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

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).

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.