The Effect of Cognitive Intervention on Cognitive Function in Older Adults With Alzheimer’s Disease: A Systematic Review and Meta-Analysis

Wang, Y-Y et al | 2021 | The Effect of Cognitive Intervention on Cognitive Function in Older Adults With Alzheimer’s Disease: A Systematic Review and Meta-Analysis | Neuropsychology Review 2021 | April 24 |

Abstract

Cognitive intervention includes cognitive stimulation, cognitive training, and cognitive rehabilitation. This systematic review was performed to re-assess the efficacy of cognitive intervention for the patients with Alzheimer’s disease (AD). Twenty studies (2012 participants) were eventually included. For global cognitive function, the combined mean difference (MD) in eight studies was 1.67 for the short term. The pooled standardized mean difference (SMD) of six RCTs was 1.61 for the medium term. The pooled SMD of seven studies was 0.79 for the long term. For depression, the pooled SMD of two trials was -0.48 for the short term. Cognitive training may show obvious improvements in global cognitive function whether after short, medium, or long-term interventions and in depression after short term intervention. However, the positive effect of the intervention on general cognitive function or depression did not seem to persist after intervention ended. There is still a lack of reliable and consistent conclusions relevant to the effect of cognitive stimulation and cognitive rehabilitation on observed outcomes, cognitive training for memory or other non-cognitive outcomes. PROSPERO registration number: CRD42019121768.The Effect of Cognitive Intervention on Cognitive Function in Older Adults With Alzheimer’s Disease: A Systematic Review and Meta-Analysis

Abstract available from the journal Neuropsychology Review 2021

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Telemedicine and Dementia Care: A Systematic Review of Barriers and Facilitators

Yi, J.S., Pittman, C., Price, C.L., Nieman, C.L. & Oh, .E.S.| 2021| Telemedicine and Dementia Care: A Systematic Review of Barriers and Facilitators| J Am Med Dir Assoc| Apr 19:S1525-8610(21)00311-X. doi: 10.1016/j.jamda.2021.03.015. Epub ahead of print. PMID: 33887231.

Abstract

Objectives: An increasing reliance on telemedicine for older adults with cognitive impairment requires a better understanding of the barriers and facilitators for this unique patient population.

Design: The study team queried PubMed, Embase, the Cochrane Library, PsycINFO, CINAHL, Scopus, and ClinicalTrials.gov on May 1, 2020, for studies in English published from January 2010 to May 2020.

Setting and participants: We conducted a systematic review of articles investigating the use of telemedicine among older adults with Alzheimer’s disease and related dementia (ADRD) or mild cognitive impairment (MCI) that focused on the patient and care partner perspectives.

Methods: Telemedicine encounter purpose, technological requirements, and findings regarding sensory needs were extracted. The Cochrane Collaboration’s Risk of Bias Tool was applied for quality assessment.

Results: The search yielded 3551 abstracts, from which 90 articles were reviewed and 17 were included. The purpose of telemedicine encounters included routine care, cognitive assessment, and telerehabilitation. All studies reported successful implementation of telemedicine, supported by patient and care partner satisfaction, similar results on cognitive assessment and diagnosis compared to in-person visits, and improvement in outcome measures following rehabilitation. Sixteen studies relied on staff and care partners to navigate technologies. Six studies reported participants reporting difficulty hearing the provider during the telemedicine visits. Five studies excluded participants with visual or hearing impairment because of the potential difficulty of using telemedicine technology. No studies reported technological adaptations to account for sensory impairment.

Conclusions and implications: Telemedicine is well received among patients and care partners, but successful delivery incorporates support staff and the care partners to navigate technologies. The exclusion of older adults with sensory impairment, especially given that it is highly prevalent, in developing telemedicine systems may further exacerbate access to care in this population. Adapting technologies for sensory needs is critical to the advancement of accessible dementia care through telemedicine.

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Exercise & socialising might be more efficacious than medication for dementia patients with depression, reports systematic review #covid19rftlks

Watt, J. A. et al. | 2021 | Comparative efficacy of interventions for reducing symptoms of depression in people with dementia: systematic review and network meta-analysis| BMJ | 372| n532| doi:10.1136/bmj.n532

This systematic review and network meta-analysis (NMA) compares the efficacy of drug interventions with non-drug interventions for reducing symptoms of depression in people with dementia.  The evidence showed that non-drug and multidisciplinary approaches are highly efficacious interventions from which people with dementia will derive benefit.

Non-drug approaches were associated with a meaningful reduction in symptoms of depression in people with dementia and without a diagnosis of a major depressive disorder. Drug approaches alone, however, were not more efficacious than usual care

Objective To describe the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia who experience depression as a neuropsychiatric symptom of dementia or have a diagnosis of a major depressive disorder.

Design Systematic review and meta-analysis.

Data sources Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, and grey literature between inception and 15 October 2020.

Eligibility criteria for study selection Randomised trials comparing drug or non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia.

Main outcome measures Pairs of reviewers screened studies, abstracted aggregate level data, and appraised risk of bias with the Cochrane risk of bias tool, which facilitated the derivation of standardised mean differences and back transformed mean differences (on the Cornell scale for depression in dementia) from bayesian random effects network meta-analyses and pairwise meta-analyses.

Results Of 22 138 citations screened, 256 studies (28 483 people with dementia) were included. Missing data posed the greatest risk to review findings. In the network meta-analysis of studies including people with dementia without a diagnosis of a major depressive disorder who were experiencing symptoms of depression (213 studies; 25 177 people with dementia; between study variance 0.23), seven interventions were associated with a greater reduction in symptoms of depression compared with usual care: cognitive stimulation (mean difference −2.93, 95% credible interval −4.35 to −1.52), cognitive stimulation combined with a cholinesterase inhibitor (−11.39, −18.38 to −3.93), massage and touch therapy (−9.03, −12.28 to −5.88), multidisciplinary care (−1.98, −3.80 to −0.16), occupational therapy (−2.59, −4.70 to −0.40), exercise combined with social interaction and cognitive stimulation (−12.37, −19.01 to −5.36), and reminiscence therapy (−2.30, −3.68 to −0.93). Except for massage and touch therapy, cognitive stimulation combined with a cholinesterase inhibitor, and cognitive stimulation combined with exercise and social interaction, which were more efficacious than some drug interventions, no statistically significant difference was found in the comparative efficacy of drug and non-drug interventions for reducing symptoms of depression in people with dementia without a diagnosis of a major depressive disorder. Clinical and methodological heterogeneity precluded network meta-analysis of studies comparing the efficacy of interventions specifically for reducing symptoms of depression in people with dementia and a major depressive disorder (22 studies; 1829 patients).

Conclusions In this systematic review, non-drug interventions were found to be more efficacious than drug interventions for reducing symptoms of depression in people with dementia without a major depressive disorder.

Full paper available from The BMJ

See also:

BMJ Opinion Social prescribing may help reduce symptoms of depression in people with dementia

In the news

iNews Exercise could be better than medication for dementia patients with depression, report claims

Cochrane Systematic Review: Medicines to treat people with vascular dementia and other vascular cognitive impairments

Battle,  C.E., Abdul-Rahim,  A.H., Shenkin,  S.D., Hewitt,  J., Quinn,  T.J. Cholinesterase inhibitors for vascular dementia and other vascular cognitive impairments: a network meta‐analysis. Cochrane Database of Systematic Reviews | Issue 2. Art. No.: CD013306. DOI: 10.1002/14651858.CD013306.pub2. Accessed 23 March 2021.

This systematic review explores the question: What is the evidence for cholinesterase inhibitors (medicines designed to improve memory and thinking in people with dementia), when used with people who have vascular dementia?

Plain Language Summary

The reviewers found 8 studies including a total of 4 373 people with vascular dementia (or vascular cognitive impairment). The studies tested the drug donepezil at two different doses (5mg and 10mg daily), against each other and against placebo. Rivastigmine and galantamine were tested against placebo only. Rivastigmine is available as a skin patch, but the studies only tested the pill version. All eight studies evaluated participants when they first started taking the medicine or placebo and again six months later. Different tests were used to measure the effects. All studies included tests of memory, thinking and reported side effects.

People taking donepezil or galantamine had better scores on memory and thinking tests than people taking placebo, but the benefits were modest and may not be large enough to be evident in daily life. 

There was no evidence of a difference for rivastigmine, but the evidence was less certain, and the doses taken by some participants may have been too low to show an effect. We found evidence that when compared to placebo, side effects such as nausea and diarrhoea, were more common in people taking donepezil 10mg and galantamine, but probably not donepezil 5mg. We were unable to draw conclusions about side effects of rivastigmine from the studies.

No vascular dementia trials comparing the different cholinesterase against each other have been conducted. Using the information from the individual studies, we made indirect assessments of how the drugs would perform if tested head‐to‐head. The results suggested that donepezil 10 mg had the greatest effect on memory and thinking, but caused more side effects than donepezil 5 mg or galantamine.

There were only a small number of studies for each drug. Certainty in the results varied between drugs and between outcomes, from high to very low certainty. The studies showed only a small benefit at most; however, in the absence of any other treatments, people living with dementia may still wish to consider use of these drugs.

The review is available in full from the Cochrane Database of Systematic Reviews 

High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis

Yeh, S.W. et al. | 2021 | High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis | Clin Rehabilation | 35| 2 | P.169-181| doi: 10.1177/0269215520961637. Epub 2020 Oct 11. PMID: 33040592.

Abstract

Objective: This study aimed to investigate the efficacy of high-intensity functional exercise among older adults with dementia.

Methods: In this systematic review and meta-analysis of randomized controlled trials, we collected articles published before August 2020 from PubMed, Embase, and the Cochrane Library to evaluate the effect of high-intensity functional exercise on older adults with dementia. Primary outcomes included improvements in balance function and gait performance (speed, cadence, and stride length). The secondary outcomes included lower limb strength, activities of daily living, psychiatric well-being, depression, and cognition. Furthermore, we performed subgroup analysis with two high-intensity functional exercise programs: the Umeå program and Hauer’s program.

Results: We identified 15 articles describing six trials including older adults with dementia undergoing high-intensity functional exercise or control activity. The meta-analysis indicated that high-intensity functional exercise, both in Hauer’s program and in the Umeå program, significantly improved balance function (pooled standardized mean difference 0.57, 95% confidence interval 0.31-0.83). Hauer’s program significantly improved gait speed, cadence, stride length, and lower limb strength. Beneficial effects on speed, cadence, and lower limb strength were retained for several months. The Umeå program facilitated activities of daily living and psychiatric well-being, with effects on activities of daily living lasting several months. In the only eligible trial, no effects on cognition were observed. Adverse effects of high-intensity functional exercise were minimal to none.

Conclusions: High-intensity functional exercise is generally safe and is recommended for older individuals with mild or moderate dementia to provide benefits in motor performance and daily functioning.

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High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis

Yeh, S-W et al. (2020) |High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis |Clinical Rehabilitation | https://doi.org/10.1177/0269215520961637

This systematic review underlines the impact of high intensity exercise on older people with dementia. The researchers reviewed some 15 articles describing six trials including older adults and controlled groups. They report that facilitated activities had an effect on of daily living and psychiatric well-being; with effects on activities of daily living being the most long-lasting. This review also highlights how adverse effects of high-intensity functional exercise were minimal to none.

Abstract

Objective:

This study aimed to investigate the efficacy of high-intensity functional exercise among older adults with dementia.

Methods:

In this systematic review and meta-analysis of randomized controlled trials, we collected articles published before August 2020 from PubMed, Embase, and the Cochrane Library to evaluate the effect of high-intensity functional exercise on older adults with dementia. Primary outcomes included improvements in balance function and gait performance (speed, cadence, and stride length). The secondary outcomes included lower limb strength, activities of daily living, psychiatric well-being, depression, and cognition. Furthermore, we performed subgroup analysis with two high-intensity functional exercise programs: the Umeå program and Hauer’s program.

High-intensity functional exercise in older adults with dementia: A systematic review and meta-analysis – Shu-Wei Yeh, Li-Fong Lin, Hung-Chou Chen, Li-Kai Huang, Chaur-Jong Hu, Ka-Wai Tam, Yi-Chun Kuan, Chien-Hsiung Hong, 2020

Results:

We identified 15 articles describing six trials including older adults with dementia undergoing high-intensity functional exercise or control activity. The meta-analysis indicated that high-intensity functional exercise, both in Hauer’s program and in the Umeå program, significantly improved balance function (pooled standardized mean difference 0.57, 95% confidence interval 0.31–0.83). Hauer’s program significantly improved gait speed, cadence, stride length, and lower limb strength. Beneficial effects on speed, cadence, and lower limb strength were retained for several months. The Umeå program facilitated activities of daily living and psychiatric well-being, with effects on activities of daily living lasting several months. In the only eligible trial, no effects on cognition were observed. Adverse effects of high-intensity functional exercise were minimal to none.

Conclusions:

High-intensity functional exercise is generally safe and is recommended for older individuals with mild or moderate dementia to provide benefits in motor performance and daily functioning (Source: Yeh, S-W et al., 2020).

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A Systematic Review of Mindfulness-Based Interventions for Patients with Mild Cognitive Impairment or Dementia and Caregivers

Shim M, Tilley J.L., Im, S., Price, K., & Gonzalez, A. (2020) A Systematic Review of Mindfulness-Based Interventions for Patients with Mild Cognitive Impairment or Dementia and Caregivers| Journal of Geriatric Psychiatry and Neurology| doi:10.1177/0891988720957104

New research has analysed the evidence base for mindfulness interventions for patients with dementia, mild cognitive impairment and their carers. It has been published in the Journal of Geriatric Psychiatry and Neurology

Abstract

The aim of this article was to systematically review the quality and efficacy of the current evidence for mindfulness-based interventions (MBIs) in patients with mild cognitive impairment (MCI), patients with dementia (PwD), and their caregivers. We identified 20 randomized controlled trials (RCTs) (11 for patients, 9 for caregivers) published in the last 15 years. Evidence suggested that MBIs are highly acceptable and credible treatments for patients with MCI, PwD and caregivers. Specifically, for PwD, the results indicated that the magnitude of post-treatment effects of MBIs are in the medium to large range for psychosocial outcomes, and in the small to medium range for cognitive functioning; however, treatment effects on dementia biomarkers were mixed, ranging from small to large, depending on the outcome measure. Findings also evidenced salutary effects of MBIs for caregivers of PwD, with post-treatment effects ranging from medium to large for caregiver stress and burden and large effects for quality of life, and mixed outcomes for cognitive functioning, with effects in the small to large range. However, confidence in these findings is relatively limited due to methodological limitations, especially in terms of poor consistency in intervention strategies, outcome measures, and other key criteria across studies. To better assess the value of MBIs for these populations and optimize treatment outcomes, we recommend further research with improved study methodology (e.g., multi-method assessment, universal criterion and outcome measures, use of active control groups, larger sample sizes, long-term follow-up) to replicate current findings and enhance our understanding of underlying treatment mechanisms of MBIs.

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Reminiscence therapy for dementia

Woods, B.,  O’Philbin, L.Farrell, E.M.Spector, A.EOrrell, M.  | Reminiscence therapy for dementiaCochrane Database of Systematic Reviews  |  2018  | Issue 3. | DOI: 10.1002/14651858.CD001120.pub3

Cochrane Library had produced an update to a systematic review, on reminiscence therapy (RT) previously updated in 2005. RT involves the discussion of memories and past experiences with other people using tangible prompts such as photographs or music to evoke memories and stimulate conversation. It is implemented widely in a range of settings using a variety of formats (Cochrane Database of Systematic Reviews). The plain language summary is given below.

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Reminiscence therapy for dementia

Review question

We wanted to find out what effect reminiscence therapy (RT) has on people with dementia. In particular, we were interested in effects on quality of life, communication, cognition (the general ability to think and remember), mood, daily activities and relationships. We were also interested in any effects on carers.

Background

RT involves discussing events and experiences from the past. It aims to evoke memories, stimulate mental activity and improve well-being. Reminiscence is often assisted by props such as videos, pictures and objects. It can take place in a group or be done with a person on their own, when it often results in some form of life-story book being created. RT helps older people with depression. It may be suitable for people with dementia both because depression is common in dementia and because people with dementia typically have a better memory for the distant past than for recent events.

Methods

We searched for randomised, controlled trials in which RT was compared with no treatment or with a non-specific activity, such as time spent in general conversation. Our search covered all trials available up to April 2017.

Results

We found 22 trials with 1972 participants to include in the review. All the participants had dementia, mostly of mild or moderate severity. Some of the participants were living at home and some were in care homes. The length of the trials varied from four weeks to two years, and the overall amount of time spent on therapy varied from three to 39 hours. Overall, we thought most of the trials were well conducted.

Looking at all the trials together, there did not seem to be an effect of RT on the quality of life reported by the participants. However, there was probably a slight benefit of treatment in the trials done in care homes, which was not seen in the trials done in the community.

People having RT scored slightly better than the control group on tests of cognition immediately after the course of treatment, but not weeks to months later. It was not clear that the effect was large enough to be important. The effect was most evident in care home studies, which used individual RT, but not in community studies, which used group RT.

We found that group RT and RT in community settings may have a positive effect on the communication and interaction of the person with dementia immediately after the end of treatment, and probably also weeks to months later, although the effect was small.

Apart from a probable slight benefit of individual RT on scales measuring depressed mood, we found no evidence for effects of RT on other outcomes, such as agitation, ability to carry out daily activities or relationships with other people. We found no evidence of harmful effects of RT for the people with dementia themselves.

We found no effect of RT on family carers other than a suggestion that it made carers slightly more anxious in two large studies of joint reminiscence work. In this type of RT, the carers and the people with dementia were both directly involved in the reminiscence sessions.

Conclusions

We were encouraged to find that the amount and quality of research on RT for dementia has increased considerably since the last version of this review. We concluded that the effects of RT vary, depending on the way it is given and whether it takes place in care homes or the community. However, there is some evidence that RT can improve quality of life, cognition, communication and possibly mood in people with dementia in some circumstances, although all the benefits were small. More research is needed to understand these differences and to find out who is likely to benefit most from what type of RT.

The abstract and the full text systematic review is available from The Cochrane Library, alternatively it can be downloaded here

Psychosocial interventions for people with dementia

New research finds good evidence to suggest that multi-component exercise with sufficient intensity improves global physical and cognitive functions and activities of daily living skills for people with dementia | Aging & Mental Health

Objectives: Over the last 10 years there has been a multitude of studies of psychosocial interventions for people with dementia. However, clinical services face a dilemma about which intervention should be introduced into clinical practice because of the inconsistency in some of the findings between different studies and the differences in the study qualities and trustworthiness of evidence. There was a need to provide a comprehensive summary of the best evidence to illustrate what works.

Methods: A review of the systematic reviews of psychosocial interventions in dementia published between January 2010 and February 2016 was conducted.

Results: Twenty-two reviews (8 physical, 7 cognitive, 1 physical/cognitive and 6 other psychosocial interventions) with a total of 197 unique studies met the inclusion criteria. Both medium to longer-term multi-component exercise of moderate to high intensity, and, group cognitive stimulation consistently show benefits. There is not sufficient evidence to determine whether psychological or social interventions might improve either mood or behaviour due to the heterogeneity of the studies and interventions included in the reviews.

Conclusion: There is good evidence that multi-component exercise with sufficient intensity improves global physical and cognitive functions and activities of daily living skills. There is also good evidence that group-based cognitive stimulation improves cognitive functions, social interaction and quality of life. This synthesis also highlights the potential importance of group activities to improve social integration for people with dementia. Future research should investigate longer-term specific outcomes, consider the severity and types of dementia, and investigate mechanisms of change.

Full reference: McDermott, O et al. | Psychosocial interventions for people with dementia: a synthesis of systematic reviews |Aging & Mental Health | Published online 17 Jan 2018

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A critical literature review of the effectiveness of various instruments in the diagnosis of dementia in adults with intellectual disabilities

Elliott-King, J. et al. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring. Published online: 29 June 2016

http://creativecommons.org/licenses/by/3.0
Image source: Charles Hamm – Wikipedia // CC BY 3.0

Currently, there is no consensus on dementia diagnostics in adults with intellectual disabilities (IDs). There are three types of assessments available: direct cognitive tests, test batteries, and informant reports.

A systematic literature search was conducted in four databases yielding 9840 records. Relevant studies were identified and selected using predefined inclusion and exclusion criteria and then coded and classified according to assessment type. This was completed by two independent researchers, with a third consulted when discrepancies arose. The review collates diagnostic instruments and presents strengths and weaknesses.

Overall 47 studies met the search criteria, and 43 instruments were extracted from the selected studies. Of which, 10 instruments were classified as test batteries, 23 were classified as direct cognitive tests, and the remaining 10 were informant reports.

This review can recommend that test batteries can offer the most practical and efficient method for dementia diagnosis in individuals with ID.

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