Cognitive therapies for dementia

Psychological therapies for dementia are starting to gain some momentum. Improved clinical assessment in early stages of Alzheimer's disease and other forms of dementia, increased cognitive stimulation of the elderly, and the prescription of drugs to slow cognitive decline have resulted in increased detection in the early stages.[1][2][3] Although the opinions of the medical community are still apprehensive to support cognitive therapies in dementia patients, recent international studies have started to create optimism.[4]

Classification and efficacy of the different therapies

Psychological therapies which are considered as a treatment for dementia include music therapy,[5] reminiscence therapy,[6] cognitive reframing for caretakers,[7] validation therapy,[8] and mental exercise.[9]

Interventions may be used in conjunction with pharmaceutical treatment and can be classified within behavior, emotion, cognition or stimulation oriented approaches. Research on efficacy is reduced.[10]

Behavioral interventions

Behavioral interventions attempt to identify and reduce the antecedents and consequences of problem behaviors. This approach has not shown success in the overall functioning of patients,[11] but can help to reduced some specific problem behaviors, such as incontinence.[12] There is still a lack of high quality data on the effectiveness of these techniques in other behavior problems such as wandering.[13][14]

Emotion-oriented interventions

Emotion-oriented interventions include reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration or snoezelen, and simulated presence therapy. Supportive psychotherapy has received little or no formal scientific study, but some clinicians find it useful in helping mildly impaired patients adjust to their illness.[10] Reminiscence therapy (RT) involves the discussion of past experiences individually or in group, many times with the aid of photographs, household items, music and sound recordings, or other familiar items from the past. Although there are few quality studies on the effectiveness of RT it may be beneficial for cognition and mood.[15] Simulated presence therapy (SPT) is based on attachment theories and is normally carried out playing a recording with voices of the closests relatives of the patient. There is preliminary evidence indicating that SPT may reduce anxiety and challenging behaviors.[16][17] Finally, validation therapy is based on acceptance of the reality and personal truth of another's experience, while sensory integration is based on exercises aimed to stimulate senses. There is little evidence to support the usefulness of these therapies.[18][19]

Cognition-oriented treatments

The aim of cognition-oriented treatments, which include reality orientation and cognitive retraining is the restoration of cognitive deficits. Reality orientation consists in the presentation of information about time, place or person in order to ease the understanding of the person about its surroundings and his place in them. On the other hand cognitive retraining tries to improve impaired capacities by exercitation of mental abilities. Both have shown some efficacy improving cognitive capacities,[20][21] although in some works these effects were transient and negative effects, such as frustration, have also been reported.[10] Most of the programs inside this approach are fully or partially computerized and others are fully paper based such as the Cognitive Retention Therapy method.[22][23]

Stimulation-oriented treatments

Stimulation-oriented treatments include art, music and pet therapies, exercise, and any other kind of recreational activities for patients. Stimulation has modest support for improving behavior, mood, and, to a lesser extent, function. Nevertheless, as important as these effects are, the main support for the use of stimulation therapies is the improvement in the patient daily life routine they suppose.[10]

A study published in 2006 tested the effects of Cognitive Stimulation Therapy (CST) on the demented elderly’s quality of life. The researchers looked at the effect of CST on cognitive function, the effect of improved cognitive function on quality of life, then the link between the three (CST, cognition, and QoL). The study found an improvement in cognitive function from the CST treatment, as measured by the Mini Mental State Examination (MMSE) and the Alzheimer’s Disease Assessment Scale (ADAS-Cog), as well as an improvement in quality of life self-reported by the participants using the Quality of Life-AD measure. The study then used regression models to explain the correlation between the CST therapy and quality of life to see if the improved cognitive function was the primary mediating factor for the improved quality of life. The models supported the correlation and proposed that it was the improved cognition more than other factors (such as reduced depression symptoms and less anxiety) that led to the participants reporting back that they had a better quality of life (with significant improvements especially in energy level, memory, relationship with significant other, and ability to do chores.) [24]

Another study that was done in 2010 by London College that tested the efficacy of the Cognitive Stimulation Therapy. Participants were tested using a Mini Mental State Examination to test their level of cognitive ability and see if they qualified as a demented patient to be included in the study. The participants had to have no other health problems allowing for the experiment to have accurate internal validity. The results clearly showed that those who were given the Cognitive Stimulation Therapy did significantly better on all memory tasks than those that did not receive the therapy. Out of the eleven memory tasks that were given ten of the memory tasks were improved by the therapeutic group. This is another study that supports the efficacy of CST, demonstrating that the elderly that have dementia greatly benefit from this treatment.. Just like it was tested in the 2006 study,[24] the improvement of the participants' cognitive abilities can ultimately improve their daily lives since it helps with social influences being able to speak, remember words etc.[25]

In July 2015 UK NHS trials were reported of a robot seal from Japan being in the managemnt of distressed and disturbed behaviour in dementia patients. "Paro", which has some artificial intelligence has the ability to "learn" and remember its own name. It can also learn the behaviour that results in a pleasing stroking response and repeat it. The robot was being evaluated in a joint project involving Sheffield Health and Social Care NHS Foundation Trust and the University of Sheffield.[26]

Summary of a Systematic Review of Psychological Approaches to the Management of Neuropsychiatric Symptoms of Dementia found in the American Journal of Psychiatry[27]

Out of 1632 total studies reviewed roughly 10% of them were included in the review. Objective was to determine the level of quality of the studies and the effectiveness of the results. Main theories of the studies explored were as follows.

Results were dependent on reality orientation and were largely insignificant.

Results were inconclusive and insignificant.

Results were insignificant.

Results varied but were very positive in improving aspects of neuropsychiatric symptoms immediately and for many months after. Also improved mood, and delayed institutionalization.

Results may have been a product of environment but concluded an improvement to behavior and depression.

Most were inconclusive. Positive results were achieved using ‘life review, sensory stimulation’ and other personalized techniques.

Results showed a possible reduction in agitation and improvement with orientation, with no other real benefits.

Results showed individual education was more effective then groups in being useful to treat neuropsychiatric symptoms.

Conclusions

The article concluded:

"Only behavior management therapies, specific types of caregiver and residential care staff education, and possibly cognitive stimulation appear to have lasting effectiveness for the management of dementia-associated neuropsychiatric symptoms. Lack of evidence regarding other therapies is not evidence of lack of efficacy. Conclusions are limited because of the paucity of high-quality research (only nine level-1 studies were identified). More high-quality investigation is needed."

References

  1. ↑ NGC - NGC Summary
  2. ↑ "Early Alzheimer's disease diagnosis gives hope: detection in initial stages could slow progression, perhaps lead to prevention".
  3. ↑ Satcher David; et al. (1999). "Alzheimer’s Disease Mental Health: A report of the Surgeon General".
  4. ↑ Werheid K, Thöne-Otto AI (May 2006). "Cognitive training in Alzheimer's dementia". Nervenarzt (in German) 77 (5): 549–557. doi:10.1007/s00115-005-1998-2. PMID 16228161.
  5. ↑ Vink, A. C.; Bruinsma, M. S.; Scholten, R. J. M. (2004). Vink, Annemiek C, ed. "Music therapy for people with dementia". The Cochrane Library: CD003477. doi:10.1002/14651858.CD003477.pub2. PMID 15266489.
  6. ↑ Woods, B.; Spector, A. E.; Jones, C. A.; Orrell, M.; Davies, S. P. (2005). Woods, Bob, ed. "Reminiscence therapy for dementia". The Cochrane Library (2): CD001120. doi:10.1002/14651858.CD001120.pub2. PMID 15846613.
  7. ↑ Vernooij-Dassen, M.; Draskovic, I.; McCleery, J.; Downs, M. (2011). Vernooij-Dassen, Myrra, ed. "Cognitive reframing for carers of people with dementia". The Cochrane Library: CD005318. doi:10.1002/14651858.CD005318.pub2. PMID 22071821.
  8. ↑ Neal, M.; Barton Wright, P. (2003). Neal, Martin, ed. "Validation therapy for dementia". The Cochrane Library (3): CD001394. doi:10.1002/14651858.CD001394. PMID 12917907.
  9. ↑ Woods, B.; Aguirre, E.; Spector, A. E.; Orrell, M. (2012). Woods, Bob, ed. "Cognitive stimulation to improve cognitive functioning in people with dementia". The Cochrane Library 2: CD005562. doi:10.1002/14651858.CD005562.pub2. PMID 22336813.
  10. 1 2 3 4 "Practice Guideline for the Treatment of Patients with Alzheimer's disease and Other Dementias" (PDF). American Psychiatric Association. October 2007. doi:10.1176/appi.books.9780890423967.152139. Retrieved 2007-12-28.
  11. ↑ Bottino CM, Carvalho IA, Alvarez AM; et al. (2005). "Cognitive rehabilitation combined with drug treatment in Alzheimer's disease patients: a pilot study". Clin Rehabil 19 (8): 861–9. doi:10.1191/0269215505cr911oa. PMID 16323385.
  12. ↑ Doody RS, Stevens JC, Beck C; et al. (2001). "Practice parameter: management of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology 56 (9): 1154–66. doi:10.1212/WNL.56.9.1154. PMID 11342679.
  13. ↑ Hermans DG, Htay UH, McShane R (2007). Htay, U Hla, ed. "Non-pharmacological interventions for wandering of people with dementia in the domestic setting". Cochrane Database Syst Rev (1): CD005994. doi:10.1002/14651858.CD005994.pub2. PMID 17253573.
  14. ↑ Robinson L, Hutchings D, Dickinson HO; et al. (2007). "Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review". Int J Geriatr Psychiatry 22 (1): 9–22. doi:10.1002/gps.1643. PMID 17096455.
  15. ↑ Woods B, Spector A, Jones C, Orrell M, Davies S (2005). Woods, Bob, ed. "Reminiscence therapy for dementia". Cochrane Database Syst Rev (2): CD001120. doi:10.1002/14651858.CD001120.pub2. PMID 15846613.
  16. ↑ Peak JS, Cheston RI (2002). "Using simulated presence therapy with people with dementia". Aging Ment Health 6 (1): 77–81. doi:10.1080/13607860120101095. PMID 11827626.
  17. ↑ Camberg L, Woods P, Ooi WL; et al. (1999). "Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease". J Am Geriatr Soc 47 (4): 446–52. PMID 10203120.
  18. ↑ Neal M, Briggs M (2003). Neal, Martin, ed. "Validation therapy for dementia". Cochrane Database Syst Rev (3): CD001394. doi:10.1002/14651858.CD001394. PMID 12917907.
  19. ↑ Chung JC, Lai CK, Chung PM, French HP (2002). Chung, Jenny CC, ed. "Snoezelen for dementia". Cochrane Database Syst Rev (4): CD003152. doi:10.1002/14651858.CD003152. PMID 12519587.
  20. ↑ Spector A, Orrell M, Davies S, Woods B (2000). Spector, Aimee E, ed. "WITHDRAWN: Reality orientation for dementia". Cochrane Database Syst Rev (3): CD001119. doi:10.1002/14651858.CD001119.pub2. PMID 17636652.
  21. ↑ Spector A, Thorgrimsen L, Woods B; et al. (2003). "Efficacy of an evidence-based cognitive stimulation therapy programme for people with dementia: randomised controlled trial". Br J Psychiatry 183 (3): 248–54. doi:10.1192/bjp.183.3.248. PMID 12948999.
  22. ↑ Early Intervention for Alzheimer's Disease
  23. ↑ Section C2 Alzheimer's Society of Canada
  24. 1 2 Woods, B.; Thorgrimsen, L.; Spector, A.; Royan, L.; Orrell, M. (2006). "Improved quality of life and cognitive stimulation therapy in dementia". Aging & Mental Health 10 (3): 219–226. doi:10.1080/13607860500431652.
  25. ↑ Li, Yuanyuan; Daniel, Michael; Tollefsbol, Trygve O (2011). "Epigenetic regulation of caloric restriction in aging". BMC Medicine 9 (1): 98. doi:10.1186/1741-7015-9-98.
  26. ↑
  27. ↑ American Journal of Psychiatry
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