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Advisory Council January 2019 Meeting Presentation: Cognitive Rehabilitation

Monday, January 28, 2019

Printer Friendly Version in PDF Format (11 PDF pages)


Cognitive rehabilitation for people living with dementia: a practical framework for enablement

Linda Clare, PhD ScD CPsychol PBPsS FAcSS
Professor of Clinical Psychology of Ageing and Dementia
University of Exeter, UK

Rehabilitation and people with dementia

  • Tackling barriers to participation and inclusion for people living with mild to moderate dementia in the community
  • Enabling people to function as well as possible -- the role of rehabilitation
  • People living with dementia are advocating for their right to rehabilitation
  • Rehabilitation approaches for people with early-stage dementia -- cognitive rehabilitation (CR)

Cognitive rehabilitation (CR) for people with early-stage dementia

  • With the right support people with mild to moderate dementia can adjust, learn strategies, and learn new skills
  • The starting point is what people with dementia would like to change, improve or manage better
  • Potential targets include everyday functioning, activities of daily living, self-care, language and communication, and social interaction
  • CR is a personalised intervention, and is carried out in the person's usual setting so that it is directly related to daily life

What do CR therapists do?

  • Use a collaborative, problem-solving approach to find out:
    • What the person is currently doing and could potentially do, and how the person's environment supports or hinders functioning
    • What the person wants to achieve (goal) and what s/he needs to be able to do in order to attain this goal
    • Where there is a mismatch between what the person can do and what the goal requires, and where and why things go wrong
  • Use a collaborative, solution-focused approach to:
    • Plan how to address the goal using evidence-based rehabilitative methods - these could involve new learning, relearning, use of compensatory strategies or assistive technology
    • Include other behavioural approaches where needed, such as anxiety management or behavioural activation
    • Support the person in carrying out the plan, and monitor progress
    • Enable family members or other carers to support the process

Feasibility studies of CR

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Clare et al, 1999, 2000, 2001, 2008

Pilot RCT: participant goal attainment

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N=69 randomised; Clare et al., 2010

Initial RCT: other positive findings

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Participants with dementia
CR > control
Bar chart.
CR > control
Clare et al., 2010

The GREAT trial: Goal-oriented cognitive Rehabilitation

  • Aim: to definitively establish whether CR is beneficial for people with early-stage AD, VaD or mixed dementia
  • Participants: We included 475 people with dementia, each with a family member as study partner. Participants had a diagnosis of Alzheimer's, vascular or mixed dementia and an MMSE score of 18 or above
  • Recruitment: 1st April 2013 to 31st March 2016
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What happened in the GREAT trial?

  • All participants identified goals and rated how they were currently doing (goal attainment). Study partners made an independent rating
  • Half were randomly selected to receive CR while the rest continued with treatment as usual (TAU)
  • CR participants had 10 weekly home visits from a CR therapist over 3 months
  • All participants and study partners rated goal attainment again after 3 months
  • CR participants had 4 more therapist visits over the next 6 months
  • All participants and study partners rated goal attainment again 9 months after starting in the trial
  • Other ratings - quality of life, mood, cognition, service use

What kinds of goals did GREAT trial participants choose?

  • Engaging in activities and personal projects
  • Trying challenging activities
  • Using appliances, devices and gadgets
  • Managing everyday tasks and situations
  • Managing shopping, cooking and baking
  • Remembering names and other details
  • Retaining information and events
  • Knowing what's happening
  • Finding belongings
  • Finding the way to places
  • Engaging in conversation
  • Keeping in contact with family and friends
  • Managing emotions
  • Caring for oneself

Examples of goals that were addressed in GREAT

  • John wanted to overcome the fear of using household appliances, mobile phones and other technology that was undermining his independence
  • Doris wanted to regain the confidence to collect her pension from the post office, and to stay safe by remembering to lock her door at night
  • Shahid wanted to feel better able to engage in conversation, and resume his activities and interests
  • Gareth wanted to stay independent and cook his own meals without burning the food, and to remember the names of his grandchildren

Did CR participants attain their goals?

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No significant changes in other measures

Participant and study partner views

  • Interviews by an independent researcher revealed that:
    • The therapist enabled participants and study partners to develop and personalise rehabilitative strategies
    • The relationship with the therapist was important
    • The therapist also provided information, education and support
    • There were improvements in participants' daily activities, and in well-being and quality of life for both
    • The intervention empowered them and helped with the psychological adjustment to living with dementia
    • They felt more confident, less anxious, and better able to cope
  • "She explored areas, you know, that I hadn't thought about, and...I found it a great help." [Person with dementia]
  • "(...) sometimes just reaching his goal, being able to do it after a few days. (...) Just little things like that, they help I think." [Family member]
  • "The therapist made you think about things that you thought you perhaps knew, but think about them in a different way ... and approach them in a different way." [Family member]
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CR for people with Parkinson's disease dementia and Lewy body dementia: CORD-PD

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Other benefits were also observed e.g. more positive quality of life ratings by both participants and family members
N = 29 randomised; Hindle, Watermeyer et al., 2018

Other emerging evidence

Study Intervention N Duration Intervention cf. control
Amieva et al 2015 (ETNA-3) France Individual goal-oriented CR + carer telephone support CR n=157 Control (usual care) n=154 Weekly for 3 m + 6-weekly for 21 m functional decline at 24 m (DAD); 6 m delay in institutionalisation. No other differences.
Kim 2015 South Korea Individual goal-oriented CR + group Cognitive training (CT) CR + CT n=22 Active control n=21 Weekly for 8 weeks goal performance, QoL and orientation (MMSE questions) at 8 weeks.
Thivierge et al 2013 Canada Structured training of problematic IADLs Immediate training n=10 Wait-list control n=10 Twice-weekly for 4 weeks performance of trained IADLs under observational assessment conditions at 8 weeks, maintained at 3 m. No differences on secondary outcomes.
Voigt-Radloff et al 2017 (REDALI-DEM) Germany Structured training of tasks and activities using errorless or trial-and-error methods Errorless training n=81 Trial-and-error training n=80 9 one-hour sessions over 8 weeks performance of trained IADLs with both training methods under observational assessment conditions at 16 weeks, maintained at 6 m. No differences on secondary outcomes.

What have we learned so far?

  • It is possible to improve and/or maintain specific everyday skills in the early stages of dementia
  • Personalised, goal-oriented cognitive rehabilitation can help people with early-stage Alzheimer's, vascular or mixed dementia to improve their everyday functioning in relation to individual goals targeted in the therapy
  • CR could form a useful component of post-diagnostic care pathways and community reablement or home care packages
  • Because it is based around personal goals, cognitive rehabilitation could be adapted for different settings or cultures

CR is recommended in the UK

  • NICE Guideline - Dementia: assessment, management and support for people living with dementia and their carers (NG97)
    • NICE guideline Published: 20 June 2018
    • 1.4 Interventions to promote cognition, independence and wellbeing
    • 1.4.4 Consider cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia.
  • The Memory Services National Accreditation Programme recommends that services offer CR to people with early-stage dementia

Implementing GREAT CR : GREAT into Practice (GREAT-iP)

  • Introducing GREAT CR into practice in 15 partner organisations providing health or social care
  • Co-producing resources with people with dementia, carers and practitioners
  • Working with each partner organisation to create and implement a tailored and sustainable implementation plan
  • Encouraging adoption through staff training followed up with ongoing supervision and support
  • Creating a community of practice


  • Focusing on enablement is central to supporting people to live as well as possible with dementia
  • Acknowledging the relevance of rehabilitation offers a tremendous opportunity to create a coherent approach to positive support for people with dementia, of any age, subtype, or severity, and their families
  • A rehabilitation model offers a guiding framework for services and for health and social care practitioners and a practical means of providing person-centred, evidence-based interventions to maintain or enhance functioning, engagement, participation and inclusion

Further information

REACH: Centre for Research in Ageing and Cognitive Health, University of Exeter

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Further information about GREAT CR and GREAT-iP:
Dr Krystal Warmoth
Professor Linda Clare

Thank you!