Cognitive Rehabilitation in Alzheimer’s Disease: A Controlled Intervention Trial

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.

Compensatory Strategy Intervention: What Older Patients Want and Why

OBJECTIVE

Compensatory strategies can improve performance of instrumental activities of daily living in people with cognitive impairment. This study investigated patient interest in compensatory strategy interventions and preference for various intervention formats.

METHODS

Semi-structured qualitative interviews with 38 older adults with cognitive impairment queried motivation to improve strategy use and interest in intervention formats/delivery methods. Two coders used thematic analysis to determine rates of interest in each intervention type and explore patient-reported barriers and facilitators to motivation and intervention models.

RESULTS

Most of the samples reported motivation to enhance compensatory strategy use. Degree of motivation was driven by current experiences with strategy use, perceived benefit of potential changes, intrinsic desire to improve life and self, and current perceived need. The vast majority were interested in hour-long, multi-session, instructor-led interventions. Just over half of the sample was interested in a self-directed virtual program, and just under half was interested in involving family/friends. Facilitators and barriers to interest in intervention formats and delivery methods varied based on participants' previous experiences, preferred learning style, content, and time commitment of the intervention, and perceived current need for intervention. One-fifth of the sample expressed no interest in any intervention type, though they expressed openness to assistance in the future as needed.

CONCLUSIONS

Older adults with cognitive impairment are generally motivated to enhance their compensatory strategy use. Clinicians/researchers designing compensatory strategy interventions should consider instructor-led formats, present individualized benefits of interventions, and demonstrate the benefits of both preventative and remedial intervention to optimize patient engagement.

Flexibly Incorporating the Dyad into Psychosocial Intervention: Considerations for Neuropalliative Care

This paper reviews dyadic psychosocial intervention approaches that flexibly incorporate both dyad members despite challenges to equitable involvement due to cognitive limitations or limited availability. We provide an overview, analysis, and examples for the following dyadic intervention approaches: (1) shared interventions that involve each dyad member equitably (i.e., higher care recipient cognition, higher care-partner availability); (2) patient-focused interventions that primarily engage care recipients with early stages of neurocognitive disorders, yet include care-partners in select sessions and target dyadic and relationship needs (i.e., higher care recipient cognition, lower care-partner availability); and (3) care-partner focused interventions that primarily engage care-partners, yet still address care recipient and relationship needs (i.e., lower care recipient cognition, higher care-partner availability). In our review, we propose a flexible definition of dyadic psychosocial intervention that considers the continuum of individuals' involvement, measurement, content, and conceptual background. We conclude with a discussion of implications for neuropalliative care.

Pathogenesis, diagnostics, and therapeutics for Alzheimer's disease: Breaking the memory barrier

Alzheimer's disease (AD) is the most common cause of dementia and accounts for 60-70 % of all cases. It affects millions of people worldwide. AD poses a substantial economic burden on societies and healthcare systems. AD is a progressive neurodegenerative disorder characterized by cognitive decline, memory loss, and impaired daily functioning. As the prevalence of AD continues to increase, understanding its pathogenesis, improving diagnostic methods, and developing effective therapeutics have become paramount. This comprehensive review delves into the intricate mechanisms underlying AD, explores the current state of diagnostic techniques, and examines emerging therapeutic strategies. By revealing the complexities of AD, this review aims to contribute to the growing body of knowledge surrounding this devastating disease.

Comparison of Cognitive Intervention Strategies for Individuals With Alzheimer's Disease: A Systematic Review and Network Meta-analysis

Accumulating evidence has shown the effectiveness of cognitive interventions, which can be divided into cognitive training (CT), cognitive stimulation (CS), cognitive rehabilitation (CR), and combined interventions (i.e., cognitive interventions combined with other non-pharmacological interventions such as physical exercise), in individuals with Alzheimer's disease (AD). However, the effectiveness of cognitive interventions varies greatly among studies and more comprehensive studies are required. We aimed to evaluate whether the current evidence shows that cognitive interventions are effective at improving cognition, neuropsychiatric symptoms, depression, quality of life, and basic activities of daily living among individuals with possible or probable AD. Randomized controlled trials of all types of cognitive intervention were identified for inclusion in pairwise and network meta-analyses. There was a moderate and statistically significant post-intervention improvement in global cognition among individuals with AD for all types of cognitive intervention compared to control interventions (39 studies, g = 0.43, 95% CI: 0.28 to 0.58, p < 0.01; Q = 102.27, df = 38, p < 0.01; I2 = 61.97%, τ2 = 0.13). Regarding the specific types of cognitive intervention, combined interventions had the highest surface under the cumulative ranking curve (SUCRA) value (90.7%), followed by CT (67.8%), CS (53.4%), and lastly CR (28.9%). Significant effects of cognitive interventions were also found for working memory, verbal memory, verbal fluency, confrontation naming, attention, neuropsychiatric symptoms, basic activities of daily living, and quality of life.

Rehabilitation delivery models to foster healthy ageing-a scoping review

Introduction

Rehabilitation is essential to foster healthy ageing. Older adults have unique rehabilitation needs due to a higher prevalence of non-communicable diseases, higher susceptibility to infectious diseases, injuries, and mental health conditions. However, there is limited understanding of how rehabilitation is delivered to older adults. To address this gap, we conducted a scoping review to describe rehabilitation delivery models used to optimise older adults' functioning/functional ability and foster healthy ageing.

Methods

We searched Medline and Embase (January 2015 to May 2022) for primary studies published in English describing approaches to provide rehabilitation to older adults. Three authors screened records for eligibility and extracted data independently and in duplicate. Data synthesis included descriptive quantitative analysis of study and rehabilitation provision characteristics, and qualitative analysis to identify rehabilitation delivery models.

Results

Out of 6,933 identified records, 585 articles were assessed for eligibility, and 283 studies with 69,257 participants were included. We identified six rehabilitation delivery models: outpatient (24%), telerehabilitation (22%), home (18.5%), community (16.3%), inpatient (14.6%), and eldercare (4.7%). These models often involved multidisciplinary teams (31.5%) and follow integrated care principles (30.4%). Most studies used a disease-centred approach (59.0%), while studies addressing multimorbidity (6.0%) and prevalent health problems of older adults, such as pain, low hearing, and vision, or incontinence were scarce. The most frequently provided interventions were therapeutic exercises (54.1%), self-management education (40.1%), and assessment of person-centred goals (40%). Other interventions, such as assistive technology (8.1%) and environmental adaptations (7.4%) were infrequent.

Conclusions

Focusing on primary studies, this scoping review provides an overview of rehabilitation delivery models that are used to foster healthy ageing and highlights research gaps that require further attention, including a lack of systematic assessment of functioning/functional ability, a predominance of disease-centred rehabilitation, and a scarcity of programmes addressing prevalent issues like pain, hearing/vision loss, fall prevention, incontinence, and sexual dysfunctions. Our research can facilitate evidence-based decision-making and inspire further research and innovation in rehabilitation and healthy ageing. Limitations of our study include reliance on published research to infer practice and not assessing model effectiveness. Future research in the field is needed to expand and validate our findings.

The effect of cognitive rehabilitation on daily functioning of patients with Alzheimer's disease: a systematic review and meta-analysis of clinical trials

Background

Alzheimer's disease (AD) is the most prevalent type of dementia and represents 60-80% of dementia cases. AD affects over 32 million people globally, and 8.1% of affected females and 5.4% of affected males were older than 65 years. Cognitive rehabilitation focuses on helping patients develop individualized strategies to obtain or maintain optimal functioning. As of now, there is no complete and systematic meta-analysis on the effects of cognitive rehabilitation on cognitive functioning in AD patients.

Objectives

To provide the most recent and extensive pooled analysis and evidence and explore the influence of cognitive rehabilitation on overall cognitive functioning in patients with AD.

Methods

We searched articles through several databases such as PubMed, Cochrane Library, Embase, and Web of Science, from the inception to June 2023. Studies on cognitive stimulation, cognitive training, and cognitive interventions, and non-English articles were excluded. The outcome measures encompassed the effects of cognitive rehabilitation on the overall cognitive functioning of people with AD (e.g., verbal fluency, behavioral memory, neuropsychiatric status and occupational performance levels).

Results

A total of 14 clinical trials were included in this analysis. The meta-analysis showed that cognitive rehabilitation significantly improved quality of life (WMD: 2.87; 95% CI: 0.79, 4.95; p = 0.007) and occupational performance levels (WMD: 1.53; 95% CI: 0.43, 2.63; p = 0.007) in patients with AD. However, it did not show a significant effect on other domains of specific cognitive functions in patients with AD.

Conclusion

Cognitive rehabilitation exhibited a moderate to large impact on both quality of life and occupational performance levels in people with AD. Future studies are required to explore the potential of various cognitive interventions across specific domains, so as to provide more insights into the management of AD.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023444390.

Cognitive rehabilitation for people with mild to moderate dementia

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Cross-Frequency Coupling and Intelligent Neuromodulation

Cross-frequency coupling (CFC) reflects (nonlinear) interactions between signals of different frequencies. Evidence from both patient and healthy participant studies suggests that CFC plays an essential role in neuronal computation, interregional interaction, and disease pathophysiology. The present review discusses methodological advances and challenges in the computation of CFC with particular emphasis on potential solutions to spurious coupling, inferring intrinsic rhythms in a targeted frequency band, and causal interferences. We specifically focus on the literature exploring CFC in the context of cognition/memory tasks, sleep, and neurological disorders, such as Alzheimer's disease, epilepsy, and Parkinson's disease. Furthermore, we highlight the implication of CFC in the context and for the optimization of invasive and noninvasive neuromodulation and rehabilitation. Mainly, CFC could support advancing the understanding of the neurophysiology of cognition and motor control, serve as a biomarker for disease symptoms, and leverage the optimization of therapeutic interventions, e.g., closed-loop brain stimulation. Despite the evident advantages of CFC as an investigative and translational tool in neuroscience, further methodological improvements are required to facilitate practical and correct use in cyborg and bionic systems in the field.

Effectiveness of Computerized Cognitive Training by VIRTRAEL on Memory and Executive Function in Older People: A Pilot Study

The prevalence of people over 60 years of age with cognitive impairment has increased in recent decades. As a consequence, numerous computerized cognitive trainings (CCT) have been developed. This pilot study aimed to determine the effectiveness of the CCT with VIRTRAEL in improving older adults' cognition. Fifty-five participants (x¯ = 72.7 years; SD = 6.5) underwent CCT, and twenty participants (x¯ = 76.1 years; SD = 7.6) received face-to-face cognitive stimulation with a paper-and-pencil methodology. Both trainings were conducted in nine sessions (45-60 min each). Participants completed a pre-post training neuropsychological assessment. ANCOVAs and the standardized clinical change were performed. VIRTRAEL's group showed a significant and greater improvement in verbal learning (p < 0.006) and delayed recall (p ≤ 0.001), working memory (p < 0.005), abstract (p < 0.002) and semantic reasoning (p < 0.015), and planning (p < 0.021). Additionally, more large clinical changes (d > 0.8) were found in the VIRTRAEL condition (in verbal learning and delayed free and cued recall) than in the standard group. Here we show that the CCT with VIRTRAEL is effective in improving cognitive function in older adults and is superior to the standard format. These preliminary findings indicate that CCT is a useful tool potentially applicable in the fight against cognitive symptomatology associated with aging and neurodegenerative diseases. VIRTRAEL represents a breakthrough in this field as it is inexpensive and easily accessible to any older person, regardless of whether they live far from health care resources.

Effects of Mindfulness-Based Interventions (MBIs) in Patients with Early-Stage Alzheimer’s Disease: A Pilot Study

Bachground In this study, we hypothesize that mindfulness-based interventions (MBIs) may improve well-being and the related outcomes in Alzheimer’s dementia patients (AD-P) at an early stage. MBIs consist of the practice of consciously observing the psychic contents in the present moment (thoughts, sensations, feelings, and other events). This attention allows one to become aware of the psychic contents and integrate them, thus favoring the quality of life and an increase in the mood of practitioners. Methods The randomized controlled study enrolled 22 AD-P at an early stage (age ≥ 60 years) treated with MBIs and 22 patients without treatment (six months of MBI training). Tests (T0–T1 six months): Mini-Mental State Examination (MMPI); Spiritual Well-Being (SWB); Beck Depression Inventory (BDI); SF36. Test-Caregiver: Everyday Cognition scales (ECOG). Results AD-P with mindfulness: Improvement of ECOG (p = 0.026), quality of life (p < 0.001), spiritual well-being (p < 0.001); decrease in depression BDI (p < 0.001). The MMSE remains unchanged. The control group of untreated patients showed a significant worsening in all these dimensions. Conclusions MBI training is effective in increasing quality of life and preventing worsening in patients with early-stage Alzheimer’s dementia.

Antidepressant Effects of a Multimodal Group Therapy Program for Mild Dementia: A Retrospective Evaluation of Clinical Routine Data

BACKGROUND

The multimodal CORDIAL treatment concept for mild dementia, combining cognitive rehabilitation, cognitive behavioral and humanistic psychology interventions, has proven its feasibility and demonstrated a reduction of depressive symptoms in individual dyadic/triadic settings.

OBJECTIVE

We investigate antidepressant effects of an adapted group-based CORDIAL program in clinical routine care.

METHODS

During 2013 and 2017, 51 outpatients with mild dementia (45% female, mean age 72.4 years, 67% Alzheimer's dementia, mean MMST 24.8) periodically received a modified CORDIAL group treatment as part of our regular outpatient care. Treatment comprised 10 bi-weekly sessions, partly involving caregivers. Systematic pre- and post-treatment assessments of clinical routine data were evaluated retrospectively (median time-interval of 6.6 months).

RESULTS

Depressive symptoms as measured by the Geriatric Depression Scale significantly decreased over time (p = 0.007, Cohen's d = 0.39), and irrespective of gender. Patients with longer disease duration before treatment start showed significantly higher initial levels of depressive symptoms (p = 0.044), followed by a reduction to a level of those with shorter disease duration (ns). Most secondary outcomes (cognitive symptoms, disease severity, quality of life, caregiver burden) remained unchanged (ns), while competence in activities of daily living declined from pre- to post-measurement (p = 0.033).

CONCLUSION

A group-based CORDIAL treatment is feasible in a clinical routine setting and demonstrated antidepressant effects comparable to those of the individual treatment design, further suggesting its implementation in regular care. Future trials might also investigate its potentially preventive effects by reducing depressive symptoms in pre-dementia stages, even at a subsyndromal level.

Non-drug Therapies for Alzheimer's Disease: A Review

Alzheimer's disease (AD) is a debilitating disease leading to great social and economic burdens worldwide. During the past decades, increasing understanding of this disease enables dynamic trials for disease interventions. Unfortunately, at present, AD still remains uncurable, and therefore, developing intervention strategies for improving symptoms and slowing down the disease process becomes a practical focus in parallel with searching for a disease-modifying medication. The aim of this review is to summarize the outcomes of AD clinical trials of non-drug therapies published in the past decade, including cognitive-oriented interventions, physical exercise interventions, brain stimulation, as well as nutrition supplementations, to find out the most effective interventions in the category by looking through the primary and secondary outcomes. The outcomes of the trials could be varied with the interventional approaches, the tested cohorts, the settings of observing outcomes, and the duration of follow-ups, which are all discussed in this review. Hence, we hope to provide crucial information for application of these interventions in real-world settings and assist with optimization of clinical trial designs in this area.

Ageing, dementia and the future - ambivalent futurework in rehabilitation-focused dementia care

Due to its goal-orientation, rehabilitation may be considered a future-oriented practice. As rehabilitation is increasingly recognized as contributing to dementia care it is important to explore how rehabilitation corresponds with the future orientation of older people with dementia.The aim of this study was to explore the futurework of home-dwelling people with mild to moderate dementia in the context of rehabilitation-focused municipal dementia care, that is, their thinking and practices regarding their future and how these correspond with institutionalized practices.The study was conducted as a case-study inspired by the methodology of Institutional Ethnography (IE). The study setting was two Danish municipalities sampled as a paradigmatic case. Eight older people living with early-stage dementia (mean age: 78 years, age range: 65-91) were strategically sampled and each interviewed recurringly within a period of six through 15 months. In total, 29 interviews were completed. An abductive analysis was subsequently conducted based on these interviews.Findings included three dimensions of futurework: Extending the present state into the near future; avoiding being confronted with an anticipated future; and adjusting to decline and preparing for future losses. Based on these findings, a notion of 'ambivalent futurework' is suggested. The futurework of older people did not always correspond with the institutional arrangements in a rehabilitation-focused dementia care. Findings show that the institutional arrangements in dementia care may support as well as challenge the futurework of the participants. Paying attention to the ambivalences of older people living with dementia and recognizing the ambivalent futurework may be essential in rehabilitation-focused dementia care.

Cognitive training for elderly patients with early Alzheimer’s disease in the Qinghai-Tibet Plateau: A pilot study

BACKGROUND

Alzheimer’s disease (AD) influences the social and economic quality of life of older adult patients and their families.

AIM

To explore the efficacy of cognitive training in clinical nursing for patients with early AD residing in the plateau area.

METHODS

This pilot study was conducted in patients with early AD treated in the Geriatric Department of the Qinghai Provincial People’s Hospital between August 2019 and March 2021. The patients were divided into a cognitive training group and a conventional nursing group using the random number table method. Patients in the conventional nursing group received conventional nursing, whereas the patients in the cognitive training group received the new nursing intervention. The mini-mental state examination (MMSE) and activities of daily living (ADL) scales were used to compare the cognitive ability and daily activities, respectively, between the two groups before and after the intervention.

RESULTS

Sixty patients were enrolled in this study, with 30 patients in the cognitive training group and conventional nursing group, respectively. The MMSE and ADL scores were significantly higher in the cognitive training group than in the conventional nursing group after the intervention (MMSE: 25.11 ± 2.02 vs 22.26 ± 1. 23, P = 0.032; ADL: 68.72 ± 4.86 vs 60.16 ± 2.27, P = 0.018).

CONCLUSION

The application of cognitive training in clinical nursing for patients with early AD could improve both their cognitive ability and ADL. This method could be applied in clinical practice to manage cognitive dysfunction in patients with early AD.

Cognitive and Physical Intervention in Metals’ Dysfunction and Neurodegeneration

Metals—especially iron, copper and manganese—are important elements of brain functions and development. Metal-dysregulation homeostasis is associated with brain-structure damage to the motor, cognitive and emotional systems, and leads to neurodegenerative processes. There is more and more evidence that specialized cognitive and motor exercises can enhance brain function and attenuate neurodegeneration in mechanisms, such as improving neuroplasticity by altering the synaptic structure and function in many brain regions. Psychological and physical methods of rehabilitation are now becoming increasingly important, as pharmacological treatments for movement, cognitive and emotional symptoms are limited. The present study describes physical and cognitive rehabilitation methods of patients associated with metal-induced neurotoxicity such as Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, Huntington’s disease and Wilson’s disease. In our review, we describe physical (e.g., virtual-reality environments, robotic-assists training) and psychological (cognitive training, cognitive stimulation, neuropsychological rehabilitation and cognitive-behavioral and mindfulness-based therapies) methods, significantly improving the quality of life and independence of patients associated with storage diseases. Storage diseases are a diverse group of hereditary metabolic defects characterized by the abnormal cumulation of storage material in cells. This topic is being addressed due to the fact that rehabilitation plays a vital role in the treatment of neurodegenerative diseases. Unfortunately so far there are no specific guidelines concerning physiotherapy in neurodegenerative disorders, especially in regards to duration of exercise, type of exercise and intensity, as well as frequency of exercise. This is in part due to the variety of symptoms of these diseases and the various levels of disease progression. This further proves the need for more research to be carried out on the role of exercise in neurodegenerative disorder treatment.

Computer aided self-regulation learning and cognitive training improve generalization ability of patients with poststroke cognitive impairment

Emerging studies suggest the application of self-regulation learning (SRL) to improve generalization abilities in poststroke patients. SRL has been proposed to have an added effect on computer-aided cognitive training (CACT). This study aimed to examine the efficacy of an intervention combining computer-aided SRL (CA-SRL) training and CACT for generalization abilities and cognitive function in patients with poststroke cognitive impairment (PSCI). A total of 75 patients recruited from a rehabilitation centre were randomly assigned to a CA-SRL group, demonstration learning (DL) group and traditional learning (TL) group. Finally, 72 patients were included in the analysis. Over 3 weeks, the patients in these three groups underwent CA-SRL or DL training combined with cognitive training. After the intervention, all outcomes significantly improved (P < 0.05). The CA-SRL group showed better improvements in all trained tasks among the groups, especially in "wash the dishes" and "change the bed". The results of the analysis for generalization abilities showed that CA-SRL group patients obtained the highest scores among the groups in untrained tasks. The mean changes in the Montreal Cognitive Assessment in both the CA-SRL and TL groups were significantly higher than those in the DL group (P < 0.001, P = 0.002) after adjusting for education level and Lawton Instrumental ADL Scale score. In general, the combination of CA-SRL and CACT is effective for PSCI patients and has a better effect on promoting skill generalization from cognitive gains than traditional training.

Efficacy of Cognitive Rehabilitation Versus Usual Treatment at Home in Patients With Early Stages of Alzheimer Disease

INTRODUCTION

Assessing the benefit of cognitive rehabilitation (CR) remains difficult.

METHOD

An observational study was conducted in 33 patients with early-stage Alzheimer disease and their caregiver included in a clinical CR program at home, compared to 17 patients who received usual treatment. Evaluation of patient's dependence and objective and subjective caregiver's burden was performed by the caregiver with a research tool focusing on impairment in daily activities related to cognitive deficits.

RESULTS

Repeated measures analysis of variance showed a time by group interaction (P < .05), with decreased patient's dependence for adapted activities at 1 year in the CR group. Lawton scale for daily activities showed also a time by group interaction (P < .05), with increased dependence at 1 year in the control group. There was a significant decrease in Mini-Mental State Examination scores in both groups at 1-year follow-up (P < .05). Concerning caregiver's subjective burden, there was a trend for the time by group interaction (P = .07), and post hoc Tukey test showed that subjective burden was decreased in the CR group (P < .05). This was confirmed by nonparametric Mann-Whitney analysis on differences between follow-up and baseline evaluation (P < .05).

CONCLUSION

This observational study in a clinical setting is in line with the benefit of CR reported in recent randomized controlled trials. The benefit obtained for adapted daily activities remained after 1 year, even if global cognition declined. Moreover, caregiver's subjective burden related to all relevant daily activities evaluated within the CR program was decreased after 1 year in our clinical setting.

The Effect of Cognitive Intervention on Cognitive Function in Older Adults With Alzheimer's Disease: A Systematic Review and Meta-Analysis

Cognitive intervention includes cognitive stimulation, cognitive training, and cognitive rehabilitation. This systematic review was performed to re-assess the efficacy of cognitive intervention for the patients with Alzheimer's disease (AD). Twenty studies (2012 participants) were eventually included. For global cognitive function, the combined mean difference (MD) in eight studies was 1.67 (95% Confidence Interval: 0.45, 2.89, p = 0.007; Q = 33.28, df = 8, p < 0.0001, τ² = 2.17, I² = 76%) for the short term. The pooled standardized mean difference (SMD) of six RCTs was 1.61 (95% Confidence Interval: 0.65, 2.56, p = 0.0009; Q = 127.66, df = 6, p < 0.00001, τ² = 1.56, I² = 95%) for the medium term. The pooled SMD of seven studies was 0.79 (95% Confidence Interval: 0.33, 1.25, p = 0.0008; Q = 35.10, df = 7, p < 0.0001, τ² = 0.33, I² = 80%) for the long term. For depression, the pooled SMD of two trials was -0.48 (95% Confidence Interval: -0.71, -0.24; p < 0.0001, I² = 4%) for the short term. Cognitive training may show obvious improvements in global cognitive function whether after short, medium, or long-term interventions and in depression after short term intervention. However, the positive effect of the intervention on general cognitive function or depression did not seem to persist after intervention ended. There is still a lack of reliable and consistent conclusions relevant to the effect of cognitive stimulation and cognitive rehabilitation on observed outcomes, cognitive training for memory or other non-cognitive outcomes. PROSPERO registration number: CRD42019121768.

Managing depressive symptoms in people with mild cognitive impairment and mild dementia with a multicomponent psychotherapy intervention: a randomized controlled trial

OBJECTIVE

To evaluate the feasibility and effectiveness of the CORDIAL program, a psychosocial intervention consisting of cognitive behavioral therapy (CBT), cognitive rehabilitation, and reminiscence to manage depressive symptoms for people with mild cognitive impairment (MCI) or dementia.

DESIGN

We conducted a randomized controlled trial, based on a two-group (intervention and control), pre-/post-intervention design.

SETTING

Participants were recruited from five different old age psychiatry and memory clinics at outpatients' hospitals.

PARTICIPANTS

Hundred and ninety-eight people with MCI or early-stage dementia were included.

INTERVENTION

The intervention group (n = 100) received 11 individual weekly sessions of the CORDIAL program. This intervention includes elements from CBT, cognitive rehabilitation, and reminiscence therapy. The control group (n = 98) received treatment-as-usual.

MEASUREMENTS

We assessed Montgomery-Åsberg Depression Rating Scale (MADRS) (main outcome), Neuropsychiatric Inventory Questionnaire, and Quality of Life in Alzheimer's disease (secondary outcomes) over the course of 4 months and at a 10-month follow-up visit.

RESULTS

A linear mixed model demonstrated that the depressive symptoms assessed by MADRS were significantly more reduced in the intervention groups as compared to the control group (p < 0.001). The effect persisted for 6 months after the intervention. No significant differences between groups were found in neuropsychiatric symptoms or quality of life.

CONCLUSION

Our multicomponent intervention, which comprised 11 individual sessions of CBT, cognitive rehabilitation, and reminiscence therapy, reduced depressive symptoms in people with MCI and dementia.

The Effect of Cognitive Training in a Day Care Center in Patients with Early Alzheimer's Disease Dementia: A Retrospective Study

OBJECTIVE

This study aimed to evaluate the effect of cognitive training programs on the progression of dementia in patients with early stage Alzheimer's disease dementia (ADD) at the day care center.

METHODS

From January 2015 to December 2018, a total of 119 patients with early ADD were evaluated. All subjects were classified into two groups according to participate in cognitive training program in addition to usual standard clinical care. Changes in scores for minimental status examination-dementia screening (MMSE-DS) and clinical dementia rating-sum of boxes (CDR-SOB) during the 12 months were compared between two groups. Multivariable logistic regression analyses were performed.

RESULTS

As compared to case-subjects (n=43), the MMSE-DS and CDR-SOB scores were significantly worse at 12 months in the control-subjects (n=76). A statistically significant difference between the two groups was observed due to changes in MMSE-DS (p=0.012) and CDR-SOB (p<0.001) scores. Multivariable logistic regression analysis showed that the cognitive training program (odds ratio and 95% confidence interval: 0.225, 0.070-0.725) was independently associated with less progression of ADD.

CONCLUSION

The cognitive training program was associated with benefits in maintaining cognitive function for patients with earlystage ADD that were receiving medical treatment.

The role of the brain in the treatment of multiple sclerosis as a connectomopathy

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system (CNS) causing a variety of symptoms. Although MS is recognized by the demyelinating process, the axonal injury can occur from the start of the disease and lead to neurodegenerative process in the disease. Although MS appears to damage the brain locally, the progressive and neurodegenerative nature of the disease indicate the general and global brain damage. Various studies have indicated this global damage at all areas of white and gray matter. Moreover, the earlier stages of mentioned disease can affect the structural and functional brain connections. Demyelinating lesions, which are local at first glance, lead to a global damage to the functional connections of the brain. Therefore, it seems that the brain network or brain connectome are broadly affected by this disease; therefore, MS can be referred as a connectomopathy. The drugs used in this disease all seek to suppress or regulate the immune system, and the human brain has always been considered as a therapeutic target. However, if the brain is generally involved in the disease, so the treatment should be general. In fact, the treatment process should target the connectomopathy. One of the methods that can be used to achieve the mentioned goal is attending to the role of the brain in its treatment.

Effectiveness of Exergaming in Improving Cognitive and Physical Function in People With Mild Cognitive Impairment or Dementia: Systematic Review

BACKGROUND

Individuals with mild cognitive impairment and dementia have impaired physical and cognitive functions, leading to a reduced quality of life compared with those without such impairment. Exergaming, which is defined as a combination of exercise and gaming, is an innovative, fun, and relatively safe way to exercise in a virtual reality or gaming environment. Therefore, exergaming may help people living with mild cognitive impairment or dementia to overcome obstacles that they may experience regarding regular exercise and activities.

OBJECTIVE

The aim of this systematic review was to review studies on exergaming interventions administered to elderly individuals with mild cognitive impairment and dementia, and to summarize the results related to physical and cognitive functions such as balance, gait, executive function, and episodic memory.

METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PsycINFO, Amed, and Nursing Database for articles published from the inception of the respective databases to January 2019. We included all clinical trials of exergaming interventions in individuals with mild cognitive impairment and dementia for review. The risk of bias was independently evaluated by two reviewers using the Cochrane Collaboration and Risk of Bias in Non-randomized Studies of Interventions tools.

RESULTS

Ten studies involving 702 participants were included for review. There was consistent evidence from 7 studies with a low risk of bias showing statistically significant effects of exergaming on cognitive functioning in people with mild cognitive impairment and dementia. With respect to physical function, 3 of 5 full-scale studies found positive results, and the intensity of most games was classified as moderate.

CONCLUSIONS

Overall, exergaming is an innovative tool for improving physical and cognitive function in people with mild cognitive impairment or dementia, although there is high heterogeneity among studies in terms of the duration, frequency, and gaming platform used. The quality of the included articles was moderate to high. More high-quality studies with more accurate outcome indicators are needed for further exploration and validation of the benefits of exergaming for this population.

Memory response and neuroimaging correlates of a novel cognitive rehabilitation program for memory problems in epilepsy: A pilot study

BACKGROUND

Memory deficits are very common in epilepsy, but no standard of care exists to effectively manage them.

OBJECTIVE

We assessed effectiveness of cognitive rehabilitation (CR) on memory and neural plasticity in people with epilepsy (PWE) reporting memory impairments.

METHODS

Nine PWE completed 6 weekly sessions adapted from 2 generic CR programs enriched with information regarding epilepsy. Participants completed neuropsychological, mood, and quality of life (QOLIE-31) measures prior and after completion of CR; 5/9 participants also completed pre- and post-CR fMRI while performing a verbal paired associates learning task. FMRI data were analyzed using group spatial independent components analysis methods; paired t-tests compared spatial activations for pre-/post-CR.

RESULTS

Improvements were seen in immediate recall in Rey Auditory Verbal Learning Task, QOLIE-31, and read word recognition in paired associates task (all p's≤0.05). FMRI changes comparing pre-to-post CR were noted through increased activation in the left inferior frontal gyrus (IFG) and anterior cingulate and decreased activation in the left superior temporal gyrus; also noted were decreased activations in the default mode network (DMN), right cingulate, right middle temporal gyrus, right supramarginal gyrus, and increased DMN activation in the left cuneus.

CONCLUSIONS

This study demonstrates feasibility of conducting CR program in PWE with fMRI as a mechanistic biomarker. Improvements in cognition and cortical plasticity await confirmation in larger samples.

Rehabilitation for People Living with Dementia: A Scoping Review of Processes and Outcomes

Objectives

The aim of this scoping review was to map intervention studies of rehabilitation for people living with dementia regarding processes and outcomes, with a particular focus on whether the intervention is person-centred, home-based, or organised adopting a multidisciplinary approach and measures outcomes relating to everyday functioning and well-being.

Methods

A systematic search of electronic databases was conducted in PubMed, CINAHL, PsycINFO, Embase, and Cochrane. Studies from 2005 to November 2018 were collected and screened for relevance and quality. Randomised control trials and prospective cohort trials reporting a statistically significant effect on one or more outcome measures were included. Included studies were mapped according to selected processes and outcome measures.

Results

Twenty-six intervention studies were included and mapped. Nineteen of the interventions were person-centred, nine were home-based, and 14 reported a multidisciplinary approach. Twelve of the interventions had activities of daily living as an outcome measure, and 14 had quality of life as an outcome measure.

Conclusion

Person-centredness appears in most rehabilitation interventions for people living with dementia. Other processes and outcomes are heterogeneously described in the research literature. Rehabilitation programmes can be home-based or take place at a centre. Although not exclusive, the organisation of rehabilitation can be multidisciplinary. Fewer than half of the intervention studies measure the impact on activities of daily living and quality of life. Future guidelines must take into account the weak evidence regarding these aspects.

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.

Efficacy of Cognitive Rehabilitation in Alzheimer Disease: A 1-Year Follow-Up Study

INTRODUCTION

The benefit of cognitive rehabilitation (CR) for patients with early-stage Alzheimer disease (AD) remains difficult to assess.

METHOD

An observational, prospective study was conducted in a sample of 52 patients with AD included in a clinical, individualized CR program. Cognitive rehabilitation consisted of 1 weekly session during 3 months at home, followed by 1 monthly contact for 9 months. Rehabilitation techniques were used by experienced therapists to adapt activities important for the patient. Evaluation of patient's dependence in activities and objective and subjective caregiver's burden was performed with a research quantitative scale immediately after the intervention and at 6-month and 1-year follow-up.

RESULTS

Analyses with repeated measure analysis of variance showed decreased patient's dependence for adapted activities at 3 months, 6 months, and 1 year. Objective and subjective percentage of caregiver's burden was also decreased at all evaluations with our research functional scale, while there was no change on Zarit's burden scale. Global cognition slightly decreased over 1 year.

CONCLUSIONS

This observational study in a clinical setting is in line with the benefit of CR for patients with mild AD reported in recent randomized controlled trials. The benefit obtained for adapted activities remained after 1 year, even if global cognition declined. Moreover caregiver's burden related to all individually relevant daily activities (from a list of 98) evaluated within the CR program was decreased after 1 year. Those preliminary results emphasize the importance of choice for the measurement instrument to report CR efficacy and claim for further validation of such tools.

Does Functional Connectivity Provide a Marker for Cognitive Rehabilitation Effects in Alzheimer's Disease? An Interventional Study

BACKGROUND

Cognitive rehabilitation (CR) is a cognitive intervention for patients with Alzheimer's disease (AD) that aims to maintain everyday competences. The analysis of functional connectivity (FC) in resting-state functional MRI has been used to investigate the effects of cognitive interventions.

OBJECTIVES

We evaluated the effect of CR on the default mode network FC in a group of patients with mild AD, compared to an active control group.

METHODS

We performed a three-month interventional study including 16 patients with a diagnosis of AD. The intervention group (IG) consisted of eight patients, performing twelve sessions of CR. The active control group (CG) performed a standardized cognitive training. We used a seed region placed in the posterior cingulate cortex (PCC) for FC analysis, comparing scans acquired before and after the intervention. Effects were thresholded at a significance of p < 0.001 (uncorrected) and a minimal cluster size of 50 voxels.

RESULTS

The interaction of group by time showed a higher increase of PCC connectivity in IG compared to CG in the bilateral cerebellar cortex. CG revealed widespread, smaller clusters of higher FC increase compared with IG. Across all participants, an increase in quality of life was associated with connectivity increase over time in the bilateral precuneus.

CONCLUSIONS

CR showed an effect on the FC of the DMN in the IG. These effects need further study in larger samples to confirm if FC analysis may suit as a surrogate marker for the effect of cognitive interventions in AD.