Cognitive rehabilitation helps people living with dementia to manage everyday activities that are important to them.
Future studies could explore how to use cognitive rehabilitation to also improve overall functioning and wellbeing.
What is dementia?
Dementia is a group of symptoms caused by changes in the brain that get worse over time. People with some types of dementia have difficulties with memory, planning, concentrating, and communicating. These and other thinking difficulties are collectively described by the umbrella term, 'cognitive impairment'. Cognitive impairment makes it harder to do daily activities and stay independent for as long as possible.
What is cognitive rehabilitation?
Cognitive rehabilitation is a personalised intervention. People have one-to-one sessions with a practitioner, usually in their own home. People identify everyday activities and tasks that they would like to manage better or do more independently. The practitioner suggests strategies and works with them to help achieve these improvements in the activities that are important to them. Family members are often involved as well.
What did we want to find out?
We explored whether cognitive rehabilitation was better than usual treatment for: doing a chosen task or activity that matters to the person; managing daily activities; feeling confident about being able to manage things; feeling depressed or anxious; having a sense of wellbeing.
We also explored whether cognitive rehabilitation was better for ensuring the wellbeing of the care partner - usually a husband, wife, or other close family member.
What did we do?
We searched for studies that rigorously tested the effects of cognitive rehabilitation for people with mild-to-moderate dementia. In these studies, some people had their usual treatment and others had their usual treatment plus cognitive rehabilitation. This made it possible to see whether cognitive rehabilitation was more helpful than usual treatment alone. We compared and summarised the results of the studies. We rated our confidence in the evidence the studies provided, based on the methods used and the numbers of people involved.
What did we find?
We found six studies. They involved 1702 people with mild-to-moderate dementia, who had between 8 and 14 sessions with a cognitive rehabilitation practitioner. Alzheimer’s disease was the most common dementia diagnosis (59% of all participants, 82% of participants with the specific diagnosis reported).
The main findings are that, compared to people who just had their usual treatment, people who had cognitive rehabilitation got better at doing their chosen tasks or activities.
This improvement was seen by the people with dementia and by their care partners.
The improvement was seen straight after cognitive rehabilitation and was still noticeable 3 to 12 months later.
Straight after cognitive rehabilitation, compared to people who just had their usual treatment, people with dementia may feel more confident about how they are managing.
There might not be any differences in the wellbeing of people with dementia and their care partners.
We are not sure if there are any differences for people with dementia in managing other tasks or activities or in feeling depressed.
Three to 12 months after cognitive rehabilitation, compared to usual treatment, care partners may have better psychological wellbeing.
There may not be any differences in how well people with dementia manage other tasks or activities, in how confident or depressed they feel, or in their wellbeing.
What are the limitations of the evidence?
Our review included six studies, but the findings are based mostly on information from one large study. We do not know if the effects of cognitive rehabilitation last more than a year. Results for several effects of cognitive rehabilitation were not clear.
How up-to-date is this evidence?
The evidence is up-to-date to October 2022.
CR is helpful in enabling people with mild or moderate dementia to improve their ability to manage the everyday activities targeted in the intervention. Confidence in these findings could be strengthened if more high-quality studies contributed to the observed effects. The available evidence suggests that CR can form a valuable part of a clinical toolkit to assist people with dementia in overcoming some of the everyday barriers imposed by cognitive and functional difficulties. Future research, including process evaluation studies, could help identify avenues to maximise CR effects and achieve wider impacts on functional ability and wellbeing.
Cognitive impairments affect functional ability in people with dementia. Cognitive rehabilitation (CR) is a personalised, solution-focused approach that aims to enable people with mild-to-moderate dementia to manage everyday activities and maintain as much independence as possible.
To evaluate the effects of CR on everyday functioning and other outcomes for people with mild-to-moderate dementia, and on outcomes for care partners.
To identify and explore factors that may be associated with the efficacy of CR.
We searched the Cochrane Dementia and Cognitive Improvement Group Specialised Register, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, and other clinical trial databases, and grey literature sources. The most recent search was completed on 19 October 2022.
We included randomised controlled trials (RCTs) comparing CR with control conditions and reporting relevant outcomes for the person with dementia and/or the care partner.
We extracted relevant data from published manuscripts and contacted trial authors if necessary. Within each of the comparisons, we pooled data for each outcome of interest and conducted inverse-variance, random-effects meta-analyses. We evaluated the certainty of the evidence using GRADEpro GDT.
We identified six eligible RCTs published in English between 2010 and 2022, which together included 1702 participants. The mean age of participants ranged from 76 to 80 and the proportion of male participants was between 29.4% and 79.3%. Most participants, in the studies where the type of dementia was reported, had a diagnosis of Alzheimer’s disease (AD; n = 1002, 58.9% of the whole sample, 81.2% of the participants for whom the specific diagnosis was reported).
Risk of bias in the individual studies was relatively low. The exception was a high risk of bias in relation to blinding of participants and practitioners, which is not usually feasible with psychosocial interventions.
Our primary outcome of everyday functioning was operationalised in the included studies as goal attainment in relation to activities targeted in the intervention. For our main comparison of CR with usual care, we pooled data for goal attainment evaluated from three perspectives (self-rating of performance, informant rating of performance, and self-rating of satisfaction with performance) at end of treatment and at medium-term follow-up (3 to 12 months). We could also pool data at these time points for 20 and 19 secondary outcomes respectively. The review findings were strongly driven by one large, high-quality RCT.
We found high-certainty evidence of large positive effects of CR on all three primary outcome perspectives at the end of treatment: participant self-ratings of goal attainment (standardised mean difference (SMD) 1.46, 95% confidence interval (CI) 1.26 to 1.66; I2 = 0%; 3 RCTs, 501 participants), informant ratings of goal attainment (SMD 1.61, 95% CI 1.01 to 2.21; I2 = 41%; 3 RCTs, 476 participants), and self-ratings of satisfaction with goal attainment (SMD 1.31, 95% CI 1.09 to 1.54; I2 = 5%; 3 RCTs, 501 participants), relative to an inactive control condition. At medium-term follow-up, we found high-certainty evidence showing a large positive effect of CR on all three primary outcome perspectives: participant self-ratings of goal attainment (SMD 1.46, 95% CI 1.25 to 1.68; I2 = 0%; 2 RCTs, 432 participants), informant ratings of goal attainment (SMD 1.25, 95% CI 0.78 to 1.72; I2 = 29%; 3 RCTs, 446 participants), and self-ratings of satisfaction with goal attainment (SMD 1.19, 95% CI 0.73 to 1.66; I2 = 28%; 2 RCTs, 432 participants), relative to an inactive control condition.
For participants at the end of treatment we found high-certainty evidence showing a small positive effect of CR on self-efficacy (2 RCTs, 456 participants) and immediate recall (2 RCTs, 459 participants).
For participants at medium-term follow-up we found moderate-certainty evidence showing a small positive effect of CR on auditory selective attention (2 RCTs, 386 participants), and a small negative effect on general functional ability (3 RCTs, 673 participants), and we found low-certainty evidence showing a small positive effect on sustained attention (2 RCTs, 413 participants), and a small negative effect on memory (2 RCTs, 51 participants) and anxiety (3 RCTs, 455 participants).
We found moderate- and low-certainty evidence indicating that at the end of treatment CR had negligible effects on participant anxiety, quality of life, sustained attention, memory, delayed recall, and general functional ability, and at medium-term follow-up on participant self-efficacy, depression, quality of life, immediate recall, and verbal fluency.
For care partners at the end of treatment we found low-certainty evidence showing a small positive effect on environmental aspects of quality of life (3 RCTs, 465 care partners), and small negative effects of CR on level of depression (2 RCTs, 32 care partners) and on psychological wellbeing (2 RCTs, 388 care partners).
For care partners at medium-term follow-up we found high-certainty evidence showing a small positive effect of CR on social aspects of quality of life (3 RCTs, 436 care partners) and moderate-certainty evidence showing a small positive effect on psychological aspects of quality of life (3 RCTs, 437 care partners).
We found moderate- and low-certainty evidence at the end of treatment that CR had negligible effects on care partners’ physical health, psychological and social aspects of quality of life, and stress, and at medium-term follow-up for the physical health aspect of care partners’ quality of life and psychological wellbeing.