Living with dementia magazine December 2010/January 2011

Research funded by the Society shows how extra support can enable people in the early stages of Alzheimer's disease to retain and learn new skills, by Caroline Bradley.

Many people with dementia can find themselves withdrawing from activities and hobbies they once enjoyed. Problems with memory loss and cognitive abilities can also make it more difficult for people to carry out everyday tasks.

New research has shown that cognitive rehabilitation can help to overcome some of these difficulties. Professor Linda Clare has recently published findings of an Alzheimer's Society-funded study into how this therapy can help people in the early stages of Alzheimer's disease. The research was based at Bangor University in North Wales.

Cognitive rehabilitation has developed from therapies offered to people who have sustained a brain injury. It supports people to maximise their potential through the restoration of memory and develop compensatory strategies.

Professor Clare says,

'The idea is to take a general problem-solving approach and build on the skills that people still have.'

As part of the study, an occupational therapist worked with people with dementia to devise a plan to address their personal goals. The therapy consists of two processes: restoration and compensation. The therapist helped people to use their remaining brain capacity better and also identified how they could compensate for what is missing by doing things differently.

A first

The Bangor research is the first randomised controlled trial (in which participants are randomly selected to receive the new treatment, placebo treatment or none, to safeguard against any bias) to investigate whether cognitive rehabilitation can help people with dementia. It involved three groups of around 20 people in the early stages of Alzheimer's disease, all of whom were taking Aricept.

All participants set personal goals. These ranged from resuming enjoyable activities such as reading, knitting or going on day trips to more practical things such as remembering details of jobs to be done around the house, learning to use a mobile phone or maintaining concentration when cooking.

The researchers recorded how well people thought they were able to perform these tasks and how satisfied they were with their performance at the beginning and end of the project.

One group of people received eight one-hour sessions of cognitive rehabilitation therapy each week, during which they actively worked to achieve their goals. The second group (the placebo group) received eight sessions of weekly relaxation therapy and the final group had no additional therapy.

Improved performance

The results showed that the people in the cognitive rehabilitation group significantly improved their goal performance and satisfaction ratings, while scores in the other two groups did not change.

MRI brain scans showed an increase in activity in certain areas of the brain for these participants. Professor Clare says,

'This is difficult to interpret exactly, but we think it shows that the brains of people in this group were able to deal with the demands of the task more efficiently.'

Those with the most improved performance had regularly practiced between therapy sessions. Having a carer involved in the therapy generally also led to better results.

Tactics

Professor Clare believes the approach can be applied to people at most stages of dementia. She says,

'This is a very personal example, but my mum has just moved to a nursing home and is not sure where she is. To help I can either write it on a memory board for her to read; the compensatory approach, or I can teach her to remember where she is; the restorative approach.

'Teaching would involve a technique called spaced retrieval, which builds on the way we all learn. You tell someone the item of information and ask them for it almost immediately, after 30 seconds, say. You then ask them again after one minute, and keep on doubling the time, so you ask again after two minutes, then four and so on until the information moves into their longer-term memory.

'For the compensatory approach to work the person needs to practice finding the information once it has been written down so it will become a habit.'

Making things possible

Professor Clare says,

'This approach is about finding ways of making things possible. Obviously you have to be realistic. You can't take away someone's memory problems, but you can address things to help people to remain engaged, and to help retain their dignity and self-respect.

This small trial has demonstrated the principle that this type of intervention can have a positive effect. A larger trial is needed to demonstrate the benefits in more detail. Professor Clare would also like to explore how cognitive rehabilitation techniques can be made available to people with dementia and their carers as a self-help tool.

Further information

Occupational therapists, clinical psychologists or other staff at your memory clinic might be able to offer advice or information on cognitive rehabilitation.

Reference
Clare, L., Linden, D.E., Woods, R.T., Whitaker,et al (2010). Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer's disease: a single-blind randomized controlled trial of clinical efficacy. American Journal of Geriatric Psychiatry.
October 2010 - Volume 18 - Issue 10 - pp 928-939

A full description of the cognitive rehabilitation approach can be found in:Clare, L. (2008). Neuropsychological rehabilitation and people with dementia.
Hove: Psychology Press