Intervention Effects of the Holistic Physio-Cognitive Rehabilitation for Alzheimer Disease and Mild Cognitive Impairment
Article information
Abstract
Background
Cognitive decline in dementia often leads to impaired activities of daily living (ADL), which worsens as the condition progresses. Although a complex rehabilitation program that includes exercise, cognitive tasks, and family guidance improves physical ability in people with dementia and mild cognitive impairment (MCI), the effects on cognitive function and ADL remain unclear. We conducted this study to clarify this point.
Methods
This retrospective observational study was conducted at the outpatient rehabilitation department of the National Center for Geriatrics and Gerontology, Japan. It analyzed 50 MCI and Alzheimer disease (AD) patients who participated in a holistic physico-cognitive rehabilitation (HPCR) program. The control group consisted of 50 patients matched by age, gender, disease, and Barthel Index (BI) from 963 MCI and AD patients who did not undergo HPCR. Cognitive function was assessed using the Mini-Mental State Examination, and ADL was evaluated with the BI.
Results
Both groups showed a significant decline in MMSE scores after 1 year. However, the intervention group maintained its ADL function, while the control group experienced a significant reduction in BI scores.
Conclusion
HPCR, combining exercise therapy and cognitive training, may help maintain ADL in patients with MCI and AD despite cognitive decline. This study suggests that rehabilitation plays a crucial role in sustaining daily functioning in dementia care.
INTRODUCTION
Currently, over 55 million people worldwide have dementia, with nearly 10 million new cases diagnosed yearly.1) In Japan, approximately 6.3 million people suffer from dementia, and when combined with the estimated 4 million people with mild cognitive impairment (MCI), one in four people aged 65 years or older may have dementia or be in the predementia stage.2) Dementia is a major cause of long-term care needs, accounting for 18.1%.3) However, dementia is not only a problem for the patient; it also places a heavy burden of care on the family, as it not only causes cognitive function problems, but also leads to a decline in their ability to perform everyday activities. As dementia progresses, the caregiving burden increases both physically and mentally, necessitating support for all aspects of life, including caregivers.
Besides providing early diagnosis and drug treatment to patients with dementia, healthcare professionals should thoroughly assess their cognitive function and impairment in activities of daily living (ADLs) and provide rehabilitation, including family guidance. We have been conducting holistic physio-cognitive rehabilitation (HPCR) for people with dementia living at home and their families and caregivers to provide continuous support for their daily and social lives. This study aimed to retrospectively compare the results of this program between patients who underwent HPCR and those who did not.
MATERIALS AND METHODS
Between April 1, 2020, and March 31, 2021, 54 patients with MCI and Alzheimer disease (AD) sought consultation at our Memory Clinic. Participants were referred by primary care physicians for rehabilitation and attended weekly outpatient sessions with a family member. Four individuals were excluded due to severe cognitive impairment (Mini-Mental State Examination [MMSE] < 11) at the initial visit or failure to undergo assessment after 1 year, leaving 50 participants for final analysis. MCI was diagnosed according to Petersen’s criteria,4) and AD according to NINCDS-ADRDA criteria.5) Participants’ ages ranged from 61 to 93 years (mean 76.0±6.8 years), with 22 males and 28 females, and a mean education level of 12.4±2.4 years. Sixteen had MCI and 34 had AD (Fig. 1).
Flowchart of the recruitment process of patients for the study. Out of 54 patients who visited the Memory Clinic, 4 were excluded, leaving 50 for analysis. An additional 50 matched control patients were selected from a pool of 963 using propensity score matching.
For comparison, 50 patients with MCI and AD who did not participate in HPCR were selected from 963 patients using propensity score matching based on age, sex, disease, and Barthel Index (BI). These variables were chosen as they are critical factors affecting ADLs and cognitive function in older populations. This method balances covariates in observational studies where random assignment is difficult, ensuring comparability between groups.6) Cognitive function was analyzed using MMSE, and daily functioning was evaluated using BI. The values were compared using the paired t-test (5% significance level).
Description of HPCR
Patients with dementia or MCI participated in 80-minute weekly rehabilitation sessions with family caregivers, with a maximum of 8–10 pairs per class, for 1 year. Classes were divided into three levels (MCI, mild to moderate dementia, and severe dementia) according to the severity of symptoms, and rehabilitation was provided at an appropriate level of difficulty (Fig. 2).
A practical example of the holistic physio-cognitive rehabilitation. Patients with dementia or MCI attended 80-minute weekly rehabilitation sessions with family caregivers, in groups of 8–10 pairs, for 1 year. Classes were divided into three levels based on symptom severity. The rehabilitation included cognitive, physical, occupational, and daily living tasks, tailored to each pair and designed to motivate participants. Family members received weekly task instructions and monthly support and education from physicians or therapists. MCI, mild cognitive impairment; NCGG, National Center for Geriatrics and Gerontology.
While each participant and their family caregiver pair received individual, tailor-made one-on-one support from a therapist, classes were held in groups to encourage interaction between participants and family caregivers. Rehabilitation included cognitive, occupational, and daily living tasks such as reality orientation training, reminiscence therapy, cognitive stimulation, cognitive function training, handicrafts, art therapy, music therapy, muscle strengthening training, balance training, motor endurance training, dual task training, ADL training, and communication training. These tasks were designed to motivate participants according to a detailed neuropsychological assessment. In addition, exercise such as stretching, muscle training, and aerobic exercise were actively implemented to maintain physical functions. Exercise materials used were the National Center for Geriatrics and Gerontology Home Exercise Program for Older People (NCGG HEPOP).7) The HEPOP is an educational tool developed to help older adults safely continue exercising at home and can be downloaded free of charge by anyone from our center’s website. It included stretching, strength training, aerobic exercise, dual task training (which involves performing cognitive and physical tasks at the same time), nutritional guidance, and oral care. While working with the patient on these tasks, family members were instructed weekly on how to support the patient. Once a month, a physician or therapist provided peer support for psychological care and self-care by educating family caregivers and providing opportunities for family caregivers to have conversations with each other to overcome caregiving challenges.
Ethical Approval
The study was conducted in accordance with the tenets of the Declaration of Helsinki and was approved by the ethics committee of the National Centre for Geriatrics and Gerontology (Approval No. 1247). Written informed consent was not obtained as this was a clinical observational study. Therefore, an opt-out method was used, and the participants were allowed to refuse to participate. In addition, this study conforms to the ethical guidelines for writing and publishing in Annals of Geriatric Medicine and Research.8)
RESULTS
The attributes of the 50 participants in both groups were matched (Table 1). Eighty percent of the intervention group and 70.0% of the control group had some type of complication; the number of complications was higher in the intervention group, but there was no significant difference in the percentage of participants with or without complications. Fig. 3 shows the results after propensity score matching. After 1 year, MMSE scores significantly decreased in both groups (intervention group: 22.9±4.1 to 20.7±5.5, p=0.021, Cohen's d=0.235; control group: 22.4±4.7 to 20.6±5.6, p=0.010, Cohen's d=0.261). The BI was maintained in the intervention group, but significantly decreased in the control group (intervention group: 99.4±2.4 to 98.1±4.9, p=0.079, Cohen's d=0.253; control group: 98.6±3.5 to 95.9±8.8, p=0.021, Cohen's d=0.336). The effect sizes were small for both outcomes.
Demographics after propensity score matching
Comparison of (A) MMSE and (B) Barthel Index between the intervention group (HPCR) and the non-intervention group (usual outpatients) after 1 year. It presents the results after propensity score matching. After 1 year, MMSE scores significantly decreased in both groups, but the Barthel Index only significantly decreased in the control group. MMSE, Mini-Mental State Examination; HPCR, holistic physio-cognitive rehabilitation.
DISCUSSION
Combined exercise programs including strength training and aerobic exercise for dementia and MCI effectively improve physical abilities such as muscle strength, balance, cardiopulmonary function, and gait, and reduce the risk of falls.9,10) However, their effects of preventing progression or improving cognitive function and behavioral and psychological symptoms of dementia remain unproven. The central symptom of dementia is ADL impairment resulting from cognitive decline, and ADL frequently decreases as the disease worsens.11) Nonetheless, continuation of the HPCR with the assistance of a family caregiver for approximately 1 hour once a week significantly maintained at least patients’ ADLs after 1 year compared with those who did not receive any non-pharmacological intervention, as shown in this study. This result may be explained by the fact that our HPCR intervention was a comprehensive treatment combining exercise therapy, cognitive training, and family guidance, resulting in the maintenance of the complex functions of ADLs. Furthermore, the intervention group tended to have a higher number of complications than the control group. Considering that worsening complications in general may decrease ADLs, the results of this study are surprising. In other words, HPCR, a multi-factor intervention that includes exercise therapy, may also contribute to the prevention of the progression of these complications, and may be able to approach the life difficulties of people with dementia. By participating in HPCR, family members learned rehabilitation methods and ways to assist their patients; thus, rehabilitation can be performed with family even on days at home or in familiar settings, when the patient does not come to the hospital. This was thought to have contributed to the maintenance of ADLs in daily life.
Limitations and Future Research
In this study, training time and frequency were conducted within the scope of insurance reimbursement in Japan. In other words, in Japan, no more than 14 units of rehabilitation (20 min/unit) per month can be performed in the chronic phase of almost all diseases, and each training session is limited to 60–80 minutes once a week. Therefore, it is desirable to verify the effectiveness of increasing the duration and frequency of training in the early stages of MCI and dementia, where greater training effectiveness is anticipated in the future.
In addition, given the changing circumstances of people with dementia and their caregivers, such as the changes that occur with age, this study does not provide a clear conclusion regarding the optimal duration of HPCR. However, this study does highlight the potential role of HPCR in maintaining ADL in people with MCI and dementia, and its value for individuals and their families who are facing a life-altering condition. In this study, nutritional guidance was provided using the HEPOP educational tool, but no individual, direct nutritional intervention was provided. However, given the complications that can lead to a decline in ADL, future studies should investigate the comprehensive effects of HPCR, including nutritional intervention that prevent sarcopenia and the worsening of complications, to deepen our understanding of its broader impact on patients with MCI and AD.
Furthermore, although there was no significant difference between the two groups in this study, there were differences in the trends between the groups in terms of the gender ratio and abnormal scores in the behavioral scale, and it is possible that a significant difference will be confirmed if the sample size is increased. Based on the results of this study, it is desirable to verify the effects of HPCR on a larger number of participants, and future studies should aim to recruit participants from diverse settings, including rural and urban areas, to enhance generalizability.
Notes
CONFLICT OF INTEREST
The researchers claim no conflicts of interest.
FUNDING
This work was supported by the Research Funding for Longevity Sciences (21-37) from the National Center for Geriatrics and Gerontology (NCGG), Japan.
AUTHOR CONTRIBUTIONS
Conceptualization, AO, SM; Data curation, IU, MK, NI; Investigation, AO, SM, IU, MK, NI, IK, HA; Methodology, AO, SM, IU, MK, NI, IK, HA; Supervision, IK, HA; Writing_original draft, AO, SM; Writing_review & editing, AO, SM, IU, MK, NI, IK, HA.