CLINICAL QUESTION
Does cognitive rehabilitation improve everyday function and well-being in patients with mild to moderate dementia?
EVIDENCE-BASED ANSWER
Cognitive rehabilitation improves participant self-ratings of goal attainment, informant ratings of goal attainment, and self-ratings of satisfaction with goal attainment at the end of treatment and at 3 to 12 months of follow-up.1 (Strength of Recommendation [SOR]: A, consistent, good-quality patient-oriented evidence.) Cognitive rehabilitation likely has a small positive effect on caregivers' social and psychological quality of life at 3 to 12 months of follow-up.1 (SOR: A, consistent, good-quality patient-oriented evidence.)
PRACTICE POINTERS
Dementia is a group of neurodegenerative conditions that predominantly occur later in life.2 More than 55 million people are living with dementia worldwide, and this number is expected to increase to 139 million by 2050.3 Practices that support independence and social participation in people with dementia could improve patient and caregiver quality of life.4
Cognitive rehabilitation is person-centered care focused on targeted areas and goals that are determined to be important by the rehabilitation recipient and their caregiver.5 Patients have one-on-one sessions with a clinician, usually in their own homes. With the help of their clinician, patients identify daily activities or tasks that they would like to manage better or perform more independently. Through goal attainment, such as being able to more successfully or independently complete the chosen task or activity, cognitive rehabilitation helps people with dementia overcome social barriers and increase independence.
The authors of this Cochrane review sought to determine the effectiveness of cognitive rehabilitation on goal attainment related to specific patient-centered activities and other functional outcomes.1 These activities or goals were determined after discussion with participants and their caregivers to formulate individualized plans that would help promote independence. Standardized, validated self-rating and informant-rating scales were obtained after cognitive rehabilitation sessions to assess participant improvement for their chosen task or activity. This Cochrane review included six studies (published between 2010 and 2022) involving 1,702 participants with mean ages of 76 to 80 years. Studies were conducted in the United Kingdom, France, and Canada. Three of the studies were multicenter randomized controlled trials, two were single-site randomized controlled trials, and one was a crossover trial. Sessions were provided once per week (in one of the included studies, sessions were twice per week), and the total hours of treatment ranged from 4 to 45 hours of contact with the clinician during the study. The studies compared cognitive rehabilitation with usual treatment in patients with mild to moderate dementia. Participants could have any dementia diagnosis, but those with dementia of the Alzheimer type made up most of the study population.
The primary outcome assessed was functional ability in targeted activities. Secondary outcomes included general functional ability, self-efficacy, mood, caregiver stress/burden, and quality of life. Follow-up intervals included the end of therapy (0 to 3 months posttreatment) and medium-term (3 to 12 months posttreatment). The targeted activities varied between study groups. Primary and secondary outcomes were assessed with standardized, validated self-rating scales that varied based on the country where the study was conducted. Examples of standardized scales include the Canadian Occupational Performance Measure and the Direct Measure of Training.
One session of cognitive rehabilitation per week led to a significant positive effect on participant self-ratings of goal attainment (standardized mean difference [SMD] = 1.46; 95% CI, 1.26 to 1.66), informant ratings of goal attainment (SMD = 1.61; 95% CI, 1.01 to 2.21), and self-ratings of satisfaction with goal attainment (SMD = 1.31; 95% CI, 1.09 to 1.54) compared with usual care at the end of treatment.1 Standardized scales were used for rating the attainment of therapeutic goals and performance during therapy. This positive effect was sustained at medium-term follow-up for all three measures: participant self-ratings of goal attainment (SMD = 1.46; 95% CI, 1.25 to 1.68), informant ratings of goal attainment (SMD = 1.25; 95% CI, 0.78 to 1.72), and self-ratings of satisfaction with goal attainment (SMD = 1.19; 95% CI, 0.73 to 1.66).
Cognitive rehabilitation had negligible effects on participant anxiety, quality of life, sustained attention, memory, delayed recall, and general functional ability at the end of treatment. It also had negligible effects on participant self-efficacy, depression, quality of life, immediate recall, and verbal fluency at medium-term follow-up.1
Cognitive rehabilitation yielded a small positive effect on social and psychological aspects of quality of life for patient caregivers at medium-term follow-up based on self-ratings (mean difference = 0.43; 95% CI, 0.11 to 0.76).
The generalized functional ability of patients who participated in cognitive rehabilitation slightly decreased at medium-term follow-up (SMD = −0.23; 95% CI, −0.43 to −0.03) as detected using informant ratings on the Disability Assessment for Dementia or Functional Activities Questionnaire.
Most of the evidence discussed in this review was derived from the largest of the six studies, although all studies yielded similar results. Further studies are needed to determine if cognitive rehabilitation is effective after 1 year because these data only span 12 months posttreatment. Guidelines, such as the dementia recommendations from the National Institute for Health and Care Excellence, suggest that clinicians consider cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia.6
The practice recommendations in this activity are available at https://www.cochrane.org/CD013388.
The views expressed are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, the U.S. Navy, or the U.S. government.
