Kalbe E. J Neurol Neuromedicine (2018) 3(2): 14-18 Neuromedicine www.jneurology.com www.jneurology.com Journal of Neurology && NeuromedicineNeuromedicine Commentary Open Access Cognitive Stimulation in Dementia: Time to Go into Detail. A Commentary Elke Kalbe1*, Ann-Kristin Folkerts1 1Medical Psychology | Neuropsychology and Gender Studies & Center for Neuropsychological Diagnostics and Intervention (CeNDI), University Hospital Co- logne, Kerpenerstraße 62, 50937 Cologne, Germany Article Info ABSTRACT Article Notes While it is undeniable that cognitive stimulation (CS) is effective in patients with Received: March 22, 2018 dementia, there is still a lack of understanding of the underlying mechanisms of Accepted: April 11, 2018 the effects, and questions like “Who benefits?” or “Which factors determine the *Correspondence: benefits?” are not yet answered. Therefore, this commentary gives an overview Prof. Dr. Elke Kalbe, Medical Psychology | Neuropsychology of different aspects (e.g., sociodemographic factors, disease characteristics, living and Gender Studies & Center for Neuropsychological setting) that need to be considered while doing research on CS to understand their Diagnostics and Intervention (CeNDI), University Hospital impact on CS effects. It is also necessary to examine the effects of CS in real-life Cologne, Kerpenerstr. 62, 50937 Cologne, Germany; settings (e.g., geriatric hospitals) with mixed samples (e.g., patients with different Telephone: +49 221 478- 96244; Fax: +49 221 478-3420, severity of dementia). Additionally, important factors for future studies on CS in Email: [email protected] dementia (e.g., reporting according to the CONSORT guidelines, more health- © 2018 Kalbe E. This article is distributed under the terms of the economics studies) are outlined. Creative Commons Attribution 4.0 International License Introduction Keywords Cognitive stimulation (CS) as a non-pharmacological intervention Dementia Alzheimer’s disease in patients with dementia has attracted great interest during the past Intervention Cognitive stimulation Cognition decade. CS is defined as conducting a range of activities (e.g., cognitive Prediction stimulating games, sensory exercises) and discussions (e.g., talking about past experiences), usually carried out in small groups of 3 to 6 patients, with1,2 the aim of a general enhancement of cognitive and social functioning . Meta-analyses have shown that demonstrated CS 2-5has positive a positive effects on various cognitive and non-cognitive symptoms2 . For example, the Cochrane review by Woods and colleagues impact on the global cognitive state, on quality of life, and on well-being, as well as on communication and social interaction – with effects over and above those of any medication. However, although the benefits of CS are undeniable, it is true that, upon closer inspection, many open questions remain. One major concern that challenges the generalisability of the found effects is that the target group of “patients with dementia” in itself is so heterogeneous and that the samples in the published studies differ so substantially. Thus, to boost the predictive power of CS, the next step will be to ask: “Do all patients benefit?” (which is unlikely) or, more precisely, “Who benefits under which circumstances?” and “Which factors determine whether a patient with dementia profits?” or “Which CSPossible intervention factors is withbest foran whichimpact patients?” on CS benefits Sociodemographic variables Many variables have the potential to have an impact on the effects of CS in patients with dementia (Table 1). For example, sociodemographic Page 14 of 18 Kalbe E. J Neurol Neuromedicine (2018) 3(2): 14-18 Journal of Neurology & Neuromedicine variables may be relevant. Age is one of them. Notably, Therefore, it is imaginable that patients in a more advanced betterwhile some results studies that examined cognitive training effects stage of the disease need CS programs that are cognitively in healthy older6-8 adults showed that younger age yield less challenging. Regarding disease severity, randomised (a finding that fits the notion that ageing9,10 controlled trials (RCTs) demonstrated that patients with. is related to reduced cognitive11 or ageand having neural no plasticity impact ),. a lower cognitive baseline level were able to benefit more13,14 with CS, conflicting results exist, with higher age being12-14 from CS than patients with higher baseline results predictive of better results Besides the interpretation that there is more “room for Gender effects may also play a role. Besides the fact that improvement” in patients with lower cognitive baseline cognitive profiles might differ in female and male patients and levels, it is also possible that the CS exercises were too easy with dementia (e.g., verbal memory is more affected15 for the fitter patients and demanded too little of them. In in female patients16 with Alzheimer´s dementia this context, also, the question of group selection needs to Parkinson´s disease ), gender effects on benefits of CS for11. be reflected upon: Are mixed groups better (so that patients patients with dementia have been reported, indicating that arewith more more homogeneous severe symptoms groups will better profit (sofrom that those all patientsthat are cognitive outcomes improve more in female participants fitter, and the fitter ones profit from helping the others)? Or withA stronger mild cognitive benefit impairmentin verbal memory/working (MCI) attending cognitivememory trainingwas also17 demonstrated for female than for male patients are cognitively challenged according to their own level of been proposed carefunctioning)? units vs. traditional This issue careis still units under investigation when it , and 18gender-specific cognitive plasticity has comes to nursing home structures22-24 (e.g., dementia special . An alternative explanation, which has ), and, to the authors’ been proposed but not yet investigated in the context of knowledge, has not yet been studied in the context of the toCS, be could involved be that in womentheir health have issuesa more than active men) attitude19 (i.e., conduct of CS interventions. Possibly, and according to the show more knowledge, positive emotion, and motivation authors´ own experiences in conducting CS on patients . Finally, participantswith dementia, can groups be implemented in which the much intervention easier in programa rather although to the authors’ knowledge, level of education has can be matched to the level of functioning and needs of the not been found (and rarely studied) to have an impact on CS benefits, it has been identified as a predictor of cognitive homogenous setting with patients of similar dementia training effects within the ACTIVE Trial with older people severity. without dementia20 (Mini Mental State Examination (MMSE) While there are studies that only include patients > 23 points) , indicating that more years of education yields with possible or probable Alzheimer´s2,3,25-28 disease, vascular a better training response. Thus, it might also be relevant . dementia, and/or mixed dementia , other etiologies for CS effects, even more so as education21 is regarded as a have not been studied separately. However, cognitive Diseasedriver of characteristicsneural and cognitive and plasticitygroup composition aphasiaand neuropsychiatric be able to participate symptoms in differ a CS betweenprogram typesdespite of dementia. For example, will a patient with progressive a cognitiveDisease characteristicsmotor rehabilitation may also program have anwith impact patients on his or her problems in understanding/communication? benefits of CS. For example, in an observational reported study that using the Are patients with frontotemporal dementia willing to 12 participate, and do they constitute a challenge in a group with MCI and dementia, Binetti et al. setting due to behavioural symptoms? Indeed, the profile of aberrantresponders motor had significantlybehaviours lessthan impairment the non-responders. in insight, non-cognitive symptoms in patients with dementia might larger functional ability and less delusions, euphoria, and have a substantial influence on the benefits of CS, and the Table 1: Factors that potentially influence effects of cognitive ourrelationships own group between symptoms might be complex and stimulation in patients with dementia. need more research.14 For example, in the RCT conducted by • Sociodemographic variables: age, gender, education low cognitive baseline which examinedscores predicted the effects better of CSoutcome versus • Disease characteristics: dementia type/etiology, disease usual care in patients with dementia in long-term care, duration, disease severity, cognitive profile, other symptoms (e.g., depression and behavioural and psychiatric symptoms, comorbidities), medication in cognition. However, this association was moderated by • Living setting: at home, day-care facility, hospital, nursing home depressive symptoms, indicating that patients with lower • Characteristics of the cognitive stimulation intervention: cognitive baseline scores only benefitted more if they were frequency, intensity, type of tasks/activities, number of not (or less) depressed. This leads to the presumption that participants therapy of depressive symptoms could be an important • Group composition: heterogeneous vs. homogeneous (e.g., precondition for success of CS. Thus, although the ultimate regarding type of dementia/symptomatology/severity of aim should be to make efficient