Do cognitive interventions improve general cognition in dementia? A meta-analysis and meta-regression

J D Huntley, R L Gould, K Liu, M Smith, R J Howard, J D Huntley, R L Gould, K Liu, M Smith, R J Howard

Abstract

Objectives: To review the efficacy of cognitive interventions on improving general cognition in dementia.

Method: Online literature databases and trial registers, previous systematic reviews and leading journals were searched for relevant randomised controlled trials. A systematic review, random-effects meta-analyses and meta-regression were conducted. Cognitive interventions were categorised as: cognitive stimulation (CS), involving a range of social and cognitive activities to stimulate multiple cognitive domains; cognitive training (CT), involving repeated practice of standardised tasks targeting a specific cognitive function; cognitive rehabilitation (CR), which takes a person-centred approach to target impaired function; or mixed CT and stimulation (MCTS). Separate analyses were conducted for general cognitive outcome measures and for studies using 'active' (designed to control for non-specific therapeutic effects) and non-active (minimal or no intervention) control groups.

Results: 33 studies were included. Significant positive effect sizes (Hedges’ g) were found for CS with the mini-mental state examination (MMSE) (g=0.51, 95% CI 0.35 to 0.66; p<0.001) compared to non-active controls and (g=0.35, 95% CI 0.06 to 0.64; p=0.019) compared to active controls. Significant benefit was also seen with the Alzheimer's disease Assessment Scale-Cognition (ADAS-Cog) (g=-0.26, 95% CI -0.445 to -0.08; p=0.005). There was no evidence that CT or MCTS produced significant improvements on general cognition outcomes and not enough CR studies for meta-analysis. The lowest accepted minimum clinically important difference was reached in 11/17 CS studies for the MMSE, but only 2/9 studies for the ADAS-Cog. Additionally, 95% prediction intervals suggested that although statistically significant, CS may not lead to benefits on the ADAS-Cog in all clinical settings.

Conclusions: CS improves scores on MMSE and ADAS-Cog in dementia, but benefits on the ADAS-Cog are generally not clinically significant and difficulties with blinding of patients and use of adequate placebo controls make comparison with the results of dementia drug treatments problematic.

Keywords: GERIATRIC MEDICINE.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Figures

Figure 1
Figure 1
Flow diagram of selection of studies.
Figure 2
Figure 2
Forest Plot of CS versus non-active controls-MMSE outcome. CS, cognitive stimulation; MMSE, mini-mental state examination.
Figure 3
Figure 3
Forest Plot of CS versus active controls-MMSE outcome. CS, cognitive stimulation; MMSE, mini-mental state examination.
Figure 4
Figure 4
Forest Plot of CS versus non-active controls-ADAS-Cog outcome. ADAS-Cog, Alzheimer's disease Assessment Scale-cognitive subscale; CS, cognitive stimulation.

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