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Three Part Question

In [elderly adults with a diagnosis of dementia] will a [cognitive rehabilitation programme] improve their [ability with activities of daily living]?

Clinical Scenario

An 80 year old lady is referred to the Hospital and Community for community rehabilitation following her hospital admission. She has a diagnosis of dementia. She lives with her husband and he reports that she is struggling with activities of her daily living (ADLs). The Occupational Therapists wonder whether there is evidence that a cognitive rehabilitation programme will improve this lady's ability with her ADLs.

Search Strategy

The Cochrane Library Issue 4 October 2003
Cinahl (1982 – April 2012)
PsychInfo (1887 – April 2012)
Medline (1966 – April 2012)
Amed (1980 – April 2012)

All searches limited to Humans, All aged 65 and over and English Language.
Cinahl and PsychInfo: [exp Memory/ OR exp Memory disorders/ OR exp Dementia/ OR exp Vascular Dementia/ OR Alzheimers AND Disease ti, ab] AND [exp Occupational Therapy/ OR exp Rehabilitation/ OR exp Rehabilitation, Geriatric/ OR exp Cognition/ exp Rehabilitation, Cognition] AND [exp Activities of daily living/ OR exp functional status.]

AMED/Medline: [exp memory disorders/ OR exp alzheimers disease/ OR exp Dementia] AND [exp Occupational Therapy/ OR exp rehabilitation] AND [exp Activities of daily living]

Search Outcome

5 articles were found that were relevant to the 3 part question. One article was a Cochrane review, one article was found to be included as part of the Cochrane review and three articles that were not found in the Cochrane review. There was a meta-analysis found however this included trials that did not answer the three part question.
In summary there is a Cochrane review and 3 relevant articles for review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Clare L, Woods B (Cochrane Database of Systematic Reviews) 2003 United Kingdom	Patients with a medical diagnosis of dementia residing at home, no age restriction, patients were excluded with a known diagnosis of fronto-temporal dementia. Patients receiving acetyl-cholinesterase inhibitors were included. -Systematic review of 9 RCT Total N = 433	Cochrane Review Level 1a	Participant scores on cognitive screening measures	NSS
			Participant scores on neuropsychological tests	NSS
			Participant self-report of functioning	NSS
			Informant report of participant functioning	NSS
			Informant reactions to memory and behaviour problems	NSS Unable to perform meta-analysis due to heterogeneity of outcome measures
Zanetti et al 2001 Italy	18 patients with mild and mild-moderate Alzheimer’s Disease Baseline and follow up assessments of patient's ability with 13 activities of daily living (ADL). Follow up completed at 4 months post intervention 2 groups: 1) Treatment- Individual sessions -procedural memory stimulation for three consecutive weeks, one hour per day and five hours per week 2)Control – No Intervention	RCT – Level 1b	Time required to complete ADLs.	Treatment group Control group – NSS Between group differences were statistically significant p.<0.025 Statistical significant difference between the groups at baseline in forward digit span.	Randomisation and treatment allocation not specified or concealed. Therapists and patients not blinded. Small sample size. Medication was a confounding variable.
Graff et al 2006 Netherlands	N=135 over 65yrs with mild to moderate dementia living in the community and their primary care givers. Day clinic of a geriatric department and in participant’s homes. Treatment: 10 sessions of Occupational Therapy over 5 weeks. Interventions: Cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision. Assessed at baseline, 6 weeks and 3 months	Assessor blind RCT	ADL function Assessment of Motor and Process Skills (AMPS) and interview of daily activities in dementia (IDDD).	ADL function- Differences were 1.5 (95 % confidence interval 1.3-1.7) for the AMPS (p<0.0001) and -11.7 (-13.6- -9.7) for the IDDD (p<0.0001)	Participants not blinded to treatment. Control group interventions not clear.
			Caregiver burden sense of competence questionnaire (SCQ).	Care giver burden - 11.0 (9.2 - 12.8) for the SCQ (p<0.0001) Treatment group > control group – there at 6 weeks (p<0.0001) and at 12weeks (p<0.0001)
Clare et al 2010 UK	69 patients- mean age 77.78, with a diagnosis of Alzheimer’s Disease, or mixed Alzheimer’s Disease and Vascular Dementia. All subjects had a MMSE score of 18 or above and were receiving a stable dose of Acetyl cholinesterase-inhibiting medication. Outcome measures were recorded pre-intervention, post-intervention and 6 months after intervention. 1)Treatment Group: N=23 (completed N=20)Intervention involved 8 weekly one hour individual cognitive rehab session in which individualised goals were set focusing on ADLs. 2)Relaxation Group: N=24 (completed N=23) Intervention involved 8 weekly one hour individual relaxation sessions. 3) Control Group: N=22 (completed N=21) No contact with the research team between initial and post intervention assessments.	Single blind RCT	Outcome measures relevant to the three part question: Canadian Occupational Performance Measure (COPM) performance scale	Group 1 – Group 2 1.175 95% CI (0.526-1.823) Group 1 – Group 3 0.908 95% CI (0.248-1.568)	One therapist administered both the cognitive rehab for the treatment group and the relaxation group. No I.T.T analysis. Sample size not justified. Statistically significant results however these are not clinically significant when using the COPM as an outcome measure. Additional care giver support was not consistent across the groups and this may have impacted on the results.
			Canadian Occupational Performance Measure (COPM) satisfaction scale Assessor blinded	Group 1- Group 2 1.222 95% CI (0.569 -1.874) Group 1- Group 3 0.865 95% CI(0.208-1.521) COPM only completed pre and post intervention as not reliable as a long term follow up measure.

Comment(s)

The available evidence to answer this question is limited. The Cochrane review indicates that there are no significant positive or negative effects of cognitive training on patients ADL performance in the studies they reviewed. However the individual studies since the Cochrane Review indicates a significant improvement in patient’s performance in ADL after Occupational Therapy interventions. This therefore highlights a need for further quality research in this area.

Clinical Bottom Line

There is some evidence to suggest that cognitive rehabilitation training in adults with dementia does improve performance in ADL.

References

1. Clare L, Woods B (Cochrane Database of Systematic Reviews) Cognitive rehabilitation and cognitive training for early stage Alzheimer's disease and vascular dementia (Review) J Wiley and sons Limited 2003; issue 4 pages 1-37
2. Zanetti, O, Zanieri, G, Di giovanni, G et al. Effectiveness of procedural memory stimulation in mild Alzheimers Disease patients: A controlled study. Neuropsychological Rehabilitation 2001; 11 (3/4), 263-272
3. Graff, MJL, Vernooij-Dassen, MJM, Thijssen, M et al. Community Based Occupational Therapy for patients with dementia and their care givers: Randomised Control Trial. BMJ Online 17th November 2006; p1-6
4. Clare L, Linden D.E.J, Woods R.T et al. Goal Orientated Cognitive Rehabilitation for People with Early Stage Alzheimer Disease: A Single-Blind Randomized Controlled Trial of Clinical Efficacy. The American Journal of Geriatric Psychiatry. Oct 2010; 18, 10 pg 928.