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RESEARCH ARTICLEA Systematic Review of Cognitive Stimulation Therapyfor Older Adults with Mild to Moderate Dementia: AnOccupational Therapy PerspectiveNatasha Yuill1*† & Vivien Hollis2 1Bethany Care Centre, Calgary, AB, Canada2Department of Occupational Therapy, University of Alberta, Edmonton, AB, Canada AbstractIn response to the need for effective non‐pharmacological approaches for individuals with mild to moderatedementia, cognitive stimulation therapy (CST) interventions aim to optimize cognitive function. The presentliterature review explored the effectiveness of CST and the congruence of this approach with occupational therapy.
Twenty‐four databases and 13 “grey” sources were searched. Relevant papers were analysed using the McMasterCritical Literature Review Guidelines, the Modified Jadad Quality Scale and the Oxford Centre for Evidence‐basedMedicine Levels of Evidence Scale. To establish the congruence of CST with occupational therapy, themes wereidentified using the International Classification of Functioning and professional values outlined by the CanadianAssociation of Occupational Therapists. Twelve studies demonstrated a trend towards delayed cognitive declinefollowing CST. This intervention strategy is congruent with occupational therapy values and may provide a usefulstructural framework to build rehabilitation programmes for this population. Psychometric properties of theMcMaster Guidelines have not yet been established, and there is no standardized way to extract quantitative datafrom this measure. There is a need for further research exploring outcomes of CST interventions within the contextof everyday function in individuals experiencing cognitive decline. Copyright 2011 John Wiley & Sons, Ltd.
Received 16 May 2010; Revised 26 September 2010; Accepted 22 November 2010 cognitive stimulation therapy (CST); dementia; systematic literature review; geriatric occupational therapy Natasha Yuill, Bethany Care Centre, 1001 17 St NW, Calgary, AB T2N 2E5, Canada.
†Email: jtyuill@shaw.ca Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.315 the year 2040, this is predicted to increase to analarming 81 million (ADI, 2005). Prevalence rates tend to vary across regions and are dependent upon It has been well established that the proportion of diagnostic criteria utilized. In North America, for individuals 65 years or older is increasing in most example, the prevalence of dementia in individuals industrialized countries. As populations age, it is 65 years or older ranges from 6 to 10%, a rate that expected that the global burden of dementia will doubles when milder cases are considered (Mathers & continue to escalate. Worldwide, there are over Leonardi, 2000). The cost of caring for this population 24 million individuals who have dementia, and by is expected to reach $604bn (US) in 2010 worldwide; Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
70% of this cost occurs in North America and Western it shares strong conceptual connections to other commonly used occupational therapy models. This The International Classification of Diseases, 10th includes the Canadian Model of Occupational Perfor- revision (ICD‐10) describes dementia as a syndrome mance, the Model of Human Occupation and the typically characterized by chronic, often progressive Occupational Performance Model (Australian) (Stamm disturbances in higher cognitive functions including et al., 2006). The comprehensive nature of the ICF is memory, thought processing, orientation, comprehen- valuable in guiding rehabilitation interventions for sion, calculation, learning capacity, language and individuals with dementia as it acknowledges relevant judgment (WHO, 2009). The most common types of factors that influence everyday function for this dementia are Alzheimer's disease (AD) and vascular dementia (VaD) (Alzheimer's Society, 2009). Accordingto the ICD‐10, AD is a neurodegenerative cerebral International Classification of Function, disease with unknown aetiology consisting of distinc- tive neuropathological and neurochemical qualities(WHO, 2009). It is primarily characterized by the accumulation of neurofibrilary tangles and amaloid Cognitive symptoms associated with dementia are plaques that damage neurons, altering brain function related to structural brain changes (ICF code s110; (Alzheimer's Society, 2009). The ICD‐10 defines VaD subcategories s1100–s1109) resulting from neuropa- as a progressive vascular disease resulting in small thology. Structural changes include cerebral atrophy, infarctions that have cumulative effects on brain ventricular enlargement and reduced brain weight function (WHO, 2009). The distinction between AD (Patterson & Clarfield, 2003). These changes may and VaD is not always clear. Most authorities consider have widespread effects upon functional status; the second most common aetiology of dementia to be a however, the most prominent impact is on cognition co‐existence of these two disorders known as mixed and behaviour. Directly affected health domains dementia, as pure VaD is uncommon (Patterson & include global (b110–b139) and specific mental Acetylcholinesterase inhibitors aim to improve the Functional changes include language disturbances, cognitive symptoms of AD and mixed dementia; difficulty carrying out motor activities, failure to however, the efficacy of these treatments remains recognize objects and disruptions in executive func- limited. Recent systematic reviews on the use of tioning (APA, 2000). The early stages of dementia acetylcholinesterase inhibitors have indicated that include difficulty learning, decreased ability to form clinical trials tend to report small effects sizes; there is new memories and significantly impaired episodic a lack of demonstrated clinical importance of such memory (personally relevant events), whereas other drugs, and evidence that they improve quality of life types of memory such as semantic memory (factual remains inconclusive (Qaseem et al., 2008; Rodda & knowledge) and procedural memory (performing Walker, 2009). The clinical value of pursuing non‐ routines or previously acquired skills) may remain pharmacological options as a first line approach is relatively intact or mildly affected (Clare & Woods, becoming increasingly recognized (Douglas et al., 2004).
2003). Psychomotor or behavioural functional Occupational therapists play a critical role in the changes (b147) are common in the moderate stages development and implementation of such strategies.
of dementia. Such changes include wandering,agitation, resisting caregiver support, decreased emo- tional or behavioural control, disorientation, confu-sion and communication difficulties (Novak & The International Classification of Function, Disability and Health (ICF) is a comprehensive framework usefulfor assessing functional status, setting goals, developing interventions, monitoring change over time andmeasuring outcomes (WHO, 2001, 2009). The ICF is This ICF component considers relevant task perfor- appropriate to be utilized by occupational therapists as mance abilities, life experiences and capacity to engage Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
in life situations (WHO, 2001). Symptoms of dementia demographic information, personal attributes, life lead to significant disruptions in social and occupa- experiences, personality or other health conditions.
tional participation (APA, 2000). The impact of For individuals with mild to moderate dementia, cognitive changes often remains unique to each memory and cognitive difficulties often result in individual, and a wide range of domains may be personal factors such as anxiety, depression, decreased affected (d110–d999). This includes, yet is not limited self‐confidence or motivation and withdrawal from to, learning and applying knowledge, general tasks and activities (Clare & Woods, 2003).
demands, communication, mobility, self‐care, domes-tic life, interpersonal relationships, leisure activities As the degree of functional impairment ranges from The charter of principles outlined by Alzheimer's mild to severe, activity and participation levels change over Disease International is consistent with the inherent time. In the mild to moderate stages, functional changes values important to occupational therapy as it strongly influence activity engagement; however, individuals still encourages the implementation of a humanistic client‐ have some ability to learn new information or skills given centred approach (ADI, 2005). Occupational therapists the appropriate environmental conditions, support and play an important role in addressing the unique needs patience (Clare & Woods, 2003). The severe stage consists of individuals with mild to moderate dementia.
of profound physical symptoms such as incontinence, Through the strategic implementation of comprehen- significantly limited mobility, extremely impaired com- sive functionally based assessments and consideration munication and dependence on others for all activities of of ICF components, occupational therapists are able to skilfully develop a holistic understanding of the impactthat cognitive changes have on the daily lives of theseindividuals. Common therapeutic goals include main- tenance or remediation of cognitive function, com- This component includes environmental and per- pensation for deficits, reduction of behavioural sonal factors. Although all environmental domains symptoms and facilitation of supportive social and outlined by the ICF are relevant to individuals with care giving relationships. Therapists continually mod- dementia, the one most commonly affected is support ify intervention strategies according to the increasing and relationships (e310–e399). Functional issues experienced by this population may directly affect As there is no cure for mild to moderate dementia, relationships with informal (e310–e325) and profes- the effectiveness of treatment is not measured by sional care providers (e340, e355–e399). The degree of complete functional recovery. Chapman et al. (2004) caregiver burden, the amount of difficulty or stress appropriately defined a positive response to treatment experienced daily by caregivers, may place additional for this population as either increased level of strain on relationships between caregivers and care functional performance, maintained ability over a recipients (LoboPrabhu et al., 2006). Risk of caregiver period where decline is commonly expected or reduced distress increases when care recipients experience rate of decline over time. Such positive functional escalating behavioural symptoms, withdraw from outcomes have the potential to maintain identity, social interactions or begin to demonstrate a pattern promote feelings of usefulness or enjoyment and of reduced participation in activities previously con- minimize anxiety that may result from progressively sidered meaningful (Egan et al., 2006; Novak & decreasing capacity in the face of environmental Campbell, 2006). Strained relationships may lead to demands (Egan et al., 2006). A randomized control further exacerbation of such symptoms, causing trial (RCT) found community occupational therapy additional stress for both caregivers and recipients.
sessions that included cognitive and behavioural Personal factors consist of background details interventions for individuals with mild to moderate pertaining to the life of an individual that are not dementia to be associated with improved functioning classified in the ICF because of the high degree of social in daily activities, reduced caregiver burden and a and cultural variances that exist between individuals higher effects size in comparison with drug trials or (WHO, 2001). Examples of these details include other psychosocial interventions (Graff et al., 2006).
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
evidence that it is beneficial (Clare & Woods, 2003).
Given the concerns regarding the potential forcognitive interventions to be insensitive experiences Research has demonstrated that maintaining a consis- for individuals with dementia, efforts to develop tent pattern of frequent participation in cognitively person‐centred cognitive stimulation approaches have stimulating activities is associated with reduced risk of developing dementia (Wilson et al., 2002). Regular Although several different cognitive stimulation participation in such activities may play a role in therapy (CST) programmes have been described in preserving the capacity of the brain to endure and the literature, they all strive toward optimizing compensate for neurodegeneration. Such a mechanism cognitive function within a socially oriented context or “cognitive reserve” was described by Stern (2002) as through an integrative and inclusive approach. Central the degree to which an individual is able to efficiently to this is the acknowledgement that global and specific recruit alternative brain networks in order to optimize cognitive functions are interrelated with other impor- cognitive function following brain damage or pathol- tant functional aspects such as participation in daily ogy. Valenzuela and Sachdev (2005) found that higher activities, interpersonal relationships and overall qual- cognitive reserves were associated with complex ity of life. Designed to be enjoyable for participants, patterns of mental activity sustained throughout the CST focuses on fostering individual strengths through life cycle and that increased mental activity in late life structured functionally oriented activities that may be was associated with lower rates of dementia.
adapted according to individual or group needs. It There is also considerable neurobiological evidence typically includes themed sessions that incorporate demonstrating the adaptability of the central nervous therapeutic techniques such as reality orientation or system, indicating structural re‐organization (neuro- reminiscence. Reality orientation is intended to plasticity), and certain degrees of functional recovery facilitate memory through the use of aids that serve are possible following damage or pathology. Kleim and as factual reminders about the self or the environment Jones (2008) described principles fundamental to (Douglas et al., 2004). Reminiscence therapy involves experience‐dependent neuroplasticity and their impli- discussion of past activities, events or experiences often cations for rehabilitation following brain damage.
through the use of concrete prompts (Spector et al., These principles are applicable to individuals with dementia, as research on animals with a pathology Cognitive stimulation therapy is relevant to occu- comparable with AD has demonstrated that stimulat- pational therapy as it is based upon fundamentals that ing environments with increased opportunities for are important to the profession including client learning enhances cellular plasticity (Herring et al., centredness, activity analysis, grading activities and 2009) reduces neuropathological hallmarks delaying meaningful occupational participation (Salmon, 2006).
memory deficits (Berardi et al., 2007) and counteracts Although CST may be administered by anyone with neurovascular dysfunction (Herring et al., 2008).
previous training and experience supporting theunique needs of individuals with mild to moderate Cognitive stimulation therapy for mild to dementia, occupational therapists are particularly well suited for this role because of their unique functionally As research suggests that rehabilitation of cognitive oriented knowledge base and skill set. Cognitive function is biologically possible, cognitive stimulation stimulation approaches have the potential to assist in approaches may have therapeutic benefits for indivi- striving towards therapeutic goals such as minimizing duals with mild to moderate dementia by facilitating psychomotor behaviours, enhancing social relation- the delay of progressive cognitive impairments (Breuil ships or reducing caregiver distress. CST programme et al., 1994; Spector et al., 2001). Such approaches leaders must be able to effectively manage individual must not be confused with cognitive training, which and group dynamics, remain flexible and person typically involves guided practice on standardized tasks centred, provide motivation and encouragement, adapt such as recall of items on word lists; this strategy is session content and interaction style, as well as somewhat controversial as it fails to consider cognition maintain a continued sensitivity to individual and within a real‐life context and as there is no significant group needs (Spector et al., 2008). Occupational Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
therapists are well equipped to meet these demands. It analysed using the McMaster Guidelines for the critical is therefore important to examine the effectiveness of review of quantitative research studies developed CST programmes and their congruence with occupa- by the McMaster University Occupational Therapy Evidence‐based Practice Research Group (Law et al.,1998). This comprehensive tool designed by a team of occupational therapists focuses specifically on thecritical review of evidence concerned with the effectiveness of occupational therapy interventions A resource librarian assisted with the selection of and development of programme evaluation tools appropriate information sources as well as search (Law, 2007). The McMaster Guidelines (Law et al., terms and combinations. An expert in the field verified 1998) were used to assist in the analysis of study the appropriateness of the search strategy. Twenty‐four design, methodology, results, conclusions and clinical computerized databases (Table A1.1) and 13 grey literature sources (Table A1.2) were searched in order From the McMaster Guideline results, a descriptive to access a wide scope of sources related to analysis table was developed to provide an overview of occupational therapy, rehabilitation, medicine, allied each study including methodology, results, implications health care, psychology and gerontology. Basic and and limitations (Table A4). Each component that could advanced searches were implemented with each be quantified through yes or no qualifiers along with information source by using the search terms described additional criteria relevant to the present study were in Table A2. Search combinations were developed by recorded and scored (Table A5). A summary of paper grouping terms in accordance with the main compo- quality based on the percentage of criteria reached on this nents of the search question: population, intervention scale is presented in Table A6. To establish the interrater and outcome. Wherever possible, ongoing searches agreement of this measure, a second independent rater with email alerts occurring at one‐week intervals were was randomly assigned six of the papers identified.
set up to take place from August 2008 to May 2009.
Blinded to the results obtained by the first rater, the The following journals were hand searched: Alzheimer's second rater was provided the papers, the analysis tools & Dementia; Dementia & Geriatric Cognitive Disorders; and the general scoring guidelines. Interrater reliability Aging Neuropsychology & Cognition; Dementia; Geriatrics for the quantified components of the McMaster Guide- & Gerontology International and all relevant occupa- lines was calculated using the interrater correlation tional therapy journals. Citations of all pertinent papers coefficient (ICC[1,1] = 0.57 [95% CI 0.45 to 0.68]). This retrieved from the search were reviewed.
calculation was obtained using the statistical softwarepackage SPSS version 13.0 (Statistical package for the social sciences inc. Chicago Illinois USA, 2004).
To analyse the quality of RCTs, a modified version Papers published in the English language were selected of the Jadad Quality Scale was used (Jadad et al., 1999).
from academic journals by comparing abstracts This scale has high interrater reliability (Oremus et al., generated from the aforementioned search. As prelim- 2001) and has been used in systematic reviews of drug inary searches yielded no relevant results prior to 1990, trials for AD (Qaseem et al., 2008). A score of 3 or the search was limited to papers published between the greater on the Jadad Quality Scale represents a good years 1990 and 2009. In order to gain a comprehensive quality RCT (Jadad et al., 1999). The updated Oxford understanding of the nature and quality of CST, a wide Centre for Evidence‐based Medicine (OCEBM) Levels range of study designs were considered for inclusion.
of Evidence Scale for therapeutic treatments described Table A3 outlines the specific inclusion criteria utilized by Howick (2009) was also implemented. This scale to identify relevant studies for the present review.
rates the level of evidence of each individual study andprovides an overall evidence grade ranging from A (high quality) to D (low quality) (Howick, 2009).
Relevant papers were identified by analysing abstracts To determine the congruence of CST with occupa- yielded in the search. Papers that met the inclusion tional therapy, common themes were extracted from criteria (Table A3) were all quantitative and were study results and organized according to ICF domain Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
(Table A7). Prominent CST programme values de- scribed in each study were identified and matched to Table A5 reports data extracted from the McMaster corresponding professional values central to the Guidelines, modified Jadad Quality Scale and OCEBM Canadian Association of Occupational Therapists as Levels of Evidence Scale. Nine studies analysed met described in Townsend and Polatajko (2007).
over 70% of the quantified McMaster Guidelinescriteria with two studies reaching over 90%. As summarized in Table A6, the majority of studiesreached the good to high quality range, and three studies were found to be of fair quality. All analysed The search yielded a total of 507 abstracts, 23 of which studies scored highly in the reporting of appropriate were relevant to the present review. Of the 23 studies results, conclusions and clinical implications. Methods identified, 12 met the inclusion criteria (Table A3).
to avoid cognitively stimulating co‐interventions were Seven of the selected studies were RCTs, three were not reported; however, this is difficult to completely quasi‐experimental cohort designs, one was a retro- control for in a clinical setting, and there is no reason spective cohort design and one was a retrospective to suspect this would be more likely to occur in one outcome study. The majority of eliminated papers group over another. Procedures to avoid contamina- described multimodal interventions that included a tion of the control group were also not reported. This range of additional components such as training was not considered to be a significant issue as activities of daily living or participation in general outcomes did not favour the control group. Results recreational activities. Other primary reasons for paper of studies that utilized the Mini‐Mental State Examina- exclusion included intervention approaches not com- tion (Folstein et al., 1975) as a sole outcome measure parable with CST or lack of focus on cognitive must be interpreted with caution as outcomes may have outcomes. One additional paper, a pilot study by been within the standard error of the assessment Quayhagen and Quayhagen (1989), was found in the citation search and did not meet the date of Overall, the seven RCTs analysed approached good publication criteria for the present review. This paper quality on this scale with a total of four studies scoring was therefore not reviewed extensively; however, it was 3, for an average score of 2.43. Studies primarily lost taken into account for the review of subsequent points for an inadequate description of randomization research completed by Quayhagen et al. (1995) and procedures and lack of double blinding. On the Quayhagen and Quayhagen (2000, 2001).
OCEBM Levels of Evidence Scale, one study scored1a, nine studies achieved a score of 2b, one scored 2c and one scored 4. As a result, an overall grade of B wasawarded representing good quality evidence.
Table A4 provides a detailed summary of the resultsobtained using the McMaster Guidelines. Among the studies analysed, there was moderate variabilitybetween study design, sample, intervention duration, Table A7 illustrates research findings from each CST outcome measures utilized and results. A common programme according to their respective ICF domain trend among the results was that CST interventions and provides an overview of the prominent Canadian were found to have the potential to enhance cognitive Association of Occupational Therapists values central function or at least slow the rate of decline. Although to each programme. The CST interventions described changes on cognitive outcome measures were relatively in each study corresponded with a wide range of values small, the results were considered to be clinically important to occupational therapy. Prominent themes meaningful because of the progressive nature of included respectfulness of individuality, recognition of dementia. Common limitations of the studies analysed capacity for self‐determination, encouragement of in the present review included small unjustified sample participation in meaningful activities and optimization sizes, lack of placebo controls, unequal amounts of of overall well‐being. Furthermore, CST programmes attention across groups and limited descriptions of consisted of therapeutic goals and outcomes relevant to occupational therapy. Half of the analysed studies Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
reported positive functional outcomes including en- (Spector et al. 2003). The authors indicated that these hanced emotional regulation and interpersonal rela- results should be interpreted cautiously because of the tionships. The studies that examined environmental inherent differences between pharmacological and factors such as caregiver outcomes suggested that CST non‐pharmacological approaches. Woods et al. (2006) programmes have the potential to reduce symptoms of found that CST participation was associated with enhanced quality of life in functionally relevant areasincluding improved relationships with significant others, energy levels and ability to perform chores.
Chapman et al. (2004) reported that CST improved components of communication while reducing symp- There is a growing foundation of research supporting toms of dementia such as apathy and irritability. The the use of CST interventions for optimizing cognitive authors of this study also found reduced caregiver function in individuals with mild to moderate distress following the intervention.
dementia. Clinical trials exploring the effectiveness ofCST have demonstrated a trend towards improvement in cognition or delayed decline relative to those whoare not receiving the intervention. The results of the Cognitive stimulation therapy provides a useful present review have demonstrated this evidence to be foundation for occupational therapists to build mul- of respectable quality. CST is appropriate for use by tidimensional programmes for individuals with mild to occupational therapists as it is a person‐centred moderate dementia. In the UK, the National Institute approach, consistent with values central to the for Clinical Excellence recommends that opportunities profession, which aims to preserve cognitive function to participate in cognitively stimulating programmes in order to enable optimal levels of engagement in should be provided to individuals with mild to moderate dementia of all types, including thosereceiving drug treatments for cognitive symptoms(NICE, 2006). Engaging individuals in such pro- grammes has the potential to play an integral role in Cognitive changes following CST are relatively modest; striving towards the achievement of therapeutic goals however, the observed trend towards improvement or for this population. The integrative and inclusive nature maintenance of cognitive function must not be CST also provides therapists with relevant information ignored. Results of studies that utilized the Mini‐ that may complement functionally based assessments or Mental State Examination (Folstein et al., 1975) as a development of person‐centred care plans.
sole outcome measure must be interpreted with Cognitive stimulation therapy is appropriate for caution, however, as outcomes may have been within implementation in both community‐based and insti- the standard error of the assessment utilized. The tutional settings. Therapy assistants may also be trained majority of studies analysed in the present review to lead CST programmes. It is important to note that utilized more than one cognitive outcome measure.
programme effectiveness may depend upon therapeu- Overall, the results of research on CST interventions tic approach and administrator experience level.
are clinically meaningful and functionally relevant.
Although some CST interventions described in the A large multicenter RCT conducted by Spector literature may be difficult to reproduce clinically et al. (2003) identified that CST might have outcomes because of limited intervention descriptions, there are comparable with pharmacological treatments. These positive components of each that may be drawn upon.
findings were based on the results of numbers needed This includes creating a climate of acceptance and to treat analysis, which involves calculating the appreciation (Koh et al., 1994), adopting a reactivation number of individuals needed to be treated to achieve approach (Bach et al., 1995), providing caregivers with one favourable outcome. The results of this study goal‐oriented home programmes (Quayhagen et al., were noteworthy as the duration of the CST trial 1995; Quayhagen & Quayhagen, 2000, 2001) and occurred over 7 weeks, a relatively short time frame implementing ongoing sessions to maintain function compared with drug trials lasting up to 30 weeks over time (Orrell et al., 2005). When adapting and Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
implementing CST programmes, the principles of supporting the use of CST interventions is of neuroplasticity described by Kleim and Jones (2008) provide a useful frame of reference for therapists asresearch by Quayhagen and Quayhagen (2001) indi- cated that cognitive changes observed appear to be related to the specific programme focus.
When interpreting the findings of the present review, it One of the most rigorously researched CST is important to consider the following strengths and programmes was developed in the UK by Spector limitations. The search strategy was extensive, covering et al. (2001, 2003). It has been extensively described in a wide range of databases and grey literature sources. It a programme manual for group leaders (Spector et al., was approved by a resource librarian and an expert in 2006). This structured programme includes 14 themed the field. A broad range of research designs was sessions implemented over 7 weeks. Session themes considered appropriate to achieve a comprehensive include physical games, sounds, childhood memories, understanding of the scope and quality of existing food, current affairs, faces and scenes, word associa- evidence corresponding to the proposed research tion, creativity, object categorization, orientation, question. The inclusion of heterogeneous study designs presented challenges to data analysis; however, multi- (Spector et al., 2006). This CST programme is clinically ple analysis tools were utilized in order to minimize reproducible and is supported by relatively high‐ bias. The quantitative and qualitative properties of quality evidence. It has been found to be cost effective selected measures were useful in the extrapolation of (Knapp et al., 2006), and a North American version is clinically relevant information from each paper.
also available (Spector et al., 2005).
The exclusion of papers prior to the year 1990 may have limited the search results, omitting relevant studies such as the work by Quayhagen and Quayhagen, The specific neurobiological mechanisms responsi- (1989) that was obtained after the database searches ble for the positive outcomes following CST are were completed. The psychometric properties of the currently not well understood. One plausible expla- McMaster Guidelines have not yet been established. As nation might be that cognitive stimulation mediates there was no standardized procedure for obtaining and neurodegeneration and facilitates neuroplasticity. A scoring quantitative data from the McMaster Guide- recent study on individuals with mild to moderate lines, general scoring guidelines were developed for the dementia found that reminiscence therapy improves purposes of the present review. Because of time blood flow in the brain, particularly the frontal lobe constraints, only six of the 12 studies were reviewed by (Tanaka et al., 2007). A similar effect may be observed a second rater. This small sample size might account for following person‐centred, integrative cognitive stimula- the moderate level of agreement observed between raters. The Jadad Quality Scale is a validated measure;however, it does not award points for single blinding procedures. This is an important consideration asdouble blinding is not always possible in clinical Despite the previously reported methodological limita- settings. An additional limitation is that change on tions to the analysed studies, overall, the evidence was cognitive measures may be considered a surrogate found to be of respectable quality. This remained outcome with limited clinical importance. This was a consistent on three different measures assessing primary reason for the inclusion of a wide range of study quality. The results obtained using the McMaster designs as it permitted the extraction of information Guidelines were favourable, particularly in the appro- illustrating the impact of cognitive changes in multiple priate reporting of results and conclusions. On average, RCTs approached an adequate score on the JadadQuality Scale. Further support was achieved on the OCEBM Levels of Evidence Scale. As the overallevidence grade awarded was B, with only one study The results of the present review have highlighted scoring below level 2c, it is clear that existing evidence future directions for research on CST interventions Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
including the need to examine the outcomes of CST • The use of CST is supported by quality evidence within the context of everyday functioning and that has demonstrated a clinically meaningful components central to the ICF. This includes initiatives degree of effectiveness in maintaining cognitive focusing on determining the effectiveness of CST in reducing caregiver burden or identifying changes in • CST is appropriate to be implemented by occupa- activity participation following the intervention. There tional therapists as the approach encompasses values is a need for future studies to establish a clearer and goals central to the profession.
distinction between the efficacy of CST in comparisonwith standard recreational activities or other cognitive approaches. Furthermore, there is currently a lack of The opportunity to engage in this research project awareness regarding the optimum duration, intensity was made possible by the Department of Occupa- and frequency of CST required in order to achieve tional Therapy and Faculty of Rehabilitation Med- icine at the University of Alberta. I would like to The results of the present review warrant more high‐ extend my thanks to all who contributed to the quality RCTs that include sample sizes comparable completion of this literature review, particularly with those used in drug trials and a placebo control Dr Vivien Hollis for her inspirational advice and group where participants receive the same amount of attention as the treatment group. There is an evengreater need for high‐quality qualitative researchexamining the ethnographic or external validity ofCST as the search strategy for the present review yielded no qualitative studies. Such findings would ADI. (2005) Media quick facts: the global impact provide a more comprehensive understanding of the of dementia. Alzheimer's Disease International. (Available impact that CST programmes have on the lives of the at: http://www.alz.co.uk/media/dementia.html) (Accessed clients and their caregivers within the context of Alzheimer's Society (2009). Alzheimer's disease. (Available at: http://www.alzheimer.ca/english/index.php) (Accessed APA (2000). Diagnostic and Statistical Manual of Mental Cognitive stimulation therapy is a supportive, func- Disorders (4th edn, text revision). Washington: American tionally oriented strategy aimed at enabling individuals with mild to moderate dementia to remain meaning- Bach D, Bach M, Bohmer F, Fruhwald T, Grilc B (1995).
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• Medical diagnosis of dementia (AD, VaD or mixed type) according • May or may not have been receiving pharmacological treatments • CST programmes or comparable approaches with respect to theoretical basis, guiding principles, methodology, selected tasks, • Integrative approach that recognizes the interrelated nature of cognitive functions within a social context (focuses on more than • Structured programme for groups or individuals• May or may not have included the involvement of family caregivers• May have occurred at various sites including community‐based programmes, adult day support and outpatient or inpatient facilities 1. Canadian Institute for Health Information − multimodal approaches including additional interventions to CST − cognitive training interventions (including spaced‐retrieval, computer‐based interventions or other interventions centred • Improved or maintained cognitive function (in comparison with 7. Intute: Nursing, Midwifery and Allied Health baseline) over a period where decline is commonly expected • Secondary outcomes associated with cognitive changes related to 9. CAOT (Canadian Association of Occupational Therapists) other relevant components/domains of the ICF 10. BJOT (British Journal of Occupational Therapy)11. WFOT (World Federation of Occupational Therapists) AD, Alzheimer's disease; CST, cognitive stimulation therapy; ICF, International Classification of Function, Disability and Health; VaD, 1. Older adulta2. Elderly3. Seniora4. Dementiaa5. Alzheimer's6. Cognitive function7. Cognitive processa8. Cognition9. Cognitive stimulation10. Cognitive therapya11. Cognitive stimulation therapya12. CST13. Rehabilitation14. Therapya15. Occupational therapy16. Psychology17. Validity18. Reliability Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Bach Breuil Chapman Koh Matsuda Orrell Spector Spector Woods Quayhagen Quayhagen Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Bach Breuil Chapman Koh Matsuda Orrell Spector Spector Woods Quayhagen Quayhagen Scoring procedures: yes = +1; no or not addressed = 0.
The Jadad Quality Scale scores were based on a rating between 0 and 5; adequate score was ≤3 (Jadad et al., 1999).
aIndicates studies examining combined effects of donepezil and cognitive stimulation therapy.
Table A6. McMaster criteria results summary Quality ratings in this summary are based upon percentage of criteria reach on the quantified data obtained from the McMaster Guidelines for review of quantitative studies (Law et al., 1988).
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.
Occup. Ther. Int. (2011) 2011 John Wiley & Sons, Ltd.

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Protocolos Dispensación activa Farmacéutica de Carbayín Alto (Asturias). REAP de quinolonas por vía oral En los últimos años, se observa una tendencia creciente dosis. Se han utilizado dosis más elevadas de 1.500 mg/día. en la demanda de quinolonas, tanto de antiguas moléculas como de nueva generación. Dentro del grupo de antibióti- • Información para la correcta a


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