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Review
. 2023 Jun 29;6(6):CD013388.
doi: 10.1002/14651858.CD013388.pub2.

Cognitive rehabilitation for people with mild to moderate dementia

Aleksandra Kudlicka  1 , Anthony Martyr  2 , Alex Bahar-Fuchs  3   4 , Julieta Sabates  4 , Bob Woods  5 , Linda Clare  2   6
Affiliations
Review

Cognitive rehabilitation for people with mild to moderate dementia

Aleksandra Kudlicka et al. Cochrane Database Syst Rev. .

Abstract
in English, Spanish

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

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

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

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

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

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

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

Antecedentes: El deterioro cognitivo afecta la capacidad funcional de las personas con demencia. La rehabilitación cognitiva (RC) es un enfoque personalizado y centrado en soluciones que pretende que las personas con demencia de leve a moderada puedan realizar las actividades cotidianas y mantener la mayor independencia posible.

Objetivos: Evaluar los efectos de la RC en la funcionalidad cotidiana y otros desenlaces de las personas con demencia leve a moderada, así como en los desenlaces de los cuidadores. Identificar y explorar los factores que pueden estar asociados con la eficacia de la RC. MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en el Registro especializado del Grupo Cochrane de Demencia y trastornos cognitivos (Cochrane Dementia and Cognitive Improvement Group), que contiene registros de MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS y otras bases de datos de ensayos clínicos, y fuentes de literatura gris. La búsqueda más reciente se completó el 19 de noviembre de 2022. CRITERIOS DE SELECCIÓN: Se incluyeron los ensayos controlados aleatorizados (ECA) que compararon la RC con condiciones control e informaron desenlaces relevantes para la persona con demencia y el cuidador. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Se extrajeron los datos pertinentes de los manuscritos publicados y se estableció contacto con los autores de los ensayos de ser necesario. Dentro de cada una de las comparaciones, se agruparon los datos de cada desenlace de interés y se realizaron metanálisis de efectos aleatorios por la inversa de la varianza. La certeza de la evidencia se evaluó mediante el método GRADE.

Resultados principales: Se identificaron seis ECA elegibles publicados en inglés entre 2010 y 2022, que en conjunto incluyeron 1702 participantes. La media de edad de los participantes varió de 76 a 80 años, y la proporción de participantes masculinos varió del 29,4% al 79,3%. La mayoría de los participantes, de los estudios en los que se informó el tipo de demencia, tenían un diagnóstico de enfermedad de Alzheimer (EA; n = 1002, 58,9% de toda la muestra, 81,2% de los participantes en los que se informó el diagnóstico específico). El riesgo de sesgo en los estudios individuales fue relativamente bajo. La excepción fue un alto riesgo de sesgo en relación con el cegamiento de los participantes y los profesionales, que no suele ser factible con las intervenciones psicosociales. El desenlace principal de la funcionalidad cotidiana se operacionalizó en los estudios incluidos como el logro de objetivos en relación con las actividades abordadas en la intervención. Para la comparación principal de la RC con la atención habitual, se agruparon los datos del logro de los objetivos evaluados desde tres perspectivas (autoevaluación del desempeño, valoración de los informantes sobre el desempeño y autoevaluación de la satisfacción con el desempeño) al final del tratamiento y en el seguimiento a medio plazo (de tres a 12 meses). También fue posible agrupar los datos en estos puntos temporales de 20 y 19 desenlaces secundarios respectivamente. Los resultados de la revisión dependieron fuertemente de un ECA grande y de calidad alta. Se encontró evidencia de certeza alta de grandes efectos positivos de la RC en los tres desenlaces principales al final del tratamiento: autoevaluaciones de los participantes sobre el logro de los objetivos (diferencia de medias estandarizada [DME] 1,46; intervalo de confianza [IC] del 95%: 1,26 a 1,66; I 2 = 0%; tres ECA, 501 participantes), valoraciones de los informantes sobre el logro de los objetivos (DME 1,61; IC del 95%: 1,01 a 2,21; I 2 = 41%; tres ECA, 476 participantes) y autoevaluaciones de la satisfacción con el logro de los objetivos (DME 1,31; IC del 95%: 1,09 a 1,54; I 2 = 5%; tres ECA, 501 participantes), en relación con una condición control inactiva. En el seguimiento a medio plazo se encontró evidencia de certeza alta que mostró un gran efecto positivo de la RC sobre las tres perspectivas de desenlaces principales: autoevaluaciones de los participantes sobre el logro de los objetivos (DME 1,46; IC del 95%: 1,25 a 1,68; I 2 = 0%; dos ECA, 432 participantes), valoraciones de los informantes sobre el logro de los objetivos (DME 1,25; IC del 95%: 0,78 a 1,72; I 2 = 29%; tres ECA, 446 participantes) y autoevaluaciones de la satisfacción con el logro de los objetivos (DME 1,19; IC del 95%: 0,73 a 1,66; I 2 = 28%; dos ECA, 432 participantes), en relación con una condición control inactiva. Con respecto a los participantes, al final del tratamiento se encontró evidencia de certeza alta que muestra un pequeño efecto positivo de la RC sobre la autoeficacia (dos ECA, 456 participantes) y el recuerdo inmediato (dos ECA, 459 participantes). También en los participantes, en el seguimiento a medio plazo se encontró evidencia de certeza moderada que mostró un pequeño efecto positivo de la RC sobre la atención auditiva selectiva (dos ECA, 386 participantes) y un pequeño efecto negativo sobre la capacidad funcional general (tres ECA, 673 participantes), además se encontró evidencia de certeza baja que mostró un pequeño efecto positivo sobre la atención sostenida (dos ECA, 413 participantes) y un pequeño efecto negativo sobre la memoria (dos ECA, 51 participantes) y la ansiedad (tres ECA, 455 participantes). Se encontró evidencia de certeza moderada y baja que indicó que al final del tratamiento la RC tuvo efectos insignificantes sobre la ansiedad, la calidad de vida, la atención sostenida, la memoria, el recuerdo retardado y la capacidad funcional general de los participantes, y en el seguimiento a medio plazo sobre la autoeficacia, la depresión, la calidad de vida, el recuerdo inmediato y la fluidez verbal de los participantes. En el caso de los cuidadores, al final del tratamiento se encontró evidencia de certeza baja que mostró un pequeño efecto positivo sobre los aspectos ambientales de la calidad de vida (tres ECA, 465 cuidadores), y pequeños efectos negativos de la RC sobre el nivel de depresión (dos ECA, 32 cuidadores) y sobre el bienestar psicológico (dos ECA, 388 cuidadores). También en los cuidadores, en el seguimiento a medio plazo se encontró evidencia de certeza alta que mostró un pequeño efecto positivo de la RC sobre los aspectos sociales de la calidad de vida (tres ECA, 436 cuidadores) y evidencia de certeza moderada que mostró un pequeño efecto positivo sobre los aspectos psicológicos de la calidad de vida (tres ECA, 437 cuidadores). Se encontró evidencia de certeza moderada y baja al final del tratamiento de que la RC tenía efectos insignificantes sobre la salud física de los cuidadores, los aspectos psicológicos y sociales de la calidad de vida y el estrés, así como en el seguimiento a medio plazo en el aspecto de la salud física de la calidad de vida de los cuidadores y el bienestar psicológico.

Conclusiones de los autores: La RC ayuda a las personas con demencia leve o moderada a mejorar su capacidad para realizar las actividades cotidianas objeto de la intervención. La confianza en estos resultados se podría reforzar si más estudios de calidad alta contribuyeran a los efectos observados. La evidencia disponible indica que la RC podría constituir una parte valiosa de un conjunto de herramientas clínicas para ayudar a las personas con demencia a superar algunas de las barreras cotidianas impuestas por las dificultades cognitivas y funcionales. Los estudios de investigación futuros, incluidos los estudios de evaluación de procesos, podrían ayudar a identificar vías para maximizar los efectos de la RC y lograr repercusiones más amplias en la capacidad funcional y el bienestar.

PubMed Disclaimer

Conflict of interest statement

Review authors did not assess eligibility, extract data, or rate evidence quality for any studies for which they are co‐authors; these studies were referred to other team members for consideration.

Aleksandra Kudlicka: author of an eligible study.

Anthony Martyr: author of an eligible study.

Alex Bahar‐Fuchs: none known.

Bob Woods: author of an eligible study.

Linda Clare: author an eligible study.

Julieta M. Sabatés: none known.

Figures

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1.1
1.1. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 1: Functional ability in targeted activities: personal goals ‐ performance (participant self‐report)
1.2
1.2. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 2: Functional ability in targeted activities: personal goals ‐ performance (informant report of participant)
1.3
1.3. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 3: Functional ability in targeted activities: personal goals ‐ satisfaction (participant self‐report)
1.4
1.4. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 4: General functional ability (informant report of participant)
1.5
1.5. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 5: Self‐efficacy (participant self‐report)
1.6
1.6. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 6: Mood: anxiety (participant self‐report)
1.7
1.7. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 7: Mood: depression (participant self‐report)
1.8
1.8. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 8: Behavioural symptoms (informant report of participant)
1.9
1.9. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 9: Quality of life (participant self‐report)
1.10
1.10. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 10: Cognition: memory, global score
1.11
1.11. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 11: Cognition: memory, immediate recall
1.12
1.12. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 12: Cognition: memory, delayed recall
1.13
1.13. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 13: Cognition: sustained attention
1.14
1.14. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 14: Cognition: auditory selective attention/working memory
1.15
1.15. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 15: Cognition: verbal letter fluency
1.16
1.16. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 16: Quality of life: physical health (care partner self‐report)
1.17
1.17. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 17: Quality of life: psychological (care partner self‐report)
1.18
1.18. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 18: Quality of life: social (care partner self‐report)
1.19
1.19. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 19: Quality of life: environmental (care partner self‐report)
1.20
1.20. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 20: Mood: anxiety (informant self‐report)
1.21
1.21. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 21: Mood: depression (informant self‐report)
1.22
1.22. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 22: Psychological wellbeing (care partner self‐report)
1.23
1.23. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 23: Stress (care partner self‐report)
1.24
1.24. Analysis
Comparison 1: Cognitive rehabilitation versus inactive control at the end of therapy, Outcome 24: Burden (care partner self‐report)
2.1
2.1. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 1: Functional ability in targeted activities: personal goals ‐ performance (participant self‐report)
2.2
2.2. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 2: Functional ability in targeted activities: personal goals ‐ performance (informant report of participant)
2.3
2.3. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 3: Functional ability in targeted activities: personal goals ‐ satisfaction (participant self‐report)
2.4
2.4. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 4: General functional ability (informant report of participant)
2.5
2.5. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 5: Self‐efficacy (participant self‐report)
2.6
2.6. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 6: Mood: anxiety (participant self‐report)
2.7
2.7. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 7: Mood: depression (participant self‐report)
2.8
2.8. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 8: Quality of life (participant self‐report)
2.9
2.9. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 9: Cognition: memory, global score
2.10
2.10. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 10: Cognition: memory, immediate recall
2.11
2.11. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 11: Cognition: memory, delayed recall
2.12
2.12. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 12: Cognition: sustained attention
2.13
2.13. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 13: Cognition: auditory selective attention/working memory
2.14
2.14. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 14: Cognition: verbal letter fluency
2.15
2.15. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 15: Quality of life: overall (care partner self‐report)
2.16
2.16. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 16: Quality of life: physical health (care partner self‐report)
2.17
2.17. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 17: Quality of life: psychological (care partner self‐report)
2.18
2.18. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 18: Quality of life: social (care partner self‐report)
2.19
2.19. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 19: Quality of life: environmental (care partner self‐report)
2.20
2.20. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 20: Mood: anxiety (informant self‐report)
2.21
2.21. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 21: Mood: depression (informant self‐report)
2.22
2.22. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 22: Psychological wellbeing (care partner self‐report)
2.23
2.23. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 23: Stress (care partner self‐report)
2.24
2.24. Analysis
Comparison 2: Cognitive rehabilitation versus inactive control at medium‐term follow‐up, Outcome 24: Burden (care partner self‐report)
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References

References to studies included in this review

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References to studies excluded from this review

Amrani 2019 {published data only}
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Fortinsky 2016 {published data only}
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    1. Gitlin LN, Marx K, Piersol CV, Hodgson NA, Huang J, Roth DL, et al. Effects of the tailored activity program (TAP) on dementia-related symptoms, health events and caregiver wellbeing: a randomized controlled trial. BMC Geriatrics 2021 ;21(1):1-4. [DOI: 10.1186/s12877-021-02511-4] - DOI - PMC - PubMed
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Jeon 2019 {published data only}
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Jiménez Palomares 2021 {published data only}
    1. Jiménez Palomares M, González López-Arza MV, Garrido Ardila EM, Rodríguez Domínguez T, Rodríguez Mansilla J. Effects of a cognitive rehabilitation programme on the independence performing activities of daily living of persons with dementia - a pilot randomized controlled trial. Brain Sciences 2021;11(319):1-12. [DOI: 10.3390/brainsci11030319] - DOI - PMC - PubMed
Juárez‐Cedillo 2020 {published data only}
    1. Juárez-Cedillo T, Gutiérrez-Gutiérrez L, Sánchez-Hurtado LA, Martínez-Rodríguez N, Juarez-Cedillo E . Randomized controlled trial of multi-component cognitive stimulation therapy (SADEM) in community-dwelling demented adults. Journal of Alzheimer's Disease 2020;78(3):1033-45. [DOI: 10.3233/JAD-200574] - DOI - PubMed
Kelly 2019 {published data only}
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Kim 2015 {published data only}
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Kumar 2013 {published data only}
    1. Kumar P, Tiwari SC, Sreenivas V, Kumar N, Tripathi RK, ABD. Profile of older adults in memory outpatients' clinic setting and effectiveness of novel occupational therapy intervention in patients with mild to moderate dementia. Indian Journal of Physiotherapy and Occupational Therapy 2013;7(3):297-302. [DOI: 10.5958/j.0973-5674.7.3.111] - DOI
Kurz 2012 {published data only}
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Livelli 2015 {published data only}
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Mountain 2022 {published data only}
    1. Mountain GA, Cooper CL, Wright J, Walters SJ, Lee E, Craig C, et al. The journeying through dementia psychosocial intervention versus usual care study: a single-blind, parallel group, phase 3 trial. Lancet Healthy Longevity 2022;3(4):e276-85. [DOI: 10.1016/S2666-7568(22)00059-9] - DOI - PubMed
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References to studies awaiting assessment

Zhang 2004 {published data only}
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References to ongoing studies

Ciro 2016 {published data only}
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