Effectiveness of Cognitive Stimulation Therapy (CST) for mild to moderate dementia: A systematic literature review and meta-analysis of randomised control trials using the original CST protocol

AIMS

We aimed to conduct a systematic literature review and meta-analysis to evaluate the efficacy of the original 14 session Cognitive Stimulation Therapy (CST) protocol in improving cognitive function and related outcomes in people with mild to moderate dementia.

METHODS

Four databases were searched, up to May 2023, for randomized controlled trials of CST using the original protocol. Pre- and post-test means and measures of dispersion for intervention and control groups were extracted for each reported outcome and used to calculate effect sizes. Effect sizes were grouped by outcome and pooled in inverse variance weighted random effects models.

RESULTS

Twelve studies were identified as meeting inclusion criteria. Of these, ten were given either a 'high' or 'medium' quality rating. The pooled results indicated that CST had a significant beneficial impact on global cognition, language, working memory, depression, neuropsychiatric symptoms, communication, self-reported quality of life and severity of dementia.

CONCLUSIONS

CST as delivered in adherence to the original 14-session protocol is an efficacious treatment for mild to moderate dementia with improvements in cognition, affective symptoms and quality of life demonstrated from global trials.

Effectiveness of Caregiver-Provided Individual Cognitive Interventions in Older Adults with Dementia

Background

In a society increasingly committed to promoting an active life in the community, new resources are needed to respond to the needs of citizens with Alzheimer's disease and other forms of dementia. The potential of several individual cognitive interventions to be provided by caregivers has been explored in the literature.

Objective

To synthesize the best available evidence on the effectiveness of caregiver-provided individual cognitive interventions in older adults with dementia.

Methods

Systematic review of experimental studies on individual cognitive interventions for older adults with dementia. An initial search of MEDLINE and CINAHL was undertaken. Another search for published and unpublished studies was performed on major healthcare-related online databases in March 2018 and updated in August 2022. This review considered studies that included older adults with dementia, aged 60 years and over. All studies that met the inclusion criteria were assessed for methodological quality using a JBI standardized critical appraisal checklist. Data were extracted using a JBI data extraction form for experimental studies.

Results

Eleven studies were included: eight randomized controlled trials and three quasi-experimental studies. Caregiver-provided individual cognitive interventions had several beneficial effects in cognitive domains, including memory, verbal fluency, attention, problem-solving, and autonomy in activities of daily living.

Conclusion

These interventions were associated with moderate improvements in cognitive performance and benefits in activities of daily living. The findings highlight the potential of caregiver-provided individual cognitive interventions for older adults with dementia.

Longitudinal measurement properties of the Montreal Cognitive Assessment

INTRODUCTION

The Montreal Cognitive Assessment (MoCA) has started to be used in longitudinal investigations to measure cognition trends but its measurement properties over time are largely unknown. This study aimed to examine the longitudinal measurement invariance of individual MoCA items.

METHOD

We used four waves of data collected between 2014 and 2017 from a cohort study on health and well-being of older adults from twelve public housing estates in Hong Kong. We identified people aged 65 years or older at baseline who answered the MoCA items across all time points and had a valid indicator of educational level. A total of 1028 participants were included. We applied confirmatory factor analysis of ordinal variables to examine measurement invariance of the Chinese (Cantonese) MoCA (version 7.0) items across four time points, stratified by educational level, where invariant items were identified by sequential model comparisons.

RESULTS

Four items exhibited a lack of measurement invariance across the four time points in both education groups (Clock Hand, abstraction, Delayed Recall, and Orientation). The items Cube and Sentence Repetition lacked longitudinal measurement invariance only in the "some education" group and the items Clock Shape and Clock Number only in the "no education" group. However, accounting for the lack of measurement invariance did not substantially affect classification properties for major neurocognitive disorder and mild cognitive impairment.

CONCLUSIONS

Our findings support using MoCA to assess changes in cognition over time in the study population while calling for future research in other populations.

Activity, Activity Personalization, and Well-Being in Nursing Home Residents With and Without Cognitive Impairment: An Integrative Review

OBJECTIVES

Engagement in personally relevant and pleasant activity is a facet of many theories of well-being. This integrated review and narrative synthesis explored the hypothesis that activity participation improves well-being for nursing home residents.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched MEDLINE, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, Embase, and CINAHL for research published between 2006 and 2018. We included peer-reviewed, English-language studies of nursing-home residents, with interventions focused on activities and on well-being or affect outcomes.

RESULTS

After screening, the search yielded 45 studies: 15 reviews of specific activities and 30 empirical articles. We found consistent support for tailored activity interventions and less consistent support for specific or generic activity interventions with the possible exception of music therapy. Research focused on specific activity types had methodological limitations and confounds with activity preferences.

CONCLUSIONS

Participation in activities may improve well-being in residents of nursing homes. Tailored activities are likely to be superior to those provided indiscriminately to all residents.

CLINICAL IMPLICATIONS

Improving quality of life in long-term care should include opportunities to engage in activities; those most effective will be tailored to individuals and no single activity will be effective for everyone.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cultural Adaptation of Cognitive Stimulation Therapy (CST) for Portuguese People with Dementia

OBJECTIVES

Portugal is one of the most aged countries in the world and dementia is increasing among the Portuguese population. It is estimated to affect around 200,000 people in Portugal. There is a clear need for non-pharmacological interventions to ameliorate the symptoms of dementia and improve the quality of life. Cognitive Stimulation Therapy (CST), a worldwide well-known program developed in the United Kingdom (UK), is recognized as a cost-effective intervention, with benefits both in cognitive function and quality of life of people with mild to moderate dementia. We tested the feasibility and cultural appropriateness and adapted CST to Portuguese people with dementia.

METHODS

The Formative Method for Adapting Psychotherapy (FMAP) model for cultural adaptation was used. A focus group discussion with health professionals and caregivers provided the basis for cultural adaptation, as well as feedback from participants, caregivers, and facilitators after a pilot study.

RESULTS

Some modifications were required, especially related to linguistic issues, in 11 of the 14 CST sessions. The adapted program was found to be acceptable and enjoyable in a small sample of people with dementia in a rehabilitation context.

CONCLUSIONS

CST seems feasible and culturally appropriate in Portugal. A systematically developed and culturally adapted manual is ready to be used in a large-scale implementation and validation of CST in Portugal.

CLINICAL IMPLICATIONS

CST is a valid program for the Portuguese culture, contributes to the availability of a structured and effective clinical intervention for PwD in Portugal and to the possibility of comparing programs across countries.

The Role of Individual Characteristics in Predicting Short- and Long-Term Cognitive and Psychological Benefits of Cognitive Stimulation Therapy for Mild-to-Moderate Dementia

Introduction: This study examined the role of individual characteristics in predicting short- and long-term benefits of the Italian version of Cognitive Stimulation Therapy (CST-IT), an evidence-based intervention for people with mild-to-moderate dementia.

Materials and Methods: Data were drawn from a sample (N = 123) of people with dementia (PwD) who took part in a multicenter controlled clinical trial of CST-IT. Assessments at pre-test, immediately after completing the treatment, and 3 months later investigated the following outcomes: general cognitive functioning and language, mood and behavior, everyday functioning, and quality of life. Age, education and baseline (pre-test) cognitive functioning, mood (depression) and behavioral and neuropsychiatric symptoms were considered as predictors of any short- and long-term benefits.

Results: Linear mixed-effects models showed that different individual characteristics -particularly education and age- influenced the benefits of CST-IT, depending on the outcome measures considered. Higher education predicted larger gains in general cognitive functioning and, along with less severe depressive symptoms, in language (magnification effects). Older age was associated with positive changes in mood (compensation effects). Albeit very modestly, older age was also associated with larger gains in everyday functioning (compensation effects). Gains in quality of life were predicted by older age and lower education (compensation effects). Baseline cognitive functioning, mood and/or behavioral symptoms broadly influenced performance too, but their role again depended on the outcomes considered.

Discussion: These findings underscore the importance of considering and further exploring how psychosocial interventions like CST are affected by individual characteristics in order to maximize their efficacy for PwD.

Prevention of Cognitive Decline in Elderly: Programs "Memory Clinic" and "Cognitive Stimulation Therapy"

The problem of preventing factors associated with the risks of cognitive decline and hindering active longevity in old age is becoming increasingly important. According to the United Nations in 2019, about 10% of the total population in the world is over the age of 65, and by 2050 this figure will already be 20%. The syndrome of mild cognitive decline is considered as a transitional state between normal physiological aging and dementia. The two modern approaches to the prevention of cognitive impairment during aging are presented. Methods for the prevention of cognitive impairments are proposed to be considered according to the level of organization of mental activity, to which they mainly appeal: based on the semantic level (training) and the level of personal meanings (stimulation programs). The experience of preventing cognitive decline in the elderly within the framework of the program of psychosocial therapy and neurocognitive rehabilitation at the “Memory Clinic” (Russia) and the “Cognitive Stimulation Therapy” (CST) program (Great Britain) is described.

A Home-Based Individual Cognitive Stimulation Program for Older Adults With Cognitive Impairment: A Randomized Controlled Trial

Objective: This study aims to assess the feasibility and meaningfulness of a home-based individual cognitive stimulation (iCS) program delivered by caregivers to persons with cognitive impairment (PwCIs). It also aims to assess whether the older adults receiving this program improved their cognitive, neuropsychiatric, and depressive symptoms and quality of life and whether their caregivers improved their mental and physical health.

Methods: A randomized controlled trial (RCT) was conducted with PwCI-caregiver dyads recruited from the community. Participants were allocated to two groups: intervention (n = 28) and control (n = 24). The intervention group received the European Portuguese version of the Individual Cognitive Stimulation Program—Making a Difference 3 (MD3-P). The control group received usual care. The iCS therapy program was implemented three times a week for 12 weeks. Caregivers were supported by the researchers to deliver the sessions at home. Participants were assessed at baseline and at the end of the intervention (week 13). Feasibility and meaningfulness were assessed through the attrition rate, adherence, and degree of satisfaction with the sessions. Four interviews were conducted (after week 13) to understand participants’ experiences.

Results: The attrition rate was 23.1%. The dyads reported that they did not have high expectations about the iCS program before starting the study. Nevertheless, as the program evolved, caregivers noted that their family members had improved some areas of functioning. Intention-to-treat analysis based on group differences revealed a significant improvement in PwCIs’ cognition, specifically in their orientation and ability to follow commands. The intervention had no impact on other variables such as caregivers’ physical and mental health.

Conclusion: The iCS program implemented by caregivers showed promising results in improving PwCIs’ cognition. The participants who completed the intervention attributed a positive meaning to the MD3-P, confirming it as a valid non-pharmacological therapeutic approach to reducing frailty in PwCIs in community settings.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier [NCT03514095].

A feasibility randomised control trial of individual cognitive stimulation therapy for dementia: impact on cognition, quality of life and positive psychology

OBJECTIVES

This study aimed to evaluate the feasibility of a 14-session programme of individual Cognitive Stimulation Therapy (iCST) for people with dementia (PWD). It addressed potential limitations in previous literature of iCST and evaluated possible impact on cognition, quality of life (QoL) and positive psychology.

METHOD

The 14-session iCST programme was developed using existing manuals for group and individual CST and consultation with experts in the field. Thirty-three PWD were recruited from care homes and randomly assigned to iCST (14, 45-min sessions) or treatment as usual (TAU) over seven weeks. Outcomes measures were assessed at baseline and follow-up after the intervention.

RESULTS

The intervention appeared feasible with high attendance to sessions, minimal levels of attrition, and ease of recruitment. Analysis of covariance indicated significant improvements in cognition (Alzheimer's Disease Assessment Scale-Cognitive subscale) for PWD receiving iCST compared to TAU. There were no significant differences between groups on follow-up scores on the standardised Mini Mental State Examination, measures of positive psychology or self- and proxy- reported QoL.

CONCLUSION

A 14-session programme of iCST delivered by professionals was feasible and acceptable to PWD and may provide benefits to cognition. A larger randomised control trial would be necessary to fully evaluate intervention impact on cognition, as well as QoL and positive psychology.

Increasing autonomy through improved care: effects of a professional care-giver training programme on the functional status of older adults

The aim of the present research was to evaluate the effectiveness of a care-giver training programme that trains professional care-givers in cognitive stimulation strategies for functional maintenance in care-dependent older adults. The sample contained 69 older adults (37 in the treatment group, 32 control group) assessed with the Barthel Index, the Mini-Mental State Examination and the Clifton Assessment Procedure for the Elderly (Cognitive Scale). Participants in the treatment group were treated by professional care-givers who were trained with the programme CUIDA-2 in communication and cognitive stimulation strategies. The results from the Barthel Index showed significant differences in the post-intervention assessment and in the follow-up assessment, where the treatment group obtained higher scores, and there were significant differences within the treatment group between the initial assessment and the post-treatment assessment, as well as between the initial assessment and the follow-up. The data obtained reflect that a training programme to train professional care-givers produced functional benefits in the older adults, and these improvements persisted over time. Moreover, the care-givers saw themselves as more competent and more satisfied with their work.

Computerised cognitive training for 12 or more weeks for maintaining cognitive function in cognitively healthy people in late life

BACKGROUND

Increasing age is associated with a natural decline in cognitive function and is the greatest risk factor for dementia. Cognitive decline and dementia are significant threats to independence and quality of life in older adults. Therefore, identifying interventions that help to maintain cognitive function in older adults or that reduce the risk of dementia is a research priority. Cognitive training uses repeated practice on standardised exercises targeting one or more cognitive domains and may be intended to improve or maintain optimal cognitive function. This review examines the effects of computerised cognitive training interventions lasting at least 12 weeks on the cognitive function of healthy adults aged 65 or older and has formed part of a wider project about modifying lifestyle to maintain cognitive function. We chose a minimum 12 weeks duration as a trade-off between adequate exposure to a sustainable intervention and feasibility in a trial setting.

OBJECTIVES

To evaluate the effects of computerised cognitive training interventions lasting at least 12 weeks on cognitive function in cognitively healthy people in late life.

SEARCH METHODS

We searched to 31 March 2018 in ALOIS (www.medicine.ox.ac.uk/alois), and we performed additional searches of MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO Portal/ICTRP (www.apps.who.int/trialsearch), to ensure that the search was as comprehensive and as up-to-date as possible to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs, published or unpublished, reported in any language. Participants were cognitively healthy people, and at least 80% of the study population had to be aged 65 or older. Experimental interventions adhered to the following criteria: intervention was any form of interactive computerised cognitive intervention - including computer exercises, computer games, mobile devices, gaming console, and virtual reality - that involved repeated practice on standardised exercises of specified cognitive domain(s) for the purpose of enhancing cognitive function; the duration of the intervention was at least 12 weeks; cognitive outcomes were measured; and cognitive training interventions were compared with active or inactive control interventions.

DATA COLLECTION AND ANALYSIS

We performed preliminary screening of search results using a 'crowdsourcing' method to identify RCTs. At least two review authors working independently screened the remaining citations against inclusion criteria. At least two review authors also independently extracted data and assessed the risk of bias of included RCTs. Where appropriate, we synthesised data in random-effects meta-analyses, comparing computerised cognitive training (CCT) separately with active and inactive controls. We expressed treatment effects as standardised mean differences (SMDs) with 95% confidence intervals (CIs). We used GRADE methods to describe the overall quality of the evidence for each outcome.

MAIN RESULTS

We identified eight RCTs with a total of 1183 participants. The duration of the interventions ranged from 12 to 26 weeks; in five trials, the duration of intervention was 12 or 13 weeks. The included studies had moderate risk of bias, and the overall quality of evidence was low or very low for all outcomes. We compared CCT first against active control interventions, such as watching educational videos. Negative SMDs favour CCT over control. Trial results suggest slight improvement in global cognitive function at the end of the intervention period (12 weeks) (standardised mean difference (SMD) -0.31, 95% confidence interval (CI) -0.57 to -0.05; 232 participants; 2 studies; low-quality evidence). One of these trials also assessed global cognitive function 12 months after the end of the intervention; this trial provided no clear evidence of a persistent effect (SMD -0.21, 95% CI -0.66 to 0.24; 77 participants; 1 study; low-quality evidence). CCT may result in little or no difference at the end of the intervention period in episodic memory (12 to 17 weeks) (SMD 0.06, 95% CI -0.14 to 0.26; 439 participants; 4 studies; low-quality evidence) or working memory (12 to 16 weeks) (SMD -0.17, 95% CI -0.36 to 0.02; 392 participants; 3 studies; low-quality evidence). Because of the very low quality of the evidence, we are very uncertain about the effects of CCT on speed of processing and executive function. We also compared CCT to inactive control (no interventions). We found no data on our primary outcome of global cognitive function. At the end of the intervention, CCT may lead to slight improvement in episodic memory (6 months) (mean difference (MD) in Rivermead Behavioural Memory Test (RBMT) -0.90 points, 95% confidence interval (CI) -1.73 to -0.07; 150 participants; 1 study; low-quality evidence) but can have little or no effect on executive function (12 weeks to 6 months) (SMD -0.08, 95% CI -0.31 to 0.15; 292 participants; 2 studies; low-quality evidence), working memory (16 weeks) (MD -0.08, 95% CI -0.43 to 0.27; 60 participants; 1 study; low-quality evidence), or verbal fluency (6 months) (MD -0.11, 95% CI -1.58 to 1.36; 150 participants; 1 study; low-quality evidence). We could not determine any effects on speed of processing because the evidence was of very low quality. We found no evidence on quality of life, activities of daily living, or adverse effects in either comparison.

AUTHORS' CONCLUSIONS

We found low-quality evidence suggesting that immediately after completion of the intervention, small benefits of CCT may be seen for global cognitive function when compared with active controls, and for episodic memory when compared with an inactive control. These benefits are of uncertain clinical importance. We found no evidence that the effect on global cognitive function persisted 12 months later. Our confidence in the results was low, reflecting the overall quality of the evidence. In five of the eight trials, the duration of the intervention was just three months. The possibility that more extensive training could yield larger benefit remains to be more fully explored. We found substantial literature on cognitive training, and collating all available scientific information posed problems. Duration of treatment may not be the best way to categorise interventions for inclusion. As the primary interest of older people and of guideline writers and policymakers involves sustained cognitive benefit, an alternative would be to categorise by length of follow-up after selecting studies that assess longer-term effects.

[Effectiveness of interventions to strengthen cognitive resources in nursing home residents : A systematic review and network meta-analysis]

BACKGROUND

Strengthening cognitive resources of residents in nursing homes is an important goal of preventive activities. The aim of this systematic review was to answer the question which intervention is most effective for nursing home residents to strengthen their cognitive resources.

METHOD

A systematic literature search was carried out in the Cochrane Library and the MEDLINE (PubMed), Embase, CINAHL, PsycINFO and PEDro databases. Reference lists of publications classified as relevant were checked and trial registries were searched. The literature selection, data extraction and assessment of the study quality were carried out by two reviewers independently. A frequentist network meta-analysis was conducted using a random effects model.

RESULTS

A total of 29 studies with 1816 participants were included. Both physical activity (standardized mean difference [SMD] = 0.70, 95%-confidence interval [CI] 0.35-1.06, p < 0.001) and cognitive activity (SMD = 0.61, 95%-CI 0.22-1.01, p < 0.01) were statistically significantly superior in strengthening cognitive resources compared to usual care. Physical and cognitive activities did not differ statistically significantly from each other. In addition, neither physical activity nor cognitive activity showed statistically significantly better cognitive resources in nursing home residents compared to social activities.

CONCLUSION

The findings imply that physical activity as well as cognitive activity could be effective to strengthen cognitive resources of nursing home residents. Considering the low-quality of available evidence, performance of high-quality studies is essential in order to verify the robustness of the statistical results.

Neuro-Advancements and the Role of Nurses as Stated in Academic Literature and Canadian Newspapers

Neurosciences and neurotechnologies (from now on called neuro-advancements) constantly evolve and influence all facets of society. Neuroethics and neuro-governance discourses focus on the impact of neuro-advancements on individuals and society, and stakeholder involvement is identified as an important aspect of being able to deal with such an impact. Nurses engage with neuro-advancements within their occupation, including neuro-linked assistive technologies, such as brain-computer interfaces, cochlear implants, and virtual reality. The role of nurses is multifaceted and includes being providers of clinical and other health services, educators, advocates for their field and their clients, including disabled people, researchers, and influencers of policy discourses. Nurses have a stake in how neuro-advancements are governed, therefore, being influencers of neuroethics and neuro-governance discourses should be one of these roles. Lifelong learning and professional development could be one mechanism to increase the knowledge of nurses about ethical, social, and legal issues linked to neuro-advancements, which in turn, would allow nurses to provide meaningful input towards neuro-advancement discussions. Disabled people are often the recipients of neuro-advancements and are clients of nurses, therefore, they have a stake in the way nurses interact with neuro-advancements and influence the sociotechnical context of neuro-advancements, which include neuro-linked assistive devices. We performed a scoping review to investigate the role of narrative around nurses in relation to neuro-advancements within academic literature and newspapers. We found minimal engagement with the role of nurses outside of clinical services. No article raised the issue of nurses having to be involved in neuro-ethics and neuro-governance discussions or how lifelong learning could be used to gain that competency. Few articles used the term assistive technology or assistive device and no article covered the engagement of nurses with disabled people within a socio-technical context. We submit that the role narrative falls short of what is expected from nurses and shows shortcomings at the intersection of nurses, socio-technical approaches to neuro-assistive technologies and other neuro-advancements and people with disabilities. Neuro-governance and neuroethic discourses could be a useful way for nurses and disabled people to co-shape the socio-technical context of neuro-advancements, including neuro-assistive technologies. Lifelong learning initiatives should be put in place to provide the knowledge necessary for nurses to take part in the neuroethics and neuro-governance discussion.

The Efficacy of Cognitive Stimulation Therapy (CST) for People With Mild-to-Moderate Dementia

Abstract. Cognitive Stimulation Therapy (CST) is an internationally used, evidence-based psychosocial intervention for people with mild-to-moderate dementia. The present review thus aimed specifically to examine the reliability of the findings and the strength of the evidence obtained in studies on the CST protocol concerning any benefit in terms of cognitive functioning, perceived quality of life, psychological, behavioral, and everyday life functioning of people with dementia, and their family caregivers’ health status, quality of life, and burden of care. A systematic literature search on studies specifically adopting the CST protocol in patients with mild-to-moderate DSM-IV dementia – eventually involving their family members – was performed. A total of 238 papers were screened and 12 finally included in the qualitative analysis after inclusion/exclusion criteria were applied. The Jadad Scale and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) method were used to appraise the studies’ methodological quality. Moderate levels of evidence emerged for general cognitive functioning, language comprehension and production, and quality of life. The levels of evidence were weaker for short-term memory, orientation, praxis, depression, social and emotional loneliness, behavior, and communication in people with dementia, and for their caregivers’ health status and anxiety symptoms. Albeit with the limited quality of reviewed evidence, and the need for more studies on CST, the present review highlights the value of this program as part of dementia care services to sustain the cognitive functioning and quality of life of people with dementia.

Computerised cognitive training for maintaining cognitive function in cognitively healthy people in late life

BACKGROUND

Increasing age is associated with a natural decline in cognitive function and is also the greatest risk factor for dementia. Cognitive decline and dementia are significant threats to independence and quality of life in older adults. Therefore, identifying interventions that help to maintain cognitive function in older adults or to reduce the risk of dementia is a research priority. Cognitive training uses repeated practice on standardised exercises targeting one or more cognitive domains and is intended to maintain optimum cognitive function. This review examines the effect of computerised cognitive training interventions lasting at least 12 weeks on the cognitive function of healthy adults aged 65 or older.

OBJECTIVES

To evaluate the effects of computerised cognitive training interventions lasting at least 12 weeks for the maintenance or improvement of cognitive function in cognitively healthy people in late life.

SEARCH METHODS

We searched to 31 March 2018 in ALOIS (www.medicine.ox.ac.uk/alois) and performed additional searches of MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO Portal/ICTRP (www.apps.who.int/trialsearch) to ensure that the search was as comprehensive and as up-to-date as possible, to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs, published or unpublished, reported in any language. Participants were cognitively healthy people, and at least 80% of the study population had to be aged 65 or older. Experimental interventions adhered to the following criteria: intervention was any form of interactive computerised cognitive intervention - including computer exercises, computer games, mobile devices, gaming console, and virtual reality - that involved repeated practice on standardised exercises of specified cognitive domain(s) for the purpose of enhancing cognitive function; duration of the intervention was at least 12 weeks; cognitive outcomes were measured; and cognitive training interventions were compared with active or inactive control interventions.

DATA COLLECTION AND ANALYSIS

We performed preliminary screening of search results using a 'crowdsourcing' method to identify RCTs. At least two review authors working independently screened the remaining citations against inclusion criteria. At least two review authors also independently extracted data and assessed the risk of bias of included RCTs. Where appropriate, we synthesised data in random-effect meta-analyses, comparing computerised cognitive training (CCT) separately with active and inactive controls. We expressed treatment effects as standardised mean differences (SMDs) with 95% confidence intervals (CIs). We used GRADE methods to describe the overall quality of the evidence for each outcome.

MAIN RESULTS

We identified eight RCTs with a total of 1183 participants. Researchers provided interventions over 12 to 26 weeks; in five trials, the duration of intervention was 12 or 13 weeks. The included studies had a moderate risk of bias. Review authors noted a lot of inconsistency between trial results. The overall quality of evidence was low or very low for all outcomes.We compared CCT first against active control interventions, such as watching educational videos. Because of the very low quality of the evidence, we were unable to determine any effect of CCT on our primary outcome of global cognitive function or on secondary outcomes of episodic memory, speed of processing, executive function, and working memory.We also compared CCT versus inactive control (no interventions). Negative SMDs favour CCT over control. We found no studies on our primary outcome of global cognitive function. In terms of our secondary outcomes, trial results suggest slight improvement in episodic memory (mean difference (MD) -0.90, 95% confidence interval (CI) -1.73 to -0.07; 150 participants; 1 study; low-quality evidence) and no effect on executive function (SMD -0.08, 95% CI -0.31 to 0.15; 292 participants; 2 studies; low-quality evidence), working memory (MD -0.08, 95% CI -0.43 to 0.27; 60 participants; 1 study; low-quality evidence), or verbal fluency (MD -0.11, 95% CI -1.58 to 1.36; 150 participants; 1 study; low-quality evidence). We could not determine any effects on speed of processing at trial endpoints because the evidence was of very low quality.We found no evidence on quality of life, activities of daily living, or adverse effects in either comparison.

AUTHORS' CONCLUSIONS

We found little evidence from the included studies to suggest that 12 or more weeks of CCT improves cognition in healthy older adults. However, our limited confidence in the results reflects the overall quality of the evidence. Inconsistency between trials was a major limitation. In five of the eight trials, the duration of intervention was just three months. The possibility that longer periods of training could be beneficial remains to be more fully explored.

Computerised cognitive training for maintaining cognitive function in cognitively healthy people in midlife

BACKGROUND

Normal aging is associated with changes in cognitive function that are non-pathological and are not necessarily indicative of future neurocognitive disease. Low cognitive and brain reserve and limited cognitive stimulation are associated with increased risk of dementia. Emerging evidence now suggests that subtle cognitive changes, detectable years before criteria for mild cognitive impairment are met, may be predictive of future dementia. Important for intervention and reduction in disease risk, research also suggests that engaging in stimulating mental activity throughout adulthood builds cognitive and brain reserve and reduces dementia risk. Therefore, midlife (defined here as 40 to 65 years) may be a suitable time to introduce cognitive interventions for maintaining cognitive function and, in the longer term, possibly preventing or delaying the onset of clinical dementia.

OBJECTIVES

To evaluate the effects of computerised cognitive training interventions lasting at least 12 weeks for maintaining or improving cognitive function in cognitively healthy people in midlife.

SEARCH METHODS

We searched up to 31 March 2018 in ALOIS (www.medicine.ox.ac.uk/alois), the specialised register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG). We ran additional searches in MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO Portal/ICTRP at www.apps.who.int/trialsearch, to ensure that the search was as comprehensive and as up-to-date as possible, to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs, published or unpublished, reported in any language. Participants were cognitively healthy people between 40 and 65 years of age (80% of study population within this age range). Experimental interventions adhered to the following criteria: intervention was any form of interactive computerised cognitive intervention - including computer exercises, computer games, mobile devices, gaming console, and virtual reality - that involved repeated practice on standardised exercises of specified cognitive domain(s) for the purpose of enhancing cognitive function; duration of the intervention was at least 12 weeks; cognitive outcomes were measured; and cognitive training interventions were compared with active or inactive control interventions.

DATA COLLECTION AND ANALYSIS

For preliminary screening of search results, we used a 'crowd' method to identify RCTs. At least two review authors working independently screened remaining citations against inclusion criteria; independently extracted data; and assessed the quality of the included trial, using the Cochrane risk of bias assessment tool. We used GRADE to describe the overall quality of the evidence.

MAIN RESULTS

We identified one eligible study that examined the effect of computerised cognitive training (CCT) in 6742 participants over 50 years of age, with training and follow-up duration of six months. We considered the study to be at high risk of attrition bias and the overall quality of the evidence to be low.Researchers provided no data on our primary outcome. Results indicate that there may be a small advantage for the CCT group for executive function (mean difference (MD) -1.57, 95% confidence interval (CI) -1.85 to -1.29; participants = 3994; low-quality evidence) and a very small advantage for the control group for working memory (MD 0.09, 95% CI 0.03 to 0.15; participants = 5831; low-quality evidence). The intervention may have had little or no effect on episodic memory (MD -0.03, 95% CI -0.10 to 0.04; participants = 3090; low-quality evidence).

AUTHORS' CONCLUSIONS

We found low-quality evidence from only one study. We are unable to determine whether computerised cognitive training is effective in maintaining global cognitive function among healthy adults in midlife. We strongly recommend that high-quality studies be undertaken to investigate the effectiveness and acceptability of cognitive training in midlife, using interventions that last long enough that they may have enduring effects on cognitive and brain reserve, and with investigators following up long enough to assess effects on clinically important outcomes in later life.

Computerised cognitive training for preventing dementia in people with mild cognitive impairment

BACKGROUND

The number of people living with dementia is increasing rapidly. Clinical dementia does not develop suddenly, but rather is preceded by a period of cognitive decline beyond normal age-related change. People at this intermediate stage between normal cognitive function and clinical dementia are often described as having mild cognitive impairment (MCI). Considerable research and clinical efforts have been directed toward finding disease-modifying interventions that may prevent or delay progression from MCI to clinical dementia.

OBJECTIVES

To evaluate the effects of at least 12 weeks of computerised cognitive training (CCT) on maintaining or improving cognitive function and preventing dementia in people with mild cognitive impairment.

SEARCH METHODS

We searched to 31 May 2018 in ALOIS (www.medicine.ox.ac.uk/alois) and ran additional searches in MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO portal/ICTRP (www.apps.who.int/trialsearch) to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in which cognitive training via interactive computerised technology was compared with an active or inactive control intervention. Experimental computerised cognitive training (CCT) interventions had to adhere to the following criteria: minimum intervention duration of 12 weeks; any form of interactive computerised cognitive training, including computer exercises, computer games, mobile devices, gaming console, and virtual reality. Participants were adults with a diagnosis of mild cognitive impairment (MCI) or mild neurocognitive disorder (MND), or otherwise at high risk of cognitive decline.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias of the included RCTs. We expressed treatment effects as mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes and as risk ratios (RRs) for dichotomous outcomes. We used the GRADE approach to describe the overall quality of evidence for each outcome.

MAIN RESULTS

Eight RCTs with a total of 660 participants met review inclusion criteria. Duration of the included trials varied from 12 weeks to 18 months. Only one trial used an inactive control. Most studies were at unclear or high risk of bias in several domains. Overall, our ability to draw conclusions was hampered by very low-quality evidence. Almost all results were very imprecise; there were also problems related to risk of bias, inconsistency between trials, and indirectness of the evidence.No trial provided data on incident dementia. For comparisons of CCT with both active and inactive controls, the quality of evidence on our other primary outcome of global cognitive function immediately after the intervention period was very low. Therefore, we were unable to draw any conclusions about this outcome.Due to very low quality of evidence, we were also unable to determine whether there was any effect of CCT compared to active control on our secondary outcomes of episodic memory, working memory, executive function, depression, functional performance, and mortality. We found low-quality evidence suggesting that there is probably no effect on speed of processing (SMD 0.20, 95% confidence interval (CI) -0.16 to 0.56; 2 studies; 119 participants), verbal fluency (SMD -0.16, 95% CI -0.76 to 0.44; 3 studies; 150 participants), or quality of life (mean difference (MD) 0.40, 95% CI -1.85 to 2.65; 1 study; 19 participants).When CCT was compared with inactive control, we obtained data on five secondary outcomes, including episodic memory, executive function, verbal fluency, depression, and functional performance. We found very low-quality evidence; therefore, we were unable to draw any conclusions about these outcomes.

AUTHORS' CONCLUSIONS

Currently available evidence does not allow us to determine whether or not computerised cognitive training will prevent clinical dementia or improve or maintain cognitive function in those who already have evidence of cognitive impairment. Small numbers of trials, small samples, risk of bias, inconsistency between trials, and highly imprecise results mean that it is not possible to derive any implications for clinical practice, despite some observed large effect sizes from individual studies. Direct adverse events are unlikely to occur, although the time and sometimes the money involved in computerised cognitive training programmes may represent significant burdens. Further research is necessary and should concentrate on improving methodological rigour, selecting suitable outcomes measures, and assessing generalisability and persistence of any effects. Trials with long-term follow-up are needed to determine the potential of this intervention to reduce the risk of dementia.

Efficacy of cognitive stimulation therapy for older adults with vascular dementia

Background:

Cognitive stimulation therapy (CST) is an evidence-based psychosocial intervention for people with mild-to-moderate dementia due to various etiological factors.

Objective:

The aim of the present study was to assess the efficacy of the CST program, Italian adaptation -CST-IT-, in individuals who have vascular dementia (VaD).

Methods:

Older adults with mild-to-moderate VaD (N = 35) were assigned to one of two programs: one group (N = 21) attended the 14 sessions of the CST-IT program, while the other, active control group (N = 14) took part in alternative activities. The following domains were examined: cognitive functioning, quality of life, mood, behavior, functional activities of daily living.

Results:

Compared with the active controls, the CST-IT group showed a greater improvement in general cognitive functioning after the intervention (i.e. score increase on the Mini-Mental State Examination and decrease on the Alzheimer's Disease Assessment Scale – Cognitive subscale). A trend towards improvement was also identified in short-term/working memory – the backward digit span task- and perceived quality of life (Quality of Life – Alzheimer's Disease scale). No significant differences emerged between the two groups for the other domains considered.

Conclusion:

The present results support the efficacy of CST in people with vascular dementia.