Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention

Enhancing cognitive flexibility and working memory in individuals with mild cognitive impairment: Exploring the impact of virtual reality on daily life activities

Mild Cognitive Impairment (MCI) serving as a transitional stage between normal aging and dementia. This study aimed to explore the impact of virtual reality (VR) on enhancing cognitive flexibility, working memory, and daily life activities. Forty participants diagnosed with MCI were randomly assigned to either an intervention group (N = 20) or a control group (N = 20). Evaluations were at baseline, post-training, and three months post-training using various cognitive assessment tools. Results showed that the VR-based cognitive rehabilitation significantly improved instrumental activities of daily living performance, visual and verbal working memory, and reduced anxiety and depression symptoms. While cognitive flexibility did not exhibit significant improvement, these findings highlight VR interventions as a potential avenue for improving cognitive and functional aspects, and alleviating psychological symptoms in individuals with MCI. Further research with larger sample sizes and extended follow-up periods is recommended to establish the long-term effectiveness of such interventions.

Suitability of Goal Attainment Scaling in Older Adult Populations with Neurodegenerative Disease Experiencing Cognitive Impairment: A Systematic Review and Meta-Analysis

INTRODUCTION

Identifying responsive outcome measures for assessing functional change related to cognition, communication, and quality of life for individuals with neurodegenerative disease is important for intervention design and clinical care. Goal Attainment Scaling (GAS) has been used as an outcome measure to formally develop and systematically measure incremental progress toward functional, patient-centered goals in clinical settings. Evidence suggests that GAS is reliable and feasible for use in older adult populations and in adult populations with cognitive impairment, but no review has assessed the suitability of GAS in older adults with neurodegenerative disease experiencing dementia or cognitive impairment, based on responsiveness. This study conducted a systematic review to evaluate the suitability of GAS as an outcome measure for older adult populations with neurodegenerative disease experiencing dementia or cognitive impairment, based on responsiveness.

METHODS

The review was registered with PROSPERO and performed by searching ten electronic scientific databases (PubMed, Medline OVID, CINAHL, Cochrane, Embase, Web of Science, PsycINFO, Scopus, OTSeeker, REHABDATA) and four registries (Clinicaltrials.gov, Grey Literature Report, Mednar, OpenGrey). A summary measure of responsiveness (post-intervention minus pre-intervention mean GAS T-score) was compared across eligible studies using a random-effects meta-analysis. Risk of bias in included studies was assessed using the NIH Quality Assessment Tool for Before-After (Pre-Post) Studies with No Control Group.

RESULTS

882 eligible articles were identified and screened by two independent reviewers. Ten studies met inclusion criteria for the final analysis. Of the ten included reports, 3 focus on all-cause dementia, 3 on multiple sclerosis, 1 on Parkinson's disease, 1 on mild cognitive impairment, 1 on Alzheimer's disease, and 1 on primary progressive aphasia. Responsiveness analyses showed pre- and post-intervention GAS goals were significantly different from zero (Z = 7.48, p < 0.001), with post-intervention GAS scores being higher than pre-intervention GAS scores. Three included studies showed a high risk of bias, 3 showed a moderate risk of bias, and 4 showed a low risk of bias. Overall risk of bias of included studies was rated as moderate.

CONCLUSION

GAS showed an improvement in goal attainment across different dementia patient populations and intervention types. The overall moderate risk of bias suggests that while bias is present across included studies (e.g., small sample size, unblinded assessors), the observed effect likely represents the true effect. This suggests that GAS is responsive to functional change and may be suitable for use in older adult populations with neurodegenerative disease experiencing dementia or cognitive impairment.

Dysexecutive Behaviors Mediate the Relationship Between Functional Impairment and Caregiver Burden in Mild Cognitive Impairment

Mild cognitive impairment (MCI) is often accompanied by executive dysfunction (ED), dysexecutive behaviors (DB), and functional impairment (FI). The respective contributions of ED, DB, and FI to caregiver burden in MCI are not well understood. The present study hypothesized that while all factors would predict caregiver burden in MCI, ED and family-reported DB would account for greater variance in caregiver burden and mediate the relationship between FI and caregiver burden. In our sample (n = 94), linear regression revealed that FI and DB predicted caregiver burden, but that DB predicted caregiver burden above and beyond the contribution of FI. DB mediated the relationship between FI and caregiver burden. These results add to a body of work demonstrating that presence of DB and FI are distressing to family members, even in mild disease stages. Because DB may account for the relationship between FI and caregiver burden, early identification of family members reporting DB in the person with MCI is imperative so that supports can be made available.

Goal setting for people with mild cognitive impairment or dementia in rehabilitation: A scoping review

INTRODUCTION

Goal setting is an integral part of the rehabilitation process and assists occupational therapists to target therapy towards achieving meaningful outcomes. People with mild cognitive impairment or dementia may experience barriers participating in goal setting due to preconceptions that the person cannot participate owing to changes in both cognitive and communicative abilities. The aim of this review was to identify goal setting approaches, common goals identified, and enablers and barriers to goal setting for people with mild cognitive impairment or dementia participating in specific rehabilitation programmes.

METHODS

Four electronic databases were searched in April 2020 for English language articles that described goal setting processes during a rehabilitation programme for people with mild cognitive impairment or dementia. Studies of all designs were included. Two authors screened citations and full text articles. Data were extracted, synthesised, and presented narratively.

RESULTS

Twenty-seven studies met the eligibility criteria. Both structured and nonstructured goal setting methods were used with common tools including the Canadian Occupational Performance Measure, the Bangor Goal Setting Interview and Goal Attainment Scaling. The nature of goals tended to depend on the scope of the rehabilitation programme in which the person was involved. Goal setting was more difficult for people with more advanced symptoms of dementia and when staff lacked skills and experience working with people with dementia. Use of a structured approach to goal setting, establishment of therapeutic rapport, individualisation of goals, and family involvement were reported to be beneficial.

CONCLUSION

Collaborative goal setting is a foundation of rehabilitation for people with dementia and should not be avoided due to preconceptions that the person cannot participate. Results suggests that occupational therapists can use a number of strategies to maximise participation and engagement and play a pivotal role in upskilling staff to enable effective goal setting for people with mild cognitive impairment or dementia.

Real-time monitoring of barriers to patient engagement for improved rehabilitation: a protocol and representative case reports

PURPOSE

There is ample evidence that patient engagement is of major clinical importance in rehabilitation, and it seems this engagement is based upon effective allocation of attention to the tasks during the rehabilitation session. It is possible to discern two types of barriers which hinder attentive engagement: (1) dysfunctional affective coping and (2) limited cognitive recruitment and specifically attention deficit. These barriers might be general for a given patient, due to pre-morbid or co-morbid dysfunctions. But more often they are evoked by tasks or challenges during the rehabilitation session which might be too complicated or stressing for the specific patient who copes with potentially grave impairments. These barriers hinder rehabilitation progress and should be monitored and overcome, by the therapist, throughout the session.

METHODS

We have developed an easy-to-use tool for monitoring a patient's attentive engagement in real-time throughout a rehabilitation session based on analysing the electrophysiological signal sampled from a simple headset. The tool then analyzes the dynamics of the marker over time to identify cognitive and affective barriers during the session. It enables the therapist to insert feedback regarding the patient's functional performance and to combine it with the analysed barriers, in order to derive automatic recommendations for overcoming the cognitive and affective barriers (if identified) for significant enhancement of the rehabilitation session.

RESULTS AND CONCLUSIONS

In this work we present the principles of the tool as well as three detailed case reports to demonstrate its potential usefulness.IMPLICATIONS FOR REHABILITATIONCognitive and affective barriers hinder patient engagment and rehabilitation success.In this work we present an easy to use electrophysiology-based tool which monitors these barriers.Based on the measured barriers and patient's performance, the tool derives treatment suggestions.

The Dementia Early Stage Cognitive Aids New Trial (DESCANT) intervention: A goal attainment scaling approach to promote self-management

OBJECTIVES

This study investigated goals identified by people with dementia and their carers to promote the self-management of symptoms and abilities; measured achievement using goal attainment scaling (GAS); and explored the reflections of Dementia Support Practitioners (DSPs) facilitating it.

METHODS AND DESIGN

Within this pragmatic randomised trial, DSPs gave memory aids, training and support to people with mild to moderate dementia and their carers at home. Data were collected across seven NHS Trusts in England and Wales (2016-2018) and abstracted from intervention records and semi-structured interviews with DSPs delivering the intervention, supplemented by a subset of the trial dataset. Measures were created to permit quantification and descriptive analysis and interview data thematically analysed. A GAS measure for this intervention in this client group was derived.

RESULTS

Engagement was high across the 117 participants and 293 goals were identified. These reflected individual circumstances and needs and enabled classification and assessment of their attainment. Seventeen goal types were identified across six domains: self-care, household tasks, daily occupation, orientation, communication, and well-being and safety. On average participants achieved nominally significant improvement regarding the specified goals of 1.4 with standard deviation of 0.6. Five interviews suggested that DSPs' experiences of goal setting were also positive.

CONCLUSIONS

GAS is useful for assessing psychosocial interventions for people with early-stage dementia. It has a utility in identifying goals, promoting self-management and providing a personalised outcome measure. There is a strong case for exploring whether these clear benefits translate to other interventions in other populations in other places.

Systematic scoping review of frameworks used to develop rehabilitation interventions for older adults

OBJECTIVES

Rehabilitation interventions for older adults are complex as they involve a number of interacting components, have multiple outcomes of interest and are influenced by a number of contextual factors. The importance of rigorous intervention development prior to formal evaluation has been acknowledged and a number of frameworks have been developed. This review explored which frameworks have been used to guide the development of rehabilitation interventions for older adults.

DESIGN

Systematic scoping review.

SETTING

Studies were not limited for inclusion based on setting.

PARTICIPANTS

Studies were included that featured older adults (>65 years of age).

INTERVENTIONS

Studies were included that reported the development of a rehabilitation intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were extracted on study population, setting, type of intervention developed and frameworks used. The primary outcome of interest was the type of intervention development framework.

RESULTS

Thirty-five studies were included. There was a range of underlying medical conditions including mild cognitive impairment and dementia (n=5), cardiac (n=4), stroke (n=3), falls (n=3), hip fracture (n=2), diabetes (n=2), breast cancer (n=1), Parkinson's disease (n=1), depression (n=1), chronic health problems (n=1), osteoarthritis (n=1), leg ulcer (n=1), neck pain (n=1) and foot problems (n=1). The intervention types being developed included multicomponent, support based, cognitive, physical activities, nursing led, falls prevention and occupational therapy led. Twelve studies (34%) did not report using a framework. Five frameworks were reported with the Medical Research Council (MRC) framework for developing and evaluating complex interventions being the most frequently cited (77%, n=17).

CONCLUSION

At present, the MRC framework is the most popular for developing rehabilitation interventions for older adults. Many studies do not report using a framework. Further, specific guidance to assist this complex field of rehabilitation research is required.

Effects of An Occupational Therapy Memory Strategy Education Group Intervention on Irish Older Adults' Self-Management of Everyday Memory Difficulties

An occupational therapy memory strategy education group (MSEG) was developed to assist clients with varying levels of memory impairment to adopt strategies to manage memory impairment in their daily lives. Participants were healthy older adults presenting with subjective memory complaints (SMC, n = 14), mild cognitive impairment (MCI, n = 33), or early stages of dementia (n = 13). Clients and their caregivers attended a one-hour session each week for six weeks. Outcome measures were taken at baseline, two weeks post completion of the group, and at a 3-month follow-up for 47 participants. Statistically significant improvements post-program were scored on the Rivermead Behavioural Memory Test (p = 0.001) and a dementia quality of life measure (p = 0.02), with increased use of external memory aids (p < 0.001) and significant improvements in participants' self-ratings of performance (p < 0.001) and satisfaction with their performance (p < 0.001) using the Canadian Occupational Performance Measure. Findings suggest positive outcomes that were maintained at 3-month follow-up and thus, support the role of occupational therapy in delivering occupation-focused memory strategy programs.

Telehealth Rehabilitation for Cognitive Impairment: Randomized Controlled Feasibility Trial

Background

Nonpharmacological interventions are needed to support the function of older adults struggling with subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and dementia due to Alzheimer disease (AD). Telerehabilitation aims to provide rehabilitation at a distance, but cognitive rehabilitation by videoconferencing has not been explored.

Objective

The objective of this study was to compare goal-oriented cognitive rehabilitation delivered in-person with videoconferencing to determine whether telehealth cognitive rehabilitation appears feasible.

Methods

Random assignment to in-person or telehealth videoconferencing cognitive rehabilitation with a combined between-subjects, multiple baseline single-case experimental design, cognitive rehabilitation was delivered by a therapist to 6 participants with SCI (n=4), MCI (n=1), or dementia due to AD (n=1).

Results

Two of the 6 participants randomly assigned to the telehealth condition withdrew before beginning the intervention. For those who participated in the intervention, 6 out of 6 goals measured with the Canadian Occupational Performance Measure improved for those in the in-person group, and 7 out of 9 goals improved for those in the telehealth group.

Conclusions

Delivery of cognitive rehabilitation by telehealth appeared feasible but required modifications such as greater reliance on caregivers and clients for manipulating materials.

An extended review of couple-centred interventions in dementia: Exploring the what and why - Part B

This scoping review is an extended version of a narrative review of couple-centred interventions in dementia shared in part A and the previous publication in this edition. The rationale for expanding study A emerged through the fact that most dyadic interventions have samples consisting of a majority of couples. The exclusion of interventions with samples of mixed relationships in part A therefore contributed to a narrow picture of joint dyadic interventions for couples in which one partner has a dementia. The aim of this second review is to explore the ‘what’ (types of interventions) and the ‘why’ (objectives and outcome measures) of dyadic interventions in which sample consists of a majority of couples/spouses and in which people with dementia and caregivers jointly participate.

Method

A five-step framework for scoping reviews guided the procedure. Searches were performed in Academic Search Premier, CINAHL, PsycINFO, PubMed, Scopus, and Web of Science.

Results

Twenty-one studies with various types of psychosocial interventions were included. The main outcome measure for people with dementia was related to cognitive function, respectively caregiver burden and depression for caregivers.

Conclusions

The findings of this extended review of joint dyadic interventions in dementia are in line with the findings of part A regarding the negative approach of outcomes, lack of a genuine dyadic approach, lack of tailored support, neglect of interpersonal issues and the overlook of the views of people with dementia. This review also recognises that measures of caregiver burden, as well as relationship quality should be considered in samples of mixed relationships due to the different significance of burden and relationship quality for a spouse as opposed to an adult child or friend.

Cognitive rehabilitation for early stage Alzheimer’s disease: a pilot study with an Irish population

Objectives

Research shows that cognitive rehabilitation (CR) has the potential to improve goal performance and enhance well-being for people with early stage Alzheimer’s disease (AD). This single subject, multiple baseline design (MBD) research investigated the clinical efficacy of an 8-week individualised CR intervention for individuals with early stage AD.

Methods

Three participants with early stage AD were recruited to take part in the study. The intervention consisted of eight sessions of 60–90 minutes of CR. Outcomes included goal performance and satisfaction, quality of life, cognitive and everyday functioning, mood, and memory self-efficacy for participants with AD; and carer burden, general mental health, quality of life, and mood of carers.

Results

Visual analysis of MBD data demonstrated a functional relationship between CR and improvements in participants’ goal performance. Subjective ratings of goal performance and satisfaction increased from baseline to post-test for three participants and were maintained at follow-up for two. Baseline to post-test quality of life scores improved for three participants, whereas cognitive function and memory self-efficacy scores improved for two.

Conclusions

Our findings demonstrate that CR can improve goal performance, and is a socially acceptable intervention that can be implemented by practitioners with assistance from carers between sessions. This study represents one of the promising first step towards filling a practice gap in this area. Further research and randomised-controlled trials are required.

Cognitive interventions in Alzheimer's and Parkinson's diseases: emerging mechanisms and role of imaging

Purpose of review

There has been recent debate about the lack of compelling scientific evidence on the efficacy of cognitive interventions. The goal of this study is to review the current state of cognitive interventions in Alzheimer's disease and Parkinson's disease, present emerging mechanisms, and discuss the role of imaging in designing effective intervention strategies.

Recent findings

Cognitive interventions appear to be promising in Alzheimer's disease and Parkinson's disease. Although feasibility has been shown in mild cognitive impairment, early Alzheimer's disease, and mild to moderate Parkinson's disease, studies to investigate long-term efficacy and mechanisms underlying these interventions are still needed.

Summary

There is a need to conduct scientifically rigorous studies to validate the efficacy of cognitive intervention trials. Future studies will greatly benefit from including longitudinal imaging in their study design. Imaging can be used to demonstrate the efficacy and mechanisms by measuring brain changes over the intervention period. Imaging can also be used to determine biological and disease-related factors that may influence the treatment response, that is, the effect modifiers. Consideration of effect modifiers will allow us to measure the treatment response in biomarkers and cognition with greater sensitivity and also aid in designing trials that will lead to better patient outcomes.

Cognitive rehabilitation in patients with nonamnestic mild cognitive impairment

Background:

The nonamnesic type of mild cognitive impairment (na-MCI) is predementia state with subtle decline incognitive domains except memory. Although cognitive rehabilitation (CR) has been investigated in amnesic type of MCI, we could not find any trial that rehabilitated na-MCI exclusively. We studied the effectiveness of CR on na-MCI.

Materials and Methods:

This study was a blinded, randomized clinical trial. Individuals with age of 60 years or more, complete self-directedness and diagnosis of na-MCI, based on Neuropsychiatry Unit Cognitive assessment tool, were selected. The 51 patients were randomly assigned into three groups: CR, lifestyle (LS) modification, and the control group (CG). Neuropsychological tests for executive functioning were assessed at the baseline, after the interventions, and 6 months later.

Results:

The mean score of the “design fluency” test increased significantly in CR, compared to LS and CG (P = 0.007). In “five-point” test, mean score increased significantly in CR (P = 0.03). There was higher mean score of Behavioral Rating Inventory of Executive Function for adults in CR (P = 0.01).

Conclusion:

Consideration of the MCI subtypes allows us to target specific cognitive domains, such as information processing, for better CR outcome. CR may result in better performance of executive functioning of daily living.