Cognitive Rehabilitation of Mildly Impaired Alzheimer Disease Patients on Cholinesterase Inhibitors
David A. Loewenstein, Ph.D., Amarilis Acevedo, Ph.D.
Sara J. Czaja, Ph.D., Ranjan Duara, M.D.
Objective: The authors evaluated the efficacy of a new cognitive rehabilitation program on memory and functional performance of mildly impaired Alzheimer disease (AD) patients receiving a cholinesterase inhibitor. Methods: Twenty-five participants in the Cognitive Rehabilitation (CR) condition participated in two 45-minute sessions twice per week for 24 total sessions. CR training included face–name association tasks, object recall training, functional tasks (e.g., making change, paying bills), orientation to time and place, visuo-motor speed of processing , and the use of a memory notebook. Nineteen participants in the Mental Stimulation (MS) condition had equivalent therapist contact and number of sessions, which consisted of interactive computer games involving memory, concentration, and problem-solving skills. Results: Compared with the MS condition, participants in CR demonstrated improved performance on tasks that were similar to those used in training. Gains in recall of face–name associations, orientation, cognitive processing speed, and specific functional tasks were present post-intervention and at a 3-month follow-up. Conclusion: A systematic program of cognitive rehabilitation can result in maintained improvement in performance on specific cognitive and functional tasks in mildly impaired AD patients. (Am J Geriatr Psychiatry 2004; 12:395–402)
Cognitive rehabilitation (CR) has been shown to be effective in improving the performance on memory and other cognitive measures among individuals who have suffered traumatic brain injury and stroke.1,2 Although there are no empirically validated cognitive treatment programs for Alzheimer disease (AD) at present, three techniques, known as spaced retrieval, dual cognitive support, and procedural memory training have demonstrated promise in their ability to enhance learning in AD patients. The spaced-retrieval technique (SRT)3,4 involves learning trials where a specific stimulus (e.g., a face) and a specific association (e.g., a name) are presented. Learning trials are separated by progressively longer time intervals filled with conversation or mental tracking tasks to prevent rehearsal of the to-be remembered information. If an error occurs on retrieval (e.g., incorrect retrieval of a name when a face is presented), corrective feedback is provided, and the interval between stimulus presentation and recall is decreased to the previous interval in which recall was correct. It has been postulated that SRT works by engaging implicit memory processes, by tapping procedural systems and by decreasing reliance on semantic or declarative mechanisms.5
Dual cognitive support involves the provision of cues and the enhancement of the saliency and organization of the to-be-remembered information at both acquisition and retrieval of the information. Such support has been associated with improved learning, as in verbal episodic memory tasks,6–8 in AD.
Procedural memory training requires the activation of the motor system. In AD, motor learning has been shown in paradigms that require the self-selection of movements.9–11 This training has also been used to improve performance on activities of daily living in AD, but these improvements seem to be short-lived.12
Thus, it appears that specific cognitive functions can be trained in mild and more moderately impaired AD patients, although no one paradigm has been developed that incorporates SRT, dual cognitive support, and functional procedural skills training as part of an integrated treatment package. Moreover, few studies have included adequate control groups or have equalized therapist contact and level of cognitive activity of the training tasks. The current investigation incorporates all of the aforementioned elements and is the first evaluation of a systematically applied CR program with AD patients who are on a stable dose of a cholinesterase inhibitor. We hypothesized that the use of specific cognitive and functional tasks in training would result in sustained improvement in cognitive and functional tasks that were similar, yet not identical, to the trained tasks.
Cognitive Rehabilitation of Mildly Impaired Alzheimer Disease Patients on Cholinesterase Inhibitors
By David A. Loewenstein, Ph.D., Amarilis Acevedo, Ph.DSara J. Czaja, Ph.D., Ranjan Duara, M.D
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