This article was downloaded by: [FU Berlin] On: 12 May 2015, At: 00:57 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Aging, Neuropsychology, and Cognition: A Journal on Normal and Dysfunctional Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nanc20
Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention a
b
c
d
Maria O’Sullivan , Robert Coen , Denis O’Hora & Agnes Shiel a
Clinical Psychology Department, HSE South, St. Finbarr’s Hospital, Cork, Ireland b
Click for updates
Mercer’s Institute for Research on Ageing, Memory Clinic, St. James’s Hospital, Dublin, Ireland c
Department of Psychology, National University of Ireland Galway, Galway, Ireland d
Department of Occupational Therapy, National University of Ireland Galway, Galway, Ireland Published online: 23 Jun 2014.
To cite this article: Maria O’Sullivan, Robert Coen, Denis O’Hora & Agnes Shiel (2015) Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention, Aging, Neuropsychology, and Cognition: A Journal on Normal and Dysfunctional Development, 22:3, 280-300, DOI: 10.1080/13825585.2014.927818 To link to this article: http://dx.doi.org/10.1080/13825585.2014.927818
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [FU Berlin] at 00:57 12 May 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Aging, Neuropsychology, and Cognition, 2015 Vol. 22, No. 3, 280–300, http://dx.doi.org/10.1080/13825585.2014.927818
Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention Maria O’Sullivana*, Robert Coenb, Denis O’Horac and Agnes Shield a Clinical Psychology Department, HSE South, St. Finbarr’s Hospital, Cork, Ireland; bMercer’s Institute for Research on Ageing, Memory Clinic, St. James’s Hospital, Dublin, Ireland; cDepartment of Psychology, National University of Ireland Galway, Galway, Ireland; dDepartment of Occupational Therapy, National University of Ireland Galway, Galway, Ireland
Downloaded by [FU Berlin] at 00:57 12 May 2015
(Received 8 November 2013; accepted 20 May 2014) This was an exploratory study, with the purpose of developing and piloting an intervention for people with mild cognitive impairment (MCI) and their family members using cognitive rehabilitation. A case series design was used with pre- and post-intervention and 3-month follow-up outcome measures. Five participants (two males, three females; mean age 75 years) with a diagnosis of MCI attended the memory clinic with a family member. Intervention consisted of six to eight individual sessions of cognitive rehabilitation consisting of personalized interventions to address individually relevant goals delivered weekly. The main rehabilitation strategies utilized were external aids, personal diary, face–name association, relaxation, and encouraging participants to develop habits and routines. The primary outcome measure was goal attainment as assessed by Goal Attainment Scaling. Secondary outcome measures included measures of memory, anxiety, depression, and activities of daily living. Qualitative data were collected post-intervention by interview. Post-intervention 84% of the goals were attained, with 68% maintained at a 3-month follow-up. Mean anxiety and depression scores decreased during the intervention. No significant changes were recorded on a test of memory. The findings suggest that the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Feedback from participants during qualitative interviews indicated that they found strategies useful and implemented them in their daily routines. The findings support the use of a dyadic cognitive rehabilitation intervention for people with MCI and memory difficulties. Keywords: mild cognitive impairment; cognitive rehabilitation; goal attainment scaling; family dyads
Mild cognitive impairment (MCI) has generated a considerable amount of interest during the last number of years, especially in relation to its significance as a possible prodromal phase of Alzheimer’s disease (Winblad et al., 2004). Many people consider there to be a trajectory of gradual cognitive decline, with MCI representing an earlier phase of decline prior to Alzheimer’s disease, as a result of the high rate (40–80% after 5-year follow-up) of conversion to dementia documented in longitudinal studies (Fisk & Rockwood, 2005; Petersen, 2004; Tuokko et al., 2003). MCI is defined as a “clinical syndrome characterised by cognitive decline which is greater than expected for the given age and level of education, but does not significantly affect everyday activities” (Sobow & Kloszewska, 2007, p. 14). MCI refers to individuals who exhibit some cognitive impairment, which is of insufficient severity to constitute dementia. *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
281
Currently, the criteria for clinically probable Alzheimer’s disease and other dementias identify people after a substantial degree of cognitive decline has taken place. The construct of MCI identifies these individuals earlier in the process of cognitive decline. Therefore, if valid therapeutic interventions become available, clinicians have the opportunity to intervene in this process, perhaps preventing or delaying further cognitive decline (Albert et al., 2011; Amieva et al., 2008; Petersen, 2004). People with MCI have cognitive impairment but minimal impairment in complex instrumental activities and are functioning more or less independently. Therefore, cognitive intervention may benefit persons with MCI because they retain the cognitive capabilities to learn and apply sets of new strategies (Belleville, 2008). There is growing interest in developing interventions for people with MCI, in order to intervene at an earlier point on the trajectory of possible neurodegeneration and to exploit cognitive plasticity. Cognitive plasticity refers to the learning potential and the “extent to which a given subject can improve his/her performance in a given task after training” (Fernandez-Ballesteros, Zamarrón, Tárraga, Moya, & Iñiguez, 2003, p. 149). Research from both human and animal studies indicates that cognitive plasticity endures across the life span and that both rehabilitative and pharmacological interventions may facilitate neuronal reorganization and recovery of function (Bach-y-Rita, 2003a, 2003b). This is supported by Fernandez-Ballesteros et al.’s (2003, 2012) finding that participants with MCI had greater learning ability relative to those with Alzheimer’s disease, supporting the plasticity model. Dickerson et al. (2005) reported similar findings using functional magnetic resonance imaging (fMRI) scanning during a recognition memory task. They found that an MCI group had significantly greater hippocampal activation compared to normal and Alzheimer’s disease groups and less atrophy compared to the Alzheimer’s disease group. The finding of greater plasticity and learning ability of individuals with MCI, relative to those with more progressed illness, may indicate that cognitive interventions will have more impact when individuals are still in the MCI phase. A dyadic approach involves including a support person (e.g., family member) in the intervention, who becomes instrumental in assisting the person with the memory difficulties to carry out memory strategies. There is very limited research incorporating this design in research with MCI. Kinsella et al. (2009) carried out a cognitive training intervention with MCI participants and included their family members. Post-intervention, they reported a significant improvement on prospective memory tasks, increased knowledge and use of memory tasks, and increased family knowledge of memory strategies. Clare et al. (2009) included a family member in a single-subject design and reported positive outcomes in relation to goal attainment. A number of studies that involved a memory intervention for people with Alzheimer’s disease that included a dyadic design reported better outcomes (Clare et al., 2010; Grandmaison & Simard, 2003) even when this involvement was just for the last 15 min of each session (Clare et al., 2010), as participants were more likely to engage in between-session practice. Given that people with MCI often present with memory difficulties, it is possible that strategies learned as part of an intervention may be forgotten once support from that intervention is withdrawn. Therefore, there is scope to include significant others in the intervention process to assist participants to retain, consolidate, and practice rehabilitation strategies. Cognitive training is the most common intervention approach in research with MCI participants. It involves repeated practice at specific, structured cognitive tasks, tailored to the person’s ability level. This approach assumes that regular “exercise” or practice has potential to improve or maintain functioning in a given domain such as memory or
Downloaded by [FU Berlin] at 00:57 12 May 2015
282
M. O’Sullivan et al.
attention, and that such improvement will generalize beyond the immediate training content. A number of recent randomized controlled studies with MCI participants have demonstrated that cognitive training can improve measures of memory, knowledge of memory strategies, mood, and psychological well-being (Gagnon & Belleville, 2012; Hampstead et al., 2012; Li et al., 2011; Martin, Clare, Altgassen, Cameron, & Zehnder, 2011; Olchik, Farina, Steibel, Teixeira, & Yassuda, 2013; Rozzini et al., 2007; Teixeira et al., 2012; Troyer, Murphy, Anderson, Moscovitch, & Craik, 2008). However, the impact on everyday living and the duration of these effects are unknown, and there are a number of methodological issues including small samples, absence of longitudinal studies, lack of functional impact measures, and generalization effects (Belleville, 2008). Currently, there are no pharmacological interventions recommended in the treatment of MCI. Cholinesterase inhibitors comprise a class of drugs with proven efficacy in dementia of the Alzheimer’s type. However, they are currently not recommended in the treatment of MCI due to adverse effects (Russ & Morling, 2012; Sobow & Kloszewska, 2007). Hence, there is scope to examine interventions that have more ecological validity. Cognitive rehabilitation is any strategy or intervention that enables a person to live with, manage, bypass, reduce, or come to terms with deficits (Wilson, 1989). The focus is on difficulties most relevant to the person with the cognitive impairment and their family members, with the aim of achieving functional improvements and well-being rather than increasing scores on standardized cognitive tests (Woods & Clare, 2008). Cognitive rehabilitation has been used for years with people with traumatic brain injury (TBI) and stroke, and there is good evidence to show that it is effective (Cicerone et al., 2011). Goal attainment is a measurement methodology that measures progress toward goals. Goals are individualized to the participant and rated at regular intervals. This methodology has been used effectively in many different settings, e.g., mental health, substance abuse, family therapy, special education, rehabilitation, and geriatric settings (Malec, 1999). In contrast to the demonstrated efficacy of cognitive rehabilitation in other populations, little research has been published in relation to using cognitive rehabilitation and goal attainment for people with MCI. Londos et al. (2008) adapted an 8-week group intervention using cognitive rehabilitation with people with TBI, for a group with MCI and reported significant improvement in goal performance and satisfaction. Clare et al. (2009) carried out a single-subject study involving an individual goal-oriented cognitive rehabilitation intervention for a 77-year-old woman with MCI. This 8-week cognitive rehabilitation intervention resulted in improvement on rehabilitation goals and significant increases in brain activation in memory-related areas on fMRI scans. Clare et al. (2010) carried out a randomized control trial (RCT) with people with early-stage Alzheimer’s disease. Results were congruent with the single-subject study, with significant improvement in goal attainment in the treatment group with no change in the control group. Results from fMRI also demonstrated greater levels of brain activation when engaged in memory testing in the intervention group relative to controls. The limited research to date supports the application of cognitive rehabilitation for people with MCI (Clare et al., 2009; Londos et al., 2008), and better outcomes have been reported for people with MCI and Alzheimer’s disease that involved a dyadic design (Clare et al., 2009, 2010; Grandmaison & Simard, 2003; Kinsella et al., 2009). The current study explored the efficacy of cognitive rehabilitation for people with MCI and adopted a dyadic approach including a significant other or support person in the intervention process, with the aim to exploit cognitive plasticity and maximize potential outcomes.
Aging, Neuropsychology, and Cognition
283
Downloaded by [FU Berlin] at 00:57 12 May 2015
Method The intervention was developed by conducting a thorough literature review in relation to cognitive rehabilitation and MCI. Evidence from RCTs involving TBI and dementia cohorts was considered. A menu of cognitive rehabilitation strategies was created and organized into five categories: psycho-education, restoration, compensation, environmental adaptation, and relaxation. Ethical approval was obtained from St. James’s Hospital, St. Vincent’s Hospital, and the National University of Ireland, Galway. This study was a case series design with pre- and post-intervention and 3-month follow-up outcome measures. All participants met the inclusion criteria of having a subjective memory complaint, objective memory impairment for age representing a change in function, essentially normal activities of daily living (ADL) performance, and absence of dementia (Petersen, 2004), indicative of an MCI classification (see Table 1). Participants were five outpatients (two males, three females), with a diagnosis of MCI who attended the memory clinic with a family member (see Table 2). Participants ranged in age from 68 to 79 years with a mean age of 75 years. Participants had essentially normal ADL performance and were living independently in the community. Two were widowed and attended with their daughters. Three were married and attended with their spouses. The duration of subjective memory complaints ranged from 1 to 6 years. One participant was prescribed a cholinesterase inhibitor. An outline of tools utilized to make diagnoses is summarized in Table 3. All participants underwent blood tests and a screening test, in all cases the mini-mental state examination, when the initial diagnosis was made. Four of the five participants had neuroimaging (MRI or CT scan) completed in order to aid diagnosis. Four participants
Table 1.
Inclusion and exclusion criteria.
Inclusion criteria
● ● ● ●
Exclusion criteria
Diagnosis of mild cognitive impairment ● Progressed to dementia ● Have a preexisting learning disability Aged 50–80 years old Living independently in the community ● Any medical or surgical conditions associated with a head injury, spinal injury, Support person available to attend epilepsy, stroke, or heart attack appointments with MCI participant ● English not first language ● Alcohol or drug dependent ● Currently depressed (meeting DSM-IV criteria for a depressive episode) ● Taking sedatives or tranquilizers ● Vision or hearing not adequate to permit participation in this study, i.e., if the participant is unable to hear the researcher speaking or unable to see the resources used in intervention ● Participated in previous cognitive training/cognitive rehabilitation intervention
79 Female
68 Female
77 Male
76 Male
2
3
4
5
73 Female
1
Married
Married
Married
Widow
Widow
Marital status
Participant characteristics.
Participant Age Gender
Table 2.
5–6 years
1.5 years
3–4 years
1–2 years
3 years
Duration of memory problem
Third level
Third level
Second level
Second level
Second level
Level of education
18
17
12
10
10
Years of education
Memory clinic
Memory clinic
Geriatrician
Memory clinic
Memory clinic
Source of referral
12 months
18 months
4 months
1 month
30 months
Length of time since diagnosis made
Downloaded by [FU Berlin] at 00:57 12 May 2015
Wife
Wife
Husband
Daughter
Daughter
Relationship status of support person
No
Yes
No
No
No
Prescribed cholinesterase inhibitors
284 M. O’Sullivan et al.
Aging, Neuropsychology, and Cognition Table 3.
Tools used to make diagnosis.
Participant 1 2 3 4 5
Downloaded by [FU Berlin] at 00:57 12 May 2015
285
Neuroimaging
Neuropscyh tests
Screening test
Blood test
Consensus meeting with multidisciplinary team
✓ – ✓ ✓ ✓
✓ ✓ – ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓ – ✓ ✓
also received a neuropsychological assessment (e.g., repeatable battery for the assessment of neuropsychological status; Montreal cognitive assessment; delayed word recall test; the cognitive and self contained part of the Cambridge examination for mental disorders of the elderly; semantic fluency; verbal fluency; clock drawing test; executive interview), and diagnosis was made at a multidisciplinary consensus meeting. The primary outcome measure was goal attainment as assessed by goal attainment scaling (GAS), which measures progress toward goals (Malec, 1999). GAS involves identifying individualized goals with the client and describing them in observable terms. A five-point scale is used with better and worse-than-expected outcomes accounted for (see Table 4 for an example of GAS). GAS was rated at weekly intervals and at 3-month follow-up. The inter-rater reliability for raters on the GAS was found to be kappa = 0.73. Secondary outcome measures completed at pre- and post- intervention and at a 3month follow-up included the Rivermead Behavioural Memory Test – Extended Version (RBMT-E; Wilson et al., 1999) to assess memory; the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) to assess anxiety and depression; and the instrumental activities of daily living (Lawton & Brody, 1969) to measure instrumental self-maintenance activities required in everyday functioning. A semi-structured interview was conducted with the dyad (MCI participant and support person) once the intervention was completed.
Intervention Intervention was delivered in a dyadic format in the memory clinic, whereby participants along with their support person participated in six to eight weekly sessions of cognitive rehabilitation to address individually relevant goals. The cognitive rehabilitation therapy program used the following components: (1) identifying and working on three to four personal rehabilitation goals relevant to everyday life; (2) psycho-education on MCI; (3) encouraging participants to develop habits and routines; (4) teaching deep breathing as a relaxation strategy; (5) encouraging participants to start using external aids to compensate for memory difficulties and teaching how to use these effectively; and (6) internal memory strategies for learning new information and associations including chunking, spaced retrieval, visual imagery, story-telling, face–name associations, method of loci, and Preview, Question, Read, Summary, Test (PQRST). The order and amount of strategies taught to each dyad varied, depending on the needs and goals of the person with MCI. Table 5 outlines the individual goals for each participant as well as the cognitive rehabilitation strategies employed during the intervention to address these goals.
Actual level now
Misplace things more than once a day
Much worse than baseline (−2)
Goal 4: To become better at recalling neighbours’ names
Get frustrated quite often due to memory difficulties (once a day)
Recall three to five neighbours’ names (first or second name) Recall three or less neighbours’ names (first or second name)
Get frustrated rarely due to memory Recall 13+ difficulties (once a week or less) neighbours’ names (first or second name) Get frustrated rarely due to memory Recall 5–12 difficulties (twice a week) neighbours’ names (first or second name) Get frustrated occasionally due to Can partially recall memory difficulties (every second approximately 5/20 day, three to four times a week) neighbours’ names
Forget short-term information nine or Get frustrated very often due to more times a week memory difficulties (twice a day or more)
Remember short-term information independently with aids (forget something once or less times a week) Somewhat better Misplace items a couple of times a Remember short-term information than baseline (+1) week (two times a week) independently with aids (forget something two to three times a week) Baseline status (0) Misplace items every second day Forget short-term information, often (three to four times a week) reminded by wife (forget something three to five times a week) Somewhat worse Misplace items five to seven times a Forget short-term information once than baseline (−1) week or twice a day (six to eight times a week)
Rarely misplace items (once a week or less)
Goal 1: Try and reduce misplacing items
Goal 2: Remember short-term information he has been told and rely less on cues from wife (e.g., Goal 3: Reduce frustration in relation information about family, dates, to memory difficulties and try and appointments, what to buy in shop) relax
Example of Goal Attainment Scale rated at weekly intervals.
Much better than baseline (+2)
Table 4.
Downloaded by [FU Berlin] at 00:57 12 May 2015
286 M. O’Sullivan et al.
5
4
3
2
1
Participant
Table 5.
External aids and habits and routines were utilized to address this goal External aids and habits and routines were utilized to address this goal A number of restoration strategies that specifically related to remembering numbers were used e.g., rehearsal, chunking, using a rhythm, and imagining the pattern of numbers Face–name association (restoration strategy) was used to deal with this goal Developing habits and routines was encouraged to address this goal External aids were focused on to address this goal
Relaxation, external aids, spaced retrieval, and PQRST were utilized to address this goal Face–name association (restoration strategy) was used to deal with this goal A relaxation exercise was introduced to target this goal
Habits and routines, relaxation, and external aids were utilized to address this goal External aids were focused on to address this goal Face–name association (restoration strategy) was initially used to deal with this goal, and when this was not successful, acceptance and being honest with people in relation to this deficit was suggested External aids were used to address this goal
A number of different strategies were used to address this goal including restoration strategies as well as external aids External aids were employed to address this goal
Habits and routines and relaxation were utilized to address this goal External aids were focused on to address this goal
Cognitive rehabilitation strategies used to address goals
(1) To reduce misplacing items (2) To remember short-term information he has been told and rely less on cues from wife (e.g., information about family, dates, appointments, what to buy in shop). (3) To reduce frustration in relation to memory difficulties and try and A relaxation exercise was used to address this goal relax (4) To become better at recalling neighbours’ names Face–name association and spaced retrieval were utilized in addressing this goal
(4) To become better at remembering people’s names
(1) To become more orientated for day and date (2) To remember what’s to be done on a day-to-day basis (3) To remember the alarm code without having to check paper
(3) To reduce the levels of frustration as a result of memory difficulties
(2) To feel more confident remembering the names of acquaintances
(4) To become better at remembering what activities have already been completed (1) To decrease repetitive questioning when going somewhere
(2) To become better at remembering to do daily activities (3) To become better at remembering names
(1) To reduce misplacing items (2) To remember dates, appointments, arrangements, and rely less on cues from family members (3) To remember all items when carrying out activities that involve multiple parts (4) To become more orientated to events that are taking part on a day-to-day basis (1) To reduce misplacing items
Goals
Participants’ goals and cognitive rehabilitation strategies used to address goals during the intervention.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition 287
288
M. O’Sullivan et al.
Results
Post hoc analysis of goals Some rehabilitation goals were similar in content, e.g., to remember appointments, to remember events, to reduce misplacing items, to remember names, and to reduce frustration in relation to memory deficits. A post hoc analysis was conducted in relation to those goals that had a similar objective, impacted on the same underlying memory process, and received the same intervention. Five hypotheses were tested to investigate if specific cognitive rehabilitation strategies benefited certain rehabilitation goals.
18 16
Goals Attained
14 12 10 8
Postintervention
6 3-month followup
4 2 0 Much better
Better
Baseline Outcomes
Worse
Much worse
Figure 1. Total goals achieved by participants post-intervention and at 3-month follow-up as rated on Goal Attainment Scales.
12 11 10 Mean HADS Scores
Downloaded by [FU Berlin] at 00:57 12 May 2015
In total, 19 goals were set, with each participant working on three to four goals. Postintervention, 16 of these goals across participants (84%) were attained in that they performed better or much better than baseline (see Figure 1). At a 3-month follow-up, 13 goals across participants (68%) were maintained at a better outcome than baseline. Mean anxiety and depression scores decreased post-intervention, and this was maintained at a 3-month follow-up (see Figure 2).
8 7 6 4
Anxiety
6
Depression
4
2
2
2
0 Pre-Intervention
Figure 2.
PostIntervention
3-month Followup
Mean anxiety and depression scores pre-intervention, post-intervention, and at follow-up.
Aging, Neuropsychology, and Cognition
289
Downloaded by [FU Berlin] at 00:57 12 May 2015
Hypothesis (a): Goals that rely on prospective memory will benefit from compensatory strategies
Participant (P) P1, P2, P4, and P5 all identified goals related to prospective memory deficits. External aids were recommended to overcome prospective difficulties. Specifically, participants were advised to purchase a personal diary. Figure 3 outlines the GAS ratings for prospective memory goals for P1, P2, P4, and P5; the broken line indicates the week this strategy was introduced. Trends in the data suggest that goals related to prospective memory deficits may benefit from compensatory strategies and that the earlier these strategies are introduced, the better the outcome. P1 and P2 were introduced to external aids early in the intervention and were both performing at a much better-than-expected level at follow-up on prospective tasks. P4 and P5 were introduced to external aids later in the intervention with mixed results. P4 performed at a better-than-expected level, while P5 performed at worse-than-expected level on prospective tasks at follow-up. There was not enough time during the intervention to give P5 additional training with this strategy and they did not continue to use the diary at followup. Qualitatively during the intervention, all three participants who continued to use the diary reported finding the personal diary effective in aiding prospective memory, and it was noted by the researcher that participants recorded progressively more information in the diary as time went on. Hypothesis (b): Goals that rely on episodic memory will benefit from compensatory strategies
Both P1 and P4 identified rehabilitation goals related to being temporally oriented. External aids such as watches, diaries, wall calendars, and white board were recommended to prime temporal orientation. Figure 4 outlines the GAS ratings for temporal orientation goals for P1 and P4; the broken line indicates the week external aids were introduced. External aids were introduced early in the intervention for P1 (on week 3) and later for P4 (on week 6). Both participants improved on orientation goals post-intervention, and this was maintained at a 3-month follow-up. An improvement was noted on the orientation goal for P1 on the week external aids were introduced, and this improvement was maintained for the duration of the intervention and at the 3-month follow-up. An improvement on the orientation goal for P4 was noted 2 weeks after the external aids were introduced, and this was maintained at the 3month follow-up. Both P1 and P4 also demonstrated gains on the orientation subtest as part of the RBMT-E from pre- to post-intervention. P1 scored 10/14 pre-intervention, 11/14 postintervention, and 12/14 at the 3-month follow-up. P4 scored 8/14 pre-intervention, 12/14 post-intervention, and 11/14 at the 3-month follow-up. Hypothesis (c): Goals that are based on retrieval deficits will benefit from environmental modification
P1, P2, and P5 all identified “misplacing items” as a rehabilitation goal. Participants were recommended to organize their environment, to identify “special places” for items, and to develop habits and routines.
290
M. O’Sullivan et al. Participant 1 Goal Attainment
2 1 0 –1 –2 0
1
2
3
4
5
6
7
8
3 month
Week Remember appointments
Participant 2 Goal Attainment
1 0 Additional training with diary on weeks 6, 7, 8, and 9
–1 –2 0
1
2
3
4
5
6
7
8
10
3 month
Week Remember daily activities
Goal Attainment
Participant 4 2 1 0 Additional training with diary on week 7
–1 –2 0
1
2
3
4
Remember daily activities
5 Week
6
7
8
3 month
6
7
8
3 month
Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2
2 1 0 –1 –2 0
1
2
3
4
5 Week
Remember short-term information ----------- = Week external aids introduced
Figure 3.
External aids used to address prospective memory goals for P1, P2, P4, and P5.
Figure 5 outlines the GAS ratings for misplacing items for P1, P2, and P5, the broken line indicates the week habits and routines were introduced. For P1 and P2, this strategy was introduced at the very start of the intervention on weeks 2 and 3, respectively. For P5, this strategy was introduced at a later stage on week 6. All three
Aging, Neuropsychology, and Cognition
291
Participant 1
Goal Attainment
2
1
0
–1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
7
8
3 month
Participant 4 2
Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
Oriented for day/date
1
0
–1
–2 0
1
2
3
4
5
6
Week Oriented for day/date ----------- = Week external aids introduced
Figure 4.
External aids used to address temporal orientation goals for P1 and P4.
participants improved on this goal post-intervention, and this was maintained at a 3month follow-up. A consistent improvement was noted for P1 on the week this strategy was introduced, and this was maintained for the duration of the intervention. For P2, an improvement was noted 2 weeks after this strategy was introduced, but a return to baseline was noted on week 7, and on this week time was spent reinforcing this strategy. A consistent improvement was noted for P2 from week 8, and this was maintained at a 3-month follow-up. Improvement was noted for P5 on week 4, prior to this strategy being introduced, and this was maintained for the duration of the intervention.
292
M. O’Sullivan et al. Participant 1 Goal Attainment
2 1 0 –1 –2 0
1
2
3
4
5 Week
Reduce misplacing
6
7
8
3 month
Participant 2
Goal Attainment
1 0 –1
Additional training with habits and routines on week 7
–2 0
1
2
3
4
5 6 Week
Reduce misplacing
7
8
3 month
7
8
3 month
Participant 5 2 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2
1 0 –1 –2 0
1
2
3
Reduce misplacing
4
5
6
Week
----------- = Week habits and routines introduced
Figure 5.
Habits and routines used to address misplacing items for P1, P2, and P5.
Hypothesis (d): Goals that are based on naming deficits will benefit from visual restoration strategies
P2, P3, P4, and P5 all identified difficulty recalling names. A restoration strategy, face–name associations, was employed to address this goal. Qualitatively, it was noted that P2, P3, P4, and P5 did not report continued use of this strategy during the intervention. Figure 6 outlines the GAS ratings for remembering names for P2, P3, P4, and P5, the broken line indicates the week face–name associations were introduced. For both P2 and P3, this strategy was introduced on week 5. For P4, this strategy was introduced on week 4, and for P5, it was introduced on week 3. Post-intervention, a decline was noted in relation to this goal for P2 and P4, while an improvement was noted for P3 and P5. These
Aging, Neuropsychology, and Cognition
293
Goal Attainment
Participant 2 2 Additional training with face– name association on week 6
1 0 –1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
Remember names Goal Attainment
1 0 –1 –2
Additional training with face– name association on week 6
0
1
2
3
4
Remember names
5 Week
6
7
8
3 month
Goal Attainment
Participant 4 2 Additional training with face– name association on week 5
1 0 –1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
Remember names Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
Participant 3 2
2 1 0 Additional training with face– name association on week 4
–1 –2
0
1
2
3
4
5 Week
6
7
8
3 month
Remember neighbour's names ----------- = Week face–name association introduced
Figure 6.
Face–name associations used to address remembering names for P2, P3, P4, and P5.
results were maintained at a 3-month follow-up for P2, P4, and P5, while P3 returned to baseline. For P2, a decline was noted following the introduction of this strategy, and time was spent reinforcing this strategy in week 6. A return to baseline was noted on week 7, but a subsequent decline was noted in week 8 which was maintained. For P3, a consistent
294
M. O’Sullivan et al. Participant 3 Goal Attainment
2 1 0 Increase in frustration due to practice of face–name association strategy
–1 –2 0
1
2
3
4
5
6
7
8
3 month
7
8
3 month
Week
Reduce frustration
Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2 1 0 –1 –2 0
1
2
3
4
5
6
Week Reduce frustration ----------- = Week breathing exercise introduced
Figure 7.
Deep breathing used to address frustration with memory for P3 and P5.
improvement was noted on the week this strategy was introduced, but this was not maintained at the 3-month follow-up. For P4, a decline was noted following the introduction of this strategy, and time was spent reinforcing this strategy on week 5; however, subsequent improvements were not maintained. For P5, a consistent improvement was noted following the introduction of this strategy, which was maintained for the duration of the intervention. Hypothesis (e): Goals that relate to frustration as a consequence of memory deficits will benefit from relaxation strategies
P3 and P5 identified frustration as a consequence of memory deficits, as a rehabilitation goal. A relaxation exercise in the format of deep breathing was introduced to address this specific goal. Figure 7 outlines the GAS ratings for reducing frustration related to memory deficits for P3 and P5; the broken line indicates the week deep breathing was introduced. For P3, this strategy was introduced at the start of the intervention, on week 2. For P5, this strategy was introduced later in the intervention on week 7. Both participants reported an improvement in frustration levels post-intervention. This was maintained at a 3-month follow-up by one participant who was exposed to this strategy earlier in the intervention (P3). For P3, an almost consistent improvement was noted following the introduction of this strategy. An exception was noted on week 7, and this was attributed to practicing the
Aging, Neuropsychology, and Cognition
295
face–name association strategy that week and finding it difficult. For P5, scores fluctuated with some improvement noted prior to the introduction of this strategy. Improvement was noted in the week following the introduction of this strategy, but this was not maintained at the 3-month follow-up. Qualitatively, P3 reported continued use of this strategy at the 3-month follow-up, whereas P5 stated that he had forgotten about this strategy.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Qualitative data A qualitative interview was conducted post-intervention with each dyad. Findings were analyzed thematically. The data analysis resulted in a core category – individuals’ perceptions of the intervention – and three sub-categories which fed into the core category, namely the experience before the process, benefits of the process, and how the process can be enhanced (see Figure 8).
“Experience before the process” Participants described feeling a number of different negative emotions before participating in the intervention. One person described how she was frustrated and worried by her memory difficulties and how at one stage she had planned to go into a nursing home if her memory deteriorated further. I got frustrated when I couldn’t do it, panicky . . .. I had meself in a home and all . . .. I made up my mind and all that if it got really bad I would just go into a home
“Benefits of the process” Reported benefits by participants related to subjective gains, objective gains and benefits unique to the intervention. Subjective gains related to reduced anxiety (consistent with ratings on the HADS, see Figure 2), increased confidence, increased awareness, and a greater acceptance of memory difficulties. One support person commented on the benefits associated with using the diary and increased acceptance.
Individuals’ perceptions of the intervention
Experience before the process •Worry •Hopelessness •Skepticism •Frustration
Benefits of the process •Subjective gains (less worried, more confident, increased awareness and acceptance) •Objective gains •Benefits unique to the intervention (having a support person, practicality)
How the process can be enhanced • Duration/sequencing of intervention • Issues related to assessment • Issues related to strategies (face–name association, volume) • Encourage participation in social groups
Figure 8. Individuals’ perceptions of the intervention – findings of the thematic analysis from postintervention interviews.
296
M. O’Sullivan et al.
I think she is less panicky. I think because she does put the stuff in the diary . . . it’s better for you knowing that you didn’t forget, you know that you remembered. I just think she panics less and it has to not matter . . . you have to be able to say to someone “oh yeah because I forgot” . . . it has to be something that you don’t hide, and I don’t think, that she tries to hide it.
Another participant described how using the diary resulted in very real qualitative changes to her everyday life in cuing her memory for past events. Just for myself really, you know when you flick back through it, saying ‘gosh yes I remember doing that’ you know.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Participants noted that the simplicity and practicality of the rehabilitation strategies, as well as the inclusion of the support person, were benefits unique to the intervention process and commented how having a support person involved reinforced learning in the clinic. Well I’d say . . . I would have forgot half of them, only X was there . . . because what I forgot she was able to remind me.
“How it can be improved” A number of participants noted specific shortcomings and made recommendations as to how the intervention could be improved. It was suggested that the intervention should last longer. after six weeks, it’s probably hard to give an overall view. You’d want to give it a year, keep at it for a year or so if that’s possible and see where you’d be then.
Participants also reported finding the face–name association strategy less helpful. All five participants reported finding the external aids and relaxation exercise useful strategies, while four out of five participants reported finding the diary and developing habits and routines useful strategies.
Discussion Each participant achieved some or all of their goals post-intervention and maintained at least two goals at a 3-month follow-up. On standardized tests, average anxiety and depression scores decreased with little change on a test of memory. There was no attrition from the study and participants were committed. The findings suggest the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Results were also positive in relation to use of relaxation strategies and were encouraging for strategies related to modifying the environment. The intervention format was dyadic and involved a family member or support person throughout the intervention. Only two other MCI studies of those reviewed in the literature involved a family member (Clare et al., 2009; Kinsella et al., 2009), and both reported positive findings in this regard. Feedback from qualitative interviews postintervention indicated that this was an asset to the intervention. Participants identified that the support person helped to reinforce learning of the rehabilitation strategies and reminded them to carry out elements of the intervention, while the support person reported
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
297
increased awareness and tolerance of memory deficits, which was viewed positively. Engaging a family member in the intervention built a realistic support network, which has the potential to ensure that any gains made during the intervention were maintained and generalized. The most frequently reported approach to cognition-focused intervention for people with MCI has been cognitive training, involving practice on standardized tasks designed to address specific aspects of cognitive functioning. While improvements have been noted on standardized tests in these studies, there is no evidence that these generalize to everyday functioning. In the current study, interventions were targeted at function, and therefore, this was where improvement was expected. There were no significant changes on a standardized test of memory in the current study, with participant scores remaining in the impaired range throughout the intervention, which was expected, given that they could not employ cognitive rehabilitation strategies during the test. However, findings in relation to functional outcomes were positive. Results from the present study are congruent with those of previous studies (Clare et al., 2009, 2010; Londos et al., 2008) which applied cognitive rehabilitation as an intervention for people with MCI and early-stage Alzheimer’s disease, with participants demonstrating goal attainment in functional tasks post-intervention. The study of MCI is still in its infancy, with evidence from the literature suggesting that it impacts a small but significant percentage of the population. Pharmacotherapy thus far has not been recommended for MCI (Russ & Morling, 2012; Sobow & Kloszewska, 2007); therefore, over the last decade, there has been a growing interest in developing cognition-focused interventions for the treatment of MCI. The need for ecological validity has been gaining momentum, and with a dearth of studies addressing this issue, the present study concentrated on developing and piloting a cognitive rehabilitation intervention for people with MCI and delivering it in a dyadic format. This initial study has yielded positive findings, which should encourage other researchers that this is an area worthy of further attention. These findings were obtained with a brief, six- to eight-session intervention. The focus on personally relevant goals was crucial in engaging participants in the intervention. Participants reported that the dyadic approach was extremely beneficial, as family members were able to reinforce learning in sessions and developed a better understanding of their memory difficulties. The current study made hypotheses regarding underlying brain processes and implemented rehabilitation strategies supported by the evidence base. The timing of changes was also recorded and reported. While the sample size prohibits making generalized claims, this study addresses the issue of efficacy by describing both the content and potential underlying processes. Weekly administration of the GAS in the present study enabled preliminary findings to be drawn in relation to the efficacy of specific strategies for various deficits. It should be noted, however, that given the ultimate objective was to be responsive to clients’ presenting goals, it was not possible to hone these hypotheses to ensure that they could be tested more stringently prior to commencing the intervention, and hence this limited what could be analyzed scientifically. Wilson’s (2002) model recommends that following evaluation of a rehabilitation intervention, it may need to be revised and earlier steps revisited. A large longitudinal study with the inclusion of a control group that follows MCI participants over time would enable researchers to identify if cognitive rehabilitation delays conversion to dementia. Findings from the current study suggest the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Future research studies could concentrate specifically on training MCI
Downloaded by [FU Berlin] at 00:57 12 May 2015
298
M. O’Sullivan et al.
participants how to use external aids to compensate for memory difficulties. Given that the nature of goals and cognitive deficits are heterogeneous, it may prove difficult to compare a wait-list control group on goal attainment measures. However, such a group could be compared on quality-of-life measures, self-perceived ability to cope with memory difficulties, and carer strain. The various categories of rehabilitation strategies (restoration, compensatory, and environmental modification) could be tested empirically against each other with different intervention groups to assess the efficacy of specific strategies with an experimental control group offered social support alone. A number of assorted formats in relation to how cognitive rehabilitation is delivered could be compared empirically in terms of goal attainment, e.g., dyad versus group versus individual to assess the optimum format. Including fMRI data if available as part of future research would also be very informative in terms of monitoring brain activation, to inform the underlying processes and cognitive plasticity theory. The findings of the present study support the use of a dyadic cognitive rehabilitation intervention for people with MCI. Further research is needed to refine how the intervention is delivered and to establish whether positive results from the current study are replicated. The current intervention is cost-effective for both the treatment provider and consumer, with the most significant cost associated with giving up time to attend appointments. Materials were typed and photocopied and investment in external aids by participants (e.g., personal diaries) could be as much or as little as they wished. This intervention could ideally be rolled out at primary care level to support people with memory difficulties and their family members in the community. Given that a considerable number of people with MCI convert to dementia, supporting people to continue living in their own environment and providing additional assistance to their family members seems sensible, in view of the substantial cost associated with provision of care (O’Shea, 2007).
References Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C., . . . Phelps, C. H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 270–279. doi:10.1016/j.jalz.2011.03.008 Amieva, H., Le Goff, M., Millet, X., Orgogozo, J., Pérès, K., Barberger-Gateau, P., . . . Dartigues, J. F. (2008). Prodromal Alzheimer’s disease: Successive emergence of the clinical symptoms. Annals of Neurology, 64, 492–498. doi:10.1002/ana.21509 Bach-y-Rita, P. (2003a). Late postacute neurologic rehabilitation: Neuroscience, engineering, and clinical programs. Archives of Physical Medicine and Rehabilitation, 84, 1100–1108. doi:10.1016/S0003-9993(03)00312-5 Bach-y-Rita, P. (2003b). Theoretical basis for brain plasticity after a TBI. Brain Injury, 17, 643–651. doi:10.1080/0269905031000107133 Belleville, S. (2008). Cognitive training for persons with mild cognitive impairment. International Psychogeriatrics, 20, 57–66. doi:10.1017/S104161020700631X Cicerone, K., Langenbahn, D., Braden, C., Malec, J., Kalmar, K., Fraas, M., . . . Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92, 519–530. doi:10.1016/j. apmr.2010.11.015 Clare, L., Linden, D., Woods, R., Whitaker, R., Evans, S., Parkinson, C., & Rugg, M. (2010). Goaloriented cognitive rehabilitation for people with early-stage Alzheimer’s disease: A single-blind randomised controlled trial of clinical efficacy. Journal of the American Geriatrics Society, 18, 928–939.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
299
Clare, L., van Paasschen, J., Evans, S., Parkinson, C., Woods, R., & Linden, D. (2009). Goaloriented cognitive rehabilitation for an individual with mild cognitive impairment: Behavioural and neuroimaging outcomes. Neurocase, 15, 318–331. doi:10.1080/13554790902783116 Dickerson, B., Salat, D., Greve, D., Chua, E., Rand-Giovannetti, E., Rentz, D., . . . Sperling, R. A. (2005). Increased hippocampal activation in mild cognitive impairment compared to normal aging and AD. Neurology, 65, 404–411. doi:10.1212/01.wnl.0000171450.97464.49 Fernandez-Ballesteros, R., Botella, J., Zamarron, M., Molina, M., Cabras, E., Schettini, R., & Tarraga, L. (2012). Cognitive plasticity in normal and pathological aging. Clinical Interventions in Aging, 7, 15–25. doi:10.2147/CIA.S27008 Fernandez-Ballesteros, R., Zamarrón, M., Tárraga, L., Moya, R., & Iñiguez, J. (2003). Cognitive plasticity in healthy, mild cognitive impairment (MCI) subjects and Alzheimer’s disease patients: A research project in Spain. European Psychologist, 8, 148–159. doi:10.1027//10169040.8.3.148 Fisk, J., & Rockwood, K. (2005). Outcomes of incident mild cognitive impairment in relation to case definition. Journal of Neurology, Neurosurgery and Psychiatry, 76, 1175–1177. doi:10.1136/jnnp.2004.053751 Gagnon, L., & Belleville, S. (2012). Training of attentional control in mild cognitive impairment with executive deficits: Results from a double-blind randomised controlled study. Neuropsychological Rehabilitation, 22, 809–835. doi:10.1080/09602011.2012.691044 Grandmaison, E., & Simard, M. (2003). A critical review of memory stimulation programs in Alzheimer’s disease. The Journal of Neuropsychiatry and Clinical Neurosciences, 15, 130–144. doi:10.1176/appi.neuropsych.15.2.130 Hampstead, B., Sathian, K., Phillips, P., Amaraneni, A., Delaune, W., & Stringer, A. (2012). Mnemonic strategy training improves memory for object location associations in both healthy elderly and patients with amnestic mild cognitive impairment: A randomized, single-blind study. Neuropsychology, 26, 385–399. doi:10.1037/a0027545 Kinsella, G., Mullaly, E., Rand, E., Ong, B., Burton, C., Price, S., & Storey, E. (2009). Early intervention for mild cognitive impairment: A randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry, 80, 730–736. doi:10.1136/jnnp.2008.148346 Lawton, M., & Brody, E. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179–186. doi:10.1093/geront/9.3_Part_1.179 Li, H., Li, J., Li, N., Li, B., Wang, P., & Zhou, T. (2011). Cognitive intervention for persons with mild cognitive impairment: A meta-analysis. Ageing Research Reviews, 10, 285–296. doi:10.1016/j.arr.2010.11.003 Londos, E., Boschian, K., Linden, A., Persson, C., Minthon, L., & Lexell, J. (2008). Effects of a goal-oriented rehabilitation program in mild cognitive impairment: A pilot study. American Journal of Alzheimer’s Disease & Other Dementias, 23, 177–183. doi:10.1177/ 1533317507312622 Malec, J. (1999). Goal attainment scaling in rehabilitation. Neuropsychological Rehabilitation, 9, 253–275. doi:10.1080/096020199389365 Martin, M., Clare, L., Altgassen, A., Cameron, M., & Zehnder, F. (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane Database of Systematic Reviews. Advance online publication. doi:10.1002/14651858. CD006220.pub2 O’ Shea, E. (2007). Implementing policy for dementia care in Ireland: The time for action is now. Dublin: The Alzheimer Society of Ireland. Olchik, M., Farina, J., Steibel, N., Teixeira, A., & Yassuda, M. (2013). Memory training (MT) in mild cognitive impairment (MCI) generates change in cognitive performance. Archives of Gerontology and Geriatrics, 56, 442–447. doi:10.1016/j.archger.2012.11.007 Petersen, R. (2004). Mild cognitive impairment as a diagnostic entity. Journal of Internal Medicine, 256, 183–194. doi:10.1111/j.1365-2796.2004.01388.x Rozzini, L., Costardi, D., Vincini Chilovi, B., Franzoni, S., Trabucchi, M., & Padovani, A. (2007). Efficacy of cognitive rehabilitation in patients with mild cognitive impairment treated with cholinesterase inhibitors. International Journal of Geriatric Psychiatry, 22, 356–360. doi:10.1002/gps.1681 Russ, T., & Morling, J. (2012).Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database of Systematic Reviews. Advance online publication. doi:10.1002/14651858. CD009132.pub2
Downloaded by [FU Berlin] at 00:57 12 May 2015
300
M. O’Sullivan et al.
Sobow, T., & Kloszewska, I. (2007). Cholinesterase inhibitors in mild cognitive impairment: A meta-analysis of randomized controlled trials. Neurologia I Neurochirurgia Polska, 41, 13–21. Teixeira, C., Gobbi, L., Corazza, D., Stella, F., Costa, J., & Gobbi, S. (2012). Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment (MCI). Archives of Gerontology and Geriatrics, 54, 175–180. doi:10.1016/j.archger.2011.02.014 Troyer, A., Murphy, K., Anderson, N., Moscovitch, M., & Craik, F. (2008). Changing everyday memory behaviour in amnestic mild cognitive impairment: A randomised controlled trial. Neuropsychological Rehabilitation, 18, 65–88. doi:10.1080/09602010701409684 Tuokko, H., Frerichs, R., Graham, J., Rockwood, K., Kristjansson, B., Fisk, J., & McDowell, I. (2003). Five-year follow-up of cognitive impairment with no dementia. Archives of Neurology, 60, 577–582. doi:10.1001/archneur.60.4.577 Wilson, B. (1989). Models of cognitive rehabilitation. In R. L. Wood & P. Eames (Eds.), Models of brain injury rehabilitation (pp. 117–141). London: Chapman & Hall. Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation. Neuropsychological Rehabilitation, 12, 97–110. doi:10.1080/09602010244000020 Wilson, B., Clare, L., Baddeley, A., Cockburn, J., Watson, P., & Tate, R. (1999). The Rivermead Behavioural Memory Test – Extended Version. Bury St. Edmunds: Thames Valley Test Company. Winblad, B., Palmer, K., Kivipelto, M., Jelic, V., Fratiglioni, L., Wahlund, L., . . . Petersen, R. C. (2004). Mild cognitive impairment – beyond controversies, towards a consensus: Report of the international working group on mild cognitive impairment. Journal of Internal Medicine, 256, 240–246. doi:10.1111/j.1365-2796.2004.01380.x Woods, B., & Clare, L. (2008). Clinical psychology of aging. Chichester: Wiley. Zigmond, A., & Snaith, R. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x
Aging, Neuropsychology, and Cognition: A Journal on Normal and Dysfunctional Development Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nanc20
Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention a
b
c
d
Maria O’Sullivan , Robert Coen , Denis O’Hora & Agnes Shiel a
Clinical Psychology Department, HSE South, St. Finbarr’s Hospital, Cork, Ireland b
Click for updates
Mercer’s Institute for Research on Ageing, Memory Clinic, St. James’s Hospital, Dublin, Ireland c
Department of Psychology, National University of Ireland Galway, Galway, Ireland d
Department of Occupational Therapy, National University of Ireland Galway, Galway, Ireland Published online: 23 Jun 2014.
To cite this article: Maria O’Sullivan, Robert Coen, Denis O’Hora & Agnes Shiel (2015) Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention, Aging, Neuropsychology, and Cognition: A Journal on Normal and Dysfunctional Development, 22:3, 280-300, DOI: 10.1080/13825585.2014.927818 To link to this article: http://dx.doi.org/10.1080/13825585.2014.927818
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [FU Berlin] at 00:57 12 May 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Aging, Neuropsychology, and Cognition, 2015 Vol. 22, No. 3, 280–300, http://dx.doi.org/10.1080/13825585.2014.927818
Cognitive rehabilitation for mild cognitive impairment: developing and piloting an intervention Maria O’Sullivana*, Robert Coenb, Denis O’Horac and Agnes Shield a Clinical Psychology Department, HSE South, St. Finbarr’s Hospital, Cork, Ireland; bMercer’s Institute for Research on Ageing, Memory Clinic, St. James’s Hospital, Dublin, Ireland; cDepartment of Psychology, National University of Ireland Galway, Galway, Ireland; dDepartment of Occupational Therapy, National University of Ireland Galway, Galway, Ireland
Downloaded by [FU Berlin] at 00:57 12 May 2015
(Received 8 November 2013; accepted 20 May 2014) This was an exploratory study, with the purpose of developing and piloting an intervention for people with mild cognitive impairment (MCI) and their family members using cognitive rehabilitation. A case series design was used with pre- and post-intervention and 3-month follow-up outcome measures. Five participants (two males, three females; mean age 75 years) with a diagnosis of MCI attended the memory clinic with a family member. Intervention consisted of six to eight individual sessions of cognitive rehabilitation consisting of personalized interventions to address individually relevant goals delivered weekly. The main rehabilitation strategies utilized were external aids, personal diary, face–name association, relaxation, and encouraging participants to develop habits and routines. The primary outcome measure was goal attainment as assessed by Goal Attainment Scaling. Secondary outcome measures included measures of memory, anxiety, depression, and activities of daily living. Qualitative data were collected post-intervention by interview. Post-intervention 84% of the goals were attained, with 68% maintained at a 3-month follow-up. Mean anxiety and depression scores decreased during the intervention. No significant changes were recorded on a test of memory. The findings suggest that the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Feedback from participants during qualitative interviews indicated that they found strategies useful and implemented them in their daily routines. The findings support the use of a dyadic cognitive rehabilitation intervention for people with MCI and memory difficulties. Keywords: mild cognitive impairment; cognitive rehabilitation; goal attainment scaling; family dyads
Mild cognitive impairment (MCI) has generated a considerable amount of interest during the last number of years, especially in relation to its significance as a possible prodromal phase of Alzheimer’s disease (Winblad et al., 2004). Many people consider there to be a trajectory of gradual cognitive decline, with MCI representing an earlier phase of decline prior to Alzheimer’s disease, as a result of the high rate (40–80% after 5-year follow-up) of conversion to dementia documented in longitudinal studies (Fisk & Rockwood, 2005; Petersen, 2004; Tuokko et al., 2003). MCI is defined as a “clinical syndrome characterised by cognitive decline which is greater than expected for the given age and level of education, but does not significantly affect everyday activities” (Sobow & Kloszewska, 2007, p. 14). MCI refers to individuals who exhibit some cognitive impairment, which is of insufficient severity to constitute dementia. *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
281
Currently, the criteria for clinically probable Alzheimer’s disease and other dementias identify people after a substantial degree of cognitive decline has taken place. The construct of MCI identifies these individuals earlier in the process of cognitive decline. Therefore, if valid therapeutic interventions become available, clinicians have the opportunity to intervene in this process, perhaps preventing or delaying further cognitive decline (Albert et al., 2011; Amieva et al., 2008; Petersen, 2004). People with MCI have cognitive impairment but minimal impairment in complex instrumental activities and are functioning more or less independently. Therefore, cognitive intervention may benefit persons with MCI because they retain the cognitive capabilities to learn and apply sets of new strategies (Belleville, 2008). There is growing interest in developing interventions for people with MCI, in order to intervene at an earlier point on the trajectory of possible neurodegeneration and to exploit cognitive plasticity. Cognitive plasticity refers to the learning potential and the “extent to which a given subject can improve his/her performance in a given task after training” (Fernandez-Ballesteros, Zamarrón, Tárraga, Moya, & Iñiguez, 2003, p. 149). Research from both human and animal studies indicates that cognitive plasticity endures across the life span and that both rehabilitative and pharmacological interventions may facilitate neuronal reorganization and recovery of function (Bach-y-Rita, 2003a, 2003b). This is supported by Fernandez-Ballesteros et al.’s (2003, 2012) finding that participants with MCI had greater learning ability relative to those with Alzheimer’s disease, supporting the plasticity model. Dickerson et al. (2005) reported similar findings using functional magnetic resonance imaging (fMRI) scanning during a recognition memory task. They found that an MCI group had significantly greater hippocampal activation compared to normal and Alzheimer’s disease groups and less atrophy compared to the Alzheimer’s disease group. The finding of greater plasticity and learning ability of individuals with MCI, relative to those with more progressed illness, may indicate that cognitive interventions will have more impact when individuals are still in the MCI phase. A dyadic approach involves including a support person (e.g., family member) in the intervention, who becomes instrumental in assisting the person with the memory difficulties to carry out memory strategies. There is very limited research incorporating this design in research with MCI. Kinsella et al. (2009) carried out a cognitive training intervention with MCI participants and included their family members. Post-intervention, they reported a significant improvement on prospective memory tasks, increased knowledge and use of memory tasks, and increased family knowledge of memory strategies. Clare et al. (2009) included a family member in a single-subject design and reported positive outcomes in relation to goal attainment. A number of studies that involved a memory intervention for people with Alzheimer’s disease that included a dyadic design reported better outcomes (Clare et al., 2010; Grandmaison & Simard, 2003) even when this involvement was just for the last 15 min of each session (Clare et al., 2010), as participants were more likely to engage in between-session practice. Given that people with MCI often present with memory difficulties, it is possible that strategies learned as part of an intervention may be forgotten once support from that intervention is withdrawn. Therefore, there is scope to include significant others in the intervention process to assist participants to retain, consolidate, and practice rehabilitation strategies. Cognitive training is the most common intervention approach in research with MCI participants. It involves repeated practice at specific, structured cognitive tasks, tailored to the person’s ability level. This approach assumes that regular “exercise” or practice has potential to improve or maintain functioning in a given domain such as memory or
Downloaded by [FU Berlin] at 00:57 12 May 2015
282
M. O’Sullivan et al.
attention, and that such improvement will generalize beyond the immediate training content. A number of recent randomized controlled studies with MCI participants have demonstrated that cognitive training can improve measures of memory, knowledge of memory strategies, mood, and psychological well-being (Gagnon & Belleville, 2012; Hampstead et al., 2012; Li et al., 2011; Martin, Clare, Altgassen, Cameron, & Zehnder, 2011; Olchik, Farina, Steibel, Teixeira, & Yassuda, 2013; Rozzini et al., 2007; Teixeira et al., 2012; Troyer, Murphy, Anderson, Moscovitch, & Craik, 2008). However, the impact on everyday living and the duration of these effects are unknown, and there are a number of methodological issues including small samples, absence of longitudinal studies, lack of functional impact measures, and generalization effects (Belleville, 2008). Currently, there are no pharmacological interventions recommended in the treatment of MCI. Cholinesterase inhibitors comprise a class of drugs with proven efficacy in dementia of the Alzheimer’s type. However, they are currently not recommended in the treatment of MCI due to adverse effects (Russ & Morling, 2012; Sobow & Kloszewska, 2007). Hence, there is scope to examine interventions that have more ecological validity. Cognitive rehabilitation is any strategy or intervention that enables a person to live with, manage, bypass, reduce, or come to terms with deficits (Wilson, 1989). The focus is on difficulties most relevant to the person with the cognitive impairment and their family members, with the aim of achieving functional improvements and well-being rather than increasing scores on standardized cognitive tests (Woods & Clare, 2008). Cognitive rehabilitation has been used for years with people with traumatic brain injury (TBI) and stroke, and there is good evidence to show that it is effective (Cicerone et al., 2011). Goal attainment is a measurement methodology that measures progress toward goals. Goals are individualized to the participant and rated at regular intervals. This methodology has been used effectively in many different settings, e.g., mental health, substance abuse, family therapy, special education, rehabilitation, and geriatric settings (Malec, 1999). In contrast to the demonstrated efficacy of cognitive rehabilitation in other populations, little research has been published in relation to using cognitive rehabilitation and goal attainment for people with MCI. Londos et al. (2008) adapted an 8-week group intervention using cognitive rehabilitation with people with TBI, for a group with MCI and reported significant improvement in goal performance and satisfaction. Clare et al. (2009) carried out a single-subject study involving an individual goal-oriented cognitive rehabilitation intervention for a 77-year-old woman with MCI. This 8-week cognitive rehabilitation intervention resulted in improvement on rehabilitation goals and significant increases in brain activation in memory-related areas on fMRI scans. Clare et al. (2010) carried out a randomized control trial (RCT) with people with early-stage Alzheimer’s disease. Results were congruent with the single-subject study, with significant improvement in goal attainment in the treatment group with no change in the control group. Results from fMRI also demonstrated greater levels of brain activation when engaged in memory testing in the intervention group relative to controls. The limited research to date supports the application of cognitive rehabilitation for people with MCI (Clare et al., 2009; Londos et al., 2008), and better outcomes have been reported for people with MCI and Alzheimer’s disease that involved a dyadic design (Clare et al., 2009, 2010; Grandmaison & Simard, 2003; Kinsella et al., 2009). The current study explored the efficacy of cognitive rehabilitation for people with MCI and adopted a dyadic approach including a significant other or support person in the intervention process, with the aim to exploit cognitive plasticity and maximize potential outcomes.
Aging, Neuropsychology, and Cognition
283
Downloaded by [FU Berlin] at 00:57 12 May 2015
Method The intervention was developed by conducting a thorough literature review in relation to cognitive rehabilitation and MCI. Evidence from RCTs involving TBI and dementia cohorts was considered. A menu of cognitive rehabilitation strategies was created and organized into five categories: psycho-education, restoration, compensation, environmental adaptation, and relaxation. Ethical approval was obtained from St. James’s Hospital, St. Vincent’s Hospital, and the National University of Ireland, Galway. This study was a case series design with pre- and post-intervention and 3-month follow-up outcome measures. All participants met the inclusion criteria of having a subjective memory complaint, objective memory impairment for age representing a change in function, essentially normal activities of daily living (ADL) performance, and absence of dementia (Petersen, 2004), indicative of an MCI classification (see Table 1). Participants were five outpatients (two males, three females), with a diagnosis of MCI who attended the memory clinic with a family member (see Table 2). Participants ranged in age from 68 to 79 years with a mean age of 75 years. Participants had essentially normal ADL performance and were living independently in the community. Two were widowed and attended with their daughters. Three were married and attended with their spouses. The duration of subjective memory complaints ranged from 1 to 6 years. One participant was prescribed a cholinesterase inhibitor. An outline of tools utilized to make diagnoses is summarized in Table 3. All participants underwent blood tests and a screening test, in all cases the mini-mental state examination, when the initial diagnosis was made. Four of the five participants had neuroimaging (MRI or CT scan) completed in order to aid diagnosis. Four participants
Table 1.
Inclusion and exclusion criteria.
Inclusion criteria
● ● ● ●
Exclusion criteria
Diagnosis of mild cognitive impairment ● Progressed to dementia ● Have a preexisting learning disability Aged 50–80 years old Living independently in the community ● Any medical or surgical conditions associated with a head injury, spinal injury, Support person available to attend epilepsy, stroke, or heart attack appointments with MCI participant ● English not first language ● Alcohol or drug dependent ● Currently depressed (meeting DSM-IV criteria for a depressive episode) ● Taking sedatives or tranquilizers ● Vision or hearing not adequate to permit participation in this study, i.e., if the participant is unable to hear the researcher speaking or unable to see the resources used in intervention ● Participated in previous cognitive training/cognitive rehabilitation intervention
79 Female
68 Female
77 Male
76 Male
2
3
4
5
73 Female
1
Married
Married
Married
Widow
Widow
Marital status
Participant characteristics.
Participant Age Gender
Table 2.
5–6 years
1.5 years
3–4 years
1–2 years
3 years
Duration of memory problem
Third level
Third level
Second level
Second level
Second level
Level of education
18
17
12
10
10
Years of education
Memory clinic
Memory clinic
Geriatrician
Memory clinic
Memory clinic
Source of referral
12 months
18 months
4 months
1 month
30 months
Length of time since diagnosis made
Downloaded by [FU Berlin] at 00:57 12 May 2015
Wife
Wife
Husband
Daughter
Daughter
Relationship status of support person
No
Yes
No
No
No
Prescribed cholinesterase inhibitors
284 M. O’Sullivan et al.
Aging, Neuropsychology, and Cognition Table 3.
Tools used to make diagnosis.
Participant 1 2 3 4 5
Downloaded by [FU Berlin] at 00:57 12 May 2015
285
Neuroimaging
Neuropscyh tests
Screening test
Blood test
Consensus meeting with multidisciplinary team
✓ – ✓ ✓ ✓
✓ ✓ – ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓
✓ ✓ – ✓ ✓
also received a neuropsychological assessment (e.g., repeatable battery for the assessment of neuropsychological status; Montreal cognitive assessment; delayed word recall test; the cognitive and self contained part of the Cambridge examination for mental disorders of the elderly; semantic fluency; verbal fluency; clock drawing test; executive interview), and diagnosis was made at a multidisciplinary consensus meeting. The primary outcome measure was goal attainment as assessed by goal attainment scaling (GAS), which measures progress toward goals (Malec, 1999). GAS involves identifying individualized goals with the client and describing them in observable terms. A five-point scale is used with better and worse-than-expected outcomes accounted for (see Table 4 for an example of GAS). GAS was rated at weekly intervals and at 3-month follow-up. The inter-rater reliability for raters on the GAS was found to be kappa = 0.73. Secondary outcome measures completed at pre- and post- intervention and at a 3month follow-up included the Rivermead Behavioural Memory Test – Extended Version (RBMT-E; Wilson et al., 1999) to assess memory; the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983) to assess anxiety and depression; and the instrumental activities of daily living (Lawton & Brody, 1969) to measure instrumental self-maintenance activities required in everyday functioning. A semi-structured interview was conducted with the dyad (MCI participant and support person) once the intervention was completed.
Intervention Intervention was delivered in a dyadic format in the memory clinic, whereby participants along with their support person participated in six to eight weekly sessions of cognitive rehabilitation to address individually relevant goals. The cognitive rehabilitation therapy program used the following components: (1) identifying and working on three to four personal rehabilitation goals relevant to everyday life; (2) psycho-education on MCI; (3) encouraging participants to develop habits and routines; (4) teaching deep breathing as a relaxation strategy; (5) encouraging participants to start using external aids to compensate for memory difficulties and teaching how to use these effectively; and (6) internal memory strategies for learning new information and associations including chunking, spaced retrieval, visual imagery, story-telling, face–name associations, method of loci, and Preview, Question, Read, Summary, Test (PQRST). The order and amount of strategies taught to each dyad varied, depending on the needs and goals of the person with MCI. Table 5 outlines the individual goals for each participant as well as the cognitive rehabilitation strategies employed during the intervention to address these goals.
Actual level now
Misplace things more than once a day
Much worse than baseline (−2)
Goal 4: To become better at recalling neighbours’ names
Get frustrated quite often due to memory difficulties (once a day)
Recall three to five neighbours’ names (first or second name) Recall three or less neighbours’ names (first or second name)
Get frustrated rarely due to memory Recall 13+ difficulties (once a week or less) neighbours’ names (first or second name) Get frustrated rarely due to memory Recall 5–12 difficulties (twice a week) neighbours’ names (first or second name) Get frustrated occasionally due to Can partially recall memory difficulties (every second approximately 5/20 day, three to four times a week) neighbours’ names
Forget short-term information nine or Get frustrated very often due to more times a week memory difficulties (twice a day or more)
Remember short-term information independently with aids (forget something once or less times a week) Somewhat better Misplace items a couple of times a Remember short-term information than baseline (+1) week (two times a week) independently with aids (forget something two to three times a week) Baseline status (0) Misplace items every second day Forget short-term information, often (three to four times a week) reminded by wife (forget something three to five times a week) Somewhat worse Misplace items five to seven times a Forget short-term information once than baseline (−1) week or twice a day (six to eight times a week)
Rarely misplace items (once a week or less)
Goal 1: Try and reduce misplacing items
Goal 2: Remember short-term information he has been told and rely less on cues from wife (e.g., Goal 3: Reduce frustration in relation information about family, dates, to memory difficulties and try and appointments, what to buy in shop) relax
Example of Goal Attainment Scale rated at weekly intervals.
Much better than baseline (+2)
Table 4.
Downloaded by [FU Berlin] at 00:57 12 May 2015
286 M. O’Sullivan et al.
5
4
3
2
1
Participant
Table 5.
External aids and habits and routines were utilized to address this goal External aids and habits and routines were utilized to address this goal A number of restoration strategies that specifically related to remembering numbers were used e.g., rehearsal, chunking, using a rhythm, and imagining the pattern of numbers Face–name association (restoration strategy) was used to deal with this goal Developing habits and routines was encouraged to address this goal External aids were focused on to address this goal
Relaxation, external aids, spaced retrieval, and PQRST were utilized to address this goal Face–name association (restoration strategy) was used to deal with this goal A relaxation exercise was introduced to target this goal
Habits and routines, relaxation, and external aids were utilized to address this goal External aids were focused on to address this goal Face–name association (restoration strategy) was initially used to deal with this goal, and when this was not successful, acceptance and being honest with people in relation to this deficit was suggested External aids were used to address this goal
A number of different strategies were used to address this goal including restoration strategies as well as external aids External aids were employed to address this goal
Habits and routines and relaxation were utilized to address this goal External aids were focused on to address this goal
Cognitive rehabilitation strategies used to address goals
(1) To reduce misplacing items (2) To remember short-term information he has been told and rely less on cues from wife (e.g., information about family, dates, appointments, what to buy in shop). (3) To reduce frustration in relation to memory difficulties and try and A relaxation exercise was used to address this goal relax (4) To become better at recalling neighbours’ names Face–name association and spaced retrieval were utilized in addressing this goal
(4) To become better at remembering people’s names
(1) To become more orientated for day and date (2) To remember what’s to be done on a day-to-day basis (3) To remember the alarm code without having to check paper
(3) To reduce the levels of frustration as a result of memory difficulties
(2) To feel more confident remembering the names of acquaintances
(4) To become better at remembering what activities have already been completed (1) To decrease repetitive questioning when going somewhere
(2) To become better at remembering to do daily activities (3) To become better at remembering names
(1) To reduce misplacing items (2) To remember dates, appointments, arrangements, and rely less on cues from family members (3) To remember all items when carrying out activities that involve multiple parts (4) To become more orientated to events that are taking part on a day-to-day basis (1) To reduce misplacing items
Goals
Participants’ goals and cognitive rehabilitation strategies used to address goals during the intervention.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition 287
288
M. O’Sullivan et al.
Results
Post hoc analysis of goals Some rehabilitation goals were similar in content, e.g., to remember appointments, to remember events, to reduce misplacing items, to remember names, and to reduce frustration in relation to memory deficits. A post hoc analysis was conducted in relation to those goals that had a similar objective, impacted on the same underlying memory process, and received the same intervention. Five hypotheses were tested to investigate if specific cognitive rehabilitation strategies benefited certain rehabilitation goals.
18 16
Goals Attained
14 12 10 8
Postintervention
6 3-month followup
4 2 0 Much better
Better
Baseline Outcomes
Worse
Much worse
Figure 1. Total goals achieved by participants post-intervention and at 3-month follow-up as rated on Goal Attainment Scales.
12 11 10 Mean HADS Scores
Downloaded by [FU Berlin] at 00:57 12 May 2015
In total, 19 goals were set, with each participant working on three to four goals. Postintervention, 16 of these goals across participants (84%) were attained in that they performed better or much better than baseline (see Figure 1). At a 3-month follow-up, 13 goals across participants (68%) were maintained at a better outcome than baseline. Mean anxiety and depression scores decreased post-intervention, and this was maintained at a 3-month follow-up (see Figure 2).
8 7 6 4
Anxiety
6
Depression
4
2
2
2
0 Pre-Intervention
Figure 2.
PostIntervention
3-month Followup
Mean anxiety and depression scores pre-intervention, post-intervention, and at follow-up.
Aging, Neuropsychology, and Cognition
289
Downloaded by [FU Berlin] at 00:57 12 May 2015
Hypothesis (a): Goals that rely on prospective memory will benefit from compensatory strategies
Participant (P) P1, P2, P4, and P5 all identified goals related to prospective memory deficits. External aids were recommended to overcome prospective difficulties. Specifically, participants were advised to purchase a personal diary. Figure 3 outlines the GAS ratings for prospective memory goals for P1, P2, P4, and P5; the broken line indicates the week this strategy was introduced. Trends in the data suggest that goals related to prospective memory deficits may benefit from compensatory strategies and that the earlier these strategies are introduced, the better the outcome. P1 and P2 were introduced to external aids early in the intervention and were both performing at a much better-than-expected level at follow-up on prospective tasks. P4 and P5 were introduced to external aids later in the intervention with mixed results. P4 performed at a better-than-expected level, while P5 performed at worse-than-expected level on prospective tasks at follow-up. There was not enough time during the intervention to give P5 additional training with this strategy and they did not continue to use the diary at followup. Qualitatively during the intervention, all three participants who continued to use the diary reported finding the personal diary effective in aiding prospective memory, and it was noted by the researcher that participants recorded progressively more information in the diary as time went on. Hypothesis (b): Goals that rely on episodic memory will benefit from compensatory strategies
Both P1 and P4 identified rehabilitation goals related to being temporally oriented. External aids such as watches, diaries, wall calendars, and white board were recommended to prime temporal orientation. Figure 4 outlines the GAS ratings for temporal orientation goals for P1 and P4; the broken line indicates the week external aids were introduced. External aids were introduced early in the intervention for P1 (on week 3) and later for P4 (on week 6). Both participants improved on orientation goals post-intervention, and this was maintained at a 3-month follow-up. An improvement was noted on the orientation goal for P1 on the week external aids were introduced, and this improvement was maintained for the duration of the intervention and at the 3-month follow-up. An improvement on the orientation goal for P4 was noted 2 weeks after the external aids were introduced, and this was maintained at the 3month follow-up. Both P1 and P4 also demonstrated gains on the orientation subtest as part of the RBMT-E from pre- to post-intervention. P1 scored 10/14 pre-intervention, 11/14 postintervention, and 12/14 at the 3-month follow-up. P4 scored 8/14 pre-intervention, 12/14 post-intervention, and 11/14 at the 3-month follow-up. Hypothesis (c): Goals that are based on retrieval deficits will benefit from environmental modification
P1, P2, and P5 all identified “misplacing items” as a rehabilitation goal. Participants were recommended to organize their environment, to identify “special places” for items, and to develop habits and routines.
290
M. O’Sullivan et al. Participant 1 Goal Attainment
2 1 0 –1 –2 0
1
2
3
4
5
6
7
8
3 month
Week Remember appointments
Participant 2 Goal Attainment
1 0 Additional training with diary on weeks 6, 7, 8, and 9
–1 –2 0
1
2
3
4
5
6
7
8
10
3 month
Week Remember daily activities
Goal Attainment
Participant 4 2 1 0 Additional training with diary on week 7
–1 –2 0
1
2
3
4
Remember daily activities
5 Week
6
7
8
3 month
6
7
8
3 month
Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2
2 1 0 –1 –2 0
1
2
3
4
5 Week
Remember short-term information ----------- = Week external aids introduced
Figure 3.
External aids used to address prospective memory goals for P1, P2, P4, and P5.
Figure 5 outlines the GAS ratings for misplacing items for P1, P2, and P5, the broken line indicates the week habits and routines were introduced. For P1 and P2, this strategy was introduced at the very start of the intervention on weeks 2 and 3, respectively. For P5, this strategy was introduced at a later stage on week 6. All three
Aging, Neuropsychology, and Cognition
291
Participant 1
Goal Attainment
2
1
0
–1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
7
8
3 month
Participant 4 2
Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
Oriented for day/date
1
0
–1
–2 0
1
2
3
4
5
6
Week Oriented for day/date ----------- = Week external aids introduced
Figure 4.
External aids used to address temporal orientation goals for P1 and P4.
participants improved on this goal post-intervention, and this was maintained at a 3month follow-up. A consistent improvement was noted for P1 on the week this strategy was introduced, and this was maintained for the duration of the intervention. For P2, an improvement was noted 2 weeks after this strategy was introduced, but a return to baseline was noted on week 7, and on this week time was spent reinforcing this strategy. A consistent improvement was noted for P2 from week 8, and this was maintained at a 3-month follow-up. Improvement was noted for P5 on week 4, prior to this strategy being introduced, and this was maintained for the duration of the intervention.
292
M. O’Sullivan et al. Participant 1 Goal Attainment
2 1 0 –1 –2 0
1
2
3
4
5 Week
Reduce misplacing
6
7
8
3 month
Participant 2
Goal Attainment
1 0 –1
Additional training with habits and routines on week 7
–2 0
1
2
3
4
5 6 Week
Reduce misplacing
7
8
3 month
7
8
3 month
Participant 5 2 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2
1 0 –1 –2 0
1
2
3
Reduce misplacing
4
5
6
Week
----------- = Week habits and routines introduced
Figure 5.
Habits and routines used to address misplacing items for P1, P2, and P5.
Hypothesis (d): Goals that are based on naming deficits will benefit from visual restoration strategies
P2, P3, P4, and P5 all identified difficulty recalling names. A restoration strategy, face–name associations, was employed to address this goal. Qualitatively, it was noted that P2, P3, P4, and P5 did not report continued use of this strategy during the intervention. Figure 6 outlines the GAS ratings for remembering names for P2, P3, P4, and P5, the broken line indicates the week face–name associations were introduced. For both P2 and P3, this strategy was introduced on week 5. For P4, this strategy was introduced on week 4, and for P5, it was introduced on week 3. Post-intervention, a decline was noted in relation to this goal for P2 and P4, while an improvement was noted for P3 and P5. These
Aging, Neuropsychology, and Cognition
293
Goal Attainment
Participant 2 2 Additional training with face– name association on week 6
1 0 –1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
Remember names Goal Attainment
1 0 –1 –2
Additional training with face– name association on week 6
0
1
2
3
4
Remember names
5 Week
6
7
8
3 month
Goal Attainment
Participant 4 2 Additional training with face– name association on week 5
1 0 –1 –2 0
1
2
3
4
5 Week
6
7
8
3 month
Remember names Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
Participant 3 2
2 1 0 Additional training with face– name association on week 4
–1 –2
0
1
2
3
4
5 Week
6
7
8
3 month
Remember neighbour's names ----------- = Week face–name association introduced
Figure 6.
Face–name associations used to address remembering names for P2, P3, P4, and P5.
results were maintained at a 3-month follow-up for P2, P4, and P5, while P3 returned to baseline. For P2, a decline was noted following the introduction of this strategy, and time was spent reinforcing this strategy in week 6. A return to baseline was noted on week 7, but a subsequent decline was noted in week 8 which was maintained. For P3, a consistent
294
M. O’Sullivan et al. Participant 3 Goal Attainment
2 1 0 Increase in frustration due to practice of face–name association strategy
–1 –2 0
1
2
3
4
5
6
7
8
3 month
7
8
3 month
Week
Reduce frustration
Participant 5 Goal Attainment
Downloaded by [FU Berlin] at 00:57 12 May 2015
2 1 0 –1 –2 0
1
2
3
4
5
6
Week Reduce frustration ----------- = Week breathing exercise introduced
Figure 7.
Deep breathing used to address frustration with memory for P3 and P5.
improvement was noted on the week this strategy was introduced, but this was not maintained at the 3-month follow-up. For P4, a decline was noted following the introduction of this strategy, and time was spent reinforcing this strategy on week 5; however, subsequent improvements were not maintained. For P5, a consistent improvement was noted following the introduction of this strategy, which was maintained for the duration of the intervention. Hypothesis (e): Goals that relate to frustration as a consequence of memory deficits will benefit from relaxation strategies
P3 and P5 identified frustration as a consequence of memory deficits, as a rehabilitation goal. A relaxation exercise in the format of deep breathing was introduced to address this specific goal. Figure 7 outlines the GAS ratings for reducing frustration related to memory deficits for P3 and P5; the broken line indicates the week deep breathing was introduced. For P3, this strategy was introduced at the start of the intervention, on week 2. For P5, this strategy was introduced later in the intervention on week 7. Both participants reported an improvement in frustration levels post-intervention. This was maintained at a 3-month follow-up by one participant who was exposed to this strategy earlier in the intervention (P3). For P3, an almost consistent improvement was noted following the introduction of this strategy. An exception was noted on week 7, and this was attributed to practicing the
Aging, Neuropsychology, and Cognition
295
face–name association strategy that week and finding it difficult. For P5, scores fluctuated with some improvement noted prior to the introduction of this strategy. Improvement was noted in the week following the introduction of this strategy, but this was not maintained at the 3-month follow-up. Qualitatively, P3 reported continued use of this strategy at the 3-month follow-up, whereas P5 stated that he had forgotten about this strategy.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Qualitative data A qualitative interview was conducted post-intervention with each dyad. Findings were analyzed thematically. The data analysis resulted in a core category – individuals’ perceptions of the intervention – and three sub-categories which fed into the core category, namely the experience before the process, benefits of the process, and how the process can be enhanced (see Figure 8).
“Experience before the process” Participants described feeling a number of different negative emotions before participating in the intervention. One person described how she was frustrated and worried by her memory difficulties and how at one stage she had planned to go into a nursing home if her memory deteriorated further. I got frustrated when I couldn’t do it, panicky . . .. I had meself in a home and all . . .. I made up my mind and all that if it got really bad I would just go into a home
“Benefits of the process” Reported benefits by participants related to subjective gains, objective gains and benefits unique to the intervention. Subjective gains related to reduced anxiety (consistent with ratings on the HADS, see Figure 2), increased confidence, increased awareness, and a greater acceptance of memory difficulties. One support person commented on the benefits associated with using the diary and increased acceptance.
Individuals’ perceptions of the intervention
Experience before the process •Worry •Hopelessness •Skepticism •Frustration
Benefits of the process •Subjective gains (less worried, more confident, increased awareness and acceptance) •Objective gains •Benefits unique to the intervention (having a support person, practicality)
How the process can be enhanced • Duration/sequencing of intervention • Issues related to assessment • Issues related to strategies (face–name association, volume) • Encourage participation in social groups
Figure 8. Individuals’ perceptions of the intervention – findings of the thematic analysis from postintervention interviews.
296
M. O’Sullivan et al.
I think she is less panicky. I think because she does put the stuff in the diary . . . it’s better for you knowing that you didn’t forget, you know that you remembered. I just think she panics less and it has to not matter . . . you have to be able to say to someone “oh yeah because I forgot” . . . it has to be something that you don’t hide, and I don’t think, that she tries to hide it.
Another participant described how using the diary resulted in very real qualitative changes to her everyday life in cuing her memory for past events. Just for myself really, you know when you flick back through it, saying ‘gosh yes I remember doing that’ you know.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Participants noted that the simplicity and practicality of the rehabilitation strategies, as well as the inclusion of the support person, were benefits unique to the intervention process and commented how having a support person involved reinforced learning in the clinic. Well I’d say . . . I would have forgot half of them, only X was there . . . because what I forgot she was able to remind me.
“How it can be improved” A number of participants noted specific shortcomings and made recommendations as to how the intervention could be improved. It was suggested that the intervention should last longer. after six weeks, it’s probably hard to give an overall view. You’d want to give it a year, keep at it for a year or so if that’s possible and see where you’d be then.
Participants also reported finding the face–name association strategy less helpful. All five participants reported finding the external aids and relaxation exercise useful strategies, while four out of five participants reported finding the diary and developing habits and routines useful strategies.
Discussion Each participant achieved some or all of their goals post-intervention and maintained at least two goals at a 3-month follow-up. On standardized tests, average anxiety and depression scores decreased with little change on a test of memory. There was no attrition from the study and participants were committed. The findings suggest the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Results were also positive in relation to use of relaxation strategies and were encouraging for strategies related to modifying the environment. The intervention format was dyadic and involved a family member or support person throughout the intervention. Only two other MCI studies of those reviewed in the literature involved a family member (Clare et al., 2009; Kinsella et al., 2009), and both reported positive findings in this regard. Feedback from qualitative interviews postintervention indicated that this was an asset to the intervention. Participants identified that the support person helped to reinforce learning of the rehabilitation strategies and reminded them to carry out elements of the intervention, while the support person reported
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
297
increased awareness and tolerance of memory deficits, which was viewed positively. Engaging a family member in the intervention built a realistic support network, which has the potential to ensure that any gains made during the intervention were maintained and generalized. The most frequently reported approach to cognition-focused intervention for people with MCI has been cognitive training, involving practice on standardized tasks designed to address specific aspects of cognitive functioning. While improvements have been noted on standardized tests in these studies, there is no evidence that these generalize to everyday functioning. In the current study, interventions were targeted at function, and therefore, this was where improvement was expected. There were no significant changes on a standardized test of memory in the current study, with participant scores remaining in the impaired range throughout the intervention, which was expected, given that they could not employ cognitive rehabilitation strategies during the test. However, findings in relation to functional outcomes were positive. Results from the present study are congruent with those of previous studies (Clare et al., 2009, 2010; Londos et al., 2008) which applied cognitive rehabilitation as an intervention for people with MCI and early-stage Alzheimer’s disease, with participants demonstrating goal attainment in functional tasks post-intervention. The study of MCI is still in its infancy, with evidence from the literature suggesting that it impacts a small but significant percentage of the population. Pharmacotherapy thus far has not been recommended for MCI (Russ & Morling, 2012; Sobow & Kloszewska, 2007); therefore, over the last decade, there has been a growing interest in developing cognition-focused interventions for the treatment of MCI. The need for ecological validity has been gaining momentum, and with a dearth of studies addressing this issue, the present study concentrated on developing and piloting a cognitive rehabilitation intervention for people with MCI and delivering it in a dyadic format. This initial study has yielded positive findings, which should encourage other researchers that this is an area worthy of further attention. These findings were obtained with a brief, six- to eight-session intervention. The focus on personally relevant goals was crucial in engaging participants in the intervention. Participants reported that the dyadic approach was extremely beneficial, as family members were able to reinforce learning in sessions and developed a better understanding of their memory difficulties. The current study made hypotheses regarding underlying brain processes and implemented rehabilitation strategies supported by the evidence base. The timing of changes was also recorded and reported. While the sample size prohibits making generalized claims, this study addresses the issue of efficacy by describing both the content and potential underlying processes. Weekly administration of the GAS in the present study enabled preliminary findings to be drawn in relation to the efficacy of specific strategies for various deficits. It should be noted, however, that given the ultimate objective was to be responsive to clients’ presenting goals, it was not possible to hone these hypotheses to ensure that they could be tested more stringently prior to commencing the intervention, and hence this limited what could be analyzed scientifically. Wilson’s (2002) model recommends that following evaluation of a rehabilitation intervention, it may need to be revised and earlier steps revisited. A large longitudinal study with the inclusion of a control group that follows MCI participants over time would enable researchers to identify if cognitive rehabilitation delays conversion to dementia. Findings from the current study suggest the strongest effect was in relation to compensatory strategies for prospective and episodic memory deficits. Future research studies could concentrate specifically on training MCI
Downloaded by [FU Berlin] at 00:57 12 May 2015
298
M. O’Sullivan et al.
participants how to use external aids to compensate for memory difficulties. Given that the nature of goals and cognitive deficits are heterogeneous, it may prove difficult to compare a wait-list control group on goal attainment measures. However, such a group could be compared on quality-of-life measures, self-perceived ability to cope with memory difficulties, and carer strain. The various categories of rehabilitation strategies (restoration, compensatory, and environmental modification) could be tested empirically against each other with different intervention groups to assess the efficacy of specific strategies with an experimental control group offered social support alone. A number of assorted formats in relation to how cognitive rehabilitation is delivered could be compared empirically in terms of goal attainment, e.g., dyad versus group versus individual to assess the optimum format. Including fMRI data if available as part of future research would also be very informative in terms of monitoring brain activation, to inform the underlying processes and cognitive plasticity theory. The findings of the present study support the use of a dyadic cognitive rehabilitation intervention for people with MCI. Further research is needed to refine how the intervention is delivered and to establish whether positive results from the current study are replicated. The current intervention is cost-effective for both the treatment provider and consumer, with the most significant cost associated with giving up time to attend appointments. Materials were typed and photocopied and investment in external aids by participants (e.g., personal diaries) could be as much or as little as they wished. This intervention could ideally be rolled out at primary care level to support people with memory difficulties and their family members in the community. Given that a considerable number of people with MCI convert to dementia, supporting people to continue living in their own environment and providing additional assistance to their family members seems sensible, in view of the substantial cost associated with provision of care (O’Shea, 2007).
References Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C., . . . Phelps, C. H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 270–279. doi:10.1016/j.jalz.2011.03.008 Amieva, H., Le Goff, M., Millet, X., Orgogozo, J., Pérès, K., Barberger-Gateau, P., . . . Dartigues, J. F. (2008). Prodromal Alzheimer’s disease: Successive emergence of the clinical symptoms. Annals of Neurology, 64, 492–498. doi:10.1002/ana.21509 Bach-y-Rita, P. (2003a). Late postacute neurologic rehabilitation: Neuroscience, engineering, and clinical programs. Archives of Physical Medicine and Rehabilitation, 84, 1100–1108. doi:10.1016/S0003-9993(03)00312-5 Bach-y-Rita, P. (2003b). Theoretical basis for brain plasticity after a TBI. Brain Injury, 17, 643–651. doi:10.1080/0269905031000107133 Belleville, S. (2008). Cognitive training for persons with mild cognitive impairment. International Psychogeriatrics, 20, 57–66. doi:10.1017/S104161020700631X Cicerone, K., Langenbahn, D., Braden, C., Malec, J., Kalmar, K., Fraas, M., . . . Ashman, T. (2011). Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Archives of Physical Medicine and Rehabilitation, 92, 519–530. doi:10.1016/j. apmr.2010.11.015 Clare, L., Linden, D., Woods, R., Whitaker, R., Evans, S., Parkinson, C., & Rugg, M. (2010). Goaloriented cognitive rehabilitation for people with early-stage Alzheimer’s disease: A single-blind randomised controlled trial of clinical efficacy. Journal of the American Geriatrics Society, 18, 928–939.
Downloaded by [FU Berlin] at 00:57 12 May 2015
Aging, Neuropsychology, and Cognition
299
Clare, L., van Paasschen, J., Evans, S., Parkinson, C., Woods, R., & Linden, D. (2009). Goaloriented cognitive rehabilitation for an individual with mild cognitive impairment: Behavioural and neuroimaging outcomes. Neurocase, 15, 318–331. doi:10.1080/13554790902783116 Dickerson, B., Salat, D., Greve, D., Chua, E., Rand-Giovannetti, E., Rentz, D., . . . Sperling, R. A. (2005). Increased hippocampal activation in mild cognitive impairment compared to normal aging and AD. Neurology, 65, 404–411. doi:10.1212/01.wnl.0000171450.97464.49 Fernandez-Ballesteros, R., Botella, J., Zamarron, M., Molina, M., Cabras, E., Schettini, R., & Tarraga, L. (2012). Cognitive plasticity in normal and pathological aging. Clinical Interventions in Aging, 7, 15–25. doi:10.2147/CIA.S27008 Fernandez-Ballesteros, R., Zamarrón, M., Tárraga, L., Moya, R., & Iñiguez, J. (2003). Cognitive plasticity in healthy, mild cognitive impairment (MCI) subjects and Alzheimer’s disease patients: A research project in Spain. European Psychologist, 8, 148–159. doi:10.1027//10169040.8.3.148 Fisk, J., & Rockwood, K. (2005). Outcomes of incident mild cognitive impairment in relation to case definition. Journal of Neurology, Neurosurgery and Psychiatry, 76, 1175–1177. doi:10.1136/jnnp.2004.053751 Gagnon, L., & Belleville, S. (2012). Training of attentional control in mild cognitive impairment with executive deficits: Results from a double-blind randomised controlled study. Neuropsychological Rehabilitation, 22, 809–835. doi:10.1080/09602011.2012.691044 Grandmaison, E., & Simard, M. (2003). A critical review of memory stimulation programs in Alzheimer’s disease. The Journal of Neuropsychiatry and Clinical Neurosciences, 15, 130–144. doi:10.1176/appi.neuropsych.15.2.130 Hampstead, B., Sathian, K., Phillips, P., Amaraneni, A., Delaune, W., & Stringer, A. (2012). Mnemonic strategy training improves memory for object location associations in both healthy elderly and patients with amnestic mild cognitive impairment: A randomized, single-blind study. Neuropsychology, 26, 385–399. doi:10.1037/a0027545 Kinsella, G., Mullaly, E., Rand, E., Ong, B., Burton, C., Price, S., & Storey, E. (2009). Early intervention for mild cognitive impairment: A randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry, 80, 730–736. doi:10.1136/jnnp.2008.148346 Lawton, M., & Brody, E. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179–186. doi:10.1093/geront/9.3_Part_1.179 Li, H., Li, J., Li, N., Li, B., Wang, P., & Zhou, T. (2011). Cognitive intervention for persons with mild cognitive impairment: A meta-analysis. Ageing Research Reviews, 10, 285–296. doi:10.1016/j.arr.2010.11.003 Londos, E., Boschian, K., Linden, A., Persson, C., Minthon, L., & Lexell, J. (2008). Effects of a goal-oriented rehabilitation program in mild cognitive impairment: A pilot study. American Journal of Alzheimer’s Disease & Other Dementias, 23, 177–183. doi:10.1177/ 1533317507312622 Malec, J. (1999). Goal attainment scaling in rehabilitation. Neuropsychological Rehabilitation, 9, 253–275. doi:10.1080/096020199389365 Martin, M., Clare, L., Altgassen, A., Cameron, M., & Zehnder, F. (2011). Cognition-based interventions for healthy older people and people with mild cognitive impairment. Cochrane Database of Systematic Reviews. Advance online publication. doi:10.1002/14651858. CD006220.pub2 O’ Shea, E. (2007). Implementing policy for dementia care in Ireland: The time for action is now. Dublin: The Alzheimer Society of Ireland. Olchik, M., Farina, J., Steibel, N., Teixeira, A., & Yassuda, M. (2013). Memory training (MT) in mild cognitive impairment (MCI) generates change in cognitive performance. Archives of Gerontology and Geriatrics, 56, 442–447. doi:10.1016/j.archger.2012.11.007 Petersen, R. (2004). Mild cognitive impairment as a diagnostic entity. Journal of Internal Medicine, 256, 183–194. doi:10.1111/j.1365-2796.2004.01388.x Rozzini, L., Costardi, D., Vincini Chilovi, B., Franzoni, S., Trabucchi, M., & Padovani, A. (2007). Efficacy of cognitive rehabilitation in patients with mild cognitive impairment treated with cholinesterase inhibitors. International Journal of Geriatric Psychiatry, 22, 356–360. doi:10.1002/gps.1681 Russ, T., & Morling, J. (2012).Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database of Systematic Reviews. Advance online publication. doi:10.1002/14651858. CD009132.pub2
Downloaded by [FU Berlin] at 00:57 12 May 2015
300
M. O’Sullivan et al.
Sobow, T., & Kloszewska, I. (2007). Cholinesterase inhibitors in mild cognitive impairment: A meta-analysis of randomized controlled trials. Neurologia I Neurochirurgia Polska, 41, 13–21. Teixeira, C., Gobbi, L., Corazza, D., Stella, F., Costa, J., & Gobbi, S. (2012). Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment (MCI). Archives of Gerontology and Geriatrics, 54, 175–180. doi:10.1016/j.archger.2011.02.014 Troyer, A., Murphy, K., Anderson, N., Moscovitch, M., & Craik, F. (2008). Changing everyday memory behaviour in amnestic mild cognitive impairment: A randomised controlled trial. Neuropsychological Rehabilitation, 18, 65–88. doi:10.1080/09602010701409684 Tuokko, H., Frerichs, R., Graham, J., Rockwood, K., Kristjansson, B., Fisk, J., & McDowell, I. (2003). Five-year follow-up of cognitive impairment with no dementia. Archives of Neurology, 60, 577–582. doi:10.1001/archneur.60.4.577 Wilson, B. (1989). Models of cognitive rehabilitation. In R. L. Wood & P. Eames (Eds.), Models of brain injury rehabilitation (pp. 117–141). London: Chapman & Hall. Wilson, B. (2002). Towards a comprehensive model of cognitive rehabilitation. Neuropsychological Rehabilitation, 12, 97–110. doi:10.1080/09602010244000020 Wilson, B., Clare, L., Baddeley, A., Cockburn, J., Watson, P., & Tate, R. (1999). The Rivermead Behavioural Memory Test – Extended Version. Bury St. Edmunds: Thames Valley Test Company. Winblad, B., Palmer, K., Kivipelto, M., Jelic, V., Fratiglioni, L., Wahlund, L., . . . Petersen, R. C. (2004). Mild cognitive impairment – beyond controversies, towards a consensus: Report of the international working group on mild cognitive impairment. Journal of Internal Medicine, 256, 240–246. doi:10.1111/j.1365-2796.2004.01380.x Woods, B., & Clare, L. (2008). Clinical psychology of aging. Chichester: Wiley. Zigmond, A., & Snaith, R. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370. doi:10.1111/j.1600-0447.1983.tb09716.x
