Cognitive therapies for dementia

Cognitive therapies for dementia are starting to gain some momemtum. 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

Interventions are used as an adjunct to pharmaceutical treatment and can be classified within behavior, emotion, cognition or stimulation oriented approaches. Research on efficacy is reduced.^[5]

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,^[6] but can help to reduced some specific problem behaviors, such as incontinence.^[7] There is still a lack of high quality data on the effectiveness of these techniques in other behavior problems such as wandering.^[8][9]

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.^[5] 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.^[10] 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.^[11][12] 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.^[13][14]

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,^[15][16] although in some works these effects were transient and negative effects, such as frustration, have also been reported.^[5] 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.^[17][18]

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.^[5]

Summary of a Systematic Review of Psychological Approaches to the Management of Neuropsychiatric Symptoms of Dementia found in the American Journal of Psychiatry^[19]

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.

• Reminiscence Therapy - using household materials, family pictures and old newspapers to stimulate memories and hopefully have the participant share their experiences.

Results were dependent on reality orientation and were largely insignificant.

• Validation Therapy - Based on personal uniqueness, promotes validating feelings of unfinished conflicts.

Results were inconclusive and insignificant.

• Reality Orientation Therapy - Uses reminders about information such as day, time and location.

Results were insignificant.

• Cognitive Stimulation Therapy - Uses information processing.

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

• Other dementia-specific therapies - “individualized special instruction” and “self-maintenance therapy”

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

• Non-dementia-specific therapies - Included many different varieties of treatments.

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

• Music Therapy - Helps reduce agitation and improve behavior during sessions and immediately after, however no long term benefits.
• Snoezelen therapy - Possible improvement in disruptive behavior during sessions, effects are only apparent for a short time after.
• Other sensory stimulation - Calming effects during sessions, no long term usefulness.
• Simulated presence therapy - Possible reduction in agitation, no other real benefits.
• Therapeutic activity programs - Results varied but overall were inconsistent and inconclusive with no real benefits.
• Montessori activities - No changes realized.
• Physical exercise - No changes realized.
• Social interaction - Possible improvement in neuropsychiatric symptoms in some participants.
• Decreased sensory stimulation - No real benefits.

• Environmental Manipulation - Changing the visual environment, adding or removing mirrors, signposting, unlocking doors and other environmental manipulations such as group living.

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

• Other studies focused on psychoeducation of Staff and family members ability to manage behavioral problems.

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". http://findarticles.com/p/articles/mi_m0857/is_11_12/ai_n17215917. ^{[dead link]}
3. ^ Satcher David et al. (1999). "Alzheimer’s Disease Mental Health: A report of the Surgeon General". http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec4.html. 
4. ^ Werheid K, Thöne-Otto AI (2006 May). "Cognitive training in Alzheimer's dementia" (in (German)). Nervenarzt 77 (5): 549–557. doi:10.1007/s00115-005-1998-2. PMID 16228161. 
5. ^ ^{a b c d} "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. http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007. Retrieved 2007-12-28. 
6. ^ 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. 
7. ^ 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. PMID 11342679. 
8. ^ 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. 
9. ^ 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. 
10. ^ 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. 
11. ^ 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. 
12. ^ 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. 
13. ^ 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. 
14. ^ 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. 
15. ^ 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. 
16. ^ 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. 
17. ^ Early Intervention for Alzheimer's Disease
18. ^ Section C2 Alzheimer's Society of Canada
19. ^ American Journal of Psychiatry