Cognitive stimulation to improve cognitive functioning in people with dementia
- PMID: 39804128
- PMCID: PMC9891430
- DOI: 10.1002/14651858.CD005562.pub3
Cognitive stimulation to improve cognitive functioning in people with dementia
Abstract
Background: Cognitive stimulation (CS) is an intervention for people with dementia offering a range of enjoyable activities providing general stimulation for thinking, concentration and memory, usually in a social setting, such as a small group. CS is distinguished from other approaches such as cognitive training and cognitive rehabilitation by its broad focus and social elements, aiming to improve domains such as quality of life (QoL) and mood as well as cognitive function. Recommended in various guidelines and widely implemented internationally, questions remain regarding different modes of delivery and the clinical significance of any benefits. A systematic review of CS is important to clarify its effectiveness and place practice recommendations on a sound evidence base. This review was last updated in 2012.
Objectives: To evaluate the evidence for the effectiveness of CS for people with dementia, including any negative effects, on cognition and other relevant outcomes, accounting where possible for differences in its implementation.
Search methods: We identified trials from a search of the Cochrane Dementia and Cognitive Improvement Group Specialized Register, last searched on 3 March 2022. We used the search terms: cognitive stimulation, reality orientation, memory therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation. We performed supplementary searches in a number of major healthcare databases and trial registers to ensure the search was up-to-date and comprehensive.
Selection criteria: We included all randomised controlled trials (RCTs) of CS for dementia published in peer review journals in the English language incorporating a measure of cognitive change.
Data collection and analysis: We used standard methodological procedures expected by Cochrane. As CS is a psychosocial intervention, we did not expect those receiving or delivering CS to be blinded to the nature of the intervention. Where necessary, we contacted study authors requesting data not provided in the papers. Where appropriate, we undertook subgroup analysis by modality (individual versus group), number of sessions and frequency, setting (community versus care home), type of control condition and dementia severity. We used GRADE methods to assess the overall quality of evidence for each outcome.
Main results: We included 37 RCTs (with 2766 participants), 26 published since the previous update. Most evaluated CS groups; eight examined individual CS. Participants' median age was 79.7 years. Sixteen studies included participants resident in care homes or hospitals. Study quality showed indications of improvement since the previous review, with few areas of high risk of bias. Assessors were clearly blinded to treatment allocation in most studies (81%) and most studies (81%) reported use of a treatment manual by those delivering the intervention. However, in a substantial number of studies (59%), we could not find details on all aspects of the randomisation procedures, leading us to rate the risk of selection bias as unclear. We entered data in the meta-analyses from 36 studies (2704 participants; CS: 1432, controls: 1272). The primary analysis was on changes evident immediately following the treatment period (median length 10 weeks; range 4 to 52 weeks). Only eight studies provided data allowing evaluation of whether effects were subsequently maintained (four at 6- to 12-week follow-up; four at 8- to 12-month follow-up). No negative effects were reported. Overall, we found moderate-quality evidence for a small benefit in cognition associated with CS (standardised mean difference (SMD) 0.40, 95% CI 0.25 to 0.55). In the 25 studies, with 1893 participants, reporting the widely used MMSE (Mini-Mental State Examination) test for cognitive function in dementia, there was moderate-quality evidence of a clinically important difference of 1.99 points between CS and controls (95% CI: 1.24, 2.74). In secondary analyses, with smaller total sample sizes, again examining the difference between CS and controls on changes immediately following the intervention period, we found moderate-quality evidence of a slight improvement in self-reported QoL (18 studies, 1584 participants; SMD: 0.25 [95% CI: 0.07, 0.42]) as well as in QoL ratings made by proxies (staff or caregivers). We found high-quality evidence for clinically relevant improvements in staff/interviewer ratings of communication and social interaction (5 studies, 702 participants; SMD: 0.53 [95% CI: 0.36, 0.70]) and for slight benefits in instrumental Activities of Daily Living, self-reported depressed mood, staff/interviewer-rated anxiety and general behaviour rating scales. We found moderate-quality evidence for slight improvements in behaviour that challenges and in basic Activities of Daily Living and low-quality evidence for a slight improvement in staff/interviewer-rated depressed mood. A few studies reported a range of outcomes for family caregivers. We found moderate-quality evidence that overall CS made little or no difference to caregivers' mood or anxiety. We found a high level of inconsistency between studies in relation to both cognitive outcomes and QoL. In exploratory subgroup analyses, we did not identify an effect of modality (group versus individual) or, for group studies, of setting (community versus care home), total number of group sessions or type of control condition (treatment-as-usual versus active controls). However, we did find improvements in cognition were larger where group sessions were more frequent (twice weekly or more versus once weekly) and where average severity of dementia among participants at the start of the intervention was 'mild' rather than 'moderate'. Imbalance in numbers of studies and participants between subgroups and residual inconsistency requires these exploratory findings to be interpreted cautiously.
Authors' conclusions: In this updated review, now with a much more extensive evidence base, we have again identified small, short-term cognitive benefits for people with mild to moderate dementia participating in CS programmes. From a smaller number of studies, we have also found clinically relevant improvements in communication and social interaction and slight benefits in a range of outcomes including QoL, mood and behaviour that challenges. There are relatively few studies of individual CS, and further research is needed to delineate the effectiveness of different delivery methods (including digital and remote, individual and group) and of multi-component programmes. We have identified that the frequency of group sessions and level of dementia severity may influence the outcomes of CS, and these aspects should be studied further. There remains an evidence gap in relation to the potential benefits of longer-term CS programmes and their clinical significance.
배경: 인지 자극(CS)은 치매 환자를 위한 중재이다. 일반적으로 소그룹과 같은 사회적 환경에서 생각, 집중 및 기억에 대한 일반적인 자극을 줄 수 있도록 다양하고 즐거운 활동을 제공한다. CS(인지 자극)는 광범위한 초점과 사회적 요소에 의해 인지 훈련 및 인지 재활 같은 다른 접근법과 구별된다. 인지기능은 물론이고 삶의 질(QoL), 기분 같은 영역을 개선하는 것을 목표로 하고 있다. 다양한 지침에서 권장되고 국제적으로 널리 시행되고 있지만 다양한 전달 방식과 이점의 임상적 중요성에 대한 질문이 남아 있습니다. CS에 대한 체계적인 검토는 그 효과를 명확히 하고 건전한 근거 기반에 실제 권장 사항을 배치하는 데 중요합니다. 이 리뷰는 2012년에 마지막으로 업데이트되었습니다. 목적: 인지 및 기타 관련 결과에 대한 부정적인 영향을 포함하여 치매 환자에 대한 CS의 효과에 대한 증거를 평가하고 구현의 차이가 나는 지점을 파악하기 위함 검색 전략: 2022년 3월 3일에 마지막으로 검색된 Cochrane Dementia and Cognitive Improvement Group Specialized Register의 검색에서 임상시험을 식별했다. 우리는 인지 자극, 현실 지향, 기억 요법, 기억 그룹, 기억 지원, 기억 자극, 글로벌 자극, 인지 심리 자극과 같은 검색어를 사용했다. 검색이 최신이고 포괄적인지 확인하기 위해 여러 주요 의료 데이터베이스 및 시험 등록에서 보충 검색을 수행했다. 선정 기준: 인지 변화의 척도를 통합한 영문 피어 리뷰 저널에 발표된 치매에 대한 CS의 모든 무작위 대조 시험(RCT)을 포함했다. 자료 수집 및 분석: Cochrane에서 기대하는 표준 방법론적 절차를 사용했다. CS는 심리사회적 개입이기 때문에 CS를 받거나 전달하는 사람들이 중재의 본질에 대해 무지할 것이라고 기대하지 않았다. 필요한 경우 연구 저자에게 연락하여 논문에 제공되지 않은 데이터를 요청했다. 적절한 경우 적용(개인 대 그룹), 세션 수 및 빈도, 설정(커뮤니티 대 요양원), 제어 조건 유형 및 치매 중증도별로 하위 그룹 분석을 수행했다. 각 결과에 대한 전반적인 근거의 질을 평가하기 위해 GRADE(Grading of Recommendations, Assessment, Development, and Evaluation) 방법론을 사용했다. 주요 결과: 37개의 RCT(참가자 2766명)를 포함했으며, 이전 업데이트 이후 26편이 출판되었다. 대부분은 CS그룹으로 평가되었고 8명은 개인별 CS로 측정되었다. 참가자의 평균 나이는 79.7세였다. 16건의 연구에는 요양원이나 병원에 있는 참가자가 포함되었다. 비뚤림 위험이 높은 영역이 거의 없는 것을 보니 연구 품질은 이전 문헌고찰 이후 개선의 징후를 보여주었다. 평가자는 대부분의 연구(81%)에서 치료 할당에 대해 명확하게 눈가림을 했고 대부분의 연구(81%)는 중재를 제공하는 사람들이 치료 매뉴얼을 사용한다고 보고했다. 그러나 상당한 수의 연구(59%)에서 무작위화 절차의 모든 측면에 대한 세부 정보를 찾을 수 없었기 때문에 선택 비뚤림의 위험을 불분명한 것으로 평가했다. 우리는 36개의 연구로부터 얻은 데이터를 메타분석에 사용했다.(참가자 2,704명, CS중재: 1423명, 대조군: 1272명), 1차 분석은 치료 기간(중앙값 10주, 범위 4~52주) 직후 명백한 변화에 대한 것이었다. 8건의 연구만이 효과가 계속 유지되는지 여부를 평가할 수 있는 데이터를 제공했다(6~12주 추적 조사에서 4건, 8~12개월 추적 조사에서 4건). 부작용은 보고되지 않았다. 전반적으로 CS와 관련된 인지의 작은 이점에 대해 중간 정수준의 근거를 발견했다(표준화 평균 차이(SMD) 0.40, 95% CI(신뢰구간) 0.25~0.55). 1,893명의 참가자가 참여한 25건의 연구에서 치매의 인지 기능에 널리 사용되는 MMSE(Mini‐Mental State Examination) 테스트를 보고했으며, 근거의 확실성은 중간 정도로서. CS중재군과 대조군의 임상적으로 중요한 차이는 1.99점이었다(95% 신뢰구간: 1.24~2,74). 총 표본 크기가 더 작은 2차 분석에서 중재 기간 직후의 변화에 대한 CS중재군과 대조군의 차이를 다시 조사한 결과, 근거의 확실성이 중간정도로서 자가 보고 QoL(삶의 질)이 약간 개선된 것을 발견했다(18개 연구, 1584명 참여자, SMD: 0.25[95% 신뢰구간 0.07~0.42]). 대리인(직원 또는 간병인)이 만든 QoL 등급에서도 마찬가지였다. 의사소통 및 사회적 상호 작용에 대한 직원/면접관 평가에서 임상적으로 관련된 개선에 대해 근거의 확실성이 높았다(연구 5건, 참가자 702명; SMD: 0.53[95% 신뢰구간 0.36~ 0.70]). 도구적 일상 생활 활동, 자가 보고 우울 기분, 직원/면접관이 평가한 불안 및 일반 행동 평가 척도에서 약간의 이점이 있었다. 도전적인 행동과 일상 생활의 기본 활동에서 약간의 개선에 대한 근거의 확실성은 중간 정도였고 직원/면접관이 평가한 우울한 기분의 약간의 개선에 대한 근거의 확실성은 낮았다. 몇몇 연구에서는 가족 간병인에 대한 다양한 결과를 보고했다. 결국 CS가 간병인의 기분이나 불안에 거의 또는 전혀 차이가 없다는 근거의 확실성은 중간 정도였다. 인지 결과와 QoL 모두와 관련하여 연구 간에 높은 수준의 불일치가 있음을 발견했다. 탐색적 하위 그룹 분석에서 적용(그룹 대 개인) 또는 그룹 연구의 경우 설정(지역사회 대 요양원), 총 그룹 세션 수 또는 제어 조건 유형(평상시 치료 대 활발한 대조군)의 효과를 찾지 못하였다. 그러나 우리는 그룹 세션이 더 빈번한 경우(주 1회에 비해 주 2회 이상)와 중재 시작 시 참가자의 평균 치매 중증도가 '보통'이 아니라 '경증'인 경우에 인지 개선이 더 컸음을 발견했다. 하위 그룹 간의 연구 및 참여자 수의 불균형과 잔류자 수 불일치가 있었으니 이러한 탐색적 결과를 신중하게 해석해야 한다. 연구진 결론: 이제 훨씬 더 광범위한 증거 기반을 갖춘 이 업데이트된 고찰에서 우리는 CS 프로그램에 참여하는 경증에서 중등도 치매 환자를 위한 작은 단기 인지 혜택을 다시 확인했다. 더 적은 수의 연구에서 우리는 또한 의사소통 및 사회적 상호작용에서 임상적으로 관련된 개선을 발견했고 삶의 질, 도전적인 기분 및 행동을 포함한 다양한 결과에서 약간의 이점을 발견했다. 개별 CS에 대한 연구는 상대적으로 적고 다양한 전달 방법(디지털과 원격, 개인과 그룹 포함) 및 다중 구성 요소 프로그램의 효과를 설명하기 위해서는 추가 연구가 필요하다. 우리는 그룹 세션의 빈도와 치매 중증도가 CS의 결과에 영향을 미칠 수 있음을 확인했으며 이러한 측면은 추가 연구가 필요하다. 장기 CS 프로그램의 잠재적 이점과 임상적 중요성에 관련해서는 근거의 격차가 남아 있다.
บทนำ: การกระตุ้นความรู้ความเข้าใจ (CS) คือวิธีการที่ใช้ (intervention) สำหรับผู้ที่มีภาวะสมองเสื่อม โดยนำเสนอกิจกรรมที่สนุกสนานต่างๆ ซึ่งโดยทั่วไปช่วยกระตุ้นการคิด สมาธิ และความจำ ในสภาพแวดล้อมทางสังคม เช่น กลุ่มเล็กๆ CS แตกต่างจากแนวทางอื่นๆ เช่น การฝึกอบรมความรู้ความเข้าใจและการฟื้นฟูสมรรถภาพทางปัญญาโดยการเน้นการกระตุ้นกว้างๆและองค์ประกอบทางสังคม โดยมีเป้าหมายเพื่อปรับปรุงในบริบทต่างๆ เช่น คุณภาพชีวิต (QoL) และอารมณ์ ตลอดจนการทำงานของการรับรู้ มีการแนะนำในแนวทางต่าง ๆ และนำไปใช้อย่างกว้างขวางในระดับสากล แต่ยังมีคำถามเกี่ยวกับวิธีการดำเนินการที่แตกต่างกันและมีประโยชน์ที่มีความสำคัญทางคลินิกหรือไม่ การทบทวนอย่างเป็นระบบเป็นสิ่งสำคัญในการชี้แจงประสิทธิภาพและให้คำแนะนำการปฏิบัติไว้ตามหลักฐานที่น่าเชื่อถือ การทบทวนวรรณกรรมนี้ได้รับการปรับปรุงล่าสุดในปี 2012 วัตถุประสงค์: เพื่อประเมินหลักฐานสำหรับประสิทธิผลของ CS สำหรับผู้ที่มีภาวะสมองเสื่อม รวมถึงผลกระทบด้านลบใดๆ ต่อความรู้ความเข้าใจและผลลัพธ์อื่นๆ ที่เกี่ยวข้อง โดยคำนึงถึงความแตกต่างในการนำไปใช้หากเป็นไปได้ วิธีการสืบค้น: เราระบุการทดลองจากการค้นหา Cochrane Dementia and Cognitive Improvement Group Specialized Register ค้นหาล่าสุดเมื่อวันที่ 3 มีนาคม 2022 เราใช้คำค้นหา: การกระตุ้นความรู้ความเข้าใจ, การปฐมนิเทศความเป็นจริง, การบำบัดความจำ, กลุ่มความจำ, การสนับสนุนหน่วยความจำ, การกระตุ้นความจำ, การกระตุ้นโดยรวม, การกระตุ้นจิตทางปัญญา เราทำการค้นหาเพิ่มเติมในฐานข้อมูลด้านการดูแลสุขภาพที่สำคัญจำนวนหนึ่งและทะเบียนการทดลองเพื่อให้แน่ใจว่าการค้นหานั้นทันสมัยและครอบคลุม เกณฑ์การคัดเลือก: เรารวมการทดลองแบบสุ่มที่มีกลุ่มควบคุม (RCTs) ทั้งหมดของ CS สำหรับภาวะสมองเสื่อมที่ตีพิมพ์ในวารสารวิชาการเป็นภาษาอังกฤษ ซึ่งรวมการวัดการเปลี่ยนแปลงทางความคิด การรวบรวมและวิเคราะห์ข้อมูล: เราใช้ขั้นตอนวิธีการมาตรฐานที่ Cochrane กำหนด เนื่องจาก CS เป็นการแทรกแซงทางจิตสังคม เราไม่ได้คาดหวังว่าผู้ที่ได้รับหรือให้ CS จะถูกปกปิดกลุ่มของการแทรกแซง หากจำเป็น เราได้ติดต่อผู้เขียนการศึกษาเพื่อขอข้อมูลที่ไม่ได้ระบุไว้ในรายงาน ตามความเหมาะสม เราดำเนินการวิเคราะห์กลุ่มย่อยตามวิธีการ (รายบุคคลเทียบกับกลุ่ม) จำนวน sessions และความถี่ สถานที่ (ชุมชนและสถานดูแลเด็ก) ประเภทของเงื่อนไขการควบคุมและความรุนแรงของภาวะสมองเสื่อม และใช้วีธี GRADE เพื่อประเมินคุณภาพของงานวิจัยในแต่ละผลลัพธ์ของการศึกษา ผลการวิจัย: เรารวม RCTs 37 ฉบับ (มีผู้เข้าร่วม 2766 คน), 26 ฉบับเผยแพร่ตั้งแต่การอัปเดตครั้งก่อน กลุ่ม CS ที่ได้รับการประเมินมากที่สุด 8 ฉบับตรวจสอบ CS แต่ละบุคคล อายุเฉลี่ยของผู้เข้าร่วมคือ 79.7 ปี การศึกษา 16 ฉบับรวมผู้เข้าร่วมที่อาศัยอยู่ในบ้านพักคนชราหรือโรงพยาบาล คุณภาพการศึกษาแสดงให้เห็นการปรับปรุงตั้งแต่การทบทวนครั้งก่อน โดยมีบางประเด็นที่มีความเสี่ยงสูงที่จะเกิดอคติ ผู้ประเมินได้รับการปกปิดอย่างชัดเจนต่อการจัดสรรการรักษาในการศึกษาส่วนใหญ่ (81%) และการศึกษาส่วนใหญ่ (81%) รายงานการใช้คู่มือการรักษาโดยผู้ที่ให้การรักษา อย่างไรก็ตาม ในการศึกษาจำนวนมาก (59%) เราไม่พบรายละเอียดในทุกแง่มุมของขั้นตอนการสุ่ม ทำให้เราให้คะแนนความเสี่ยงของอคติในการคัดเลือกว่าไม่ชัดเจน เราป้อนข้อมูลในการวิเคราะห์อภิมานจากการศึกษา 36 ฉบับ (ผู้เข้าร่วม 2704 คน CS: 1432, กลุ่มควบคุม: 1272) การวิเคราะห์เบื้องต้นเกี่ยวกับการเปลี่ยนแปลงที่เห็นได้ชัดทันทีหลังจากระยะเวลาการรักษา (ความยาวเฉลี่ย 10 สัปดาห์ ช่วง 4 ถึง 52 สัปดาห์) มีเพียงการศึกษา 8 ฉบับเท่านั้นที่ให้ข้อมูลที่ช่วยให้สามารถประเมินได้ว่าผลกระทบนั้นยังคงอยู่หรือไม่ (การศึกษา 4 ฉบับ ติดตามผล 6 ถึง 12 สัปดาห์; 4 ฉบับ ติดตามผล 8 ถึง 12 เดือน) ไม่มีรายงานผลกระทบด้านลบ โดยรวมแล้ว เราพบหลักฐานที่มีคุณภาพปานกลางว่ามีประโยชน์เล็กน้อยในการรับรู้ที่เกี่ยวข้องกับ CS (ความแตกต่างของค่าเฉลี่ยมาตรฐาน (SMD) 0.40, 95% CI 0.25 ถึง 0.55) ในการศึกษา 25 ฉบับ ซึ่งมีผู้เข้าร่วม 1893 คน ซึ่งรายงานการทดสอบ MMSE (Mini‐Mental State Examination) ที่ใช้กันอย่างแพร่หลายสำหรับการทำงานของการรับรู้ในภาวะสมองเสื่อม มีหลักฐานที่มีคุณภาพปานกลางของความแตกต่างที่สำคัญทางคลินิก 1.99 คะแนนระหว่าง CS และกลุ่มควบคุม (95% CI: 1.24, 2.74) ในการวิเคราะห์ระดับทุติยภูมิ ซึ่งมีขนาดตัวอย่างทั้งหมดน้อยลง ตรวจสอบความแตกต่างอีกครั้งระหว่าง CS และกลุ่มควบคุมเกี่ยวกับการเปลี่ยนแปลงทันทีหลังจากช่วงแทรกแซง เราพบหลักฐานคุณภาพปานกลางของการปรับปรุงเล็กน้อยใน QoL ที่รายงานด้วยตนเอง (การศึกษา 18 ฉบับ ผู้เข้าร่วม 1584 คน; SMD: 0.25 [95% CI: 0.07, 0.42]) เช่นเดียวกับการให้คะแนน QoL ที่จัดทำโดยตัวแทน (เจ้าหน้าที่หรือผู้ดูแล) เราพบหลักฐานคุณภาพสูงสำหรับการปรับปรุงที่เกี่ยวข้องทางคลินิกในการให้คะแนนการสื่อสารและปฏิสัมพันธ์ทางสังคมของพนักงาน/ผู้สัมภาษณ์ (การศึกษา 5 ฉบับ ผู้เข้าร่วม 702 คน; SMD: 0.53 [95% CI: 0.36, 0.70]) และมีประโยชน์เล็กน้อยวัดโดยเครื่องมือกิจกรรมในชีวิตประจำวัน (instrumental Activities of Daily Living) อารมณ์ซึมเศร้าที่รายงานด้วยตนเอง ความวิตกกังวลที่ประเมินโดยเจ้าหน้าที่/ผู้สัมภาษณ์ และมาตราส่วนการให้คะแนนพฤติกรรมทั่วไป เราพบหลักฐานคุณภาพปานกลางสำหรับการปรับปรุงเล็กน้อยในพฤติกรรมที่ท้าทายและในกิจกรรมพื้นฐานของชีวิตประจำวัน และหลักฐานคุณภาพต่ำสำหรับการปรับปรุงเล็กน้อยในอารมณ์ซึมเศร้าที่ประเมินโดยพนักงาน/ผู้สัมภาษณ์ การศึกษาบางฉบับรายงานผลลัพธ์ที่หลากหลายสำหรับผู้ดูแลในครอบครัว เราพบหลักฐานที่มีคุณภาพปานกลางว่า CS โดยรวมสร้างความแตกต่างเล็กน้อยหรือไม่มีเลยต่ออารมณ์หรือความวิตกกังวลของผู้ดูแล เราพบความไม่สอดคล้องกันในระดับสูงระหว่างการศึกษาที่เกี่ยวข้องกับทั้งผลลัพธ์ทางปัญญาและ QoL ในการวิเคราะห์กลุ่มย่อยเชิงสำรวจ เราไม่พบผลกระทบของวิธีการ (กลุ่มเทียบกับรายบุคคล) หรือการศึกษากลุ่ม สถานที่ (ชุมชนกับสถานดูแล) จำนวนเซสชันทั้งหมดของกลุ่มหรือประเภทของเงื่อนไขการควบคุม (การรักษาตามปกติเทียบกับ ตัวควบคุมที่ใช้งานอยู่) อย่างไรก็ตาม เราพบว่าการปรับปรุงความรู้ความเข้าใจมีมากขึ้นเมื่อเซสชันแบบกลุ่มมีบ่อยขึ้น (2 ครั้งต่อสัปดาห์หรือมากกว่านั้นเมื่อเทียบกับสัปดาห์ละครั้ง) และความรุนแรงของภาวะสมองเสื่อมโดยเฉลี่ยในกลุ่มผู้เข้าร่วมในช่วงเริ่มต้นของการแทรกแซงคือ 'เล็กน้อย' แทนที่จะเป็น 'ปานกลาง' ความไม่สมดุลของจำนวนการศึกษาและผู้เข้าร่วมระหว่างกลุ่มย่อยและความไม่สอดคล้องกันที่เหลืออยู่ ทำให้ต้องตีความการค้นพบเชิงสำรวจเหล่านี้อย่างระมัดระวัง ข้อสรุปของผู้วิจัย: ในการทบทวนฉบับปรับปรุงนี้ ขณะนี้มีหลักฐานที่กว้างขวางมากขึ้น เราได้พบประโยชน์ทางปัญญาในระยะสั้นเล็กน้อยอีกครั้งสำหรับผู้ที่มีภาวะสมองเสื่อมระดับเล็กน้อยถึงปานกลางที่เข้าร่วมโปรแกรม CS จากการศึกษาจำนวนน้อย เรายังพบการปรับปรุงที่เกี่ยวข้องทางคลินิกในการสื่อสารและปฏิสัมพันธ์ทางสังคม และผลประโยชน์เล็กน้อยในผลลัพธ์ต่างๆ รวมถึง QoL อารมณ์และพฤติกรรมที่ท้าทาย มีการศึกษาค่อนข้างน้อยเกี่ยวกับ CS ส่วนบุคคล และจำเป็นต้องมีการวิจัยเพิ่มเติมเพื่อระบุประสิทธิผลของวิธีการจัดส่งที่แตกต่างกัน (รวมถึงแบบดิจิทัลและระยะไกล รายบุคคลและกลุ่ม) และของโปรแกรมที่มีหลายองค์ประกอบ เราพบว่าความถี่ของกิจกรรมกลุ่มและระดับความรุนแรงของภาวะสมองเสื่อมอาจส่งผลต่อผลลัพธ์ของ CS และควรศึกษาประเด็นเหล่านี้เพิ่มเติม ยังคงมีช่องว่างของหลักฐานที่เกี่ยวข้องกับผลประโยชน์ที่เป็นไปได้ของโปรแกรม CS ระยะยาวและความสำคัญทางคลินิก.
پیشینه: تحریک شناختی (cognitive stimulation; CS)، مداخلهای است برای افراد مبتلا به دمانس، و شامل طیف وسیعی از فعالیتهای لذتبخشی است که معمولا در یک محیط اجتماعی، مانند یک گروه کوچک، خدمات تحریک تفکر، تمرکز و حافظه را ارائه میدهد. CS با تمرکز گسترده و عناصر اجتماعی خود از رویکردهای دیگری مانند آموزش شناختی و توانبخشی شناختی متمایز میشود و هدف آن بهبود حوزههایی مانند کیفیت زندگی (QoL)، خلقوخو و همچنین عملکرد شناختی فرد بیمار است. استفاده از این روش در دستورالعملهای بالینی مختلف توصیه شده و بهطور گستردهای در سطح بینالمللی اجرا میشود، هرچند در مورد روشهای مختلف ارائه و اهمیت بالینی هرگونه مزیت حاصل از آن هنوز هم سوالاتی وجود دارد. برای روشن شدن اثربخشی آن و ارائه توصیههای عملی بر پایه شواهد معتبر، انجام یک مرور سیستماتیک درباره CS مهم است. این مرور آخرین بار در سال 2012 بهروز شد. اهداف: ارزیابی شواهد مربوط به اثربخشی CS در افراد مبتلا به دمانس، از جمله هرگونه تاثیرات منفی بر شناخت و دیگر پیامدهای مرتبط، و تا جایی که امکانپذیر است باید در اجرای آن، تفاوتها در نظر گرفته شود. روشهای جستوجو: کارآزماییها را از طریق جستوجو در پایگاه ثبت تخصصی گروه دمانس و بهبود شناختی در کاکرین شناسایی کردیم، آخرین جستوجو در 3 مارچ سال 2022 انجام شد. از اصطلاحات جستوجوی زیر استفاده کردیم: تحریک شناختی، آگاهی از واقعیت، حافظه درمانی، گروههای حافظه، حمایت از حافظه، تحریک حافظه، تحریک کلی، تحریک روانی شناختی. جستوجوهای تکمیلی را در تعدادی از بانکهای اطلاعاتی اصلی مراقبت سلامت و پایگاههای ثبت کارآزمایی انجام دادیم تا اطمینان حاصل کنیم که جستوجو بهروز و جامع است. معیارهای انتخاب: همه کارآزماییهای تصادفیسازی و کنترل شده (randomised controlled trials; RCTs) را در رابطه با بررسی تاثیر CS در درمان دمانس وارد کردیم که در مجلات با داوری همتا (peer review) به زبان انگلیسی منتشر شده، و شامل معیار تغییرات شناختی بودند. گردآوری و تجزیهوتحلیل دادهها: از پروسیجرهای استاندارد روششناسی (methodology) مورد نظر کاکرین استفاده کردیم. از آنجایی که CS یک مداخله روانیاجتماعی است، انتظار نداشتیم کسانی که CS را دریافت کردند یا کسانی که آن را به شرکتکنندگان ارائه دادند نسبت به ماهیت مداخله کورسازی شوند. در صورت لزوم، با نویسندگان مطالعه تماس گرفته و اطلاعاتی را که در مقالات ارائه نشده بودند، درخواست کردیم. در صورت لزوم، تجزیهوتحلیل زیر گروه را بر اساس روش (فردی در برابر گروهی)، تعداد جلسات و دفعات، محیط (جامعه در برابر خانه مراقبت)، نوع شرایط کنترل و شدت دمانس انجام دادیم. از روشهای درجهبندی توصیه، ارزیابی، توسعه و ارزشیابی (Grading of Recommendations Assessment, Development and Evaluation; GRADE) برای ارزیابی کیفیت کلی شواهد برای هر پیامد استفاده کردیم. نتایج اصلی: تعداد 37 RCT (با 2766 شرکتکننده) را در این مرور گنجاندیم، 26 مورد از زمان نسخه بهروز شده قبلی منتشر شدند. اکثرا CS گروهی را ارزیابی کردند؛ در هشت مورد هم CS فردی مورد بررسی قرار گرفت. میانه (median) سنی شرکتکنندگان 79.7 سال بود. شانزده مطالعه شامل شرکتکنندگان ساکن در خانههای مراقبت یا بیمارستانها بودند. سطح کیفیت مطالعه نسبت به مرور قبلی ارتقا یافت، با حیطههای اندکی که خطر بالای سوگیری (bias) داشت. ارزیابان به وضوح نسبت به تخصیص درمان در اکثر مطالعات (81%) کور شده بودند، و بیشتر مطالعات (81%) استفاده از کتابچه راهنمای درمان را توسط کسانی که مداخله را ارائه دادند گزارش کردند. با این حال، در تعداد قابلتوجهی از مطالعات (59%)، نتوانستیم جزئیات مربوط به تمام جنبههای پروسیجرهای تصادفیسازی را پیدا کنیم، که باعث شد خطر سوگیری انتخاب را نامشخص ارزیابی کنیم. دادههای 36 مطالعه را در متاآنالیزها وارد کردیم (2704 شرکتکننده؛ CS: 1432، کنترل: 1272). آنالیز اولیه روی تغییرات مشهود بلافاصله پس از دوره درمان انجام شد (میانه (median): 10 هفته، 4 تا 52 هفته). فقط هشت مطالعه دادههایی را ارائه دادند که امکان ارزیابی تاثیرات بعدی را فراهم کردند (چهار مورد در پیگیری 6 تا 12 هفته، چهار مورد در پیگیری 8 تا 12 ماه). تاثیرات منفی گزارش نشدند. بهطور کلی، شواهدی را با کیفیت متوسط حاکی از یک مزیت کوچک در شناخت مرتبط با CS به دست آوردیم (تفاوت میانگین استاندارد شده (SMD): 0.40؛ 95% CI؛ 0.25 تا 0.55). در 25 مطالعه، با 1893 شرکتکننده، که استفاده از تست پُرکاربرد MMSE (آزمون کوتاه وضعیت ذهنی (Mini‐Mental State Examination)) را برای عملکرد شناختی در دمانس گزارش کردند، شواهدی با کیفیت متوسط حاکی از تفاوت بالینی مهم 1.99 امتیازی بین CS و گروه کنترل وجود داشت (95% CI؛ 1.24 تا 2.74). در آنالیزهای ثانویه، با حجم نمونه کلی کمتر، مجددا با بررسی تفاوت بین CS و کنترلها از لحاظ بروز تغییرات بلافاصله پس از مداخله، شواهدی را با کیفیت متوسط حاکی از بهبود جزئی در QoL گزارش شده توسط خود بیمار یافتیم (18 مطالعه، 1584 شرکتکننده؛ SMD: 0.25؛ [95% CI؛ 0.07 تا 0.42]) همچنین در رتبهبندیهای QoL بر اساس پراکسیها (کارکنان یا مراقبان) این مزیت مداخله دیده شد. شواهدی را با کیفیت بالا برای بهبودهای مرتبط بالینی در رتبهبندی کارکنان/مصاحبهگر از ارتباطات و اثر متقابل (interaction) اجتماعی (5 مطالعه، 702 شرکتکننده؛ SMD: 0.53؛ [95% CI؛ 0.36، 0.70]) و برای مزایای جزئی در فعالیتهای ابزاری زندگی روزانه (instrumental)، خلقوخوی افسرده بر اساس گزارش خود فرد، اضطراب رتبهبندی شده توسط کارکنان/مصاحبهگر و مقیاسهای رتبهبندی رفتار کلی فرد پیدا کردیم. شواهدی با کیفیت متوسط برای بهبودهای جزئی در رفتار و در فعالیتهای زندگی پایه (basic) روزانه و شواهدی با کیفیت پائین برای بهبود جزئی در خلقوخوی افسرده رتبهبندی شده توسط کارکنان/مصاحبهگر پیدا شد. مطالعات معدودی طیف وسیعی را از پیامدها برای مراقبان خانواده گزارش کردند. شواهدی را با کیفیت متوسط پیدا کردیم که نشان میدهد CS کلی تفاوتی اندک یا عدم تفاوت را در خلقوخو یا اضطراب مراقبین بر جای میگذارد. سطح بالایی را از ناهمگونی بین مطالعات را در رابطه با پیامدهای شناختی و QoL یافتیم. در آنالیزهای زیرگروه اکتشافی، تاثیر روش (گروهی در برابر فردی) یا، برای مطالعات گروهی، محیط (جامعه در برابر خانه مراقبت)، تعداد کل جلسات گروهی یا نوع شرایط کنترل (درمان طبق معمول در برابر کنترلهای فعال) را شناسایی نکردیم. با این حال، متوجه شدیم در جایی که جلسات گروهی به دفعات بیشتری برگزار شد (دو بار در هفته یا بیشتر در برابر یک بار در هفته) و جایی که میانگین شدت دمانس میان شرکتکنندگان در شروع مداخله به جای «متوسط»، در سطح «خفیف» بود، بهبود شناخت بیشتر رخ داد. عدم تعادل در تعداد مطالعات و شرکتکنندگان بین زیرگروهها و ناهمگونی باقیمانده، نیازمند این است که این یافتههای اکتشافی با احتیاط تفسیر شوند. نتیجهگیریهای نویسندگان: در این مرور بهروز شده، اکنون با یک مجموعه شواهد بسیار گستردهتر، باز هم مزایای شناختی کوچک و کوتاهمدت را برای افراد مبتلا به دمانس خفیف تا متوسط که در برنامههای CS شرکت میکنند، شناسایی کردهایم. از تعداد کمتری از مطالعات، همچنین بهبودهای مرتبط بالینی در ارتباطات و اثر متقابل (interaction) اجتماعی و مزایای جزئی را در طیف وسیعی از پیامدها از جمله QoL، خلقوخو و رفتار چالش برانگیز، به دست آوردهایم. مطالعات نسبتا کمی در مورد CS فردی وجود دارد، انجام پژوهشهای بیشتری برای تشریح اثربخشی روشهای مختلف ارائه (از جمله دیجیتال و از راه دور، فردی و گروهی) و برنامههای چند جزئی مورد نیاز است. به این نتیجه رسیدیم که فراوانی جلسات گروهی و سطح شدت دمانس ممکن است بر پیامدهای CS تاثیر بگذارند، و این جنبهها باید بیشتر مورد مطالعه قرار گیرند. در رابطه با مزایای بالقوه برنامههای طولانیمدتتر CS و اهمیت بالینی آنها شکاف شواهد وجود دارد.
Contexte: La stimulation cognitive (SC) est une intervention destinée aux personnes atteintes de démence qui propose une série d'activités agréables stimulant de manière générale la pensée, la concentration et la mémoire, généralement dans un cadre social comme un petit groupe. La SC se distingue d'autres approches telles que l'entraînement cognitif et la rééducation cognitive par son orientation générale et ses éléments sociaux, visant à améliorer des domaines tels que la qualité de vie (QV) et l'humeur, ainsi que la fonction cognitive. Préconisée dans diverses recommandations et largement mise en œuvre au niveau international, des questions subsistent quant aux différents modes d'administration et à l'importance clinique des bénéfices éventuels. Une étude systématique de la SC est importante pour clarifier son efficacité et établir des recommandations pratiques sur des données probantes solides. Cette revue a été mise à jour pour la dernière fois en 2012.
Objectifs: Évaluer les données probantes de l'efficacité de la SC pour les personnes atteintes de démence, y compris les effets négatifs, sur la cognition et d'autres critères de jugement pertinents, en tenant compte si possible des différences dans sa mise en œuvre. STRATÉGIE DE RECHERCHE DOCUMENTAIRE: Nous avons identifié des essais à partir d'une recherche dans le registre spécialisé du groupe Cochrane sur la démence et les autres troubles cognitifs, consulté pour la dernière fois le 3 mars 2022. Nous avons utilisé les termes de recherche suivants: stimulation cognitive, orientation vers la réalité, thérapie de la mémoire, groupes de mémoire, soutien de la mémoire, stimulation de la mémoire, stimulation globale, psychostimulation cognitive. Nous avons effectué des recherches supplémentaires dans un certain nombre de grandes bases de données sur les soins de santé et de registres d'essais pour nous assurer que la recherche était à jour et complète. CRITÈRES DE SÉLECTION: Nous avons inclus tous les essais contrôlés randomisés (ECR) de la SC pour la démence publiés dans des revues avec comité de lecture en langue anglaise et incorporant une mesure du changement cognitif. RECUEIL ET ANALYSE DES DONNÉES: Nous avons suivi les procédures méthodologiques standard prévues par Cochrane. Comme la SC est une intervention psychosociale, nous ne nous attendions pas à ce que les personnes recevant ou délivrant la SC soient prévenues à la nature de l'intervention. Quand cela était nécessaire, nous avons contacté les auteurs des études pour leur demander des données non fournies dans les articles. Le cas échéant, nous avons effectué une analyse en sous‐groupe en fonction de la modalité (individuelle ou de groupe), du nombre de séances et de leur fréquence, du contexte (communauté ou établissements de soins), du type de condition de contrôle et de la gravité de la démence. Nous avons utilisé les méthodes GRADE pour évaluer la qualité globale des données probantes pour chaque critère de jugement. RÉSULTATS PRINCIPAUX: Nous avons inclus 37 ECR (avec 2766 participants), dont 26 publiés depuis la mise à jour précédente. La plupart ont évalué des groupes de SC ; huit ont examiné la SC individuelle. L'âge médian des participants était de 79,7 ans. Seize études ont inclus des participants résidant dans des maisons de soins ou des hôpitaux. La qualité des études a montré des signes d'amélioration depuis la revue précédente, avec peu d’éléments à risque de biais élevé. Les évaluateurs étaient clairement en aveugle par rapport à l'allocation des traitements dans la plupart des études (81%) et la plupart des études (81%) ont rapporté l'utilisation d'un manuel de traitement par ceux qui délivraient l'intervention. Cependant, dans un nombre important d'études (59 %), nous n'avons pas pu trouver de détails sur tous les aspects des procédures de randomisation, ce qui nous a conduits à classer le risque de biais de sélection comme incertain. Nous avons saisi dans les méta‐analyses les données de 36 études (2704 participants ; SC : 1432, contrôles : 1272). L'analyse principale a porté sur les changements manifestes immédiatement après la période de traitement (durée médiane de 10 semaines ; intervalle de 4 à 52 semaines). Seules huit études ont fourni des données permettant d'évaluer si les effets se sont maintenus par la suite (quatre avec un suivi de 6 à 12 semaines ; quatre avec un suivi de 8 à 12 mois). Les effets négatifs n’ont pas été rapportés. Dans l'ensemble, nous avons trouvé des données probantes de qualité modérée d'un léger bénéfice sur la cognition associé à la SC (différence de moyennes standardisée (DMS) 0,40, IC à 95 % 0,25 à 0,55). Dans les 25 études, avec 1893 participants, qui ont rapporté le test MMSE (Mini‐Mental State Examination) largement utilisé pour la fonction cognitive dans la démence, il y avait des données probantes de qualité modérée d'une différence cliniquement importante de 1,99 points entre les SC et les contrôles (IC à 95%: 1.24, 2.74). Dans les analyses secondaires, avec des tailles d'échantillon totales plus petites, évaluant à nouveau la différence entre les SC et les contrôles sur les changements immédiatement après la période d'intervention, nous avons trouvé des données probantes de qualité modérée d'une légère amélioration de la qualité de vie autodéclarée (18 études, 1584 participants ; DMS : 0,25 [IC à 95 % : 0,07, 0,42]) ainsi que dans les évaluations de la qualité de vie effectuées par des mandataires (personnel ou soignants). Nous avons trouvé des données probantes de haute qualité pour des améliorations cliniquement pertinentes dans les évaluations du personnel/intervieweur de la communication et de l'interaction sociale (5 études, 702 participants ; DMS : 0,53 [IC à 95 %: 0,36, 0,70]) et pour de légers bénéfices dans l’échelle d'évaluation instrumental Activities of Daily Living (activités de la vie quotidienne), l'humeur dépressive autodéclarée, l'anxiété évaluée par le personnel/interviewer et les échelles d'évaluation du comportement général. Nous avons trouvé des données probantes de qualité modérée pour de légères améliorations dans le comportement problématique et dans les activités de base de la vie quotidienne et des données probantes de faible qualité pour une légère amélioration de l'humeur dépressive évaluée par le personnel/interviewer. Quelques études ont rapporté une série de critères de jugement pour les aidants familiaux. Nous avons trouvé des données probantes de qualité modérée suggérant que, dans l'ensemble, la SC a fait peu ou pas de différence sur l'humeur ou l'anxiété des soignants. Nous avons constaté un niveau élevé d'incohérence entre les études en ce qui concerne les critères de jugement cognitifs et la qualité de vie. Dans les analyses exploratoires de sous‐groupes, nous n'avons pas identifié d'effet de la modalité (groupe ou individu) ou, pour les études de groupe, du cadre (communauté ou établissements de soins), du nombre total de sessions de groupe ou du type de condition de contrôle (traitement habituel ou contrôles actifs). Cependant, nous avons constaté que les améliorations cognitives étaient plus importantes lorsque les sessions de groupe étaient plus fréquentes (deux fois par semaine ou plus contre une fois par semaine) et lorsque la gravité moyenne de la démence parmi les participants au début de l'intervention était « légère » plutôt que « modérée ». Le déséquilibre dans le nombre d'études et de participants entre les sous‐groupes et l'incohérence résiduelle exigent que ces résultats exploratoires soient interprétés avec prudence.
Conclusions des auteurs: Dans cette mise à jour de la revue, qui s'appuie désormais sur une base beaucoup plus vaste de données probantes, nous avons à nouveau identifié de petits bénéfices cognitifs à court terme pour les personnes atteintes de démence légère à modérée qui participent à des programmes de stimulation cognitive. Dans un plus petit nombre d'études, nous avons également constaté des améliorations cliniquement significatives en matière de communication et d'interaction sociale, ainsi que de légers bénéfices dans une série de critères de jugement, notamment la qualité de vie, l'humeur et les comportements problématiques. Il existe relativement peu d'études sur la stimulation cognitive individuelle, et des recherches supplémentaires sont nécessaires pour déterminer l'efficacité des différentes méthodes d'enseignement (notamment numériques et à distance, individuelles et collectives) et des programmes à composantes multiples. Nous avons identifié que la fréquence des sessions de groupe et le niveau de sévérité de la démence pourraient influencer les critères de jugement de la SC, et ces aspects devraient être étudiés de manière approfondie. Il existe un manque de données probantes sur les bénéfices potentiels des programmes de SC à long terme et leur pertinence clinique.
Antecedentes: La estimulación cognitiva (EC) es una intervención para personas con demencia que ofrece una serie de actividades amenas que estimulan de forma general el pensamiento, la concentración y la memoria, normalmente en un contexto social, como un pequeño grupo. La EC se distingue de otros enfoques, como el entrenamiento cognitivo y la rehabilitación cognitiva, por su enfoque amplio y sus elementos sociales, cuyo objetivo es mejorar aspectos como la calidad de vida (CdV) y el estado de ánimo, además de la función cognitiva. Aunque se recomienda en varias guías y se aplica ampliamente a escala internacional, sigue habiendo dudas sobre las distintas formas de administración y la importancia clínica de sus posibles efectos beneficiosos. Es importante elaborar una revisión sistemática de la EC para aclarar su efectividad y basar las recomendaciones prácticas en evidencia sólida. Esta revisión se actualizó por última vez en 2012.
Objetivos: Evaluar la evidencia de la efectividad de la EC para las personas con demencia, incluidos los efectos negativos, sobre la cognición y otros desenlaces relevantes, teniendo en cuenta, en la medida de lo posible, las diferencias en su aplicación. MÉTODOS DE BÚSQUEDA: Se identificaron ensayos a partir de una búsqueda en el Registro especializado del Grupo Cochrane de Demencia y trastornos cognitivos (Cochrane Dementia and Cognitive Improvement Group), última búsqueda realizada el 3 de marzo de 2022. Se utilizaron los términos de búsqueda: cognitive stimulation, reality orientation, memory therapy, memory groups, memory support, memory stimulation, global stimulation, cognitive psychostimulation. Se realizaron búsquedas complementarias en varias de las principales bases de datos de asistencia sanitaria y registros de ensayos para garantizar que la búsqueda estuviera actualizada y fuera exhaustiva. CRITERIOS DE SELECCIÓN: Se incluyeron todos los ensayos controlados aleatorizados (ECA) de la EC para la demencia publicados en revistas de revisión por pares en inglés que incorporaran una medida de cambio cognitivo. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane. Como la EC es una intervención psicosocial, no se esperaba que se ocultara la naturaleza de la intervención a quienes recibían o administraban la EC. Cuando fue necesario, se estableció contacto con los autores de los estudios para solicitar datos no proporcionados en los artículos. Cuando fue apropiado, se realizaron análisis de subgrupos según la modalidad (individual versus grupal), el número de sesiones y la frecuencia, el contexto (comunitario versus residencial), el tipo de condición de control y la gravedad de la demencia. Se utilizó el método GRADE para evaluar la calidad general de la evidencia para cada desenlace.
Resultados principales: Se incluyeron 37 ECA (con 2766 participantes), 26 publicados desde la actualización anterior. La mayoría evaluaron la EC grupal; ocho examinaron la EC individual. La mediana de edad de los participantes fue 79,7 años. Dieciséis estudios incluyeron participantes internos en residencias u hospitales. La calidad de los estudios mostró indicios de mejoría desde la revisión anterior, con pocas áreas de alto riesgo de sesgo. La mayoría de estudios (81%) ocultaron la asignación al tratamiento a los evaluadores y la mayoría de los estudios (81%) informaron de que quienes administraron la intervención utilizaron un manual de tratamiento. Sin embargo, en un número considerable de estudios (59%), no se pudieron encontrar detalles sobre todos los aspectos de los procedimientos de asignación al azar, lo que hizo que el riesgo de sesgo de selección se considerara incierto. En los metanálisis se introdujeron los datos de 36 estudios (2704 participantes; EC: 1432, controles: 1272). El análisis principal se centró en los cambios evidentes inmediatamente después del periodo de tratamiento (duración media de 10 semanas; intervalo: 4 a 52 semanas). Solo ocho estudios proporcionaron datos que permitieron evaluar si los efectos se mantenían posteriormente (cuatro con un seguimiento de 6 a 12 semanas; cuatro con un seguimiento de 8 a 12 meses). No se notificaron efectos negativos. En general, se encontró evidencia de calidad moderada de un pequeño efecto beneficioso en la cognición asociado con la EC (diferencia de medias estandarizada [DME] 0,40; IC del 95%: 0,25 a 0,55). En los 25 estudios, con 1893 participantes, que informaron sobre la prueba MMSE (Mini‐Mental State Examination) ampliamente utilizada para la función cognitiva en la demencia, hubo evidencia de calidad moderada de una diferencia clínicamente importante de 1,99 puntos entre los que recibieron EC y los controles (IC del 95%: 1,24 a 2,74). En los análisis secundarios, con tamaños muestrales totales más pequeños, que examinaron de nuevo la diferencia entre la EC y los controles sobre los cambios inmediatamente después del periodo de intervención, se encontró evidencia de calidad moderada de una ligera mejoría en la CdV autoinformada (18 estudios, 1584 participantes; DME: 0,25 [IC del 95%: 0,07 a 0,42]), así como en las valoraciones de la CdV realizadas por sus representantes (personal o cuidadores). Se encontró evidencia de calidad alta de mejorías clínicamente relevantes en las calificaciones del personal/encuestadores relacionadas con la comunicación y la interacción social (cinco estudios, 702 participantes; DME: 0,53 [IC del 95%: 0,36 a 0,70]) y de ligeros efectos beneficiosos en las escalas de calificación instrumentales Activities of Daily Living (actividades cotidianas), estado de ánimo depresivo autoinformado, ansiedad calificada por el personal/encuestadores y comportamiento general. Se encontró evidencia de calidad moderada de mejorías leves en el comportamiento desafiante y en la Activities of Daily Living y evidencia de calidad baja de una mejoría leve en el estado de ánimo depresivo calificado por el personal/encuestadores. Unos pocos estudios informaron sobre una serie de desenlaces relacionados con los cuidadores familiares. Se encontró evidencia de calidad moderada de que, en general, la EC tuvo poca o ninguna repercusión en el estado de ánimo o la ansiedad de los cuidadores. Se encontró un alto nivel de inconsistencia entre los estudios en relación con los desenlaces cognitivos y la CdV. En los análisis exploratorios de subgrupos, no se identificó un efecto de la modalidad (grupal versus individual) o, en los estudios por conglomerados, del contexto (comunidad versus residencial), el número total de sesiones grupales ni el tipo de control (tratamiento habitual versus controles activos). Sin embargo, se observó que las mejorías en la cognición fueron mayores cuando las sesiones grupales eran más frecuentes (dos veces por semana o más versus una vez por semana) y cuando la gravedad media de la demencia entre los participantes al inicio de la intervención era "leve" en lugar de "moderada". El desequilibrio en el número de estudios y participantes entre los subgrupos y la inconsistencia residual requieren que estos hallazgos exploratorios se interpreten con cautela.
Conclusiones de los autores: En esta revisión actualizada, ahora con una base de evidencia mucho más grande, se han vuelto a identificar pequeños efectos beneficiosos cognitivos a corto plazo en las personas con demencia leve a moderada que participan en programas de EC. A partir de un número menor de estudios, también se han encontrado mejorías clínicamente relevantes en la comunicación y la interacción social y ligeros efectos beneficiosos en una serie de desenlaces que incluyen la CdV, el estado de ánimo y el comportamiento desafiante. Existen relativamente pocos estudios sobre la EC individual y es necesario seguir investigando para determinar la efectividad de los distintos métodos de administración (digital y a distancia, individual y grupal) y de los programas multicomponentes. Se ha identificado que la frecuencia de las sesiones grupales y el nivel de gravedad de la demencia podrían influir en los desenlaces de la EC y estos aspectos se deben estudiar más a fondo. Aún falta de evidencia en relación con los posibles efectos beneficiosos de los programas de EC a largo plazo y su importancia clínica.
Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conflict of interest statement
The authors have produced various training materials in dementia care, including cognitive stimulation therapy manuals, in order to disseminate research findings to care workers, family caregivers and others. Royalties for the manuals are received by the International Cognitive Stimulation Therapy Centre, based at University College London. AS receives fees for providing training in cognitive stimulation approaches.
Figures
Update of
- doi: 10.1002/14651858.CD005562.pub2
References
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