NIHR Signal Goal-setting can help people with early-stage dementia improve function
Published on 7 May 2019
Goal-setting as part of cognitive rehabilitation delivered by occupational therapists helped people with early dementia progress towards independence in daily tasks, with benefits lasting for nine months. This approach focuses on the everyday tasks needing concentration and memory and prioritising those that matter most to individuals, from using the cooker or answering the phone. The intervention was well-received, but the cost-effectiveness is not clear, because quality of life continued to deteriorate.
Therapists delivered ten sessions of cognitive rehabilitation over three months, with another four sessions over the next six months. Rehabilitation was intended to identify goals important to the person with dementia and their carer (including basic self-care and participation in events). The therapist identified barriers to achievement and worked on helping people to overcome them.
Compared to people with early dementia treated with usual care, those given cognitive rehabilitation were more likely to show progress towards their goals after three months. However, secondary outcomes such as quality of life did not show improvement for patients or carers, meaning that the intervention was not cost-effective by usual measures.
- Mental health and illness, Public and patient involvement, Dementia, Primary care
Why was this study needed?
There are an estimated 850,000 people with dementia in the UK, with numbers expected to rise over future decades. There is no cure for dementia, although medicines may slow the disease for some people. Many people with dementia are cared for at home by partners or other family members. Adapting to caring for someone with dementia can put strain on carers, and access to help is limited in some areas.
Cognitive rehabilitation is a problem-solving approach to dementia care, targeted at the individual to help them and their carers manage everyday activities at home. These would be identified as important to the person with dementia and might range from doing the shopping to remembering upcoming dates on the calendar. If successful, it may help people adjust better to the diagnosis of dementia and retain their abilities for longer, despite their cognitive problems. There have been no previous randomised trials of cognitive rehabilitation in people with dementia.
What did this study do?
The GREAT randomised controlled trial recruited and randomised 475 people with dementia, each with a supporting carer, to either cognitive rehabilitation or usual care. All participants identified one to three goals at the study start such as learning to use new technology, locating items in the home or taking part in social activities. The trial was carried out at eight NHS sites in England and Wales.
Those assigned to cognitive rehabilitation had ten sessions in their own home with an occupational therapist or nurse trained in the technique. The therapist helped participants identify three goals and ways around the problems that prevented them from achieving them. They also had four maintenance sessions in the final six months of the study.
The study was well-designed and used standardised assessment tools so the results should be reliable.
What did it find?
- People in the cognitive rehabilitation group said their abilities to achieve their goals had improved by an average of 2.57 points on a 10-point scale after three months. A difference of 2 points was considered clinically significant. This improvement was maintained after nine months.
- People in the treatment as usual group said their abilities to achieve their goals had improved by an average of less than one point after three months, with no further improvement after nine months. The difference between the control group and rehabilitation group was judged to show a large effect size (Cohen’s d 0.81).
- According to carers, ability improved by 2.7 points in the cognitive rehabilitation group compared to 0.83 points in the treatment as usual group by three months, and slightly deteriorated by nine months.
- However, secondary outcomes including cognition, quality of life, carer stress, health status, self-efficacy and depression and anxiety showed no significant differences between the groups, with small or no effect sizes.
- The cost of delivering the intervention in the trial was £1,733 per participant, not including the costs of training. Measured by cost per quality-adjusted life years (QALY), the intervention was not cost-effective for the participant or their carer from an NHS and social care perspective.
What does current guidance say on this issue?
NICE guidance from 2018 says clinicians should “consider cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia.”
It also recommends offering “a range of activities to promote wellbeing that is tailored to the person's preferences” but says cognitive training and interpersonal therapy should not be offered.
What are the implications?
This is the first randomised controlled trial to show that cognitive rehabilitation has a lasting effect on the ability of people with dementia to manage everyday activities. However, the intervention is expensive, and the study did not show benefits in terms of quality of life.
Commissioners will need to consider whether improvements in ability to achieve functional goals is worthwhile for a condition marked by deteriorating quality of life and whether the benefit of these improvements is worth the cost of the intervention. NICE says cognitive rehabilitation should be considered for people with mild dementia. This trial provides new evidence to aid that decision.
Citation and Funding
Clare L, Kudlicka A, Oyebode J R et al. Goal-oriented cognitive rehabilitation for early-stage Alzheimer's and related dementias: the GREAT RCT. Health Technol Assess. 2019;23(10).
The trial was funded by the NIHR Health Technology Assessment Programme (project number11/15/04).
Clare L, Kudlicka A, Oyebode JR et al. Individual goal‐oriented cognitive rehabilitation to improve everyday functioning for people with early‐stage dementia: A multicentre randomised controlled trial (the GREAT trial). Int J Geriatr Psychiatry. 2019;34:709–21.
NICE. Dementia: assessment, management and support for people living with dementia and their carers. NG97. London: National Institute for Health and Care Excellence; 2018.
This large and well-conducted trial showed that cognitive rehabilitation helped people mildly affected by dementia to improve their goal setting and attainment.
Disappointingly, this wasn’t accompanied by improvements in self-efficacy, depression and anxiety, cognitive functioning, quality of life or carer stress. I don’t believe that it would or should change practice.
Robert Howard, Professor of Old Age Psychiatry, UCL
The commentator is a trustee of the charity Alzheimer’s Research UK