Use of environmental manipulation and classroom and modified informal reality orientation with institutionalized, confused elderly patients

Cognitive stimulation to improve cognitive functioning in people with dementia

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The value of reality orientation in 1987

When considering the value of Reality Orientation (RO) it is extremely difficult to avoid reference to the many and various meanings, misinterpre tations and misunderstandings which have formed the basis of some criticisms. However, these should be covered in the other part of this critique. Here, RO will be taken to imply an approach (or philosophy) which is continuous and focuses on regaining and maintaining, as far as possible, normal living patterns relevant to each particular individual with impairments of social or intel lectual functions. This includes group sessions, or intensive individual sessions, where the focus could be on relearning verbal or spatial in formation, daily living activities, social behaviour or solving problem behaviours.

Research and evaluation have required a break down of RO into specific aspects in order to assess their relative values. In practice, RO is multi faceted, and carers will use whatever facet or facets that are relevant to the needs of the in dividual.

Reality Orientation Thirty Years Later: Are We Still Confused?

Reality Orientation (RO) intervention represents the first significant attempt at rehabilitation programming for the disoriented, institutionalized elderly. Early anecdotal accounts reported sweeping positive effects. A first sign of hope for this severely disabled population, RO rapidly became widely implemented and continues to be a commonly accepted approach by numerous disciplines. However, careful examination of the research and clinical practice literature reveals many difficulties with the conventional RO classroom programme. Reliable research is limited and weakly supports a modest, temporary gain in verbal orientation after involvement in conventional classroom RO. The actual significance of these gains for these severely disabled elderly persons and their caregivers is doubtful. Although not yet clearly articulated, other approaches (eg. sensory stimulation, environmental manipulation) and a reformulation of RO itself are showing promise of effecting a broader range of functional behaviours (eg. self-feeding). Orientation information presented for reassurance, not re-articulation, is proving to be both more nurturing for clients and more clinically significant.

Functional analysis-based interventions for challenging behaviour in dementia

BACKGROUND

Functional analysis (FA) for the management of challenging behaviour is a promising behavioural intervention that involves exploring the meaning or purpose of an individual's behaviour. It extends the 'ABC' approach of behavioural analysis, to overcome the restriction of having to derive a single explanatory hypothesis for the person's behaviour. It is seen as a first line alternative to traditional pharmacological management for agitation and aggression. FA typically requires the therapist to develop and evaluate hypotheses-driven strategies that aid family and staff caregivers to reduce or resolve a person's distress and its associated behavioural manifestations.

OBJECTIVES

To assess the effects of functional analysis-based interventions for people with dementia (and their caregivers) living in their own home or in other settings.

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 3 March 2011 using the terms: FA, behaviour (intervention, management, modification), BPSD, psychosocial and Dementia.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with reported behavioural outcomes that could be associated with functional analysis for the management of challenging behaviour in dementia.

DATA COLLECTION AND ANALYSIS

Four reviewers selected trials for inclusion. Two reviewers worked independently to extract data and assess trial quality, including bias. Meta-analyses for reported incidence, frequency, severity of care recipient challenging behaviour and mood (primary outcomes) and caregiver reaction, burden and mood were performed. Details of adverse effects were noted.

MAIN RESULTS

Eighteen trials are included in the review. The majority were in family care settings. For fourteen studies, FA was just one aspect of a broad multi-component programme of care. Assessing the effect of FA was compromised by ill-defined protocols for the duration of component parts of these programmes (i.e. frequency of the intervention or actual time spent). Therefore, establishing the real effect of the FA component was not possible.Overall, positive effects were noted at post-intervention for the frequency of reported challenging behaviour (but not for incidence or severity) and for caregiver reaction (but not burden or depression). These effects were not seen at follow-up.

AUTHORS' CONCLUSIONS

The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.

Cognitive stimulation to improve cognitive functioning in people with dementia

BACKGROUND

Cognitive stimulation is an intervention for people with dementia which offers a range of enjoyable activities providing general stimulation for thinking, concentration and memory usually in a social setting, such as a small group. Its roots can be traced back to Reality Orientation (RO), which was developed in the late 1950s as a response to confusion and disorientation in older patients in hospital units in the USA. RO emphasised the engagement of nursing assistants in a hopeful, therapeutic process but became associated with a rigid, confrontational approach to people with dementia, leading to its use becoming less and less common.Cognitive stimulation is often discussed in normal ageing as well as in dementia. This reflects a general view that lack of cognitive activity hastens cognitive decline. With people with dementia, cognitive stimulation attempts to make use of the positive aspects of RO whilst ensuring that the stimulation is implemented in a sensitive, respectful and person-centred manner.There is often little consistency in the application and availability of psychological therapies in dementia services, so a systematic review of the available evidence regarding cognitive stimulation is important in order to identify its effectiveness and to place practice recommendations on a sound evidence base.

OBJECTIVES

To evaluate the effectiveness and impact of cognitive stimulation interventions aimed at improving cognition for people with dementia, including any negative effects.

SEARCH METHODS

The trials were identified from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register, called ALOIS (updated 6 December 2011). The search terms used were: cognitive stimulation, reality orientation, memory therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation. Supplementary searches were performed in a number of major healthcare databases and trial registers to ensure that the search was up to date and comprehensive.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of cognitive stimulation for dementia which incorporated a measure of cognitive change were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two review authors using a previously tested data extraction form. Study authors were contacted for data not provided in the papers. Two review authors conducted independent assessments of the risk of bias in included studies.

MAIN RESULTS

Fifteen RCTs were included in the review. Six of these had been included in the previous review of RO. The studies included participants from a variety of settings, interventions that were of varying duration and intensity, and were from several different countries. The quality of the studies was generally low by current standards but most had taken steps to ensure assessors were blind to treatment allocation. Data were entered in the meta-analyses for 718 participants (407 receiving cognitive stimulation, 311 in control groups). The primary analysis was on changes that were evident immediately at the end of the treatment period. A few studies provided data allowing evaluation of whether any effects were subsequently maintained. A clear, consistent benefit on cognitive function was associated with cognitive stimulation (standardised mean difference (SMD) 0.41, 95% CI 0.25 to 0.57). This remained evident at follow-up one to three months after the end of treatment. In secondary analyses with smaller total sample sizes, benefits were also noted on self-reported quality of life and well-being (standardised mean difference: 0.38 [95% CI: 0.11, 0.65]); and on staff ratings of communication and social interaction (SMD 0.44, 95% CI 0.17 to 0.71). No differences in relation to mood (self-report or staff-rated), activities of daily living, general behavioural function or problem behaviour were noted. In the few studies reporting family caregiver outcomes, no differences were noted. Importantly, there was no indication of increased strain on family caregivers in the one study where they were trained to deliver the intervention.

AUTHORS' CONCLUSIONS

There was consistent evidence from multiple trials that cognitive stimulation programmes benefit cognition in people with mild to moderate dementia over and above any medication effects. However, the trials were of variable quality with small sample sizes and only limited details of the randomisation method were apparent in a number of the trials. Other outcomes need more exploration but improvements in self-reported quality of life and well-being were promising. Further research should look into the potential benefits of longer term cognitive stimulation programmes and their clinical significance.

WITHDRAWN: Reality orientation for dementia

BACKGROUND

Reality Orientation (RO) was first described as a technique to improve the quality of life of confused elderly people, although its origins lie in an attempt to rehabilitate severely disturbed war veterans, not in geriatric work. It operates through the presentation of orientation information (eg time, place and person-related) which is thought to provide the person with a greater understanding of their surroundings, possibly resulting in an improved sense of control and self-esteem. There has been criticism of RO in clinical practice, with some fear that it has been applied in a mechanical fashion and has been insensitive to the needs of the individual. There is also a suggestion that constant relearning of material can actually contribute to mood and self-esteem problems. There is often little consistent application of psychological therapies in dementia services, so a systematic review of the available evidence is important in order to identify the effectiveness of the different therapies. Subsequently, guidelines for their use can be made on a sound evidence base.

OBJECTIVES

To assess the evidence of effectiveness for the use of Reality Orientation (RO) as a classroom-based therapy on elderly persons with dementia.

SEARCH STRATEGY

Computerised databases were searched independently by 2 reviewers entering the terms 'Reality Orientation, dementia, control, trial or study'. Relevant web sites were searched and some hand searching was conducted by the reviewer. Specialists in the field were approached for undocumented material, and all publications found were searched for additional references.

SELECTION CRITERIA

All randomized controlled trials (RCTs), and all controlled trials with some degree of concealment, blinding or control for bias (second order evidence) of Reality Orientation as an intervention for dementia were included. The criteria for inclusion/exclusion involved systematic assessment of the quality of study design and the risk of bias, using a standard data extraction form. A measure of cognitive and/or behavioural change was needed.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by both reviewers, using a previously tested data extraction form. Authors were contacted for data not provided in the papers. Psychological scales measuring cognitive and behavioural changes were examined.

MAIN RESULTS

6 RCTs were entered in the analysis, with a total of 125 subjects (67 in experimental groups, 58 in control groups). Results were divided into 2 subsections: cognition and behaviour. Change in cognitive and behavioural outcomes showed a significant effect in favour of treatment.

AUTHORS' CONCLUSIONS

There is some evidence that RO has benefits on both cognition and behaviour for dementia sufferers. Further research could examine which features of RO are particularly effective. It is unclear how far the benefits of RO extend after the end of treatment, but and it appears that a continued programme may be needed to sustain potential benefits.

Acute confusion/delirium protocol

This abbreviated version of the Acute Confusion/Delirium Research-Based protocol provides clinical guidelines for the assessment and management of acute confusion/delirium in the elderly individual. A screening and ongoing surveillance program that is based on identified risk factors is recommended to prevent or minimize episodes of acute confusion in this age group. This protocol is part of a series of protocols developed to help clinicians use the best evidence available in the care of older adults.

Psychosocial interventions for individuals with dementia: an integration of theory, therapy, and a clinical understanding of dementia

We reviewed six psychosocial interventions for individuals with dementia. Interventions are described in terms of theoretical basis, how knowledge about dementia is incorporated, techniques, and empirical support. Psychodynamic approaches appear helpful for understanding intrapsychic concerns of demented individuals. Support groups and cognitive/behavioral therapy assist early stage individuals to build coping strategies and reduce distress. Reminiscence and life review provide mild to moderate stage individuals with interpersonal connections. Behavioral approaches and memory training target specific cognitive and behavioral impairments and help to optimize remaining abilities. Reality orientation reflects a similar goal, yet is probably more useful for its interpersonal functions.

Promoting well-being and independence for people with dementia

This paper reviews the research evidence relating to non-pharmacological interventions with people with dementia aiming to improve well-being and independence. There have been a number of attempts to improve the person's level of independent functioning through programmes training and supporting self-care skills, mobility, continence, orientation and participation in activities. Well-being has been less often directly addressed, although recently studies have begun to specifically target aspects of it. Increased independence does not necessarily lead to greater well-being, and it is clear that the greatest potential for increasing function is in tackling the excess disability which many care giving situations in effect impose on the person with dementia. In carrying out research in this area, the limitations of randomized controlled trials are evident, and there is much to be said for the reporting of series of carefully controlled single-case studies in addition to group studies. Further development of methods of measuring well-being in people with dementia is also required.

Procedural memory stimulation in Alzheimer's disease: impact of a training programme

The study evaluates the efficacy of a procedural memory stimulation programme in mild and mild-moderate Alzheimer's disease (AD). Twenty basic and instrumental activities of daily living have been selected, and divided into two groups, comparable for difficulty. Ten normal elderly subjects (age 68.0 +/- 4.8 years; MMSE score: 28.7 +/- 0.9; education: 7.6 +/- 3.5 years) were asked to perform the two groups of daily activities and the time required to perform the tasks of each group was recorded and used as a reference. Ten mild and mild-moderate AD patients (age 77.2 +/- 5.3 years; MMSE score: 19.8 +/- 3.5; education: 7.3 +/- 4.7 years) without major behavioural disturbances constituted the experimental group. Patients were evaluated in all 20 daily activities and the time employed was recorded at baseline and after a 3-week training (1 h/d, 5 d/week) period. Five patients were trained during the 3 weeks on half of the 20 daily activities and the other five patients were trained on the remainder. This procedure was adopted in order to detect separately the improvement in "trained" and "not trained" activities, allowing to control better the effects of the intervention. The assessment of the functional impact of the training was directly measured, through the variation of time employed to perform tasks before and after training. After 3 weeks of training a significant improvement was observed for the trained activities, from 3.6 to 1.9 standard deviations below the performance of the normal elderly controls (P < 0.05). AD patients improved also in not-trained activities from 3.5 to 2.7 standard deviations below the controls' performance (P < 0.05). The rehabilitation of activities of daily living through developing procedural memory strategies may be effective in mild and mild-moderate AD patients.

The impact of dementia on the sufferer and available treatment interventions: an overview

An overview of the psychological and behavioral consequences of dementia on sufferers is provided. Psychological interventions for improving the quality of life of patients, difficulties of diagnosis, the role of general practitioners, and th contribution of psychologists in the management of dementia are discussed.

Life events and senile dementia. I. Admission, deterioration and social environment change

This study examines the frequency of life events before admission and before deterioration in 70 dementia patients, in comparison with 50 dementia controls living in the community and 50 fit elderly people matched for age and sex. We hypothesized that there would be an excess of events connoting changes in routine and the social environment. Specific scales were developed to measure these aspects of events. Our results supported the initial hypothesis, confirming that it is the social disruptiveness of change rather than the threat implied by life events that is associated with deterioration. The findings are discussed in the light of current models of the dementia process.

Nursing-home staff perception of behavior disturbance and management of confused residents

An exploratory study was conducted to identify nursing-home staff's perceptions of confused residents' behavior problems and what they did to intervene. Six focus groups were conducted at two nursing homes. A convenience sample of 58 health care providers participated: registered nurses and licensed practical nurses; certified nursing assistants; social workers; clinical nurse specialists; therapeutic recreation therapists; and physical, speech, and occupational therapists. Four categories of behavior disturbances emerged: verbal, fear-related, wandering, and level of awareness-related. Four categories emerged from intervention data analysis: interpreting reality, maintaining normalcy, meeting basic needs, and managing behavior disturbances.

Effects of reality orientation therapy on elderly patients in the community

Twenty-three institutionalized subjects, confused and disoriented as to time, space and persons, were divided into two groups: the study group and the control group. The study group then participated in a 3-month period of formal Realithy Orientation Therapy (ROT). At the end of the 3 months of therapy significant differences emerged in the scores of MMSE, OSGP and GDS obtained by the two groups. Moreover, significant positive differences were observed only in the study group, comparing the tests' results before and after therapy. Even the comparison of the results obtained at the end of the sessions and 3 months after the interruption of the therapy revealed a difference in the trends that emerged for the two groups.

Dementia day care and its effects on symptoms and institutionalization--a controlled Swedish study

OBJECTIVE

To examine the effects of Day Care (DC) on demented patients.

DESIGN

A prospective non-randomized concurrent-control study.

PARTICIPANTS

55 demented patients in DC and 44 controls.

SETTING

Sundsvall, an industrial community in northern Sweden.

MAIN OUTCOME MEASURE

Cognition, ADL-functions, behaviour and institutionalization.

RESULTS

Measurements of cognition, ADL-functions, and behaviour showed no or only small differences between the groups. After one year, 24% of the patients in the DC-group were institutionalized, compared with 44% of the controls. In the control group, the exhaustion of spouse and supervision need were highly correlated to institutionalization (p < 0.001), while high physical nursing load was correlated to institutionalization in the DC-group (p < 0.01).

CONCLUSION

DC postpones institutionalization, probably because of less exhaustion of spouses and decreased supervision need.

Can changes in ward routines affect the severity of dementia? A controlled prospective study

An extensive new caring program--including the introduction of Individual Care Plans and changes in ward organization, caring techniques, and caring philosophy--was introduced at two psychogeriatric wards with severely demented patients. The hypotheses were that the patients (n = 31) would improve in psychosocial capacity and orientation and the staff work load would decline in contrast to two other wards with a similar clientele (n = 31). After ten months the milieu was more "homelike," routines were more flexible, and the staff communicated more with the patients. However, the hypotheses were not proven. All patients in both groups deteriorated in ADL capacity, orientation, and behavior. The patients in the program wards became significantly more restless and disoriented and ate less than the patients in the contrast wards. The conclusion is that, despite optimal care, a humanistic approach, and support from staff, the progression of dementia symptoms is inevitable.

The effect of therapy on the mental health of the elderly

This research synthesis was undertaken to study the effects of treatment on the mental health of elderly people. Forty-one controlled studies were analyzed using meta-analytic techniques. Type of treatment along with subject, therapist, setting, and methodological characteristics of the studies were identified and their contributions to mental health outcomes measured. Results indicated that the mean outcome of the experimental group, treated with any type of treatment improved from the fiftieth percentile to the seventieth percentile relative to the mean of the untreated control groups. This research synthesis supports the belief that, in general, treatment is effective in enhancing the mental health of the elderly.