Dementia Care

38 / 68

generally best to perform a systematic
review of individual high-quality studies
investigating the treatment (usually
randomised controlled trials or well-
designed single case studies) and to then
summarise the results using statistical
techniques (meta-analysis).
Comprehensive systematic reviews
conducted by the authors first in 2001
(Clare et al 2001) and most recently
updated in 2013 (Bahar-Fuchs et al 2013)
identified only a single trial that met the
definition of CR, so it was not possible to
perform a meta-analysis. A careful look
at the literature revealed that a confusion
regarding terms and definitions prevails
in the professional community, and that
studies that describe cognitive training
and cognitive stimulation are sometimes
referred to as ‘cognitive rehabilitation’ by
study authors, while lacking some of its
defining components.
We and others (Hampstead et al 2014;
Lampit et al 2014) have argued that
increasing the methodological standard
of trials in this field, including improving
the clarity around definitions of different
cognition-focused intervention
approaches, is a priority. To this end, a
group of international experts in this area
of research, led by the first author,
recently formed CIDER (Cognitive
Interventions Design, Evaluation and
Reporting), which aims to publish
guidelines to improve the
methodological quality of trials in this
area (Bahar-Fuchs et al 2014; Bahar-Fuchs
et al 2016). (We expect to have a CIDER
website available in 2017).
The only trial that met our inclusion
criteria (Clare et al 2010) was a single-
blind randomised controlled trial (RCT)
in which 69 participants with mild-
moderate dementia (Alzheimer’s disease
or mixed Alzheimer’s disease and
vascular dementia) were allocated to
eight weeks of either CR, relaxation
therapy (RT), or to a no-treatment (NT)
condition.
The trial found that relative to the RT
and NT conditions, immediately after the
intervention participants in the CR
condition showed improvements in self-
rated performance and satisfaction with
relation to goals they had set for
themselves.
Participants in the CR condition were
also more satisfied with their memory
performance than participants in the no-
treatment condition at the six-month
follow-up assessment. Caregivers of
participants in the CR and RT conditions
reported improvements in their social
relationships relative to caregivers of
participants in the no-treatment
condition.
The GREAT study
A large multi-site follow-up to that study,
led by Professor Linda Clare (co-author
here) is currently underway in the UK
(Clare et al 2013). The GREAT study
(short title: Living Well with Memory
Difficulties,
involves individuals with Alzheimer’s
disease or mixed Alzheimer’s disease
and vascular dementia. These people are
randomly allocated to either a Treatment
as Usual (TAU) condition or to 10-weeks
of CR over three months followed by
four maintenance sessions over six
months.
CR intervention focuses on addressing
individual therapy goals, with
components on compensatory strategies,
practical techniques for learning new
information, practice in maintaining
attention and concentration, and
techniques for stress management.
The study began in 2012, and data
collection is expected to be completed by
December 2016. Results are expected to
be available in 2017. If the pilot trial
findings are confirmed, GREAT will
provide definitive evidence in support of
CR as a clinically-effective and cost-
effective intervention for people with
mild-moderate Alzheimer’s disease. It
will pave the way for a wider
implementation of this intervention
approach in the healthcare system in the
UK, and possibly in other countries,
including Australia.
Challenges and opportunities
CR provides a useful conceptual
framework for support of people with
dementia and their families; it opens an
opportunity for delaying the progression
of functional disability by better
management of cognitive deficits and so
may help to maintain better quality of life
and independence.
As the evidence for efficacy gradually
develops, various challenges and
opportunities may need to be considered
for its full potential to be realised. Among
these are the role of emerging
technologies, applicability of CR to the
context of dementia prevention, the
development of agreed upon outcome
measures, and addressing prevailing
unhelpful views regarding the ‘point’ of
rehabilitation for people with dementia.
Emerging technologies
Emerging technologies already play an
increasingly central role in rehabilitation
of people with various needs. This trend
will no doubt continue and change the
way rehabilitation goals are achieved
while remaining true to the fundamental
principles of being function-led and
individually tailored.
Already digital technology is used
38 Australian Journal of Dementia Care October/November 2016 Vol 5 No 5
DCRC SPEC I AL I SSUE : THE B I G P I CTURE I N DEMENT I A RESEARCH
Learning with dementia
Evidence from experimental studies shows that, when provided
with appropriate support, people with early stage or mild dementia
can learn or relearn relevant information, as well as adapt their
behaviour and develop new routines, skills and habits. Cognitive
rehabilitation (CR) builds on this evidence and exploits this
knowledge to identify the most relevant methods of helping the
person with dementia better manage everyday activities.
For example, when people with dementia learn new information
while limiting their opportunity to make memory errors they
sometimes recall information better than they do through trial and
error – an approach known as errorless learning (Haslam et al 2011).
Another technique that has been successfully used to support
learning in people with dementia is known as spaced retrieval. The
simple principle underlying this technique is that when the time
interval between the learning and subsequent recalling of information
is very short (eg 30 seconds), and increases systematically in fixed
increments of time, there is a greater chance that information will
create a stronger trace in the person’s long-term memory store.
Using spaced retrieval, we and others have demonstrated that
people with mild dementia recalled face-name associations for up to
nine months (Clare et al 1999; Clare et al 2003b).
Importantly, people with dementia respond differently to various
evidence-based techniques, and a CR therapist will assist the
person and their family to identify the technique(s) that are most
helpful for the individual in question.
Although much of the work on CR to date has been carried out on
people with mild Alzheimer’s disease (AD) dementia or mixed AD
and vascular-type dementia, principles of CR have also been
applied in intervention studies targeting people with other forms of
dementia, including semantic dementia (eg Savage et al 2013), and
work is currently under way with people with Parkinson’s disease
(Hindle et al 2016).