight the importance of PCDT interventions in preventing and slowing down cognitive impairment in pre-ageing and older adults. Registration: PROSPERO Number (CRD42020213962).

Analysis of Physical-Cognitive Tasks Including Feedback-Based Technology for Alzheimer's Disorder in a Randomized Experimental Pilot Study

INTRODUCTION

Alzheimer's disease causes great changes, with the prefrontal cortex being the most frequently damaged zone; these changes affect physical and cognitive behavior and compromise autonomy.

OBJECTIVE

The objective of this study was to evaluate the effects of physical-cognitive tasks on memory, attention, balance, gait, and risk of falling in Alzheimer's by using feedback-based technology.

METHODS

Forty patients with Alzheimer's were recruited from an Alzheimer's Association; of these, 15 met the inclusion criteria and were included in the pilot RCT (eight in the control group; seven in the experimental group).

ASSESSMENT TOOLS

The Cognitive Mini-Examination Scale, Oddball Test and Attention Network, Berg Scale, Tinetti, Timed Up and Go, and Geriatric Deterioration Scale. The experimental group was treated with physical-cognitive tasks by using combined feedback-based technology (visual, acoustic, simultaneous, immediate, and terminal feedback, as well as knowledge of the results and performance) under the supervision of physiotherapists twice per week for 16 thirty-minute sessions. The control group underwent their usual care (pharmacological treatment, mobility exercises, and cognitive stimulation sessions).

RESULT

In the experimental group, the contrast tests showed differences for the re-test (except in attention), with the significative Timed Up and Go test being significant (p = 0.020). The interaction between groups showed significant differences for the experimental group according to the MEC (p = 0.029; d = 0.14) and Tinetti (p = 0.029; d = 0.68).

DISCUSSION/CONCLUSION

Memory, balance, gait, and risk of falling improved in the Alzheimer's patients through the use of physical-cognitive tasks involving combined feedback-based technology. The effects on attention were inconclusive. The outcomes should be treated with caution due to the sample. This can promote intergenerational bonds, use at home, and adherence to treatment.

The Importance of Technology in the Combined Interventions of Cognitive Stimulation and Physical Activity in Cognitive Function in the Elderly: A Systematic Review

BACKGROUND

Numerous studies have been developed in an attempt to understand which factors best predict improvements in cognitive function in the elderly such as exergaming. The aim of this study was to investigate and systematize literature on intervention programs that simultaneously include cognitive stimulation and physical activity, understand the importance of the use of new technology, including exergaming or computer programs, and understand their impact on cognitive function in older adults, giving indications about their contribution to healthy aging.

METHODS

A narrative approach was used for extraction and synthesis of the data. Relevant studies were identified from electronic databases such as PubMed, Scopus, Web of Science, and Academic Search Complete.

RESULTS

Thirty-two articles, involving 2815 participants, were identified. All selected studies were randomized controlled studies. The studies were published between 2011 and 2020. All studies included a combination of cognitive and physical interventions. Many of the studies used technology to administer the cognitive stimulation program.

CONCLUSIONS

Most of the analyzed studies used exergaming in physical and cognitive interventions, demonstrating that this new form of intervention exerts lasting and stable benefits in cognition. However, we concluded that more studies are needed to compare interventions that use exergaming or computer programs with traditional interventions.

Effects of multi-domain intervention on intrinsic capacity in older adults: A systematic review of randomized controlled trials (RCTs)

Intrinsic capacity is central to the maintenance of function in older adults, and maintaining optimal intrinsic capacity is of great importance to promote healthy aging. The purpose of this systematic review and meta-analysis was to analyze the impact of multi-domain interventions on intrinsic capacity in older adults, intervention components, and potential interactions between components. A total of 6740 published articles were screened until August 2022, and the review included 25 randomized controlled trials that analyzed populations, interventions, control groups, and outcomes. The meta-analysis showed improvements in the primary outcome indicators in the intervention group compared to the control group. These included increased scores on the Mini-Mental State Examination as an indicator of cognitive function, decreased scores on the Geriatric Depression Scale (GDS-15) as an indicator of psychological ability and increased scores on the Short Physical Performance Battery (SPPB) as an indicator of physical performance, with only the SPPB indicator analyzed showing greater heterogeneity. Significant improvements were also seen in the secondary indicators Time-to-Walk Test (TUG), gait speed, Chair Stand Test (CST), grip strength values and BMI. There was insufficient data for the Mini Nutritional Assessment (MNA) as an indicator of vitality to conduct a meta-analysis. Studies were of moderate to high quality. The results of this review indicate that multi-domain interventions can maintain the level of intrinsic capacity in older adults and are equally effective in older adults with declining self-care abilities.

Cognitive stimulation and activities of daily living for individuals with mild-to-moderate dementia: A scoping review

Introduction:

Dementia is a progressive syndrome that interferes with the individual’s ability to perform activities of daily living (ADL). Cognitive stimulation (CS) is a non-pharmacological approach aimed to mitigate the impact of dementia symptoms. While CS has been shown to provide benefits for cognition and quality of life, the evidence supporting its use in improving ADL outcomes is reduced. The aim of this review was to chart what is known from the literature about the use of CS in improving ADL outcomes.

Method:

A scoping review of the use of CS in improving ADL outcomes for individuals with mild-to-moderate dementia was conducted, following a scoping review methodological framework. Eight databases were searched, including all articles published up until June 2022.

Findings:

A three-step search strategy yielded 788 results. Following screening and review, 36 papers met the inclusion criteria for this review. Studies were charted and discussed in the areas of (1) cognitive stimulation therapy; (2) group CS programmes; (3) multi-component CS interventions; (4) individual CS programmes and (5) other types of CS.

Conclusion:

The review identified a range of CS programmes from across 13 countries worldwide. Multi-component CS interventions involving ADL-focused activities reported the most benefits for ADL outcomes.

Cognitive stimulation to improve cognitive functioning in people with dementia

BACKGROUND

Cognitive stimulation (CS) is an intervention for people with dementia offering a range of enjoyable activities providing general stimulation for thinking, concentration and memory, usually in a social setting, such as a small group. CS is distinguished from other approaches such as cognitive training and cognitive rehabilitation by its broad focus and social elements, aiming to improve domains such as quality of life (QoL) and mood as well as cognitive function. Recommended in various guidelines and widely implemented internationally, questions remain regarding different modes of delivery and the clinical significance of any benefits. A systematic review of CS is important to clarify its effectiveness and place practice recommendations on a sound evidence base. This review was last updated in 2012.

OBJECTIVES

To evaluate the evidence for the effectiveness of CS for people with dementia, including any negative effects, on cognition and other relevant outcomes, accounting where possible for differences in its implementation.

SEARCH METHODS

We identified trials from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register, last searched on 3 March 2022. We used the search terms: cognitive stimulation, reality orientation, memory therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation. We performed supplementary searches in a number of major healthcare databases and trial registers to ensure the search was up-to-date and comprehensive.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) of CS for dementia published in peer review journals in the English language incorporating a measure of cognitive change.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. As CS is a psychosocial intervention, we did not expect those receiving or delivering CS to be blinded to the nature of the intervention. Where necessary, we contacted study authors requesting data not provided in the papers. Where appropriate, we undertook subgroup analysis by modality (individual versus group), number of sessions and frequency, setting (community versus care home), type of control condition and dementia severity. We used GRADE methods to assess the overall quality of evidence for each outcome.

MAIN RESULTS

We included 37 RCTs (with 2766 participants), 26 published since the previous update. Most evaluated CS groups; eight examined individual CS. Participants' median age was 79.7 years. Sixteen studies included participants resident in care homes or hospitals. Study quality showed indications of improvement since the previous review, with few areas of high risk of bias. Assessors were clearly blinded to treatment allocation in most studies (81%) and most studies (81%) reported use of a treatment manual by those delivering the intervention. However, in a substantial number of studies (59%), we could not find details on all aspects of the randomisation procedures, leading us to rate the risk of selection bias as unclear. We entered data in the meta-analyses from 36 studies (2704 participants; CS: 1432, controls: 1272). The primary analysis was on changes evident immediately following the treatment period (median length 10 weeks; range 4 to 52 weeks). Only eight studies provided data allowing evaluation of whether effects were subsequently maintained (four at 6- to 12-week follow-up; four at 8- to 12-month follow-up). No negative effects were reported. Overall, we found moderate-quality evidence for a small benefit in cognition associated with CS (standardised mean difference (SMD) 0.40, 95% CI 0.25 to 0.55). In the 25 studies, with 1893 participants, reporting the widely used MMSE (Mini-Mental State Examination) test for cognitive function in dementia, there was moderate-quality evidence of a clinically important difference of 1.99 points between CS and controls (95% CI: 1.24, 2.74). In secondary analyses, with smaller total sample sizes, again examining the difference between CS and controls on changes immediately following the intervention period, we found moderate-quality evidence of a slight improvement in self-reported QoL (18 studies, 1584 participants; SMD: 0.25 [95% CI: 0.07, 0.42]) as well as in QoL ratings made by proxies (staff or caregivers). We found high-quality evidence for clinically relevant improvements in staff/interviewer ratings of communication and social interaction (5 studies, 702 participants; SMD: 0.53 [95% CI: 0.36, 0.70]) and for slight benefits in instrumental Activities of Daily Living, self-reported depressed mood, staff/interviewer-rated anxiety and general behaviour rating scales. We found moderate-quality evidence for slight improvements in behaviour that challenges and in basic Activities of Daily Living and low-quality evidence for a slight improvement in staff/interviewer-rated depressed mood. A few studies reported a range of outcomes for family caregivers. We found moderate-quality evidence that overall CS made little or no difference to caregivers' mood or anxiety. We found a high level of inconsistency between studies in relation to both cognitive outcomes and QoL. In exploratory subgroup analyses, we did not identify an effect of modality (group versus individual) or, for group studies, of setting (community versus care home), total number of group sessions or type of control condition (treatment-as-usual versus active controls). However, we did find improvements in cognition were larger where group sessions were more frequent (twice weekly or more versus once weekly) and where average severity of dementia among participants at the start of the intervention was 'mild' rather than 'moderate'. Imbalance in numbers of studies and participants between subgroups and residual inconsistency requires these exploratory findings to be interpreted cautiously.

AUTHORS' CONCLUSIONS

In this updated review, now with a much more extensive evidence base, we have again identified small, short-term cognitive benefits for people with mild to moderate dementia participating in CS programmes. From a smaller number of studies, we have also found clinically relevant improvements in communication and social interaction and slight benefits in a range of outcomes including QoL, mood and behaviour that challenges. There are relatively few studies of individual CS, and further research is needed to delineate the effectiveness of different delivery methods (including digital and remote, individual and group) and of multi-component programmes. We have identified that the frequency of group sessions and level of dementia severity may influence the outcomes of CS, and these aspects should be studied further. There remains an evidence gap in relation to the potential benefits of longer-term CS programmes and their clinical significance.

The Molecular Effects of Environmental Enrichment on Alzheimer's Disease

Environmental enrichment (EE) is an environmental paradigm encompassing sensory, cognitive, and physical stimulation at a heightened level. Previous studies have reported the beneficial effects of EE in the brain, particularly in the hippocampus. EE improves cognitive function as well as ameliorates depressive and anxiety-like behaviors, making it a potentially effective neuroprotective strategy against neurodegenerative diseases such as Alzheimer's disease (AD). Here, we summarize the current evidence for EE as a neuroprotective strategy as well as the potential molecular pathways that can explain the effects of EE from a biochemical perspective using animal models. The effectiveness of EE in enhancing brain activity against neurodegeneration is explored with a view to differences present in early and late life EE exposure, with its potential application in human being discussed. We discuss EE as one of the non pharmacological approaches in preventing or delaying the onset of AD for future research.

Non-pharmacological intervention effects on apathy caused by central nervous system organic diseases: A network meta-analysis

BACKGROUND

To evaluate the best non-pharmacological interventions on apathy in patients with central nervous system (CNS) organic diseases.

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library electronic databases, China national knowledge infrastructure, Wanfang and Chinese biomedical literature database studies published from 2011 to May 29, 2021. A combination of subject words and free words were used for searching. Randomized controlled trials (RCTs) of non-pharmacological interventions for apathy in patients with central nervous organic disease were included. Two researchers independently identified the eligible RCTs and extracted information. The risk of bias within each individual trial was assessed using the Cocharane Collaboration's tool. Review Manager 5.4 and ADDIS 1.16.5 were used for data analysis.

RESULTS

A total of 5324 related studies were obtained in the initial screening, and final 8 RCTs including 334 patients were included, involving 4 non-pharmacological interventions of cognitive intervention, repetitive transcranial magnetic stimulation (rTMS), music therapy and occupational therapy. Direct comparison results showed that rTMS, cognitive intervention, and occupational therapy were superior to the conventional group (P < .05). Network Meta repeated rTMS, cognitive intervention was superior to the conventional group (P < .05), while the other groups did not differ from with the conventional group (P > .05). The order of superiority was rTMS, cognitive intervention, occupational therapy, music therapy, and conventional group.

CONCLUSION

Current evidence suggests that rTMS and cognitive interventions are more effective than the conventional intervention in improving apathy in patients with CNS organic diseases. It still needs more non-pharmacological intervention studies with high quality, larger sample sizes for further exploration.

An integrated intervention of computerized cognitive training and physical exercise in virtual reality for people with Alzheimer's disease: The jDome study protocol

Introduction

Alzheimer's disease is a neurodegenerative syndrome characterized by cognitive deficits, loss of daily functions, and mental and behavioral disorders, which cause stress and negatively affect the quality of life. Studies in the field suggest that combining cognitive training with physical activity can reduce the risk of developing the disease and, once neurodegeneration has begun, it slows its progress. In particular, virtual reality and augmented reality administer cognitive stimulation while providing a link to autobiographical memory through reminiscence, enabling the improvement of the person's quality of life. The present protocol aims to evaluate the effectiveness of cognitive and physical treatments, integrated with the addition of virtual reality and reminiscence elements, using the Brainer software, in which people will find cognitive training, and the jDome® BikeAround™ system, which will allow participants to pedal along a personalized path projected on a schematic, using an exercise bike connected to the system.

Methods and analysis

For this study, 78 patients with mild Alzheimer's dementia were recruited and divided into the Experimental Group (EG) and Control Group (CG). Sixteen treatment sessions of 60 min each were conducted for both groups (2 training sessions per week, for 8 weeks), including 1 patient at a time. The EG received cognitive treatment with Brainer and physical training with jDome, while the CG received cognitive treatment with Brainer and physical training with a classic bicycle. The evaluation mainly focused on the assessment of the person's cognitive status. Other analyses were conducted on the quality of life, mood, behavioral disorders, and physical function, which were considered secondary outcomes.

Discussions

The ultimate goal of the present study is to test the effectiveness of a treatment for people with mild Alzheimer's focused on the integration of cognitive training and aerobic physical activity, using an exercise bike, with the addition of virtual reality and reminiscence elements.

Ethics and dissemination

The study was approved by the Ethics Committee of the IRCCS INRCA. It was recorded in ClinicalTrials.gov on 2 June 2022 with the number NCT05402423. The study findings will be used for publication in peer-reviewed scientific journals and presentations in scientific meetings.

Effectiveness of cognitive stimulation therapy (CST) on cognition, quality of life and neuropsychiatric symptoms for patients living with dementia: A meta-analysis

INTRODUCTION

Many scholars have explored the effect of cognitive stimulation therapy (CST) on dementia patients, however, due to different experimental designs and insufficient sample sizes, research results are inconsistent. Furthermore, there is a scarcity of high-quality quantitative results.

OBJECTIVE

To assess the effectiveness of CST for improving cognition, quality of life (QoL) and neuropsychiatric symptoms in people with dementia (PwD).

METHODS

Chinese and English databases were searched for randomized controlled trials (RCTs) between establishment of and April 2022, with another search done in May 2022. Finally, 10 studies on the application of CST in PwD for improving cognition, QoL, behavior, language and activities of daily living were reviewed.

RESULTS

Based on the results of the 10 RCTs, CST significantly improved cognitive performance (MMSE: WMD = 1.98, 95% CI: 1.24-2.72, P<0.01), QoL (WMD = 3.12, 95% CI: 2.52-3.72, P<0.01), language (NLT: WMD = 2.71, 95% CI: 1.07-4.35, P<0.01) and activities of daily living (DAD: WMD = 7.27, 95% CI: 0.97-13.56, P<0.01) in PwD. However, no significant improvements in ADAS-Cog (WMD = 0.55, 95% CI: -3.04-4.14, P = 0.76), depression (SMD = -0.12,95% CI: -0.29-0.04, P = 0.15), anxiety (RAID: WMD = -1.05, 95% CI: -3.85-1.75, P = 0.46) or neuropsychiatric symptoms (NPI: WMD = 0.23, 95% CI: -2.62-3.07, P = 0.88) were found.

CONCLUSION

CST improved the cognitive ability, QoL, language and activities of daily living of PwD. However, the effect of neuropsychiatric symptoms on PwD requires further exploration.

Nonpharmacological approaches reduce symptoms of depression in dementia: A systematic review and meta-analysis

BACKGROUND

Depression is a common psychological symptom associated with dementia. Pharmacological approaches are often used despite two large negative trials of efficacy. This meta-analysis examines nonpharmacological (i.e., psychosocial) approaches for symptoms of depression in people living with dementia and reports statistical and clinical significance.

METHODS

Relevant studies published between 2012 and 2020 were sourced by searching electronic databases: MEDLINE, EMBASE, PsychINFO, Social Work Abstracts and the Cochrane Central Register of Controlled Trials. Studies were assessed for methodological quality. Random-effects meta-analysis was performed to calculate a pooled effect size (ES) and 95% confidence intervals (CI).

RESULTS

Overall, 37 nonpharmacological studies were identified including 2,636 participants. The mean quality rating was high (12/14, SD=1.4). Meta-analysis revealed that nonpharmacological approaches were significantly associated with reduced symptoms of depression with a medium effect size (ES=-0.53, 95%CI [-0.72, -0.33], p < 0.0001). There was considerable heterogeneity between studies. Meta-regression revealed this was not driven by intervention type or setting (residential versus community).

CONCLUSIONS

Nonpharmacological approaches such as reminiscence, cognitive stimulation/ rehabilitation, therapeutic, music-based approaches and education/ training, have the potential to reduce symptoms of depression in dementia.

A pilot study of AID-COMp: An innovative speech-language intervention for patients with early-stage major neurocognitive disorder

BACKGROUND

Major neurocognitive disorder (MND) alters cognition, memory and language, and consequently affects communication. Speech-language therapy (SLT) may alleviate communication difficulties.

AIMS

This pilot study explored the effects of intensive SLT emphasizing memory, language, and discourse impairment and complementary communication strategies, called Aid for Communication-For Persons Who Live with MND (AID-COMp).

METHODS & PROCEDURES

We employed a mixed design using quantitative and qualitative methods with four dyads, including a person living with MND (PwMND) and a family carer. The design included a control period, and we tested participants before (T1) and after 2 months without therapy (T2). AID-COMp was then provided intensively three times per week for 10 sessions and participants were tested again (T3). Participants were also involved in an individual qualitative interview after therapy ended, probing their experience and possible effects on their lives. AID-COMp included: (1) spaced retrieval to teach the use of a memory book; (2) semantic and phonological therapy for lexical access; (3) discourse treatment based on the analysis of the macrostructure and microstructure of stories in pictures and texts; and (4) PACE therapy for generalization. Carers were not included in treatment, did not attend sessions and were only involved in the evaluations. Measures included language, communication, cognitive and well-being tests. Paired t-tests (one-tailed) compared scores for the control period, that is, T1 versus T2. We compared scores after therapy (T3) with those at T2. Interviews were transcribed verbatim and analysed qualitatively.

OUTCOMES & RESULTS

For the control period, only text comprehension scores significantly decreased in PwMND. After therapy, improvements occurred on the Boston Naming Test (BNT), the Mini-Mental State Exam (MMSE) and the well-being measure for the PwMND. Carer scores were unchanged after therapy except for their perception of the PwMND's communication which improved. Qualitative findings comprised three themes: (1) understanding therapy; (2) recovering abilities and relationships; and (3) naming further needs.

CONCLUSIONS & IMPLICATIONS

We hypothesize that AID-COMp addressed the underlying impairments associated with MND and provided various tools to PwMND for composing effectively with them. Indeed, AID-COMp appears to provoke some degree of improvement of language skills, cognition and emotional well-being. These improvements may lead to more confidence in conversation and the recovery of relationships between the PwMND and their entourage. It is also possible that improvements acted positively on one another. These preliminary findings warrant further controlled studies with more participants, including a qualitative exploration of participant experiences.

WHAT THIS PAPER ADDS

What is already known on the subject MND affects cognition and communication, which are crucial to a good relationship between a carer and a person with MND. Interventions involving only PwMND have been shown to be effective, but do not address all the communication impairments in the mild stage of MND. These interventions may require many therapy sessions. Generally, SLT interventions do not examine the potential effects of an intervention on carers. What this paper adds to existing knowledge AID-COMp, an intensive intervention of 10 sessions over 1 month, was provided to people living with MND in the community. It included training the person with MND in using a memory notebook combined with semantic and phonological therapy, a new discourse therapy and PACE therapy, addressing several communication deficits. After a control period of 2 months without intervention and a 1-month intensive intervention, the results showed significant improvement in naming, cognition and communication, and PwMND well-being. Moreover, the carers witnessed the impacts of therapy in their everyday life interactions with the PwMND. What are the potential or actual clinical implications of this work AID-COMp can provide communication support for PwMND that has further benefits reported by both PwMND and carers. We described AID-COMp in detail to inspire clinicians in providing SLT for unserved PwMND. Future research studies should use controlled designs, more participants and a qualitative component.

Apathy as a Treatment Target in Alzheimer's Disease: Implications for Clinical Trials

Apathy is one of the most prevalent, stable and persistent neuropsychiatric symptom across the neurocognitive disorders spectrum. Recent advances in understanding of phenomenology, neurobiology and intervention trials highlight apathy as an important target for clinical intervention. We conducted a comprehensive review and critical evaluation of recent advances to determine the evidence-based suggestions for future trial designs. This review focused on 4 key areas: 1) pre-dementia states; 2) assessment; 3) mechanisms/biomarkers and 4) treatment/intervention efficacy. Considerable progress has been made in understanding apathy as a treatment target and appreciating pharmacological and non-pharmacological apathy treatment interventions. Areas requiring greater investigation include: diagnostic procedures, symptom measurement, understanding the biological mechanisms/biomarkers of apathy, and a well-formed approach to the development of treatment strategies. A better understanding of the subdomains and biological mechanisms of apathy will advance apathy as a treatment target for clinical trials.

Systematic Review of Exercise for Caregiver-Care Recipient Dyads: What Is Best for Spousal Caregivers-Exercising Together or Not at All?

Background and Objectives

Though exercise for care recipients receives considerable emphasis, few dyadic studies focus on caregivers. This systematic review identified dyadic exercise interventions, which measured outcomes for older adult caregivers. Studies that met inclusion criteria were examined to better understand whether caregivers derived greater benefit from exercising with care recipients, or not exercising at all.

Research Design and Methods

PRISMA guidelines were followed to identify quantitative studies of dyadic exercise interventions in which caregivers enrolled with care recipients, and either coparticipated in exercise; or while their care recipients exercised independently, caregivers received a separate, nonexercise intervention or usual care (UC). To be included, studies had to measure physical or psychosocial outcomes for caregivers. Study quality was assessed via the Downs and Black checklist.

Results

Eleven studies met inclusion criteria. In six, the dyad exercised; in five, care recipients exercised while caregivers received a separate program, or UC. Results suggest that caregivers may improve both psychosocial and physical health when exercising together with care recipients. Caregivers who did not exercise but received a separate, nonexercise intervention, such as support, education, or respite, showed psychosocial benefits. Those who received UC were less likely to derive physical or psychosocial benefits. Included studies were fair to good quality with moderate to high risk of bias.

Discussion and Implications

Often examined secondarily, caregivers are overlooked for participation in interventions with care recipients. This analysis suggests that caregivers may benefit from dyadic interventions in which they either exercise together with their care recipients or receive a separate nonexercise intervention or respite.

Exploring the Effects of a Golf Program on Psychological and Social Wellbeing for People With Dementia, Carers, and Staff

There is a paucity of evidence regarding the effects of sport and physical activity on wellbeing in dementia. The present study is the first known study to involve golf with this population. People with dementia (n = 10) and carers (n = 5) participated in a 6-week golf program, facilitated by golf center staff (n = 3). Multiple avenues of data collection were utilized and were subject to thematic analysis. Five central themes were identified: emotion, respite, losing the "dementia" label, friendship/camaraderie, and improving relationships. Underlying subthemes were also identified, while potential links between themes were highlighted. Themes were also considered in terms of which participants (person with dementia, carer, and staff) provided evidence for each theme. This study presents preliminary support for the role of golf to enhance the psychological and social wellbeing of people with early stages of dementia, carers, and staff. Potential mechanisms and future research are discussed.

Physical exercise improves quality of life, depressive symptoms, and cognition across chronic brain disorders: a transdiagnostic systematic review and meta-analysis of randomized controlled trials

We performed a meta-analysis to synthesize evidence on the efficacy and safety of physical exercise as an add-on therapeutic intervention for quality of life (QoL), depressive symptoms and cognition across six chronic brain disorders: Alzheimer's disease, Huntington's disease, multiple sclerosis, Parkinson's disease, schizophrenia and unipolar depression. 122 studies ( = k) (n = 7231) were included. Exercise was superior to treatment as usual in improving QoL (k = 64, n = 4334, ES = 0.40, p < 0.0001), depressive symptoms (k = 60, n = 2909, ES = 0.78, p < 0.0001), the cognitive domains attention and working memory (k = 21, n = 1313, ES = 0.24, p < 0.009), executive functioning (k = 14, n = 977, ES = 0.15, p = 0.013), memory (k = 12, n = 994, ES = 0.12, p = 0.038) and psychomotor speed (k = 16, n = 896, ES = 0.23, p = 0.003). Meta-regression showed a dose-response effect for exercise time (min/week) on depressive symptoms (β = 0.007, p = 0.012). 69% of the studies that reported on safety, found no complications. Exercise is an efficacious and safe add-on therapeutic intervention showing a medium-sized effect on QoL and a large effect on mood in patients with chronic brain disorders, with a positive dose-response correlation. Exercise also improved several cognitive domains with small but significant effects.

Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis

OBJECTIVE

To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia.

MAIN OUTCOME MEASURES

Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses.

RESULTS

Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference -2.93, 95% credible interval -4.35 to -1.52), cognitive stimulation combined with a cholinesterase inhibitor (-11.39, -18.38 to -3.93), massage and touch therapy (-9.03, -12.28 to -5.88), multidisciplinary care (-1.98, -3.80 to -0.16), occupational therapy (-2.59, -4.70 to -0.40), exercise combined with social interaction and cognitive stimulation (-12.37, -19.01 to -5.36), and reminiscence therapy (-2.30, -3.68 to -0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients).

CONCLUSIONS

In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017050130.

The Impact of a Twelve-Month Comprehensive Program of Cognitive Training for Alzheimer Patients: A Pilot Study

Research has shown that non-pharmacological therapies can be useful in the treatment of Alzheimer’s disease (AD), significantly delaying cognitive decay. However, most AD interventions did not last beyond six months. Hence, little is known about the effect of these programs in the AD patients after six months of treatment. The purpose of this study was to evaluate the efficacy of the twelve-month Comprehensive Program of Cognitive Training (CPCT) for a sample of AD patients and to compare the results with the average annual rate of change. Thirty-nine AD patients participated in the study. The CPCT consists of a set of cognitive stimulations, intervention in activities of daily life (ADL), and motor training for 12 months. All patients were evaluated at baseline and in three-month intervals via the Mini Mental State Examination (MMSE), the Cambridge Cognitive Examination (CAMCOG), the Lawton Instrumental Activities of Daily Living Scale (IADL), and the Global Deterioration Scale (GDS). After CPCT implementation, there were no significant differences in the MMSE, IADL, and GDS evaluations between baseline and twelve months. Concerning the CAMCOG evaluation, there was no significant difference between the baseline and sixth-month assessments. Overall, the participants’ cognitive functioning did not decline when compared to the average annual rate of change. The CPCT extends the benefit of non-pharmacological interventions for AD patients to twelve months. Its implementation might provide the patients’ relatives with some guarantee concerning the delay of the disease. Future research may investigate the efficacy of the CPCT in comparison with a control group and over a more extended period.

Neuroanatomical Abnormalities in Older Depressed Adults With Apathy: A Systematic Review

OBJECTIVE

Apathy is a common phenomenon in late-life depression and is associated with poor outcomes. Apathy is often unrecognized in older depressed adults, and efficacious treatment options are lacking. This review provides a systematic review of the neuroanatomical abnormalities associated with apathy in late-life depression. In addition, the review summarizes the neuroimaging findings from studies of neurodegenerative and focal brain injury conditions that frequently present with apathy. The goal is to elucidate cerebral network abnormalities that give rise to apathy in older adults with mood disturbances and to inform future treatment targets.

METHOD

Systematic literature review.

RESULTS

The few studies that have directly examined the neuroanatomical abnormalities of apathy in late-life depression suggest disturbances in the anterior cingulate cortex, insula, orbital and dorsal prefrontal cortex, striatum, and limbic structures (ie, amygdala, thalamus, and hippocampus). Studies examining the neuroanatomical correlates of apathy in other aging populations are consistent with the pattern observed in late-life depression.

CONCLUSIONS

Apathy in late-life depression appears to be accompanied by neuroanatomical abnormalities in the salience and reward networks. These network findings are consistent with that observed in individuals presenting with apathy in other aging-related conditions. These findings may inform future treatments that target apathy.

A Novel Microtubule-Binding Drug Attenuates and Reverses Protein Aggregation in Animal Models of Alzheimer's Disease

Age-progressive neurodegenerative pathologies, including Alzheimer’s disease (AD), are distinguished and diagnosed by disease-specific components of intra- or extra-cellular aggregates. Increasing evidence suggests that neuroinflammation promotes protein aggregation, and is involved in the etiology of neurological diseases. We synthesized and tested analogs of the naturally occurring tubulin-binding compound, combretastatin A-4. One such analog, PNR502, markedly reduced the quantity of Alzheimer-associated amyloid aggregates in the BRI-Aβ_1–42 mouse model of AD, while blunting the ability of the pro-inflammatory cytokine IL-1β to raise levels of amyloid plaque and its protein precursors in a neuronal cell-culture model. In transgenic Caenorhabditis elegans (C. elegans) strains that express human Aβ_1–42 in muscle or neurons, PNR502 rescued Aβ-induced disruption of motility (3.8-fold, P < 0.0001) or chemotaxis (1.8-fold, P < 0.05), respectively. Moreover, in C. elegans with neuronal expression of Aβ_1–42, a single day of PNR502 exposure reverses the chemotaxis deficit by 54% (P < 0.01), actually exceeding the protection from longer exposure. Moreover, continuous PNR502 treatment extends nematode lifespan 23% (P ≤ 0.001). Given that PNR502 can slow, prevent, or reverse Alzheimer-like protein aggregation in human-cell-culture and animal models, and that its principal predicted and observed binding targets are proteins previously implicated in Alzheimer’s, we propose that PNR502 has therapeutic potential to inhibit cerebral Aβ_1–42 aggregation and prevent or reverse neurodegeneration.

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.

Immediate Intervention Effects of Standardized Multicomponent Group Interventions on People with Cognitive Impairment: A Systematic Review

BACKGROUND

There is no curative medical treatment for dementia. Therefore, researchers turned their attention to non-pharmacological treatment approaches. Many reviews analyzed the efficacy of single-component interventions, but there has been no systematic review of multicomponent interventions so far.

OBJECTIVE

The aim was to systematically review studies using standardized multicomponent group interventions for persons with dementia or persons with mild cognitive impairment (MCI) and to analyze their immediate intervention effects.

METHODS

The databases PubMed, PsycINFO, PSYNDEX, and CINAHL were systematically searched. We included randomized controlled trials with people with MCI or dementia, which implemented interventions with at least two components that targeted different outcome domains. Additionally, the intervention had to be standardized and in a group setting.

RESULTS

Nine studies met the inclusion criteria with a total sample size of N = 513 participants. Six studies applied two, two studies applied three, and one study applied four components. Four studies, which combined at least a physical and a cognitive component, had a positive effect on non-cognitive symptoms of dementia. Two of these interventions additionally had a positive effect on cognitive abilities. One study reported a positive effect on activities of daily living and another study showed an effect on quality of life.

CONCLUSION

In spite of the heterogeneity of the studies, multicomponent interventions suggest a positive effect on non-cognitive symptoms, especially the combination of cognitive and physical components. Single studies had also an effect on additional outcome domains. By trend the effects are dependent on application rate and used assessments.

A mixed methods systematic review of multimodal non-pharmacological interventions to improve cognition for people with dementia

Objective

Multimodal non-pharmacological interventions have been argued to have the potential to complement current pharmacological approaches to improving quality of life for people living with dementia. The aim of this review was to identify, synthesise and appraise the evidence for the effectiveness of multimodal non-pharmacological interventions for improving cognitive function specifically.

Method

After a comprehensive search strategy including grey literature, 26 studies were reviewed. The inclusion criteria concerned adults with a primary diagnosis of dementia. Studies used two or more different modes of intervention, and measured a cognitive outcome. Due to differences in the conceptualisations of the term ‘multimodal’, a typology of modes and methods was developed to facilitate classification of candidate studies.

Results

Twenty-one group studies and five case studies were found. Group studies used two or three modes of intervention and multiple methods to implement them. Interventions utilised were cognitive, physical, psychological and psychosocial, nutrition, fasting, gut health, sleep hygiene, stress reduction, detoxification, hormonal health and oxygen therapy. Five individual case studies were found in two separate papers. Each personalised patient treatment utilised in-depth assessments and prescribed up to nine different modes. In 19 (90%) of the 21 group comparisons, participants were reported to have cognitive improvements, stability with their dementia or a delay in their decline. The extent of these improvements in terms of meaningful clinical change was variable.

Conclusion

Multimodal non-pharmacological interventions have the potential to complement singular therapeutic approaches by addressing multiple modifiable risk factors currently understood to contribute towards cognitive decline.

Shiatsu as an adjuvant therapy for depression in patients with Alzheimer's disease: A pilot study

OBJECTIVES

Among the complementary and alternative medicine, Shiatsu might represent a feasible option for depression in Alzheimer's disease (AD). We evaluated Shiatsu on mood, cognition, and functional independence in patients undergoing physical activity.

DESIGN

Single-blind randomized controlled study.

SETTING

Dedicated Community Center for patients with AD.

INTERVENTIONS

AD patients with depression were randomly assigned to the "active group" (Shiatsu + physical activity) or the "control group" (physical activity alone). Shiatsu was performed by the same therapist once a week for ten months.

MAIN OUTCOME MEASURES

Global cognitive functioning (Mini Mental State Examination - MMSE), depressive symptoms (Geriatric Depression Scale - GDS), and functional status (Activity of Daily Living - ADL, Instrumental ADL - IADL) were assessed before and after the intervention.

RESULTS

We found a within-group improvement of MMSE, ADL, and GDS in the active group. However, the analysis of differences before and after the interventions showed a statistically significant decrease of GDS score only in the active group.

CONCLUSIONS

The combination of Shiatsu and physical activity improved depression in AD patients compared to physical activity alone. The pathomechanism might involve neuroendocrine-mediated effects of Shiatsu on neural circuits implicated in mood and affect regulation.

Effect of a Comprehensive Intervention on Plasma BDNF in Patients with Alzheimer's Disease

A comprehensive intervention (CI) on patients with Alzheimer’s disease was assessed by measuring plasmabrain-derived neurotrophic factor (pBDNF) and ADAS-Cog score (ADAS-Cog_score) before, immediately after (FU1), and 6 (FU2) and 24 months (FU3) after the CI. Baseline pBDNF was higher in patients with moderate AD (but not mild AD) than in healthy controls. At FU1, pBDNF and ADAS-Cog_score decreased significantly. At FU2 and FU3, patients’ cognitive status worsened and pBDNF further increased versus baseline, suggesting that CI interruption may be a stress event that prevents return to homeostasis. CI exerted positive short-term effects, but more information is needed on long-term consequences.

A systematic review of non-pharmacological treatments for apathy in dementia

OBJECTIVE

Apathy is one of the most frequent neuropsychiatric symptoms encountered in dementia. Early diagnosis and timely treatment of apathy in dementia are crucial because apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress.

DESIGN

Extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies which have investigated the effect of non-pharmacological treatments of apathy in dementia. Quality of the studies was appraised.

RESULTS

A total of 1303 records were identified and 120 full-texts assessed. Forty-three unique studies were reviewed. A variety of interventions were found to be effective in reducing apathy in demented patients, particularly when provided in a multidisciplinary manner. However, quantification of the effect was limited by the marked methodological heterogeneity of the studies and the small number of studies where apathy was the primary outcome measure.

CONCLUSIONS

Treatment of apathy in dementia is a complex and underexplored field. Certain studies suggest promise for a variety of non-pharmacological interventions. Standardized and systematic efforts primarily focusing on apathy may establish a benefit from individualized treatments for specific disease groups.

Effectiveness of Occupational Therapy Interventions to Enhance Occupational Performance for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to describe the evidence for the effectiveness of interventions designed to establish, modify, and maintain occupations for adults with Alzheimer's disease (AD) and related neurocognitive disorders.

METHOD

Titles and abstracts of 2,597 articles were reviewed, of which 256 were retrieved for full review and 52 met inclusion criteria. U.S. Preventive Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

RESULTS

Articles were categorized into five themes: occupation-based, sleep, cognitive, physical exercise, and multicomponent interventions. Strong evidence supports the benefits of occupation-based interventions, physical exercise, and error-reduction learning.

CONCLUSION

Occupational therapy practitioners should integrate daily occupations, physical exercise, and error-reduction techniques into the daily routine of adults with AD to enhance occupational performance and delay functional decline. Future research should focus on establishing consensus on types and dosage of exercise and cognitive interventions.

Pharmacological and Nonpharmacological Treatment for Apathy in Alzheimer Disease : A systematic review across modalities

OBJECTIVE

Apathy is one of the most frequent neuropsychiatric symptoms encountered in Alzheimer disease (AD). Early diagnosis and timely treatment of apathy in AD seem to be of great importance, since apathy has been associated with poor disease outcome, reduced daily functioning, and caregiver distress.

DESIGN

Within this context, we conducted an extensive electronic search from the databases included in the National Library of Medicine as well as PsychInfo and Google Scholar for studies that have investigated the effect of pharmacological and nonpharmacological treatments of apathy in AD.

RESULTS

Acetylcholinesterase inhibitors, gingko biloba, methylphenidate, and a variety of nonpharmacological interventions were found to be successful in reducing apathy in patients with AD. Methodological heterogeneity of the studies and the small amount of studies where apathy was a primary outcome measure are limiting factors to evaluate for group effects.

CONCLUSION

Treatment of apathy in AD is a complicated and an underexplored field. Standardized and systematic efforts primarily focused on the study of apathy in AD may establish a benefit from individualized treatment for specific disease groups that would stem from a combination of both pharmacological and nonpharmacological interventions.

Cognitive Training Interventions for Patients with Alzheimer's Disease: A Systematic Review

BACKGROUND

Cognitive training (CT) refers to guided cognitive exercises designed to improve specific cognitive functions, as well as enhance performance in untrained cognitive tasks. Positive effects of CT on cognitive functions in healthy elderly people and persons with mild cognitive impairment have been reported, but data regarding the effects of CT in patients with dementia is unclear.

OBJECTIVE

We systematically reviewed the current evidence from randomized controlled trials (RCTs) to find out if CT improves or stabilizes cognition and/or everyday functioning in patients with mild and moderate Alzheimer's disease.

RESULTS

Altogether, 31 RCTs with CT as either the primary intervention or part of a broader cognitive or multi-component intervention were found. A positive effect was reported in 24 trials, mainly on global cognition and training-specific tasks, particularly when more intensive or more specific CT programs were used. Little evidence of improved everyday functioning was found.

CONCLUSIONS

Despite some positive findings, the inaccurate definitions of CT, inadequate sample sizes, unclear randomization methods, incomplete datasets at follow-up and multiple testing may have inflated the results in many trials. Future high quality RCTs with appropriate classification and specification of cognitive interventions are necessary to confirm CT as an effective treatment option in Alzheimer's disease.

ImpRess: an Implementation Readiness checklist developed using a systematic review of randomised controlled trials assessing cognitive stimulation for dementia

BACKGROUND

Research reporting results of clinical trials, psychosocial or technological interventions frequently omit critical details needed to inform implementation in practice. The aim of this article is to develop an Implementation Readiness (ImpRess) checklist, that includes criteria deemed useful in measuring readiness for implementation and apply it to trials of cognitive stimulation in dementia, providing a systematic review of their readiness for widespread implementation.

METHODS

Five electronic databases were searched. After initial screening of papers, two reviewers assessed quality and scored the included studies based on the ImpRess checklist specifically developed for this review.

RESULTS

Twenty studies met the inclusion criteria. As determined by the ImpRess checklist, scores ranged from 11 to 29 out of 52. According to the checklist the most comprehensive and ready to implement version of cognitive stimulation was Cognitive Stimulation Therapy.

CONCLUSIONS

Reports of interventions rarely include consideration of implementation in practice. Contrary to the growing number of reporting guidelines, crucial items within the ImpRess checklist have been frequently overlooked. This study was able to show that the ImpRess checklist was feasible in practice and reliable. The checklist may be useful in evaluating readiness for implementation for other manualised interventions.

Exercise as a treatment for depression: A meta-analysis

BACKGROUND

This meta-analysis of randomized controlled trials (RCTs) examines the efficacy of physical exercise as treatment for unipolar depression, both as an independent intervention and as an adjunct intervention to antidepressant medication.

METHODS

We searched PsycINFO, EMBASE, MEDLINE, CENTRAL, and Sports Discus for articles published until November 2014. Effect sizes were computed with random effects models. The main outcome was reduction in depressive symptoms or remission.

RESULTS

A total of 23 RCTs and 977 participants were included. Physical exercise had a moderate to large significant effect on depression compared to control conditions (g=-0.68), but the effect was small and not significant at follow-up (g=-0.22). Exercise compared to no intervention yielded a large and significant effect size (g=-1.24), and exercise had a moderate and significant effect compared to usual care (g=-0.48). The effects of exercise when compared to psychological treatments or antidepressant medication were small and not significant (g=-0.22 and g=-0.08, respectively). Exercise as an adjunct to antidepressant medication yielded a moderate effect (g=-0.50) that trended toward significance.

LIMITATIONS

Use of the arms with the largest clinical effect instead of largest dose may have overestimated the effect of exercise.

CONCLUSIONS

Physical exercise is an effective intervention for depression. It also could be a viable adjunct treatment in combination with antidepressants.

Effects of cognitive stimulation on neuropsychiatric symptoms in elderly with Alzheimer's disease: A systematic review

Introduction:

Neuropsychiatric symptoms are frequent in Alzheimer's disease and negatively affect patient quality of life.

Objective:

To assess the effectiveness of cognitive stimulation on neuropsychiatric symptoms in elderly patients with Alzheimer's disease.

Methods:

The included articles were reviewed between December 2015 and June 2016, and the inclusion criteria were: (1) studies involving older adults diagnosed with Alzheimer's disease; (2) studies published in English, Spanish or Portuguese; (3) studies that determined the effect of cognitive stimulation on neuropsychiatric symptoms in elderly patients with Alzheimer's disease; (4) controlled trials.

Results:

Out of the total 722, 9 articles matched the inclusion criteria. Depression, apathy and anxiety were the most frequent symptoms.

Conclusion:

Studies reported significant results post-treatment, suggesting cognitive stimulation can be effective for these neuropsychiatric symptoms, thus improving the quality of life of Alzheimer's disease patients and their caregivers.

Quantitative systematic review of the effects of non-pharmacological interventions on reducing apathy in persons with dementia

AIM

To review the quantitative evidence concerning the effects of non-pharmacological interventions on reducing apathy in persons with dementia.

BACKGROUND

Apathy, a prevalent behavioural symptom among persons with Alzheimer Disease, is defined as a disorder of motivation with deficits in behavioural, emotional and cognitive domains and is associated with serious social and physical obstacles. Non-pharmacological interventions show promise as symptom control modalities among persons with dementia.

DESIGN

Quantitative systematic review.

DATA SOURCES

CINAHL, PubMed, PSYCHinfo and Cochrane Trials databases were searched for published English language research inclusive through December 2014, with no early year limiters set.

REVIEW METHODS

Comprehensive searches yielded 16 international randomized controlled trials or quasi-experimental studies based on inclusion criteria and a rigorous quality appraisal process.

RESULTS

A narrative summary analysis revealed that non-pharmacological interventions for apathy varied substantially and lacked specificity, conceptual clarity and were methodologically heterogeneous. Select interventions demonstrated effectiveness, but lacked systematic long-term follow-up. Limitations include publication bias and lack of a meta-analytic approach due to the methodological heterogeneity of included studies.

CONCLUSION

Study results demonstrate promise for the use of non-pharmacological interventions, particularly music-based interventions, in reducing apathy levels in individuals with dementia. Intervening to reduce apathy may have a positive clinical impact and healthcare providers should be encouraged to incorporate positive sources of interest and intellectual stimulation into care. However, future research is needed to examine the aetiologic mechanism and predictors of apathy, to improve evidence-based interventions and specificity and to optimize dosage and timing of non-pharmacological interventions across the disease trajectory.

Outcomes of a multimodal cognitive and physical rehabilitation program for persons with mild dementia and their caregivers: a goal-oriented approach

Background

Nonpharmacological interventions such as exercise and cognitive rehabilitation programs have shown promise in reducing the impact of dementia on the individual and the caregiver. In this study, we examine the effect of a multimodal cognitive and physical rehabilitation program for persons with mild dementia and their caregivers using conventional measures of cognition, behavior, quality of life (QoL), and caregiver burden together with goal attainment scaling (GAS), an individualized outcome measure.

Methods

Goals were set at baseline, and GAS score was calculated at the end of the program. Participants were also assessed with the Chinese Mini-Mental State Examination, functional and behavioral scales (Barthel Index), Instrumental Activities of Daily Living, Neuropsychiatric Inventory Questionnaire, QoL, and caregiver burden using EuroQol-five dimension questionnaire and Zarit Burden Interview (ZBI). Differences in median scores postintervention were obtained. Further analysis of caregiver burden was undertaken utilizing the multidimensional classification of burden on the ZBI.

Results

Thirty-four (61.8%) patients were assessed to have met their goals (GAS score≥50). Mean (standard deviation) GAS score was 48.6 (6.5). Cognition goals were set in only 20.6%, followed by goals to improve engagement and socialization; reduce caregiver stress; and improve physical function, behavior, and mood. Median scores in the cognitive, functional, and QoL measures did not differ significantly pre- and postintervention. The intervention had a positive impact on role strain, a unique dimension of caregiver burden.

Conclusion

This study provides evidence that a multimodal approach combining physical exercise and cognitive rehabilitation improves goal attainment and caregiver burden in individuals and caregivers of persons with mild dementia.

Effect of a high-intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized controlled trial

BACKGROUND

Dementia is among the leading causes of functional loss and disability in older adults. Research has demonstrated that nursing home patients without dementia can improve their function in activities of daily living, strength, balance and mental well being by physical exercise. The evidence on effect of physical exercise among nursing home patients with dementia is scarce and ambiguous. Thus, the primary objective of this study was to investigate the effect of a high intensity functional exercise program on the performance of balance in nursing home residents with dementia. The secondary objective was to examine the effect of this exercise on muscle strength, mobility, activities of daily living, quality of life and neuropsychiatric symptoms.

DESIGN AND METHODS

This single blinded randomized controlled trial was conducted among 170 persons with dementia living in nursing homes. Mean age was 86.7 years (SD = 7.4) and 74% were women. The participants were randomly allocated to an intervention (n = 87) or a control group (n = 83). The intervention consisted of intensive strengthening and balance exercises in small groups twice a week for 12 weeks. The control condition was leisure activities.

RESULTS

The intervention group improved the score on Bergs Balance Scale by 2.9 points, which was significantly more than the control group who improved by 1.2 points (p = 0.02). Having exercised 12 times or more was significantly associated with improved strength after intervention (p<0.05). The level of apathy was lower in the exercise group after the intervention, compared to the control group (p = 0.048).

CONCLUSION

The results from our study indicate that a high intensity functional exercise program improved balance and muscle strength as well as reduced apathy in nursing home patients with dementia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02262104.

Do cognitive interventions improve general cognition in dementia? A meta-analysis and meta-regression

OBJECTIVES

To review the efficacy of cognitive interventions on improving general cognition in dementia.

METHOD

Online literature databases and trial registers, previous systematic reviews and leading journals were searched for relevant randomised controlled trials. A systematic review, random-effects meta-analyses and meta-regression were conducted. Cognitive interventions were categorised as: cognitive stimulation (CS), involving a range of social and cognitive activities to stimulate multiple cognitive domains; cognitive training (CT), involving repeated practice of standardised tasks targeting a specific cognitive function; cognitive rehabilitation (CR), which takes a person-centred approach to target impaired function; or mixed  CT and stimulation (MCTS). Separate analyses were conducted for general cognitive outcome measures and for studies using 'active' (designed to control for non-specific therapeutic effects) and non-active (minimal or no intervention) control groups.

RESULTS

33 studies were included. Significant positive effect sizes (Hedges’ g) were found for CS with the mini-mental state examination (MMSE) (g=0.51, 95% CI 0.35 to 0.66; p<0.001) compared to non-active controls and (g=0.35, 95% CI 0.06 to 0.64; p=0.019) compared to active controls. Significant benefit was also seen with the Alzheimer's disease Assessment Scale-Cognition (ADAS-Cog) (g=-0.26, 95% CI -0.445 to -0.08; p=0.005). There was no evidence that CT or MCTS produced significant improvements on general cognition outcomes and not enough CR studies for meta-analysis. The lowest accepted minimum clinically important difference was reached in 11/17 CS studies for the MMSE, but only 2/9 studies for the ADAS-Cog. Additionally, 95% prediction intervals suggested that although statistically significant, CS may not lead to benefits on the ADAS-Cog in all clinical settings.

CONCLUSIONS

CS improves scores on MMSE and ADAS-Cog in dementia, but benefits on the ADAS-Cog are generally not clinically significant and difficulties with blinding of patients and use of adequate placebo controls make comparison with the results of dementia drug treatments problematic.

Impact of a cognitive rehabilitation intervention on neuropsychiatric symptoms in mild to moderate Alzheimer's disease

The main goal of this study was to evaluate the impact of a cognitive rehabilitation programme on 12 behavioural and psychological symptoms of dementia (BPSD) in patients with mild to moderate Alzheimer's disease (AD). This six-month single-blind block-randomised cross-over controlled study was conducted with 15 mild to moderate AD participants and their caregivers. All participants received a four-week home-based cognitive rehabilitation programme to learn/re-learn an instrumental activity of daily living. They were assessed up until three months following the end of the intervention. The Neuropsychiatric Inventory (NPI-12) was employed to evaluate patients' BPSD at seven assessment points during the course of the study. A general linear mixed model analysis performed on the NPI data revealed that aberrant motor behaviours (AMB) increased significantly more in the treatment condition than in the control condition. In addition, both groups registered a significant reduction of delusional symptoms during the second half of the study. Employing a multi-symptom approach to assess participants' BPSD, this cross-over randomised controlled study showed that an individualised cognitive rehabilitation intervention was generally well-tolerated by mild to moderate AD patients. Future cognitive rehabilitation studies conducted with this population should pay attention to AMB symptom changes.

The Benefits of Rehabilitation for Palliative Care Patients

Palliative care requires an interdisciplinary team approach to provide the best care for patients with life-threatening illnesses. Like palliative medicine, rehabilitation also uses an interdisciplinary approach to treating patients with chronic illnesses. This review article focuses on rehabilitation interventions that can be beneficial in patients with late stage illnesses. Rehabilitation may be useful in improving the quality of life by palliating function, mobility, activities of daily living, pain relief, endurance, and the psyche of a patient while helping to maintain as much independence as possible, leading to a decrease in burden on caregivers and family. Rehabilitative services are underutilized in the palliative care setting, and more research is needed to address how patients may benefit as they approach the end of their lives.

Use of physical and intellectual activities and socialization in the management of cognitive decline of aging and in dementia: a review

Lifestyle nonpharmacological interventions can have a deep effect on cognitive aging. We have reviewed the available literature on the effectiveness of physical activity, intellectual stimulation, and socialization on the incidence of dementia and on the course of dementia itself. Even though physical activity appears to be beneficial in both delaying dementia onset and in the course of the disease, more research is needed before intellectual stimulation and socialization can be considered as treatments and prevention of the disease. Through our paper, we found that all three nonpharmacological treatments provide benefits to cognition and overall well-being in patients with age-related cognitive impairments. These interventions may be beneficial in the management of dementia.