Interventions Within the Scope of Occupational Therapy to Improve Cognitive Performance for Individuals with Dementia and Mild Cognitive Impairment (2018–2022)

Abstract

Systematic review briefs provide a summary of the findings from systematic reviews evaluated in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each systematic review brief summarizes the evidence on a theme related to a systematic review topic. This systematic review brief presents findings related to interventions to improve cognitive function for individuals living with Alzheimer’s disease and related dementias and mild cognitive impairment.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation for people living with Alzheimer’s disease and other related neurological conditions and their care partners?”

Current Theme Reported

This systemic review brief addresses interventions to improve cognitive performance for individuals with Alzheimer’s disease and related dementias (ADRD) and mild cognitive impairment.

Clinical Scenario

Decline in cognitive performance is the hallmark feature of Alzheimer’s Disease and Related Dementias (Centers for Disease Control and Prevention [CDC], 2019). Impairments in cognition impact an individual’s ability to engage in meaningful occupations including activities of daily living, instrumental activities of daily living, social participation, and health management. Occupational therapy practitioners are recognized as healthcare professionals who evaluate and address functional cognition for people with a variety of cognitive impairments including dementia (Wolf et al., 2019). Research suggests that when individuals with dementia receive interventions to improve their cognitive function, it also improves their engagement in meaningful activities (Yuill & Hollis, 2011).

Given the negative impact of cognitive impairment on function, there has been a significant amount of research on strategies to improve cognitive performance (Duan et al., 2018). The purpose of this review brief is to identify interventions that have research to support their use in improving cognitive function in people living with dementia or mild cognitive impairment.

Summary of Key Findings

Seven Level 1a systematic reviews related to interventions focusing on addressing cognition for people experiencing ADRD and mild cognitive impairment were included. They were divided into five subthemes based on intervention type including cognitive therapies (Ham et al., 2021; Duan et al., 2018; Chow et al., 2021), music (Lee et al., 2022; Dorris et al., 2021), exercise (Duan et al., 2018; Hui et al., 2021), dance (Wu et al., 2021), and reminiscence (Duan et al., 2018; Lee et al., 2022) (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventative Services Task Force (2018).

Table 1.

Interventions to Improve Cognitive Performance for Individuals With Dementia and Mild Cognitive Impairment

Author, Year Level of Evidence (types of study designs) Risk of Bias (RoB) Setting	Systematic Review Details	Findings From Reviews
Subtheme: Cognitive Therapy Three Level 1a reviews provide strong strength of evidence to support the use of cognitive-oriented approaches, especially when combined with another intervention like medication or standard occupational therapy, were effective at improving cognitive performance in individuals with MCI and forms of dementia.
Ham et al. (2021) Level 1a—SR with meta-analysis of all seven studies RoB Low Setting Home, community-based, hospital, dementia center, not described	Participants N = 453 participants, diagnosed with AD, majority in their 70s Number of Articles Seven RCT Databases Searched MEDLINE, CINAHL, PubMed, and Academic Search Complete Outcome(s) of Interest Cognition Intervention(s) of Interest OT-based with a combination intervention, included other treatment modalities (5/7) and intervention using only OT which includes a cognitive-oriented approach (2/7) Delivery Methods Group (3), individual (3), mixed (1) Dose Ranges 1–5 hr, 1–3×/wk, 8–24 wk (most effective programs >1×/wk for >16 wk)	In the meta-analysis, the impact of OT programs with a cognition-oriented approach as well as OT programs with a cognition-oriented approach and a multimodal approach, had a statistically significant moderate effect size for improving cognition. Group interventions were more likely to use multiple treatment modalities and occur with a greater frequency and duration which improved intervention effectiveness.
Chow et al. (2021) Level 1a—SR with five studies included in meta-analysis RoB Low Setting Not stated	Participants N = 966 total participants, N = 294 included in meta-analysis, age 70–77 with MCI Number of Articles 10 RCT, five included in meta-analysis Databases Searched PubMed, Cochrane Central Register of Controlled Trials (Cochrane), Excerpta Medica Database (EMBASE), Scopus, CINAHL, Psychological Abstracts (PsycINFO), and Web of Science, EMBASE and ProQuest Dissertations and Theses Outcome(s) of Interest Cognitive performance (memory and executive function) Intervention(s) of Interest Psychosocial interventions including behavioral therapy, cognitive therapy, and CBT. Interventions to enhance memory include behavior modification and activation, memory training, visual imagery, storytelling, memory aids, journaling, and exercise. Delivery Methods Group (7), individual (3) Dose Ranges 2–20 mo. Interventions addressing memory that are longer in duration (more than 2 mo) have more therapeutic encounters (more than 10) and are delivered individually had larger effect sizes.	Significant improvement in memory with a small effect size; however, large heterogeneity was observed in the five studies pooled for meta-analysis.
Duan et al. (2018) Level 1a—SRs with meta-analysis RoB Moderate Setting Not reported	Participants N = 682, mean age 74–84, people with AD (no MCI, no non-AD) (no way to determine number of participants in meta-analysis) Number of Articles 11 RCTs, six included in meta-analysis Databases Searched MEDLINE, EMBASE, PsycINFO through OVID database, CENTRAL through the Cochrane Library Outcome(s) of Interest Cognitive symptoms Intervention(s) of Interest Combination of psychosocial intervention and ChEls 4 studies N = 285 ▪ Cognitive stimulation and acetylcholinesterase inhibitor ▪ Mindfulness-based Alzheimer’s stimulation and acetylcholinesterase inhibitor ▪ Cognitive training and acetylcholinesterase inhibitor Delivery Methods Group and individual Dose Ranges 10 wk to 2 yr	Cognitive therapy + acetylcholinesterase inhibitor was the best psychosocial/drug combined intervention for improving cognitive symptoms. It was statistically better than medication alone or therapy alone.
Subtheme: Music Interventions Two Level 1a reviews provide strong strength of evidence to support the use of music interventions paired with movement to improve cognitive performance for individuals with MCI and dementia.
Lee et al. (2022) Level 1a—systematic review with meta-analysis RoB Low Setting Not stated	Participants N = 3,443 participants total with n = 2,551 included in meta-analysis, mean age ranged from 69.1 to 94.9 yr; female participants ranged from 40% to 100% with any form of dementia; 11 music intervention articles, N = 386; six articles that addressed cognition n = 104 Number of Articles 36 RCTs, 30 included in the meta-analysis Databases Searched PubMed, CINAHL, PsychINFO, Embase, Cochrane Database of Systematic Reviews Outcome(s) of Interest Cognition (21 articles) Intervention(s) of Interest Music intervention completing movements while accompanied by music Delivery Methods Individual and group+ Dose Ranges 10–90 min for 1–21 sessions	Music interventions had a small effect size but was statistically significant for improving cognitive performance.
Dorris et al. (2021) Level 1a—with meta-analysis RoB Moderate Setting Long-term care facilities, day centers, specialty outpatient units, and community.	Participants N = 1,472 total (n = 495 in meta-analysis) participants; mean age in studies ranged from 68.925 to 87.926 yr; probable MCI or mild to moderate dementia Number of Articles 21 articles, nine included in meta-analysis Databases Searched Medline (Ovid), APA PsycInfo (Ovid), CINAHL (Ebsco), and Embase (Elsevier) Outcomes Cognitive function Intervention Active music-making, as defined by “physically participating in music”; 17 studies used recreating music by singing/playing instruments, 10 used improvisation, six used movement, one used imagery, one used breathing entrainment, and two had other characteristics: one created attention exercises where participants reacted to a stimulus, such as clapping when hearing a drum but refraining when hearing a drum preceded by a cymbal, one created dual task training Delivery Interventions performed by psychologists, music therapist, occupational therapists, and professional musicians. No details on if individual or group intervention used. Dose Ranges 4–40 wk, sessions were from 30 min 2 hr in length and happened from one to five times a week.	Music making for MCI or dementia showed a small, but statistically significant positive effect on cognitive performance.
Subtheme: Exercise Two Level 1a reviews provide strong strength of evidence to support the use of exercise, specifically the use of WP and exercise paired with memory games and music therapy, to improve cognitive performance in individuals with a form of dementia.
Duan et al. (2018) Level 1a—SRs with meta-analysis RoB Moderate Setting Not reported	Participants N = 682, mean age 74–84, people with AD (no MCI, no non-AD) (no way to determine number of participants in meta-analysis) Number of Articles 10 RCTs, six included in meta-analysis Databases Searched MEDLINE, EMBASE, PsycINFO through OVID database, CENTRAL through the Cochrane Library Outcome(s) of Interest Cognitive symptoms Intervention(s) of Interest ▪ Home-based exercise (HE) 1 study, N = 161 ▪ GE 1 study, N = 161 ▪ WP 1 study N = 21 Delivery Methods Group and individual Dose Ranges 6 mo to 1 yr	WP intervention and home-based exercise were significantly better than the control at improving cognition. WP was more effective compared with other treatments in the study including the home exercise program.
Hui et al. (2021) Level 1a—14 RCT RoB Low Setting Residential homes	Participants N = 1,161 participants, studies ranged from n = 21 to 189 older adults, age 62+, individuals with moderate to severe dementia Number of Articles 14 RCT Databases Searched CINAHL, MEDLINE, PsycINFO, EMBASE, CENTRAL, and Web of Science Outcome(s) of Interest Cognition Intervention(s) of Interest Multisensory stimulation intervention (6), multicomponent interventions (5), exercise programs (2), and reminiscence program (1) Delivery Methods Caregiver and physical therapist administered Dose Ranges 15 min/day for 15 mo (cycling) and 30 min/day for 6 mo (walking)	Significant improvement in cognitive function in interventions which included aerobic exercise, memory games, and music therapy Exercise program group had statistically significant improvement in cognitive performance (control group had decline).
Subtheme: Dance for MCI One Level 1a review provides moderate strength of evidence to support the use of group dance training to improve global cognitive performance in individuals diagnosed with a MCI.
Wu et al. (2021) Level 1a—RCT and meta-analysis RoB Low Setting Not stated	Participants N = 455, 31 to 201 across the eight studies with the mean age of the participants ranging from 65 to 81 yr old. All had MCI. Number of Articles Eight RCT, seven in meta-analysis on cognition Databases Searched Cochrane Library, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Science Direct and ProQuest Dissertations and Theses Outcomes Cognition (eight studies), memory (six studies), visuospatial, language Intervention Dance training Delivery Group, in person led by professional dance instructor Dose Ranges 12–40 wk, 1–3 sessions/wk for 35–60 min	Dance interventions significantly improved global cognition, memory, visuospatial, and language, in older adults with MCI.
Subtheme: Reminiscence Two Level 1a reviews provide strong strength of evidence to support the use of RT to improve cognitive performance in individuals diagnosed with a form of dementia.
Duan et al. (2018) Level 1a—(SRs with meta-analysis) RoB Moderate Setting Not reported	Participants N = 682, mean age 74–84, people with AD (no MCI, no non-AD) (no way to determine number of participants in meta-analysis) Number of Articles 11 RCTs, six articles included in meta-analysis Databases Searched MEDLINE, EMBASE, PsycINFO through OVID database, CENTRAL through the Cochrane Library Outcome(s) of Interest Cognitive symptoms Intervention(s) of Interest RT, two studies n = 144 Delivery Methods Group and individual Dose Ranges 4–12 wk	RT had a significantly positive effective on cognitive performance compared with control groups.
Lee et al. (2022) Level 1a—systematic review with meta-analysis RoB Low Setting Not stated	Participants N = 3,443 participants total with n = 2,551 included in meta-analysis, mean age ranged from 69.1 to 94.9 yr; female participants ranged from 40% to 100% with any form of dementia Number of Articles 36 RCTs, 30 were included in the meta-analysis Databases Searched PubMed, CINAHL, PsychINFO, Embase, Cochrane Database of Systematic Reviews Outcome(s) of Interest Cognition (21 studies) Intervention(s) of Interest RT (14, n = 580) Delivery Methods Individual and group Dose Ranges 10–60 min/wk for 1–21 sessions	RT had moderate positive effect on cognition that was statistically significant.

Note: AD = Alzheimer’s disease; CBT = cognitive behavioral therapy; GE = group exercise; MCI = mild cognitive impairment; OT = occupational therapy; RT = reminiscence therapy; WP = walking programs.

Bottom Line for Occupational Therapy Practice

Seven Level 1a systematic reviews of randomized controlled trials were identified and met inclusion for the review. Six of the reviews included a meta-analysis. Many of the studies evaluated multiple types of interventions (Duan et al., 2018; Chow et al., 2021; Lee et al., 2022). For some of the systematic reviews, the number of articles on a specific intervention is as few as one and as many as 17 studies. There was heterogeneity within each systematic review regarding intervention types which makes drawing definitive conclusions on efficacy challenging.

Cognitive Therapy

A cognitive-oriented approach when combined with standard occupational therapy had a moderate effect size for improving cognition (Ham et al., 2021), while cognitive training combined with acetylcholinesterase inhibitor was more effective than medication alone or cognitive training alone at improving cognitive performance (Duan et al., 2018). This speaks to the importance of occupational therapy interventions as a central part of addressing cognitive function in collaboration with other interventions.

Chow et al. (2021) looked specifically at individuals with mild cognitive impairment and found that interventions to enhance memory which included behavior modification and activation, memory training, visual imagery, storytelling, memory aids, journaling, and exercise, improved memory, and it was statistically significant. The most effective interventions were longer than 8 wk, and both individual and group interventions were effective for individuals with dementia. When addressing cognition, practitioners should use multiple intervention strategies to maximize the benefit of the intervention. In addition, interventions should be person-centered whenever possible. For an individual experiencing dementia, the practitioner should understand their occupational history and which interventions may appeal most to their interests as this will be more likely to elicit participation. The benefits of using a cognitive training approach are going to diminish as a person continues to decline in function as a cognitive approach does require the use of memory and insight which declines during the progression of dementia. For this reason, practitioners should use assessments to determine an individual’s cognitive level prior to choosing to use this type of intervention as there is no research to support its use in the later stages of dementia.

Music-Based Interventions

There is strong strength of evidence to support the use of music-based interventions for improving cognition for people with dementia. The strongest support for sensory stimulation exists for use of music with movement (Lee et al., 2022; Dorris et al., 2021). Using meta-analysis, both research groups demonstrated a small but positive effect on music interventions. Sessions ranged in duration from 10 min to 2 hr and lasted anywhere from 1 to 40 wk were shown to be effective. Music-based interventions must be active, and not just consist of background noise. Incorporating movement, instruments, or singing promotes a greater positive impact on cognitive performance. This intervention can be used in conjunction with other effective interventions, such as reminiscence, which the clinician can address both personally significant information, like favorite songs, while incorporating movements or playing of instruments.

Exercise Interventions

Strong strength of evidence exists for the use of exercise to improve cognitive performance in people with mild to severe dementia. Duan et al. (2018) found that walking programs were an effective intervention at improving cognitive performance. Hui et al. (2021) found exercise, especially when combined with memory games and music, resulted in a significant improvement in cognition compared with the control group, which showed a decline in function. Interventions typically lasted at least 10 wk and ran as long as 2 yr. All exercise requires close monitoring from the clinician and knowledge of how comorbidities may impact an individual’s ability to safely participate. In addition, volition is an important component of choosing this specific intervention as adherence to an exercise program will be poor if the individual does not enjoy exercise.

Dance for Mild Cognitive Impairment

Wu et al. (2021) looked at dance interventions for individuals with mild cognitive impairment. Findings indicate interventions led by an instructor in a group setting for 35–60 min for 12 to 40 wk resulted in improved global cognition, memory, visuospatial, and language, in older adults with mild cognitive impairment. There is no research to support the use of dance in individuals who have been diagnosed with dementia to address cognition.

Reminiscence

There is strong strength of evidence to support the use of reminiscence to improve cognitive performance in people living with dementia based on two Level 1a studies with meta-analyses. Duan et al. (2018) included two studies which showed that reminiscence therapy had a positive impact of cognitive performance, while Lee et al. (2022) included 14 studies which found that reminiscence had a moderate positive effect on cognition for people with a diagnosed form of dementia. Interventions ranged in duration from 4 to 21 wk with each session lasting 10–60 min.