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Evaluation of a long term non pharmacological treatment for patients with Mild Cognitive Impairment (MCI) and Mild Alzheimer

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Title: Evaluation of a long term non pharmacological treatment for patients with Mild Cognitive Impairment (MCI) and Mild Alzheimer


1
Evaluation of a long term non pharmacological
treatment for patients with Mild Cognitive
Impairment (MCI) and Mild Alzheimers disease
(MILD AD)
  • Tsolaki, M., Kounti, F., Poptsi, E., Agogiatou,
    C., Soumbourou, A., Nikolaidou, E.,
    Zafeiropoulou, M., Bacoglidou, E.
  • 1. School of
    Psychology,Thessaloniki
  • 2. Medicine School,
    Thessaloniki
  • 3. Greek Association of
    Alzheimers Disease

2
Revised MCI criteria according to consensus
conference, Stockholm (2003)
  • Not normal, absence of dementia
  • Cognitive decline
  • Subjective (self report)
  • Objective (1.5 SD)
  • Some decline in function, but
  • Preserved basic ADL/minimal impairment in complex
    IADLs
  • Winblad et al (2004). J Intern Med. 256240-246

3
Mild Alzheimers Disease (MILD ?D)
  • Presence of both
  • Memory Disorder
  • Impairment in at least one additional cognitive
    domain
  • Impaired social function
  • Impaired performance in ADL
  • (American Psychiatric Association, 2000)

4
BRAIN PLASTICITY
  • Environment
  • Behaviors
  • Emotions
  • Increase the risk of neural death
  • But also facilitate the regeneration of
  • neurons
  • (Percacclo et al, 2007. Gobbio Marq, 2005.
    Mateer Kerns, 2000)

5
BRAIN PLASTICITY
  • The adult brain DOES regenerate itself at least
    in some areas as hippocampus
  • (Van Praag, Kemper Gage, 2000 Gould, 1999.
    Swanson, 1982)

6
COGNITIVE REHABILITATION
  • Systematic and intense cognitive practice can
    activate regeneration in the brain
  • (Steiner et al, 2006. Recanzone, 1993)
  • Targeting to the facilitation of neuronal
    regeneration through systematic and well
    structured new experience and learning
  • (Percacclo et al, 2007. Nakatomi et al, 2002.
    Robertson Murre, 1999)

7
AIMS OF COGNITIVE REHABILITATION
  • Long term changes in synaptic connectivity, as
    a result of behavior and experience
  • (Nakatomi et al, 2002. Gobbio Marq, 2005.
    Mateer Kerns, 2000)

8
COGNITIVE AND PSYCHOLOGICAL REHABILITATION
  • HOLISTIC THERAPEUTIC APPROACH
  • Health is an entity
  • Body
  • Mind
  • Emotions
  • Cooperation / dynamic balance with physical and
    social environment
  • (Biderman et al., 2005)

9
COGNITIVE AND PSYCHOLOGICAL REHABILITATION
  • The best therapeutic choice for
  • MCI and Alzheimers disease patients
  • are Interventions which improve spirit, body and
    soul
  • (Ferlisi et al., 2007. Spector et al.,2000,
    Zanetti et al., 1999. De Vreese et al., 2001)

10
COGNITIVE AND PSYCHOLOGICAL REHABILITATION
PROGRAM
  • Holistic Therapeutic Approach

11
COGNITIVE AND PSYCHOLOGICAL REHABILITATION
PROGRAM
  • AIMS
  • Cognitive and functional improvement of MCI
    patients
  • Inhibition of the progressive cognitive and
    functional deterioration of MILD AD patients
    after 4 years

12
PARTICIPANTS (N57/100)
EXPERIMENTAL GROUPS EXPERIMENTAL GROUPS CONTROL GROUPS CONTROL GROUPS
MCI MILD AD MCI MILD AD p p!
GENDER M/F 17/25 (11M / 6F) 8/25 (4M / 4F) 7/25 (3M / 4F) 25/25 (13M / 12F) .345 .925
EDUCATION 9.64 (5.01) 10.25 (4.59) 8.42 (4.54) 7.88 (4.72) .983 .182
AGE 70.58 (6.14) 71.75 (7.59) 65.85 (10.57) 70.08 (8.34) 1.000 .785
MMSE 27.23 (2.48) 24.50 (2.56) 26.14 (2.41) 22.84 (3.10) .335 .182
WITH/ WITHOUT AChIs 4 / 13 7 / 1 2 / 5 15 / 10 .806 .104
CDR 0.5 1 0.5 1
p between MCI groups p! between MILD AD groups
13
PARTICIPANTS
  • Inclusion criteria
  • Insight (awareness of the disease)
  • Absence of primary or secondary
  • depression
  • Spared sensory abilities, reading and writing
    skills
  • Pharmacological treatment cholinesterase
  • inhibitors
  • Absence of aphasic disorders (language
  • comprehension and speech production)

14
REHABILITATION PROGRAM
  • 1.Practice of attention and parameters of
    executive function
  • 2.Practice of Language skills
  • 3.Cognitive Motion Therapy
  • 4.Reality Orientation in Current
  • events
  • 5.Mental imagery under relaxation

15
Practice of attention and parameters of
executive function
16
Practice of Language skills
17
Cognitive Motion Therapy
18
Reality Orientation in Current events
19
Mental imagery under relaxation
20
DURATION OF REHABILITATION PROGRAM
  • 4 ½ hours sessions per week
  • 24 weeks every year under Rehabilitation therapy
  • 24 weeks without Rehabilitation therapy
  • Duration 4 years
  • Group intervention (groups of 5-6
  • patients)

21
PSYCHOMETRIC ASSESSMENT
  • 1st assessment just before the non
    pharmacological therapy
  • 2nd assessment 3 years after the end of it
  • 3rd assessment 4 years after the end of it

22
PSYCHOMETRIC ASSESSMENT
  • ADL
  • Functional Cognitive Assessment Scale (FUCAS)
  • Functional Rating Scale of Symptoms of Dementia
    (FRSSD)
  • Cognitive Function
  • Mini Mental State Examination (MMSE)
  • Montreal Cognitive Assessment (M?CA)
  • CAMCOG
  • WAIS-R
  • Verbal Fluency (FAS)
  • TRAIL MAKING A, B

23
PSYCHOMETRIC ASSESSMENT
  • Cognitive Function
  • Rey Auditory-Verbal Learning Test (RAVLT)
  • PYRAMIDS AND PALM TREES (PPT)
  • Rivermead Behavioural Memory Test (RBMT)
  • Test of Every Day Attention (???)
  • Rey Ostereith Complex Figure Test (ROCFT)
  • STROOP
  • ?oston Naming Test (BNT)
  • Emotional performance
  • Geriatric Depression Scale (GDS)

24
RESULTS
  • Statistics
  • SPSS
  • Non parametric tests
  • Wilcoxon for two related samples
  • Mann Whitney for two independent samples

25
RESULTS
  • Comparison between experimental / controls with
    MCI after 3 years
  • 3 years later
  • Significant difference in cognitive functions
  • Attention, CAMCOG (p .008)
  • Delayed recall, CAMCOG (p. 018)
  • Memory function, CAMCOG (p. 042)
  • Visual recall, CAMCOG (p. 004)
  • Naming, CAMCOG (p. 034)
  • General Cognitive performance, MMSE (p .014)
  • Experimental group had better scores

26
RESULTS
  • Comparison between experimental / controls with
    MCI after 3 years
  • 3 years later
  • Significant difference in ADL
  • Social response, FRSSD (p .010)
  • Attention, FRSSD (p .047)
  • ADL, FRSSD (p .006)
  • Emotional performance, GDS (p .039)
  • Experimental group had better scores

27
Performance of experimental and controls with MCI
before the Rehabilitation therapy 3 years later
FUNCTION EXPERIMENTAL GROUP EXPERIMENTAL GROUP CONTROL GROUP CONTROL GROUP p p!
ATTENTION-ONCENTRATION BEFORE 3 YEARS LATER BEFORE 3 YEARS LATER
Attention GAMCOG 6.05 (1.19) 6.81 (.75) 5.57 (1.90) 5.50 (1.87) .364 .008
VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY
Delayed recall GAMCOG 2.41 (.87) 2.81 (.40) 1.71 (1.38) 1.83 (1.16) .141 .018
General memory CAMCOG 20.52 (2.48) 21.75 (2.59) 20.14 (2.85) 18.00 (4.85) .348 .042
VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY
Visual recall CAMCOG 3.76 (1.28) 4.68 (1.01) 3.71 (1.11) 2.33 (2.06) .442 .004
LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE
Naming CAMCOG 11.58 (1.22) 12.43 (.96) 11.57 (1.27) 11.00 (1.67) .438 .034
DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION
Social response FRSSD .17 (.39) .13 (.35) .00 (.00) 1.00 (.70) .514 .010
Attention FRSSD .70 (.77) .33 (.61) .50 (1.00) 1.00 (.70) .332 .047
Daily function FRSSD 3.94 (1.78) 2.80 (1.85) 3.00 (2.16) 6.00 (2.23) .223 .006
Cognitive performance CAMCOG 89.94 (7.16) 96.43 (7.64) 89.57 (8.38) 88.83 (10.79) .508 .065
Cognitive performance MMSE 27.23 (2.48) 29.06 (1.34) 26.57 (2.22) 27.00 (2.19) .221 .014
Emotional performance GDS 2.20 (2.00) .81 (1.75) 1.80 (2.04) 1.60 (1.14) .375 .039
28
RESULTS
  • Comparison between experimental and controls with
    MILD AD after 3 years
  • Significant difference in
  • Recall of recent events, GAMCOG (p .018)
  • General memory function, CAMCOG (p .025)
  • Written recall, CAMCOG (p .021)
  • Ideatic praxis, CAMCOG (p .009)
  • Praxis, CAMCOG (p .009)
  • Visual perception, CAMCOG (p .014)
  • Visual shape perception, CAMCOG (p .011)
  • Abstract thinking, CAMCOG (p .001)
  • Experimental group had better scores

29
RESULTS
  • Comparison between experimental and controls with
    MILD AD after 4 years
  • 4 years later Significant difference in
  • Recall of recent events, GAMCOG (p .015)
  • Repetition, CAMCOG (p .021)
  • Visual perception, CAMCOG (p .042)
  • Abstract thinking, CAMCOG (p .008)
  • Experimental group had better scores

30
ABILITY EXPERIMENTAL GROUP EXPERIMENTAL GROUP EXPERIMENTAL GROUP CONTROL GROUP CONTROL GROUP CONTROL GROUP p p! p
ATTENTION-CONCETRATION BEFORE 3 YEARS LATER 4 YEARS LATER BEFORE 3 YEARS LATER 4 YEARS LATER
Attention GAMCOG 5.62 (1.59) 6.12 (1.72) 6.50 (1.00) 4.56 (1.95) 3.88 (2.76) 5.11 (2.42) .084 .035 .196
Calculation CAMCOG 1.75 (.46) 2.00 (.00) 1.75 (.50) 1.69 (.55) 1.41 (.71) 1.44 (.88) .581 .022 .412
VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY
Recall of recent events GAMCOG 2.75 (1.03) 2.87 (.83) 3.25 (.95) 2.91 (1.23) 1.82 (1.13) 1.33 (1.18) .228 .018 .015
Memory function CAMCOG 7.25 (1.03) 16.25 (3.80) 7.50 (1.29) 7.11 (1.16) 11.58 (5.86) 7.00 (.00) .374 .025 .465
Written recall CAMCOG 3.50 (1.51) 3.25 (1.83) 1.00 (1.15) 2.60 (1.67) 1.58 (1.73) 1.44 (1.42) .108 .021 .340
PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS PRAXIS
Ideokinetic praxis CAMCOG 4.12 (1.45) 4.87 (.35) 4.50 (.57) 4.56 (.78) 4.11 (.92) 4.00 (1.41) .259 .030 .431
Ideatic praxis CAMCOG 3.75 (.70) 4.00 (.00) 3.50 (.57) 3.68 (.74) 3.44 (.51) 3.00 (1.22) .481 .009 .428
Praxis CAMCOG 15.00 (1.60) 15.75 (2.96) 14.25 (2.62) 13.73 (2.57) 12.52 (2.92) 11.88 (4.04) .112 .009 .268
LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE
Repetition CAMCOG .75 (.46) .62 (.51) 1.00 (.00) .56 (.50) .50 (.84) .33 (.70) .301 .437 .021
VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY
Visual perception CAMCOG 6.00 (2.26) 6.62 (1.06) 6.00 (1.82) 5.34 (1.89) 4.70 (2.05) 4.00 (1.87) .136 .014 .042
Visual shape perception CAMCOG 3.62 (1.06) 3.75 (.88) 3.25 (1.50) 2.65 (1.69) 2.35 (1.57) 2.00 (1.41) .053 .011 .079
EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION
Abstract thinking CAMCOG 5.00 (2.07) 6.50 (1.77) 6.75 (.95) 4.17 (2.03) 3.41 (2.09) 2.88 (2.61) .207 .001 .008
Sequence of steps FUCAS 6.37 (.51) 6.71 (1.11) 6.75 (1.50) 7.00 (2.12) 8.44 (2.55) 6.00 (.00) .437 .061 .666
Orientation in place FUCAS 7.25 (.46) 7.57 (.97) 9.00 (1.63) 9.00 (3.77) 10.44 (3.84) 8.00 (.00) .299 .059 .199
Telephone communication FUCAS 10.00 (1.92) 10.28 (2.36) 8.50 (1.73) 8.66 (1.50) 13.11 (5.06) 11.00 (.00) .050 .116 .066
Distribution of time FUCAS 6.62 (.91) 6.71 (1.11) 6.00 (.00) 6.88 (2.02) 8.44 (3.00) 7.00 (.00) .125 .436 .067
DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION DAILY FUNCTION
Personal hygiene FRSSD .00 (.00) .28 (.48) .00 (.00) .36 (.84) .88 (1.27) 1.37 (1.18) .265 .229 .060
Cognitive performance CAMCOG 80.00 (8.00) 80.50 (13.08) 73.75(10.34) 70.26 (14.01) 57.76 (19.36) 57.11 (18.32) .057 .088 .053
Cognitive performance MMSE 24.50 (2.56) 24.00 (3.20) 22.25 (3.30) 22.80 (24.50) 19.33 (6.84) 19.88 (6.84) .056 .060 .429
31
RESULTS
  • Comparison before the Rehabilitation Therapy and
    3 years later of the experimental group with MCI
  • 3 years later better performance in
  • Attention (p .047)
  • Verbal memory (p .005)
  • Visual memory (p .032)
  • Language (p .014)
  • Executive function (p .047)
  • Global Cognitive performance, MMSE (p .002)
  • Global Cognitive performance, CAMCOG (p .001)
  • Cognitive performance, MOCA (p .015)
  • Emotional performance, GDS (p .047)

32
RESULTS
  • Comparison before the Rehabilitation Therapy and
    4 years later, of the experimental group with MCI
  • 4 years later better performance in
  • Attention, CAMCOG, TEA, (p .032)
  • Visual memory, (p .031)
  • Language, (p .040)
  • Executive function, (p .047)
  • Global Cognitive performance, CAMCOG (p .016)

33
RESULTS
  • Comparison before the Rehabilitation Therapy and
    3 years later, of the experimental group with
    MILD AD
  • 3 years later better performance in
  • Verbal semantic memory with phonological help,
    BNT (p .031)
  • Stability in the rest of cognitive functions

34
RESULTS
  • Comparison before the Rehabilitation Therapy and
    4 years later of the experimental group with MILD
    AD
  • 4 years later
  • Cognitive and functional stabilization

35
FUNCTION BEFORE AFTER 3 YEARS AFTER 4 YEARS p p!
ATTENTION-CONCENTRATION ?? (??) ?? (??) ?? (??)
Orientation GAMCOG 8.25 (1.48) 8.00 (1.51) 6.50 (2.38) .406 .248
Attention-Concentration GAMCOG 5.62 (1.59) 6.12 (1.72) 6.50 (1.00) .253 .374
Word naming STROOP 68.12 (22.33) 70.57 (16.26) 60.00 (10.36) .404 .309
Color naming STROOP 37.00 (7.67) 43.71 (14.67) 42.75 (8.53) .148 .127
Trail Making A 76.42 (14.85) 100.85 (58.07) 111.50 (45.66) .251 .190
VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY VERBAL MEMORY
Immediate word recall RALVT 3.57 (1.51) 3.71 (2.98) 5.00 (2.16) .109 .250
VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY VISUAL MEMORY
Copy of Reys complex figure ROCFT 29.85 (4.14) 28.21 (11.09) 28.50 (4.20) .501 .313
Delayed recall of Reys complex figure ROCFT 4.64 (1.88) 5.85 (6.08) 5.12 (.85) .500 .251
Visual recall CAMCOG 1.62 (1.06) 2.37 (1.76) 1.50 (1.73) .187 .250
Visual figure perception CAMCOG 3.62 (1.06) 3.75 (.88) 3.25 (1.50) .501 .376
General visual perception CAMCOG 6.00 (2.27) 6.62 (1.06) 6.00 (1.28) .297 .248
Speed of semantic and no verbal memory PPT 361.62 (127.51) 465.14 (134.38) 347.00 (81.84) .079 .313
LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE LANGUAGE
Naming CAMCOG 11.50 (1.30) 11.25 (1.98) 10.50 (1.29) .420 .251
Mean of language ability FAS 8.76 (3.25) 11.09 (2.61) 11.58 (4.28) .064 .063
Verbal semantic memory without help BNT 38.12 (8.35) 42.00 (10.45) 41.00 (10.55) .312 .437
Verbal semantic memory with phonological help BNT 48.37 (5.42) 52.85 (5.78) 50.50 (7.41) .031 .374
Speed of verbal semantic memory BNT 678.37 (379.77) 482.57 (125.91) 504.00 (116.43) .287 .437
EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION EXCECUTIVE FUNCTION
Number of trials WCST 105.16 (26.44) 98.71 (23.23) 91.66 (31.46) .439 .500
Perseverate responses WCST 19.83 (17.58) 17.28 (15.05) 8.66 (4.61) .501 .625
Categories number WCST 4.83 (1.60) 4.71 (2.21) 5.33 (1.15) .501 .499
Memory FUCAS 7.25 (1.03) 8.14 (.89) 7.50 (1.29) .190 .499
General executive function FUCAS 48.87 (5.33) 50.42 (5.57) 49.75 (5.50) .533 .313
Trail Making B 363.83 (175.18) 333.00 (64.45) 230.50 (142.12) .344 .252
Cognitive performance MMSE 24.50 (2.56) 24.00 (3.20) 22.25 (3.30) .420 .125
Cognitive performance CAMCOG 80.00 (8.00) 80.50 (13.08) 73.75 (10.34) .362 .186
Cognitive performance MOCA 16.00 (2.64) 18.57 (3.90) 18.25 (5.31) .125 -----
Emotional performance GDS 1.00 (1.00) .57 (.78) .50 (1.00) .249 -----
36
RESULTS
  • MCI experimental group
  • Cognitive performance was still improving after 4
    years in patients on Rehabilitation program
  • Almost all cognitive functions had been improved
  • Cognitive improvement was transferred to ADL
  • MCI experimental patients 4 years later were
    diagnosed as healthy elderly

37
RESULTS
  • MILD AD experimental group
  • Stabilization of cognitive, emotional and
    functional performance for a period of 4 years
    after the beginning of the Rehabilitation therapy

38
CONCLUSIONS
  • Long term Rehabilitation therapy improved
    cognitive, emotional and functional performance
  • In MCI patients who were healthy elderly after 4
    years therapy
  • The progressive impairment of AD patients,
    characteristic of the disease process, was
    inhibited for at least 4 years

39
THANK YOU!!!
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