Linda Clare

Nonpharmacological Therapies in Alzheimer’s Disease: A Systematic Review of Efficacy

Introduction: Nonpharmacological therapies (NPTs) can improve the quality of life (QoL) of people with Alzheimer’s disease (AD) and their carers. The objective of this study was to evaluate the best evidence on the effects of NPTs in AD and related disorders (ADRD) by performing a systematic review and meta-analysis of the entire field. Methods: Existing reviews and major electronic databases were searched for randomized controlled trials (RCTs). The deadline for study inclusion was September 15, 2008. Intervention categories and outcome domains were predefined by consensus. Two researchers working together detected 1,313 candidate studies of which 179 RCTs belonging to 26 intervention categories were selected. Cognitive deterioration had to be documented in all participants, and degenerative etiology (indicating dementia) had to be present or presumed in at least 80% of the subjects. Evidence tables, meta-analysis and summaries of results were elaborated by the first author and reviewed by author subgroups. Methods for rating level of evidence and grading practice recommendations were adapted from the Oxford Center for Evidence-Based Medicine. Results: Grade A treatment recommendation was achieved for institutionalization delay (multicomponent interventions for the caregiver, CG). Grade B recommendation was reached for the person with dementia (PWD) for: improvement in cognition (cognitive training, cognitive stimulation, multicomponent interventions for the PWD); activities of daily living (ADL) (ADL training, multicomponent interventions for the PWD); behavior (cognitive stimulation, multicomponent interventions for the PWD, behavioral interventions, professional CG training); mood (multicomponent interventions for the PWD); QoL (multicomponent interventions for PWD and CG) and restraint prevention (professional CG training); for the CG, grade B was also reached for: CG mood (CG education, CG support, multicomponent interventions for the CG); CG psychological well-being (cognitive stimulation, multicomponent interventions for the CG); CG QoL (multicomponent interventions for PWD and CG). Conclusion: NPTs emerge as a useful, versatile and potentially cost-effective approach to improve outcomes and QoL in ADRD for both the PWD and CG.

Rehabilitation of executive functioning: An experimental–clinical validation of Goal Management Training

Two studies assessed the effects of a training procedure (Goal Management Training, GMT), derived from Duncans theory of goal neglect, on disorganized behavior following TBI. In Study 1, patients with traumatic brain injury (TBI) were randomly assigned to brief trials of GMT or motor skills training. GMT, but not motor skills training, was associated with significant gains on everyday paper-and-pencil tasks designed to mimic tasks that are problematic for patients with goal neglect. In Study 2, GMT was applied in a postencephalitic patient seeking to improve her meal-preparation abilities. Both naturalistic observation and self-report measures revealed improved meal preparation performance following GMT. These studies provide both experimental and clinical support for the efficacy of GMT toward the treatment of executive functioning deficits that compromise independence in patients with brain damage.

A meta-analysis of cognitive deficits in adults with a diagnosis of schizophrenia.

This review identified 1275 studies examining cognitive deficits in people with schizophrenia, published between 1990 and 2003. Data from 113 studies (4365 patients and 3429 controls) were combined in a meta-analysis carried out on the five cognitive domains of IQ, memory, language, executive function, and attention. Studies were excluded where they lacked a suitable control group or failed to present complete information. In all five cognitive domains, analysis indicated a consistent trend for patients to perform more poorly than healthy controls, with significant heterogeneity across studies. Sources of heterogeneity were analyzed and a need to ensure more appropriate composition of patient and control groups and to adopt a more refined and methodologically correct, hypothesis-driven approach was identified.

Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer's disease: A review

Memory difficulties are a defining feature of Alzheimers disease (AD), with significant implications for people with AD and family members. Interventions aimed at helping with memory difficulties, therefore, may be important in reducing excess disability and improving well-being. There is a long tradition of cognition-focused intervention in dementia care. In this review we offer broad definitions and descriptions of three approaches to cognition-focused intervention for people with dementia—cognitive stimulation, cognitive training and cognitive rehabilitation—and attempt to clarify the underlying concepts and assumptions associated with each. Cognitive training and cognitive rehabilitation are the main approaches used with people who have early-stage AD. We review a range of studies describing the implementation of these two approaches, and evaluate the evidence for their effectiveness. With regard to cognitive training, the evidence currently available does not provide a strong demonstration of efficacy, but findings must be viewed with caution due to methodological limitations. It is not possible at present to draw firm conclusions about the efficacy of individualised cognitive rehabilitation interventions for people with early-stage dementia, due to the lack of any randomised controlled trials (RCTs) in this area, although indications from single-case designs and small group studies are cautiously positive. Further research is required that takes account of the conceptual and methodological issues outlined here.

Intervening with everyday memory problems in dementia of Alzheimer type : An errorless learning approach

Dementia of Alzheimer Type (DAT) is increasingly detected at an earlier stage of the disorder, when interventions to assist with everyday memory difficulties might be most valuable. Some learning is possible in DAT and a number of factors have been identified which may facilitate performance, although applications to everyday memory problems have been limited. The concept of errorless learning has not previously been directly examined in relation to DAT, but might provide a useful additional strategy. In the present study, 6 participants with early stage DAT (MMSE scores 21 – 26) received individually tailored interventions, based on errorless learning principles and targeted at a specific everyday memory problem. Five of the participants showed significant improvement on the target measures, and maintained this improvement up to 6 months later. The results suggest that it is feasible to intervene with everyday memory problems in the early stages

Memory in schizophrenia: What is impaired and what is preserved?

This study assesses the pattern of long-term memory performance in a sample of 12 schizophrenic patients who were selected on the basis of showing a memory deficit in the absence of gross overall intellectual impairment. When compared with 12 control subjects matched for age, sex and estimated premorbid IQ, presence of an episodic memory deficit was confirmed for both prose recall and forced-choice word and face recognition. Semantic memory was assessed using the sentence verification task developed by Collins and Quillian, an unpaced category judgement task, and the Mill Hill Vocabulary Scale. The schizophrenic patients were slower on sentence verification and they made significantly more errors in all three tasks. Procedural tasks included pursuit rotor performance, speed of repeatedly assembling a jigsaw puzzle and rate of improvement in reading transformed script. Here, while the schizophrenic patients showed poor overall performance on the pursuit rotor and jigsaw learning, their rate of learning on all three procedural tasks was comparable with that of the controls. When examined on two implicit memory tasks involving biasing of spelling of homophones and word stem completion, the patients showed a normal degree of priming in both. Implications for the nature of the memory deficit in schizophrenia are discussed.

Executive functions in Parkinson's disease: systematic review and meta-analysis.

Impairment of executive function (EF) is commonly reported as a feature of PD. However, the exact pattern of executive impairment remains unclear. Also, there is an ongoing discussion surrounding the definition and conceptualization of EF, which might affect the clarity of research evidence on cognition in PD. The aim of this systematic review was to describe the pattern of executive impairment in early‐stage PD emerging from the research literature and to identify critical issues for improving consistency in this field. The PsychInfo, MEDLINE, Science Direct, CINAHL, and Cochrane Library databases were searched using the term “Parkinsons disease” combined with each of 14 cognitive abilities defined as representing aspects of EF. The review was limited to studies that investigated EF as the central variable in early‐stage, nondemented PD patients. The review identified 33 studies of EF that were operationalized in terms of 30 abilities tested by 60 measures and variously interpreted. Many measures were used only once, so only a small part of the available research evidence could be synthesized in the meta‐analysis. The meta‐analysis was undertaken using data from five commonly used tests of EF drawn from 18 studies. This revealed consistent evidence for cognitive difficulties across all five EF tests. Research on EF in PD is characterized by a considerable lack of clarity with regard to measure selection and interpretation. The findings support the view that EF impairments are evident in PD. However, the clinical significance of the cognitive abnormalities reported has yet to be clarified. 2011 Movement Disorder Society

Making sense of dementia and adjusting to loss: Psychological reactions to a diagnosis of dementia in couples

The current emphasis on early detection and disclosure of a diagnosis of dementia highlights the need to examine couples’ shared constructions of, and responses to, the diagnosis, and to explore the appraisals that couples make about the illness at an early stage. While the experiences of carers and of people with dementia have mostly been considered separately, further investigation of the shared experience of couples where one partner is developing dementia is required. This study adopted a family systems perspective to investigate psychological reactions to a diagnosis of dementia in nine couples where one partner had received a diagnosis of either Alzheimers disease or vascular dementia, with particular emphasis on the possible relevance of psychological responses to loss. Interpretative phenomenological analysis was used to explore participants’ experiences of receiving a diagnosis of dementia, which were compared and contrasted across couples. Ten themes were subsumed under two higher-order themes, ‘Not quite the same person, tell me what actually is wrong’ and ‘Everythings changed, we have to go from there’, and linked through the overarching theme of ‘Making sense and adjusting to loss’. A model is presented that encapsulates the oscillating processes couples appeared to go through in making sense of the experience of early-stage dementia and adjusting to the losses and difficulties evoked by the illness, which appeared to be similar to the process of adjustment outlined in dual-process models of grief. The findings suggest that couples who receive a diagnosis of dementia may be supported by helping them to create a joint construction that enables them to make sense of their situation, find ways of adjusting to the changes experienced in their roles and identity, and manage the losses they face in the early stages of dementia.

Goal-Oriented Cognitive Rehabilitation for People With Early-Stage Alzheimer Disease: A Single-Blind Randomized Controlled Trial of Clinical Efficacy

OBJECTIVES To provide evidence regarding the clinical efficacy of cognitive rehabilitation (CR) in early-stage Alzheimer disease (AD). DESIGN Single-blind randomized controlled trial comparing CR with relaxation therapy and no treatment. SETTING Outpatient, community-based setting. PARTICIPANTS Sixty-nine individuals (41 women, 28 men; mean age 77.78 years, standard deviation 6.32, range = 56-89) with a diagnosis of AD or mixed AD and vascular dementia and a Mini-Mental State Examination score of 18 or above, and receiving a stable dose of acetylcholinesterase-inhibiting medication. Forty-four family carers also contributed. INTERVENTION Eight weekly individual sessions of CR consisting of personalized interventions to address individually relevant goals supported by components addressing practical aids and strategies, techniques for learning new information, practice in maintaining attention and concentration, and techniques for stress management. MEASUREMENTS The primary outcomes were goal performance and satisfaction, assessed using the Canadian Occupational Performance Measure. Questionnaires assessing mood, quality of life and career strain, and a brief neuropsychological test battery were also administered. A subset of participants underwent functional magnetic resonance imaging (fMRI). RESULTS CR produced significant improvement in ratings of goal performance and satisfaction, whereas scores in the other two groups did not change. Behavioral changes in the CR group were supported by fMRI data for a subset of participants. CONCLUSIONS The findings support the clinical efficacy of CR in early-stage AD. CR offers a means of assisting people with early-stage AD and their families in managing the effects of the condition.

Errorless learning in the rehabilitation of memory impairment: a critical review.

This review considers the origins of the errorless learning (EL) concept, its application in memory rehabilitation, the evidence for its effectiveness, and the theoretical basis for the observed findings. The evidence suggests that EL offers valuable benefits for at least some people with memory impairments when teaching certain types of tasks. However, the benefits are not evident for all groups, some findings are equivocal, and there are some limitations associated with this approach. We discuss methodological issues impacting on these mixed findings, consider which theoretical explanations might account for the findings regarding benefits and limitations of EL, and comment on the implications for rehabilitation practitioners of the current state of evidence in this area.