Translating cognitive and everyday activity deficits into cognitive interventions in mild dementia and mild cognitive impairment Clarissa Giebel and David Challis University of Manchester, Manchester, UK Correspondence to: Clarissa Giebel, E-mail: [email protected]

Mild dementia is marked by deficits in cognition and everyday activities. However, few studies have translated findings from both areas of functioning into effective cognitive rehabilitation. The purpose of this review was to critically evaluate the existing literature on the type and success of interventions and on their extent of use of cognitive theory. Given the limited evidence base in this population, further insights were obtained from studies on mild cognitive impairment (MCI), which involves fewer cognitive and everyday functioning problems than dementia. Methods: From the literature searches, 11 studies on mild dementia and three studies on MCI were obtained. Studies were only included if the interventions either targeted instrumental activities of daily living or activities of daily living directly or as an outcome measure or if the interventions focused on real-life aspects not captured in the standardised daily activities. For inclusion, patients needed a diagnosis of dementia or MCI, and Mini-Mental State Examination scores had to be above 17 for mild dementia. Results: The majority of interventions indicated improved everyday activity performance in early dementia and MCI. Focusing on individual, as opposed to global, daily activities appeared to be an important determinant of intervention success in mild dementia but not in MCI. However, few attempts had been made to develop interventions grounded in evidence-based models. Conclusions: This review highlights the need for further translation of the understanding of cognitive and everyday activity deficits into successful interventions for daily activities in MCI and early dementia. Hence, research is first required to link individual activities with cognitive domains. Copyright # 2014 John Wiley & Sons, Ltd.


Key words: Dementia; Mild Cognitive Impairment; Cognitive Impairment; Activities of Daily Living; Cognitive Interventions; Translation History: Received 14 January 2014; Accepted 30 May 2014; Published online 2 July 2014 in Wiley Online Library ( DOI: 10.1002/gps.4170

Introduction The early stages of dementia are marked by increasing deficits in cognition (Mioshi et al., 2007; Grober et al., 2008), in performance of complex instrumental activities of daily living (IADLs) (Lawton and Brody, 1969), and to a smaller degree more basic ADLs (Katz et al., 1963). With cognition found to be a crucial determinant of everyday activity performance (Cahn-Weiner et al., 2007; Arrighi et al., 2013), the translation of experimental findings into real-life Copyright # 2014 John Wiley & Sons, Ltd.

interventions is a critical next step to address deficits and promote independence. Developing nonpharmacological treatments is one of the main priorities of dementia research in the Prime Minister’s challenge on dementia (DH, 2012). In order to develop such interventions, a comprehensive understanding is required of the relationships between cognition and daily functioning. This is particularly important for mild dementia, as increasing or maintaining independence early will have greater benefits both for people with dementia (PwD) and Int J Geriatr Psychiatry 2015; 30: 21–31


their informal caregivers. This is because ADL and IADL dependence leads to reduced well-being (Avila et al., 2004; Giebel et al., 2014a, 2014b). Regarding everyday functioning in mild dementia, few studies have either addressed global everyday activity performance (Pocnet et al., 2013) or specific activities (Pérès et al., 2008). In some instances, people with mild and moderate dementia were assessed jointly (Hallikainen et al., 2012), which makes it difficult to draw conclusions about deterioration particular to each stage. Overall, it appears that PwD experience more problems with complex IADLs (Mioshi et al., 2007; Pocnet et al., 2013), including telephoning, shopping, food preparation, laundry, transportation, housekeeping, finance and medication management. Arguably, IADLs require higher levels of cognitive functioning, whereas basic ADLs (bathing, continence, dressing, feeding, toileting and transfer) are based to a greater extent on more basic physical processes. In particular, activities such as finance management (Marson et al., 2000) and medication adherence (Brown et al., 2011) are subject to early and pre-diagnostic impairment (Pérès et al., 2008). However, the relationship of individual IADLs to specific cognitive domains has received relatively little attention in mild dementia, with short-term memory and executive function being linked to tasks of finance management (Earnst et al., 2001) and hot drink preparation (Ramsden et al., 2008), respectively. To develop targeted interventions, a solid evidence base of detailed cognitive and everyday function performance and particularly their cognitive associations is required. Thus, designing interventions that incorporate tasks to improve specific cognitive domains, such as short-term memory, and strategies that directly target an individual activity might prove to be successful. It is this review’s objective to evaluate the existing evidence for the translation of knowledge on cognition and everyday function into efficacious interventions. Reduced levels of cognitive and daily functioning are also reported in patients with mild cognitive impairment (MCI) (Brown et al., 2011; Gold, 2012), although MCI, by definition, excludes everyday problems (Petersen, 2000). In particular, finance management, medication adherence and shopping are performed with greater difficulty than basic ADLs (Tuokko et al., 2005). With mild dementia incorporating only limited ADL deficits, if any, (Giebel et al., 2014a), findings by Tuokko et al. (2005) further validate the distinction between IADL and ADL impairments in a stage potentially prior to dementia. As with research on mild dementia, very little focus has been placed on the relationship between specific cognitive domains and daily activities Copyright # 2014 John Wiley & Sons, Ltd.

C. Giebel and D. Challis

in MCI, although overall performance levels are positively related (Reppermund et al., 2011). Tuokko et al. (2005) showed that processing speed, the time required to process information, is a crucial determinant of daily activity performance in MCI. Interestingly, although episodic and working memory and executive functioning were also assessed, their individual contribution to activity performance was not explored. Clearly, this relationship necessitates further investigation in both MCI and mild dementia, in the course of which research should incorporate and develop evidence from other clinical and healthy populations (Woods et al., 2009; Lam et al., 2013). Although some previous reviews have evaluated cognitive interventions in MCI (Simon et al., 2012; Huckans et al., 2013), no review has explicitly focused on everyday function-related cognitive rehabilitation (CR) that addresses everyday activities. Similarly, no review has targeted CR on ADLs and IADLs in mild dementia. Therefore, the aim of this review was to evaluate literature on cognitive interventions for everyday performance in MCI and mild dementia, assessing the degree to which CR was grounded in the theories of cognitive neuropsychology. In particular, this review is intended to assess the components of efficacious interventions, as a first stage as set out in the MRC framework for developing and evaluating complex interventions (MRC, 2000). Evaluating the components of successful interventions can support their further development and implementation. However, it was not expected that interventions would be grounded in theoretical or evidence-based models because of the lack of a framework linking cognition and everyday functioning. The review was intended to also begin to make explicit this link. Method The databases of PubMed, PsychInfo and Google Scholar were searched for studies with the following keywords: early dementia, mild dementia, preclinical dementia, probable dementia, Alzheimer’s disease, mild cognitive impairment, everyday functioning, independence, activities of daily living, instrumental activities of daily living, face-name associations, intervention and cognitive rehabilitation. Further hand searches were subsequently performed in the literature identified. The literature search was conducted in May 2013. Studies were excluded if there was no diagnosis of dementia and if the PwD included scored 17 or lower on the Mini-Mental State Examination (MMSE) (Folstein et al., 1975). Some literature suggests a cut-off value of 18 and above for mild dementia (Tombaugh Int J Geriatr Psychiatry 2015; 30: 21–31

Translation into cognitive interventions


and McIntyre, 1992), whereas some studies argue that this score already implies the moderate stage of dementia (Perneczky et al., 2006). Although a score of 18 or higher includes a large range of cognitive functions, and thus daily activity performance, most literature has applied this low MMSE cut-off. Ideally, only studies with a higher MMSE cut-off of 23 (Galasko et al., 1990) would have been included, but such literature was limited. For MCI literature, patients needed to have a diagnosis of MCI. The foci of interventions for both patient groups were daily activities or everyday problems that are relevant within the participants’ real life, such as face-name associations of people frequently encountered. Hence, studies solely evaluating an intervention for learning new face-name pairs were excluded, so that no interventions relating to this were found for MCI (i.e. Jean et al., 2010; Hampstead et al., 2011). After the exclusion criteria were applied, 13 studies in total were included in this review, of which, 11 interventions were aimed at mild dementia (Table 2) and three interventions at MCI (Table 3). One study described an intervention tested on both MCI and mild dementia patients. All studies included in the review were quality assessed by both researchers with the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project, 2003), which examines selection bias, study design, confounders, blinding, data collection methods and withdrawals and dropouts. Overall scores range from 1 (strong, with no weak rating amongst the six categories) to 3 (weak, with two or more weak ratings amongst the six categories). Any disagreements between the researchers’ ratings were reviewed through discussion. Quality ratings of studies Results of the quality assessment are shown in Table 1. Overall, studies were considered relatively weak by Table 1 Quality ratings of included studies Study Avila et al., 2004 Clare et al., 1999 Clare et al., 2000 Clare et al., 2001 Clare et al., 2002 Clare et al., 2003 Clare et al., 2009 Clare et al., 2010 Dunn and Clare, 2007 Kinsella et al., 2009 Kurz et al., 2009 Kurz et al., 2012 Löwenstein et al., 2004

R1 rating

R2 rating

3 2 2 3 3 3 3 1 2 1 1 2 3

3 3 3 3 2 3 3 1 3 1 2 1 3

Copyright # 2014 John Wiley & Sons, Ltd.

both researchers, with a mean rating score of 2.31. There was full agreement on seven studies. Cognitive interventions in mild dementia Everyday activity interventions

Impaired ability to perform everyday activities is one of the earliest and most apparent signs of dementia (Pérès et al., 2008). Although linked to deficits in cognition (Barberger-Gateau et al., 1992; Cahn-Weiner et al., 2007), only a limited corpus of literature has focused on CR to maintain or improve IADL or ADL performance in mild dementia. In one recent study, Kurz et al. (2012) attempted to cognitively rehabilitate mild AD patients and improve their abilities to perform basic ADLs. Kurz et al. (2012) applied a 12-week intervention programme involving PwD and their informal caregivers incorporating external memory aids, daily routine description, daily breakdown of tasks and reminiscence. Although the intervention group did not perform better post-intervention compared with controls, they reported higher levels of quality of life. Caregivers rated the training sessions as feasible, and their level of commitment was not considered to have impacted upon the results. The authors argued that the limited time frame and the lack of real-life applicability, amongst other factors, could explain the limited effect on ADL abilities. However, previous literature does not support the argument that a 12-week intervention is too brief for ADL improvements in dementia (Josephsson et al., 1993; Dechamps et al., 2011). In fact, some programmes only lasted one week (Dechamps et al., 2011) or three weeks (Zanetti et al., 1997) and resulted in increased everyday activity performance in moderate dementia. It should be mentioned that although these interventions were more intensive, on the basis of daily sessions as opposed to the overall 12 h within 12 weeks employed by Kurz et al. (2012). In contrast to the issue of brevity of intervention, it is possible that the lack of a coherent theoretical link between individual cognitive domains and everyday activities employed in the intervention may have accounted for the results. In particular, the authors provided no description of the learning strategies employed and their selection criteria. To lend additional credence to this argument, the same authors merely referred to the efficacy of memory aids in a previous intervention (Kurz et al., 2009), lacking specific reports of efficacy. Therefore, real-life applicability and the integration of evidence-based models are arguably crucial to success. Int J Geriatr Psychiatry 2015; 30: 21–31

Copyright # 2014 John Wiley & Sons, Ltd.

Clare et al., 2003

Mild AD (n = 1) b

Clare et al., 2001 Clare et al., 2002

Mild AD (n = 1)

Minimal and mild dementia (n = 12)

Minimal and mild AD (n = 6)

Clare et al., 2000

Face-name associations Clare et al., Mild AD (n = 1) 1999

Löwenstein et al., 2004

Mild AD-1 (n = 100) Mild AD-2 (n = 100) Mild AD-1 (n = 25) Mild AD-2 (n = 19)

Kurz et al., 2012


23 c 22 d 22.9 (19–29)e 20.9 (12–26)f

24 +/ 2.1


24.5 +/ 4.5

23.4 +/ 2.9

25.1 (21–29)

25.0 (21–29)

23.9 +/ 2.1

27.8 +/ 1.1 28 +/ 1.0

Mild D (n = 10) MCIIntervention (n = 18) MCIWaiting list (n = 12)

Kurz et al., 2009


22.2 +/ 2.2


Everyday activities Avila et al., Mild AD (n = 5) 2004



13 g




22 h/ week

14 (group and individual)

Number of sessions






Length (weeks)

Table 2 Cognitive interventions for everyday impairments in early dementia

EL, continued daily practice postintervention


EL, external memory aids for time

EL, vanishing cues, expanding rehearsal, verbal elaboration

Spaced retrieval, procedural memory training, dual cognitive support

Motor movements, verbal associations, categorisation, telephone use, messages, diary use, preparing a sandwich Journal round, memory training, external memory aids, motor training, self-assertiveness, creative work, activity planning, relaxation techniques, health education, medical information, stress management Daily routines, external memory aids, activity planning

Learning techniques

Face-name associations of social club members Face-name associations, personal information, time and day knowledge see Clare et al. (1999) Face-name associations of familiar famous people or socia club members Face-name associations of social club members

Face-name associations, orientation, finances

Global ADL performance

Global ADL performance

Telephone use, messages, diary use

Everyday activities

1, 3 and 6 months postintervention

1 and 2 years post-intervention 1, 3, 6 and 12 months postintervention

3, 6 and 9 months postintervention 6 months postintervention

3 months postintervention

6 months postintervention

4 weeks postintervention



Carer support in between sessions

Carers involved in intervention

Weekly information groups

Monthly carer support, carers involved in homework tasks

Carer involvement

24 C. Giebel and D. Challis

Int J Geriatr Psychiatry 2015; 30: 21–31


AD, Alzheimer’s disease; ADL, activities of daily living; EL, errorless learning; EF, effortful learning; PwD, person with dementia; SD, standard deviation. Inconsistent with reports of MMSE score of 25 in the study of Clare et al. (2001). b Follow-up study of the same participant involved in the study of Clare et al. (1999) . c 1 year after post-intervention, d 2 years after post-intervention. e At baseline. f 12-month follow-up. g The number of sessions is not clearly described, yet it can be assumed from Table 3 of the study. a

3 Mild dementia (n = 10) Dunn and Clare, 2007

24.8 (18–28) 23.4 (16 26)


EL and EF

Face-name pairs of famous and unfamiliar people

If available, invited to help in the implementation of techniques between sessions — 6 months postintervention Personalised goals Practical aids, facename learning, maintaining attention, stress management 8 8 23.1 +/ 3.1 (18–27) Minimal and mild AD (n = 20) Clare et al., 2010

Length (weeks) MMSE Sample Authors

Table 2. (Continued)

Number of sessions

Learning techniques

Everyday activities


Carer involvement

Translation into cognitive interventions

Copyright # 2014 John Wiley & Sons, Ltd.

The benefits of these factors within IADL training were shown in a 14-week neuropsychological rehabilitation programme involving informal caregivers (Avila et al., 2004). Mildly impaired PwD were trained individually, and in conjunction with their caregivers, weekly on food preparation, telephoning and messaging and using a diary within a real-life applicable learning environment. The programme was based on the technique of errorless learning, whereby every error made by PwD was immediately corrected so as to avoid remembering incorrect information. In support of the notion that interventions warrant a strong theoretical foundation and clear focus, attention to a few specific IADLs (Avila et al., 2004) as opposed to overall performance measures by questionnaire (Kurz et al., 2009, 2012) seems a vital element. In particular, the authors justify their focus on implicit memory in the intervention, in that implicit memory (memory for procedures) is found largely intact in mild AD and can therefore be employed as a pathway into compensating for impaired explicit memory (such as long-term memory). Similarly, Löwenstein et al. (2004) incorporated three established memory techniques of spaced retrieval, procedural memory training and dual cognitive support in successful relearning of finance management in mild dementia. Similarly to Avila et al. (2004), the authors justify their decision to use specific learning techniques by reference to previous evidence of their efficacy in dementia. However, despite this, both studies fail to refer explicitly to any theoretical foundations or evidence linking individual cognitive domains with individual daily activities. Considering that both interventions resulted in improved daily task performance without specifically targeting cognitive domains, the focus on individual activities and the learning techniques employed would appear to be effective steps. Real-life interventions for face-name associations

Further knowledge can be drawn from laboratorybased studies without specific focus on daily activities yet with important real-life applications. Clare and colleagues (Clare et al., 1999, 2000, 2001, 2002, 2003, 2010; Dunn and Clare, 2007) have addressed the issue of facename associations and taught these to people in the mild and intermediate stages of dementia. In a singlecase study, Clare et al. (1999) taught a very early AD patient with face-name associations of their social club members through errorless learning. The participant showed marked improvements and remembered nearly all names correctly at 9-month follow-up. In a naturalistic 2-year follow-up, performance gains were Int J Geriatr Psychiatry 2015; 30: 21–31


maintained without having received in-depth training (Clare et al., 2001). However, naming abilities dropped to a greater extent during the second than during the first year. This could be attributed to the level of testing, which was weekly and monthly throughout the first and second years, respectively, which highlights the importance of maintaining training in interventions. Although all studies consistently reported improved memory for this aspect of daily life, the studies lacked representativeness because of their small samples. When assessing the impact of the intervention in larger samples, however, the authors reported similar positive effects in early AD, which were maintained at 6-month follow-up (Clare et al., 2002; Dunn and Clare, 2007). In addressing other everyday problems, including autobiographical memory and calendar use, Clare et al. (2000) tailored some interventions to the patients’ individual problems. Again, errorless learning was employed in addition to the use of an electronic memory aid, and carers received support between sessions. With one of the participants described in a previous study (Clare et al., 1999), significant memory improvements were preserved in five of six participants up to six months post-intervention. Interestingly, the majority of participants continued practising after the intervention had finished, although the participant without significant improvements had limited training to the intervention phase. This might explain the lack of improvement maintenance post-intervention but not the lack of significant improvement during the intervention. One explanation for this discrepancy between the two patients who were trained on the same activities (one with significant and one without improvements), focusing on calendar use, may be the varying amount of external memory aids. That is, the participant with significant improvements received training on the basis of two memory aids. In contrast, the intervention for the participant without significant memory gains involved a trial of four different memory aids lacking a specific structure to their application. Consequently, there was confusion in the learning environment and therefore an inability to focus on any one memory tool. Although larger studies lend further support to the efficacy of goal-oriented CR in mild AD (Clare et al., 2010), there was little reference to the intervention components, including learning techniques, incorporation of daily practice between sessions and the degree of caregiver involvement. This prohibits comparability between interventions. Taking into account the value placed on theoretical models within the interventions, it emerged that interventions only employed psychological theory in the form of previously validated learning strategies, Copyright # 2014 John Wiley & Sons, Ltd.

C. Giebel and D. Challis

such as errorless learning. This may have further contributed to the success of relearning certain tasks or associations. However, no theory as to the role of different cognitive domains, which were tested as part of most interventions, and their associations with face-name associations or knowledge of the time and day were integrated in the studies. Therefore, it appears that this level of theoretical understanding may be more critical in interventions focusing on individual IADLs. Summary

Overall, the literature describes interventions with some degree of efficacy for everyday problems in mild dementia. Upon closer review, however, it emerges that efficacy was predominantly reported in interventions targeting face-name associations of familiar people. Nevertheless, the majority of these studies were either based on single-case evaluations with limited representativeness or on samples of patients with a large range of MMSE scores (18–27/28/29) (Clare et al., 2002, 2010; Dunn and Clare, 2007). This latter factor means that there was no account taken of variations in cognitive decline and its possible effect on intervention outcome. In contrast, the efficacy of interventions aimed at daily activities varied. As highlighted in Table 2, the four interventions evaluated provided little scope for comparison because of a variety of different components, such as learning technique, duration, frequency of training and degree of carer involvement. Most importantly, the general tendency in this small evidence base seemed to be a lack of solid theoretical foundations for the interventions employed. Cognitive interventions in mild cognitive impairment Everyday activity interventions

Only three interventions were aimed at improving daily functioning or used everyday performance as an outcome measure without directly targeting ADLs or IADLs in MCI. Contrary to mild dementia, Kurz et al. (2009) reported significant improvements for MCI patients using medical information, memory training and creative work (Table 3). Considering that (i) daily functioning only represented an outcome measure and that (ii) the intervention itself was neither grounded in evidence nor incorporated detailed learning techniques to target individual activities, it could be suggested that this general approach may only be suitable for less cognitively impaired Int J Geriatr Psychiatry 2015; 30: 21–31

Copyright # 2014 John Wiley & Sons, Ltd.

Kurz et al., 2009

23.9 +/ 2.1

28 +/ 1.0

D, dementia; EL, errorless learning; SR, spaced retrieval.

MCIWaiting list (n = 12) Mild D (n = 10)

26.8 +/ 1.8

MCIWaitlist (n = 22) MCIIntervention (n = 18) 27.8 +/ 1.1

25.9 +/ 2.8

MCIIntervention (n = 22)

Kinsella et al., 2009


MMSE mean +/ SD (range)

MCI (n = 1)


Clare et al., 2009

Everyday activities





Length (weeks)

Table 3 Cognitive interventions for everyday impairments in mild cognitive impairment

22 h per week

Five weekly 1.5-h sessions

One session per week

Number of sessions

Journal round, memory training, external memory aids, motor training, self-assertiveness, creative work, activity planning, relaxation techniques, health education, medical information, stress management

EL, spaced retrieval, verbal categorisation and elaboration, visual imagery, coping strategies

Memory strategies, attention practice, coping with stress

Learning technique

Weekly information groups

Carer involvement


2. Envelope task

2. Writing a card or letter 1. Appointment card reminder

1. Socialising activity

Everyday activities

Translation into cognitive interventions 27

Int J Geriatr Psychiatry 2015; 30: 21–31


populations. In contrast, PwD may require detailed techniques that can address better maintained cognitive functions to counter the deficits experienced with other domains. Support for this comes from evidence of effectiveness of interventions with a clearer focus on specific activity elements and cognitive functions in mild AD (Avila et al., 2004; Löwenstein et al., 2004). Therefore, it might be inferred that MCI patients require less specific foundations within interventions to increase daily activity performance. However, the contributing factor to everyday function improvements remains unknown as a variety of general strategies were employed. In more real-life focused interventions targeting specific activities, MCI patients markedly improved their performance also. Kinsella and colleagues (2009) focused on tasks associated with prospective memory, where patients were better able to remind the experimenter about information for a future appointment post-intervention. Patients were also less likely to forget to write their name on an envelope handed to them, following a delay from receiving the task instructions. With these tasks generally not contributors to daily dependency, it was noteworthy that one patient was able to transfer her intervention success to more efficiently adhering to her medication. Further confirming the trend of effective interventions, Clare et al. (2009) showed that weekly socialising and letter writing improved after eight weekly therapy sessions for patient AB. Although both studies were successful, the authors failed to describe the specific techniques by which learning was accomplished. In particular, Kinsella et al. (2009) associated their two tasks with prospective memory, which is the only study explicitly mentioning some link between cognition and everyday activities. However, no details on the content of the strategies of errorless learning and spaced retrieval were provided. Additionally, Clare et al. (2009) referred to anticipated outcomes for different elements of memory processing by means of increases in brain activation, but their methods of CR were not theoretically founded, in targeting specific cognitive domains in order to improve performance on the two tasks employed. Although these interventions point towards the possibility of improving elements of everyday activities, tasks such as letter writing fail to contribute markedly to daily independence. It is tasks of cooking, shopping or laundry that represent an integral part of living independently. Basic ADLs such as feeding and toileting are even more vital. However, MCI patients require ADL assistance only in very few exceptional cases (Tuokko et al., 2005), indicating that the main focus in intervention research should be on impaired and complex IADLs. Copyright # 2014 John Wiley & Sons, Ltd.

C. Giebel and D. Challis

Discussion This is the first review to evaluate the literature on CR in mild dementia and MCI aimed at improving everyday task performance whilst also considering the degree of reliance placed on explicit evidence-based models of the relationship between cognitive and everyday function. With variations in the efficacy of the interventions, key findings emerged regarding the focus, application and integration of psychological theory and different intervention components. Considering first the focus of the studies evaluated, it emerged that only a small number addressed IADLs or basic ADLs directly across both groups. Although Avila et al. (2004) and Löwenstein et al. (2004) addressed cooking, messaging and telephoning, as well as finances, respectively, the majority of studies focused either on global performance (Kurz et al., 2009, 2012) or on tasks relevant to daily life but not vital for living independently (Clare et al., 2009; Kinsella et al., 2009). This problem was particularly pronounced in MCI interventions. One possible explanation is that MCI is, by definition (Petersen, 2000), not linked to daily task dependency. However, recent literature suggests that MCI patients experience problems with tasks such as shopping and housework (Tuokko et al., 2005; Reppermund et al., 2011; Seelye et al., 2013). This suggests not only a need to rethink the MCI classification but, in the light of this review, warrants shifting the focus of CR to IADLs. However, in mild dementia, daily activity problems represent part of the dementia diagnosis, so that this factor cannot account for the limited number of studies. The most likely explanation is the difficulty in targeting daily activities by creating a naturalistic environment, which inevitably cannot be completely equal to the home setting of patients. The missing evidence linking cognitive and everyday function deficits may also partly explain the limitations of this research area. More studies, involving larger numbers of participants, are required to address IADL, and if impaired ADL, performance directly. One critical element contributing to the efficacy of interventions is the application of evidence-based models grounded in psychological theory. This was lacking in most studies, as expected. Considering that the association between cognition and everyday function is based on little evidence within the target populations (Earnst et al., 2001; Okonkwo et al., 2006; Ramsden et al., 2008) and in healthy (Insel et al., 2006) and other clinical populations (Lam et al., 2013), it seems plausible that interventions lack a solid theoretical foundation. Although no theoretical model exists which links individual cognitive Int J Geriatr Psychiatry 2015; 30: 21–31

Translation into cognitive interventions

functions, such as inhibition as part of executive function, or short-term memory, to individual elements of different daily activities, one potential gateway into the theoretical understanding of this relationship could be the contention scheduling model (Norman and Shallice, 1980, 1986; Cooper and Shallice, 2000; Cooper, 2002). This model describes how actions are selected and triggered on the basis of environmental cues. In particular, it has previously been associated with everyday tasks such as preparing a sandwich (Cooper and Shallice, 2000). However, the model was not designed for the indepth evaluation of the relationship between cognition and daily activities, so that further research is necessary to clarify this relationship and formulate it into an overarching theoretical framework. Comparison of interventions is proved to be difficult because of both the limited number of interventions and the variation in the components of each intervention. One element that may impact on CR efficacy is the duration and the frequency of practice. In contrast to Kurz et al. (2009, 2012) who did not report significant improvements in ADL abilities, Avila et al. (2004) and Löwenstein et al. (2004) administered their interventions twice weekly for 14 weeks and for 12–16 weeks, respectively. This is likely to have reduced the rate of forgetting in between sessions, which may have impacted on the weekly intervention sessions of Kurz et al. (2012), in addition to other treatment differences. Support for the effect of frequent stimuli practice on memory for face-name associations comes from Clare et al. (1999, 2001). The continuation of practice and weekly testing postintervention strengthened memory whilst testing monthly as opposed to weekly incurred weaker treatment effects. Interestingly, Löwenstein et al. (2004) reported maintained abilities for face-name associations post-intervention without daily practice. However, this may arise from the result of a threemonth, as opposed to a 2-year, follow-up. Nevertheless, the authors highlight the potential effect of continued use of memory notebooks on preserved levels of orientation. This has implications for real-life interventions, as continued practice seems pivotal for maintaining high cognitive functioning. The paucity of literature and its varied methodologies warrant further investigation of the relevance of practice frequency. Another component that varied between interventions was carer involvement. Considering that dependency in daily activities causes distress for both carers and PwD (Ballard et al., 2001; Andersen et al., 2004), it is important to identify (i) whether carer involvement in interventions increases functional outcome and (ii) enhances carer and PwD well-being. Copyright # 2014 John Wiley & Sons, Ltd.


Support for the interaction between daily activity performance and quality of life comes from the study of Avila et al. (2004). However, no study has directly compared the effect of an intervention with and without carer involvement. In weekly or monthly support groups (Avila et al., 2004; Kurz et al., 2009, 2012), carers were informed about different aspects of either MCI or dementia and thus offered a peersupport forum in which different experiences could be shared. With regard to the post-treatment stages, or during the intervention, carers can play a vital role in implementing learning strategies at home in order to maintain the improvements achieved from the intervention. Therefore, it would seem that carers should be involved in the intervention from the beginning to be knowledgeable about techniques and to feel a valued part of the process. Finally, it should be noted that the quality rating of the majority of the studies was considered weak, using the tool employed. One reason is a bias of the tool towards trials, which resulted in single-case studies being rated as weak because of lack of blinding. This indicates a lack of appropriate tools for the quality assessment of interventions in this field. Nonetheless, these ratings further suggest that there is room and need for more rigorous cognitive interventions in early dementia and MCI that focus on everyday activity performance. Conclusion This review would appear to be the first to explicitly evaluate literature on CR aimed at improving everyday task performance in mild dementia and MCI. Considering that CR aims to be grounded in the theory of cognitive neuropsychology, the fact that so few interventions have addressed the underlying cognitive mechanisms is disappointing. Although most studies described efficacious interventions, little focus has been given to more than one everyday activity. Hence, future research is required to provide evidence-based models on the relationship between specific cognitive and everyday function domains and to translate these into effective interventions to promote independence and associated well-being. Such developments are consistent with the National Dementia Strategy (DH, 2009) and the recent G8 summit on dementia (2013), which prioritise better support and treatment to ensure improved quality of life. Conflict of interest None declared. Int J Geriatr Psychiatry 2015; 30: 21–31


C. Giebel and D. Challis

Key points

• • • •

Few cognitive interventions address basic or instrumental activities of daily living directly. Most interventions fail to integrate evidence-based models for cognition and everyday functioning. The relationship between cognition and everyday functioning needs to be further assessed. Comparing interventions is difficult because of different components, such as duration, practice frequency, stimuli and degree of carer involvement.

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Translating cognitive and everyday activity deficits into cognitive interventions in mild dementia and mild cognitive impairment.

Mild dementia is marked by deficits in cognition and everyday activities. However, few studies have translated findings from both areas of functioning...
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