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The authors say their intervention did not improve independence in activities of daily living for people with dementia as measured by the BADLS. In this context they do not mention their work showing that participants improved in functional ability on their chosen personal goals. Using data from 7 of 10 trial sites and devising a goal attainment scaling method to evaluate 266 goals set by 111 participating dyads, results ‘strongly suggested’ that participants improved on their individual goals.
This fits with the emerging pattern of findings from personalised rehabilitative interventions that aim to support functioning and self-management in the early stages of dementia. Positive outcomes in personal goal attainment have been demonstrated in several large trials which are not mentioned in the discussion of this paper, for example GREAT and REDALI-DEM. However, none of the large trials of cognitive rehabilitation or related approaches has reported improvements on general measures of functional ability or other secondary outcomes, although some significant effects have been seen in smaller trials.[4,5]
The DESCANT intervention may have had several limitations, including short duration, limited number of sessions, manualised delivery by practitioners who are not qualified health professionals, and limited scope in the choice of goals, aids, and strategies. The focus of the intervention is unlikely to have influenced many domains covered by the BADLS (e...
The DESCANT intervention may have had several limitations, including short duration, limited number of sessions, manualised delivery by practitioners who are not qualified health professionals, and limited scope in the choice of goals, aids, and strategies. The focus of the intervention is unlikely to have influenced many domains covered by the BADLS (e.g., teeth-cleaning, toileting, drinking, mobility, transfers, etc), so the lack of effect on the primary outcome measure is not surprising and might have been anticipated. Yet despite these limitations it seems this intervention, like others, did promote personal goal attainment.
Personal goal attainment is valued by people with dementia and carers who find cognitive rehabilitation helpful and say that it enhances confidence and well-being and assists in adjusting to the diagnosis. It might also have longer-term benefits. The ETNA-3 trial tested a personalised cognitive rehabilitation intervention provided by qualified health professionals comprising weekly individual sessions for 3 months followed by six-weekly maintenance sessions with telephone support for the carer over a 21-month period. This resulted in significantly lower functional disability and a six-month delay in institutionalisation at the two-year follow up relative to group cognitive training, group reminiscence therapy and usual care.
Some inaccuracies require comment. First, contrary to what is suggested in the discussion of this paper, the precursor trial to GREAT adopted a rigorous design consistent with criteria for high-quality evidence. Participants had eight home visits from an experienced occupational therapist, and where indicated were supported to learn to use relevant aids and adaptations. Second, it is not the case that other studies have recruited fewer participants and offered fewer sessions. ETNA-3 randomised 653 people with dementia in 40 trial sites and provided an extensive intervention schedule. GREAT randomised 475 people with dementia in eight trial sites and offered ten sessions with up to four maintenance sessions.
In conclusion, it is time to stop setting unrealistic expectations about what outcomes interventions should achieve. Instead, we should focus on what is most meaningful for people with dementia and their families and build on what we know can be done. We know that we can enable people with dementia to improve their functioning in relation to chosen activities that are important and meaningful for them using evidence-based cognitive rehabilitation strategies, which include but are not limited to the use of aids and adaptations. A recent implementation study8 has shown that the GREAT intervention is equally effective when offered within normal services and can be provided at modest cost. Supporting functional ability in areas that are personally meaningful may have worthwhile long-term benefits for people with dementia and their families.
1. Chester H, Beresford R, Clarkson P, et al. The Dementia Early Stage Cognitive Aids New Trial (DESCANT) intervention: A goal attainment scaling approach to promote self-management. International Journal of Geriatric Psychiatry 2021;36(5):784-93. doi: 10.1002/gps.5479
2. Clare L, Kudlicka A, Oyebode JR, et al. Individual goal-oriented cognitive rehabilitation to improve everyday functioning for people with early-stage dementia: a multi-centre randomised controlled trial (the GREAT trial). International Journal of Geriatric Psychiatry 2019;34:709-12. doi: 10.1002/gps.5076
3. Voigt-Radloff S, de Werd MME, Leonhart R, et al. Structured relearning of activities of daily living in dementia: the randomised controlled REDALI-DEM trial on errorless learning. Alzheimer's Research and Therapy 2017;9:22. doi: 10.1186/s13195-017-0247-9
4. Clare L, Linden DE, Woods RT, et al. 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 2010;18:928-39. doi: 10.1097/JGP.0b013e3181d5792a
5. Hindle JV, Watermeyer TJ, Roberts J, et al. Goal-oriented cognitive rehabilitation for dementias associated with Parkinson’s disease. International Journal of Geriatric Psychiatry 2018;33:718-28. doi: 10.1002/gps.4845
6. Amieva H, Robert PH, Grandoulier AS, et al. Group and individual cognitive therapies in Alzheimer’s disease: the ETNA3 randomized trial. International Psychogeriatrics 2016;28:707-17. doi: 10.1017/S1041610215001830
7. Bahar-Fuchs A, Clare L, Woods RT. Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. Cochrane Database of Systematic Reviews 2013(6) doi: 10.1002/14651858.CD003260.pub2
8. Clare L, Kudlicka A, Collins RA, et al. Implementing a home-based personalised cognitive rehabilitation intervention for people with mild-to-moderate dementia: GREAT into Practice. 2022 (preprint) doi: 10.21203/rs.3.rs-1458590/v1