Effects of home-based interventions on cognitive performance in patients with dementia: A systematic review and meta-analysis

Abstract

Background

With increasing age, dementia is a common disease in the elderly population，especially Alzheimer's disease. Owing to the nature of the disease, the function of patients deteriorates, which places a heavy burden on the country and family. Home-based training programs have been shown to improve cognitive function in patients with dementia.

Objective

To examine the effects and methods of home-based interventions on the cognitive performance of patients with dementia.

Methods

This systematic review and meta-analysis was conducted on the basis of the PRISMA statement. This protocol was registered in advance at PROSPERO (CRD42021277269). Six English electronic databases, including PubMed, EMBASE, the Cochrane Library, Web of Science, SCOPUS, and OTseeker, were searched and updated to January 31, 2024. Two researchers independently completed the literature retrieval and data extraction. RevMan 5.3 software was used to analyze the data. The standardized mean difference and the 95% confidence interval were used for statistical analysis. Subgroup analyses were performed by assessment tools, intervention duration and intervention methods.

Results

Twenty randomized controlled trials with 3543 participants were included in the qualitative synthesis, and 17 studies were included in the meta-analysis. Compared with the control intervention, the home-based intervention significantly improved cognitive performance (SMD = 0.45; 95% CI = [0.17, 0.74]; p = 0.002).

Conclusions

Moderate to high evidence shows that home-based interventions significantly improve the cognitive performance of patients with dementia, especially their comprehensive cognitive function.

Keywords

Alzheimer's disease cognition dementia home care services systematic review

Introduction

Dementia currently affects more than 55 million people worldwide, and nearly 10 million new cases are diagnosed every year in various countries. In 2050, the number is predicted to reach 139 million.^1,2 Various neuropathological diseases can underlie dementia syndromes, but the most prevalent cause is Alzheimer's disease, accounting for 60–70%,² followed by vascular dementia. Dementia is usually chronic or progressive and requires long-term and ongoing rehabilitation to improve or maintain functional performance in elderly individuals.

Dementia is a complex syndrome with different clinical features and is characterized by deterioration of cognitive function, behavior, and psychology.³ The main early manifestation is the deterioration of cognitive function, especially episodic memory, semantic memory, visuospatial function, and executive function. As it is a neurodegenerative disease, its symptoms and functional performance change over time, especially the degradation of cognitive functions, such as memory, comprehensive ability and executive function, which leads to a decline in daily functioning.⁴ Studies have confirmed that the cognitive function of patients is positively correlated with their functional performance, moreover, their cognitive function can be used to predict the recovery of functional performance.⁵

Since dementia is also a common disease in the elderly population, with increasing age, the prevention and treatment of dementia is gradually playing an important role in the healthcare of countries. Nearly 60% of people with dementia live in developing countries. Neither family nor state finances have sufficient financial resources to support the long-term hospitalization of people with dementia, so most patients live at home with their caregivers. In this context, home-based training without going to hospitals and related institutions can effectively reduce economic costs and has an irreplaceably important position.

At present, it has been proven that home-based cognitive stimulation can effectively improve the cognitive function of patients.^6,7 Home-based physical exercise and cognitive training programs are also conducive to the recovery of cognitive function,⁸ especially moderate-intensity rehabilitation exercises, which can promote improvements in patients’ global cognitive function, thus promoting improvements in their balance, mobility and quality of life.⁹ To date, three published systematic reviews have explored the effects of home-based interventions on dementia patients,^9–11 all of which suggest improvements in cognitive function. de Almeida et al.⁹ explored the comprehensive impact of home-based physical activities on dementia.¹⁰ The physical activities involved included cardiopulmonary function, muscle strength and endurance, flexibility and various neuromotor functions. In 2024, Abdullahi et al. analyzed the effects of home-based and telerehabilitation exercise on the health and disease cost of Alzheimer's disease patients,¹¹ and only a few relevant studies were included. In 2022, Tan et al. conducted a systematic review of home-based, nonexercise interventions for dementia,⁹ which also included few studies and did not carry out quantitative analysis. Therefore, to further explore appropriate home-based interventions that can improve cognitive performance in patients with dementia, we conducted a meta-analysis of randomized controlled trials and examined the effects of home-based training on cognitive function in patients with dementia.

Methods

Literature registration and search strategy

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement.¹² Registration of this protocol was performed in advance at PROSPERO (CRD42021277269), with a focus on home-based rehabilitation methods for understanding dementia.

Six English electronic databases, PubMed, EMBASE, the Cochrane Library, Web of Science, SCOPUS, and OTseeker were searched from inception to August 31, 2021 (updated to January 31, 2024). The keywords “dementia”, “Alzheimer”, “frontotemporal dementia”, “Lewy bodies”, “cognition”, “memory”, “home-based”, “training”, and “rehabilitation” were used to search for relevant studies. The detailed search strategy of this review is available in Supplemental Material 1. In addition, potentially eligible studies were manually retrieved by searching the reference lists of systematic reviews on similar topics. Each step of literature retrieval was carried out independently by two researchers (Mr Wang & Mrs. Ma).

Inclusion and exclusion criteria

Studies were eligible if they met the following inclusion criteria: (1) participants in two groups were clinically and definitively diagnosed with dementia; (2) nondrug rehabilitation interventions were used in the experimental groups, including cognitive training, exercise training, psychosocial intervention and so on. All of the methods were designed to promote cognitive performance of patients, and the interventions were implemented at patients’ homes rather than at medical institutions, other socialized placements or nursing homes. (3) In the control group, conventional interventions, such as counseling and education, placebo treatment, regular follow-up or delayed treatment, were also completed at the patients’ homes. (4) The main outcomes focused on patients’ cognitive function, with the assessment tools of the Mini-Mental State Examination (MMSE), the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and the Montreal Cognitive Assessment (MoCA).^13,14 The secondary outcomes paid attention to patients’ functional performance and caregivers’ stress, with the assessment tools of the quality of Life in Alzheimer's Disease (QOL-AD), the Zarit Caregiver Burden (ZBI), etc. (5) All included studies were randomized controlled trials.

Studies were excluded if they (1) were duplicated studies; (2) had no full-text article or insufficient data reported and were unable to obtain complete data; (3) were published in any language other than English; (4) were not a research article or an experimental research; or (5) had no definitive diagnosis of dementia or were diagnosed with mild cognitive impairment (MCI).

Data extraction

During the process of screening related articles, two researchers (Mr Wang & Mrs. Ma) independently and separately searched the six online databases, synthesized records together and deleted duplicated articles via EndNote. And then independently selected articles through screening titles, abstracts and full texts. If there were any disagreements, a third author (Prof. Yang) provided some suggestions.

Data extraction followed the protocol of the Cochrane Collaboration and was independently performed by two authors,^15,16 with third-party arbitration (Prof. Yang) for inconsistent results. The extracted data of the included studies were as follows: first author, publication date, diagnosis, number of participants, educational level, age and sex, countries, home-based interventions of the two groups, assessment tools and adverse effects.

Methodological quality

The PEDro scale was chosen to assess the methodological quality of the included studies. Two authors (Mr Wang & Mrs. Ma) independently scored the studies, and any disagreements were discussed with the third author. This scale comprises 11 items, and the total score is 10. The eligibility criterion was the first item in the PEDro, which was related to external validity and no score. The other 10 items were random allocation, allocation concealment, baseline comparability, blinding of subjects, blinding of therapists, blinding of assessors, key outcome measures for certain subjects, treatment and intention analysis, between-group statistical comparison, and point and variability measures. A total score less than 4 points indicated poor quality, 4 or 5 points indicated fair quality, and a score greater than 6 points indicated good quality.^17,18

Data analysis

RevMan 5.3 software was used to analyze the data of the included studies. The mean difference (MD) and 95% confidence interval (CI) were used during continuous outcome measurement for statistical analysis. However, the standardized mean difference (SMD) was used instead of the MD when different assessment tools for the same outcome were used in different studies. Meta-analyses were performed by choosing a random effects model with the inverse-variance method to aggregate the effects and their 95% CIs. A two-sided p value < 0.05 indicated significance.¹⁹ According to Cochrane's handbook, the I² statistic was able to show heterogeneity across studies. When I²> 50%, obvious heterogeneity in a data pool was detected, and subgroup analysis or sensitivity analysis was further conducted to explore the source of heterogeneity.²⁰ Subgroup analyses were performed on the main outcome of the meta-analysis, including assessment tools, intervention duration, and types of intervention, to explore potential sources of heterogeneity in cognitive function. There are many kinds of cognitive assessment tools, including cognitive screening assessment, global cognitive assessment, cognitive component assessment (such as memory, attention, and executive ability), and cognitive assessment specifically for dementia. Therefore, all the results of the evaluation of cognitive function included in the studies were summarized and analyzed. The dementia-specific or comprehensive cognitive assessment results are firstly selected, followed by the results of other cognitive component assessments. In addition, different cognitive assessment tools have different evaluation criteria; some of the higher the score is, the more serious the dysfunction is, and some are just the opposite. Therefore, the data of the studies with higher scores and more serious dysfunction were recorded as negative scores. If the data included in the studies could not be directly used for analysis, we tried to request the author to provide the original data; if not, the data would not be used. To obtain the aggregate effect, the original data were preferred. All synthesized results are shown in forest plots. For the main outcome, publication bias was investigated via a visual funnel plot test.

Results

The retrieval process and included studies

A total of 2778 potential studies were identified after these six databases were searched, and 103 studies were supplemented through manual retrieval of related references. After duplicate studies were checked and deleted, 2050 studies remained. After screening titles and abstracts, 1789 studies were excluded; thus, 261 studies were filtered through full-text reading. A total of 241 studies were excluded through full-text reading, 20 RCTs met the inclusion criteria for qualitative synthesis,^21–40 and 17 studies were considered eligible for meta-analysis.^{21,22,24–32,34–37,39,40} The detailed retrieval process is shown in Figure 1.

Figure 1.

Flowchart for searching and selection of the included studies.

The characteristics of the included studies

The characteristics of these 20 studies are summarized in Table 1. A total of 3543 participants were included, including 1703 women and 1818 men, as well as an additional 22 participants in one study whose gender was unknown.²⁸ 1836 subjects were assigned to the home-based intervention group, including 888 women, 935 men, and 13 participants whose gender was unknown; 1707 subjects were assigned to the control group, including 815 women, 883 men, and 9 participants whose gender was unknown. The sample size ranged from 22 to 494. Eight studies were multicenter RCT trials with comparatively larger sample sizes.^{22,23,25,27,31,32,38,40} Five studies were conducted in the United Kingdom;^{27,31,32,35,38} four studies were conducted in Germany;^23,26,28,34 three studies were conducted in the United States;^33,36,37 two studies were conducted in the Netherlands;^21,30 in addition, studies have also been conducted in France,²² Australia,²⁴ Denmark,²⁵ Finland,²⁹ Turkey,³⁹ and China.⁴⁰ Most of the participants were elderly, with the average age was between seventy and eighty years. The educational level of the participants was quite different among the studies, and eight of them were unclear.^{28,31,34,35,37–40}

Table 1.

Characteristics of the included studies.

Study	Education (y)	Country	Participantsn (M/F)	Age	Intervention & frequency	Drop-out n	Adverse events	Outcome measurements
Van Dijk, 2005²¹	T: 10.3 ± 3.9; C:10.7 ± 3.3	Netherlands	T: 32 (17/15); C: 30 (22/8)	T: 71.0 ± 7.8; C: 72.5 ± 8.2	T: HB verum treatment by CG; C: HB placebo by CG; FC:30 min/day, 7 days/week, 6 weeks	0	NR	Cognition: DS-F/B, VMST, EWT, RBMT, SCWT: CFT; ADL & QOL: Kaz ADL
de Rotrou, 2011²²	T: 9.0 ± 4.5; C:8.0 ± 4.6	French	T: 79 (29/50); C: 78 (34/44)	T: 78.6 ± 6.1; C: 78.7 ± 6.6	T: PEP+HB stimulation by CG; C: delayed treatment; FC:12 sessions,2 h/week, 12 weeks in PEP	T: 3-months: 7; 6-months:20; C: 3-months: 9; 6-months: 20	NR	Cognition: ADAS-Cog; Caregiver burden: ZBI;
Kurz, 2012²³	T: 12.8 ± 3.08; C: 12.2 ± 3.00	Germany	T: 100 (50/50); C: 101 (63/38)	T: 72.4 ± 8.55; C: 75.0 ± 7.05	T: CR+CB+written HB training suggestions; C: site-standard medical management; FC:12 weekly 1-h sessions in CR+CB	T: 3-months: 8; 9-months: 17; C: 3-months:4; 9-months: 13	NR	Cognition: MMSE, TMT, WMSRLM, RWFT; ADL & QOL: Bayer-ADL, DEMQOL; Caregiver burden: ZBI
Vreugdenhil, 2012²⁴	T: 10.1 (6–17); C: 10.3 (7–17)	Australia	T: 20 (11/9); C: 20 (5/15)	T: 73.5 (51–83); C: 74.7 (58–89)	T: usual treatment + HB exercises and walking supervised by CG; C: usual treatment + HB exercise training education; FC:≥30 min/day,7days/week,4monhts	0	NR	Cognition: MMSE, ADAS-Cog; ADL & QOL: BI, IADL; Caregiver burden: ZBI
Phung, 2013²⁵	T: 0 y = 60; ＜3 y = 39; ≥3 y = 64; C: 0 y = 57; ＜3 y = 49; ≥3 y = 61	Denmark	T: 163 (76/87); C: 167 (75/92)	T: 76.5 ± 7.7; C: 75.9 ± 6.6	T: IPI (include HB psycho training)+ FUS; C: FUS; FC: 7 individual counseling+5–8 times’ telephone counseling in 3–4 weeks, 5 standard group courses in 8–12 months in IPI; FUS at 3, 6, 12, and 36 months	T: 67; C: 63	NR	Cognition: MMSE; ADL & QOL: QoL-AD, ADCS-ADL
Holthoff, 2015²⁶	T: 12.33 ± 2.13; C: 13.13 ± 2.70	Germany	T: 15 (7/8); C: 15 (8/7)	T: 72.40 ± 4.34; C: 70.67 ± 5.41	T: HB PA using movement trainer+ monthly clinical visits; C: monthly clinical visits +a counseling; FC: 30 min/time, 3 times/week, 2 weeks in PA	T: 3-months: 0; 6-months: 2; C: 3-months: 0；6-months: 1	NR	Cognition: MMSE, Executive function and language; ADL & QOL: ADCS-ADL
Orgeta, 2015²⁷	T: ≥14 y = 113; C: ≥14 y = 100	UK	T: 180 (97/83); C: 176 (94/82)	T: 78.40 ± 7.30; C: 78.00 ± 7.70	T: HB CS by CG + ongoing support; C: TAU; FC: 3X30 min’ sessions/week, 24 sessions in 25 weeks in CS	T: 46; C: 37	51 SAEs, T: 25; C:26	Cognition: MMSE, ADAS-Cog; ADL & QOL: QoL-AD, EQ-5D
André, 2016²⁸	unclear	Germany	T: 13; C: 9	T: 80.3 ± 5.8; C: 75.8 ± 7.4	T: HB verum anodal tDCS; C: HB sham tDCS; FC:2 mA for 20 min/day, 4 days	0	No	Cognition: ADAS-Cog, Visual short-term memory, Verbal working memory, Go/no-go task
Koivisto, 2016²⁹	T: 7.9 ± 3.59； C: 7.4 ± 3.11	Finland	T :84 (42/42); C: 152 (73/79)	T: 75.8 ± 7.13; C: 75.5 ± 6.19	T: PI+annually follow up + individual counseling + individual service plan for HB training; C: basic counseling+annually follow up; FC: 4 courses in 16days in PI	T: 30; C: 76	NR	Cognition: MMSE, CDR-SOB; ADL & QOL: QoL-AD, ADCS-ADL
Prick, 2017³⁰	T: 3.91 ± 1.42; C: 4.11 ± 1.45	Netherlands	T: 57 (31/26); C: 54 (39/15)	T: 76 ± 7.61; C: 78 ± 7.17	T: HB PA training(+supervised by CG) + psycho-educational support; C: minimal education+usual care + monthly phone calls + delayed treatment; FC:PA-30 min/time, 3days/week; visit-1 time/week/first month, 1 time/2 weeks/next 8 weeks; education &phone calls-3 times	T: 3 months: 5; 6 months: 7; C: 3 months: 8; 6 months: 4	NR	Cognition: DS-F, DS-B, EWT, RBMT, CFT
Lamb, 2018³¹	Unclear	UK	T: 329 (195/134); C: 165 (106/59)	T: 76.9 ± 7.9; C: 78.4 ± 7.6	T: usual care + supervised exercise+ support for ongoing HB physical activity; C: usual care; FC:60–90 min/time, 2 times/week+150 min/week home-based physical activity in 4 months	T: 6 months: 29; 12 months: 48; C: 6 months: 20; 12 months: 28	T: n = 23, 25 AEs+4 related SAEs; C: No	Cognition: ADAS-Cog; ADL & QOL: QoL-AD, the Bristol ADL, EQ-5D; Caregiver burden: ZBI
Clare, 2019³²	T: 12.57 ± 3.33; C: 12.58 ± 3.42	UK	T: 238 (124/114); C: 236 (124/112)	T: 78.25 ± 7.13; C: 78.87 ± 7.01	T: usual treatment + HB CR; C: usual treatment; FC:10 sessions/3 months+4 maintenance sessions/next 6 months	T: 3-monhts: 20; 9-months: 10; C: 3-months: 9; 9-months: 9	T: n = 54, 66 SAEs; C: n = 32, 36 SAEs; Before randomization: 9 SAEs	Cognition: RBMT; ADL & QOL: DEMQOL
Dawson, 2019³³	T: College-38.5% C: College-60%	USA	T: 13 (7/6); C: 10 (3/7)	T: 73.8 ± 8.5; C: 74.0 ± 10.4	T: MIHB functional exercise by a trained practitioner; C: continuation of current levels of activity; FC: 2 times/week, 24 sessions in 12 weeks	0	21 AEs (6.7%); 5 MAEs + 16 AEs	Cognition: TMT-B; ADL & QOL: ADL, IADLs
Nordheim, 2019³⁴	unclear	Germany	T: 55 (32/23); C: 53 (34/19)	unclear	T: HB socio and psycho-therapeutic support; C: one to two hours of standards consultation; FC: 7 sessions + 2 additional telephone sessions in 10–12 weeks	T: 1 month: 7; 6-months: 3; C: 1 month: 6; 6-months: 4	NR	Cognition: MMSE; ADL & QOL: QoL-AD, ADL, IADL
Nyman, 2019³⁵	unclear	UK	T: 42 (24/18); C: 43 (27/16)	T: 77.9 ± 8.3; C: 78.2 ± 7.5	T: Tai Chi sessions+HB practice discussion; C: usual Care; FC: 45 min+45 min/1 time/week, 20 sessions	T: 6; C: 8	No	Cognition: M-ACE; Caregiver burden: CBI
Mehling, 2020³⁶	T: 16.9 ± 4.2; C: 16.1 ± 3.2	USA	T: 14 (7/7); C: 15 (6/9)	T: 82.6 ± 6.0; C: 77.3 ± 5.2	T: PLIE program +home support materials for HB training; C: delayed treatment; FC 2 days/week+ three home visits, 12 weeks	T: 3-months: 2; 6-months: 4; C: 3-months: 1; 6-months: 1	19 MAEs+6 unprovoked falls	Cognition: ADAS-Cog; ADL & QOL: QoL-AD
Nizamutdinov, 2021³⁷	unclear	USA	T: 38 (22/16); C: 19 (10/9)	T: 72.4 ± 8.2; C: 77.8 ± 5.2	T: HB tNIR light by CG; C: HB placebo by CG; FC:2X6 min sessions/day/8 weeks	0	NR	Cognition: MMSE, ADAS-Cog, CDT, DS-F/B, CFT-A/P…
Clarkson, 2022³⁸	unclear	UK	T: 234 (112/122); C: 234 (108/126)	T: 80 ± 6.7; C: 81 ± 7.2	T: memory aids prescription/training/support with DSPs; C: usual care+ clinical guidance; FC: 4 sessions in 4 weeks	T: 3-months: 41; 6-months: 17; C: 3-months: 56; 6-months: 7;	43 SAEs in 42 participants (T = 24; C = 18).	Cognition: MMSE; ADL & QOL: Bristol ADLS, DEMQOL, RIDDD
Menengic, 2022³⁹	unclear	Turkey	T: 10 (3/7); C: 10 (3/7)	T: 77.7 ± 5.29; C: 80.6 ± 6.11	T: online real-time supervised motor-cognitive dual-task exercise; C: delayed treatment; FC:25 sessions/6 weeks	0	No	Cognition: MMSE; ADL & QOL: Katz-ADL, FIM; Caregiver burden: ZBI
Kor, 2024⁴⁰	unclear	China	T: 120 (49/71); C: 120 (49/71)	T: 82.8 ± 7.8; C: 83.3 ± 8.1	T: CDCST + phone call follow up; C: usual care services; FC:45 min/time, 3 times/week, 45 sessions over 15 weeks	0	No	Cognition: MoCA-5-min; ADL & QOL: QoL-AD; Caregiver burden: ZBI

y: years; T: treatment; C: control; (MI)HB: (moderate-intensity) home-based; CG: care giver; FC :frequency characteristics; PEP: psychoeducational program; CR: cognitive rehabilitation; CB: cognitive-behavior; (I)PI: (intensive) psychosocial intervention; FUS: follow-up support; PA: physical activity; CS: cognitive stimulation; TAU: treatment as usual; PLIE: Preventing Loss of Independence through Exercise; tNIR: transcranial near-infrared; DSP: dementia support practitioner; CDCST: caregiver-delivered cognitive stimulation therapy; NR: no report; (M/S)AEs: (minor/serious) adverse events; CFT-A/P: the Category Fluency test-animals/professional; DEMQOL: DEmentia quality of life; ADCS-ADL: the Activities of Daily Living Scales in Alzheimer's disease; EQ-5D: the European Quality of Life-5 Dimensions; CBI: The Caregiver Burden Inventory; RIDDD: the Revised Interview for Deterioration in Daily Living Activities in Dementia; FIM: the Functional Independence Measurement.

A two-parallel group and various types of home-based interventions were implemented. Transcranial and transcutaneous stimulation,^21,28,37 psychosocial intervention,^22,25,29,34 exercise training,^{24,26,30,31,33,35,36} cognitive rehabilitation,^23,27,32,40 memory aid application,³⁸ and motor-cognitive dual-task exercise were the main home-based therapeutic methods.³⁹ Transcutaneous electrical nerve stimulation (TENS), transcranial direct current stimulation (tDCS) and transcranial near-infrared (tNIR) light were the specific methods used in the transcranial and transcutaneous stimulation groups. Four studies applied home-based psychosocial intervention, which mainly employed teaching courses to enable the participants to learn important strategies, such as problem-solving techniques, emotion management, communication skills, daily routine coping skills, crisis management, and social support. Furthermore, diverse forms of counseling and follow-up were additional services. Exercise training was the most popular intervention, and seven studies demonstrated a therapeutic effect on exercise. Supervised walking, physical activities, aerobic exercise, balance, strength, synthesis training and tai chi were included in these studies. In these four studies, cognitive training was used to improve participants’ capability and function through direct training, cognitive skills and strategies training, which increased the generalizability of these strategies in sessions and written materials. In the control group, placebo or sham treatment was applied in the transcranial and transcutaneous stimulation studies.; delayed treatment, consultation, usual treatment, education and follow-up were conducted in other studies. According to these 20 studies, the intensity and duration clearly differed. During exercise training, the intensity and frequency ranged from 30 min to 90 min once, from twice a week to daily. More detailed information can be found in Supplemental Material 2.

Four studies explicitly reported that the intervention had no adverse events (AEs),^28,35,39,40 while 10 studies didn't report.^{21–26,29,30,34,37} Six studies adequately described AEs during the intervention,^{27,31–33,36,38} and four of them were considered irrelevant to the trials.^27,32,36,38 Finally, study-related AEs,^31,33 which are typically minor and temporary, such as dizziness, back spasms and headache, are observed during exercise training. The detailed information is available in Supplemental Material 3.

Assessment of cognitive performance

Approximately 20 types of cognitive assessment tools were utilized among the studies. MMSE,^{23–27,29,34,37–39} as well as ADAS-Cog are the most commonly used tools and are global cognitive function tests.^{22,24,27,28,31,36,37} In addition, the Mini-Adden Brooke Cognitive Examination (MACE) and MoCA-5 min were also used.^35,40 Many cognitive component assessment tools are memory-focused tests, such as the digit span-backward (DS-B) test, the visual memory span (VMST) test, the eight words test (EWT), the Rivermead Behavioral Memory Test (RBMT),²¹ the Wechsler Memory Scale Revised Logical Memory (WMSRLM),²³ the visual short-term memory test, the verbal working memory test, and the CDR global and the sum of boxes score (CDR-SOB).²⁸ In addition, the digit span-forward (DS-F) test is an attention-focused test²¹; the category fluency test (CFT) and the Regensburg Word Fluency Test (RWFT) are fluency-focused;^21,23 and the Stroop color word test (SCWT),²¹ the trail-making test (TMT),²³ the go/no-go task,²⁸ and the clock drawing test (CDT) focus on executive function.³⁷

Methodological quality

The comprehensive PEDro scores of the studies for methodological quality are available in Table 2. Nineteen studies reported high quality.^{21–37,39,40} Six of them had 6 points^{22,23,27,28,33,35}; another eight had 7 points^{21,24–26,29,30}; and the other five had 8 points.^{31,32,34,36,37} Only one study was of moderate quality, with a score of 5 points.³⁸

Table 2.

The PEDro scale for methodological quality.

Study	Item number in PEDro											Total score
Study	1	2	3	4	5	6	7	8	9	10	11	Total score
Van Dijk, 2005²¹	Yes	√		√	√			√	√	√	√	7
de Rotrou, 2011²²	Yes	√		√			√		√	√	√	6
Kurz, 2012²³	Yes	√					√	√	√	√	√	6
Vreugdenhil, 2012²⁴	Yes	√		√			√	√	√	√	√	7
Phung, 2013²⁵	Yes	√	√	√			√		√	√	√	7
Holthoff, 2015²⁶	Yes	√		√			√	√	√	√	√	7
Orgeta, 2015²⁷	Yes	√					√	√	√	√	√	6
André, 2016²⁸	Yes	√			√			√	√	√	√	6
Koivisto, 2016²⁹	Yes	√	√	√	√		√			√	√	7
Prick, 2017³⁰	Yes	√	√	√				√	√	√	√	7
Lamb, 2018³¹	Yes	√	√	√			√	√	√	√	√	8
Clare, 2019³²	Yes	√	√	√			√	√	√	√	√	8
Dawson, 2019³³	Yes	√		√				√	√	√	√	6
Nordheim, 2019³⁴	Yes	√	√	√			√	√	√	√	√	8
Nyman, 2019³⁵	Yes	√		√			√		√	√	√	6
Mehling, 2020³⁶	Yes	√	√	√			√	√	√	√	√	8
Nizamutdinov, 2021³⁷	Yes	√			√	√	√	√	√	√	√	8
Clarkson, 2022³⁸	Yes	√		√					√	√	√	5
Menengic, 2022³⁹	Yes	√		√			√	√	√	√	√	7
Kor, 2024⁴⁰	Yes	√	√	√				√	√	√	√	7

“√”: score of 1. The brief criteria of the PEDro scale are “1”: eligibility; “2”: random allocation; “3”: allocation concealment; “4”: baseline comparability; “5”: blinding of subjects; “6”: blinding of therapists; “7”: blinding of assessors; “8”: key outcome measures for certain subjects; “9”: treatment and intention analysis; “10”: between-group statistical comparison; and “11”: point and variability measures.

Outcomes of the meta-analysis

Comprehensive outcomes

Statistical analysis revealed the comprehensive effect of home-based interventions on the cognitive performance of patients with dementia. A meta-analysis of 17 studies revealed that the combined effect size of home-based interventions on cognitive performance was significant (SMD = 0.45; 95% CI = [0.17, 0.74]; p = 0.002),^{21,22,24–32,34–37,39,40} indicating that home-based interventions can improve the cognitive performance of patients with dementia. However, the heterogeneity test results revealed a high degree of heterogeneity among the studies (χ² = 163.61, I2 = 90%, p < 0.00001) (Figure 2).

Figure 2.

Comprehensive cognitive outcomes.

Twelve studies analyzed the effect of home-based interventions on the functional performance of dementia patients,^{21,24–27,29,31,32,34,36,39,40} and the results revealed that, compared with regular clinic visits or education, home-based interventions had no significant effect on functional performance (SMD = 0.06; 95% CI = [-0.32, 0.45]; p = 0.75). The heterogeneity test results also revealed a high degree of heterogeneity among the studies (χ² = 149.98, I2 = 93%, p < 0.00001). Six studies analyzed the impact of home-based interventions on caregivers’ stress.^{22,24,31,35,39,40} The results revealed that these two intervention categories had no significant effect on caregivers’ stress (SMD = -0.17; 95% CI = [-0.42, 0.07]; p = 0.17); that is, caregivers’ stress was similar under both intervention strategies. The heterogeneity test results revealed moderate heterogeneity among the studies (X2 = 10.25, I2 = 61%, p = 0.04) (available in Supplemental Material 4).

Cognitive outcomes of the subgroup analysis

Subgroup analysis by cognitive assessment tools

The included studies adopted different cognitive assessment tools to analyze the cognitive performance of patients with dementia. Compared with the results of the cognitive assessment tools, the results revealed that the combined effect of studies using the MMSE to assess patients’ cognitive function was significant (SMD = 0.89; 95% CI = [0.26, 1.51]; p = 0.005), but heterogeneity remained very high (χ² = 122.89, I² = 94%, p < 0.00001). ADAS-Cog (SMD = -0.07; 95% CI = [-0.30, 0.17]; p = 0.58) and DS-F (SMD = 0.03; 95% CI = [-0.27, 0.33]; p = 0.86) were not significant, although the heterogeneity was lower (Figure 3).

Figure 3.

Subgroup analysis by cognitive assessment tools.

Subgroup analysis by intervention methods

Compared with the intervention methods used among the studies, the combined effect sizes of cognitive performance for transcranial and transcutaneous stimulation interventions (SMD = 0.62; 95% CI = [-0.01, 1.26]; p = 0.06), psychosocial interventions (SMD = 0.61; 95% CI = [-0.34, 1.55]; p = 0.21), exercise training (SMD = 0.40; 95% CI = [-0.07, 0.87]; p = 0.09), and cognitive interventions (SMD = 0.20; 95% CI = [-0.28, 0.68]; p = 0.41) were not significant. There was moderate heterogeneity in studies that used transcranial and transcutaneous stimulation interventions (χ² = 5.96, I² = 66%, p = 0.05). The included studies that used psychosocial intervention (χ² = 91.62, I² = 97%, p < 0.00001), exercise training (exercise training), and cognitive intervention (χ² = 26.49, I² = 92%, p < 0.00001) showed high heterogeneity (Figure 4).

Figure 4.

Subgroup analysis by intervention methods.

Subgroup analysis by intervention duration

The immediate cognitive performance after home-based intervention was compared with cognitive performance after follow-up, it was found that both the immediate cognitive performance (SMD = 0.22; 95% CI = [0.05, 0.39]; p = 0.01) and cognitive performance after follow-up (SMD = 0.49; 95% CI = [0.07, 0.92]; p = 0.02), the combined effect sizes were significant. The heterogeneity of immediate cognitive performance after home-based intervention (χ² = 41.30, I² = 66%, p = 0.0002) was moderate, whereas that after follow-up (χ² = 143.33, I² = 94%, p < 0.00001) was high (Figure 5).

Figure 5.

Subgroup analysis by intervention duration.

Sensitivity and publishing bias

According to this systematic review and meta-analysis, the funnel plot test of the effects of home-based interventions on the comprehensive cognitive performance of patients with dementia revealed asymmetry (Figure 6). The figure shows that 5 studies fall outside the dotted line and 3 studies intersect the dotted line, indicating the presence of multiple outliers among the included studies. The 17 included studies were excluded one by one to conduct sensitivity analysis on the comprehensive performance of cognitive function in dementia. The results revealed that no study had a significant impact on the results, indicating its good stability. Moreover, a sensitivity analysis of different subgroups was conducted. The results revealed the following: (1) In the subgroup analysis by home-based intervention methods, after one study was excluded,²¹ the results (SMD = 0.97; 95% CI = [0.48, 1.46]; p = 0.0001) of the subgroup using transcranial and transcutaneous stimulation interventions became significant, with I² values ranging from 66% to 0%. (2) In the subgroup analysis by intervention duration, the combined effect of the subgroup of cognitive performance after follow-up changed to nonsignificant, after two studies were eliminated one by one.^26,34 (3) The results of the remaining subgroups were stable.

Figure 6.

Funnel plot for studies of comprehensive cognitive performance.

Discussion

Our findings suggest that home-based interventions can significantly improve cognitive function in patients with dementia compared with home-based education, counseling, and regular clinic visits and that the quality of evidence is high. Because of the obvious heterogeneity, subgroup analysis was performed by cognitive assessment tools, intervention methods and intervention duration. (1) According to subgroup analysis by cognitive assessment tools, the results revealed that the improvement in the comprehensive cognitive function of dementia patients with home-based intervention was more significant. (2) Both immediate cognitive performance after home-based intervention and cognitive performance after follow-up were improved. (3) According to subgroup analysis by intervention methods, there were no significant differences among these types of intervention.

de Almeida et al. published a meta-analysis on the impact of home-based physical activity on dementia,¹⁰ and the results showed that home-based physical activity could effectively delay the decline in cognitive function. In 2024, Abdullahi et al. published a meta-analysis on the mental,¹¹ physical and disease costs of home-based and tele-rehabilitation exercise in Alzheimer's disease patients and reported similar results. With respect to global cognitive function, the improvement in the experimental group after the intervention was significantly greater than that in the control group. Both of these findings were consistent with our findings. In addition, de Almeida et al. reported that there was obvious heterogeneity among the studies,¹⁰ which also coincided with our research results. The difference was that Abdullahi et al. reported no significant heterogeneity among the groups after intervention,¹¹ but there was significant heterogeneity during follow-up. Both of them used exercise; one was physical exercise, and the other was tele-rehabilitation exercise. However, the results of our subgroup analysis revealed that there were no significant differences in exercise training. This might be related to the different purposes of the studies and the number of studies included. de Almeida et al. focused on the impact of home-based physical activity on multiple capabilities and functions of dementia, including cognition, behavior and psychology; participation in activities of daily living; health status; and family burden, few studies related to cognition were included. In 2024, Abdullahi et al. focused on exploring the impact of home-based and tele-rehabilitation exercise on patients’ cognition,¹¹ thus, only three relevant studies were included.

In addition, Tan et al. published a systematic review in which the main purpose was to confirm the effects of home-based nonexercise interventions on the behavior, function, cognition, and emotion of dementia patients.⁹ The results suggested that home-based nonexercise interventions also promoted cognition in patients with dementia, and the effect lasted for a longer period of time. This finding was similar to what we found. However, owing to the limited number of studies, quantitative analysis could not be further conducted. The home-based nonexercise interventions included individualized cognitive stimulation, cognitive rehabilitation, reality orientation, caregiver psychoeducational memory training and multicomponent interventions.

Therefore, how do these different interventions improve cognitive function in people with dementia? Studies corroborated that well-planned physical exercise training was beneficial to the cognition of individuals with mild or moderate dementia.^9,11,41 Therefore, there was a strong association between physical exercise and cognition, and the association might be related to physical intensity and forms of exercise. Walking, muscle strength training and aerobic exercise are common forms of physical activity. Muscle strength training has been proven to have the potential to maintain cognition and reduce the physical limitations of older adults with dementia.⁴² Furthermore, therapeutic exercises have shown potential for preventing dementia and might be a strategy to delay the progression of this disease.⁴³ This delay and improvement might be attributed to the effects of therapeutic exercise on changes in blood flow and neural plasticity. After well-planned regular therapeutic exercise, the level of beta-amyloid proteins in brain cells decreases, thus leading to fewer amyloid plaques and neural disruption.⁴⁴ A similar situation was observed in the hippocampus area, and the volume and blood flow changed, with synapse reconnection.⁴⁵ Additionally, the level of brain-derived neurotrophic factor increases, which may be conducive to neurogenesis.⁴⁶

Cognitive rehabilitation has been proven to improve cognitive function and slow the progression of cognitive decline in dementia patients.^47,48 The mechanism was similar to that of exercise training. A recent study revealed that memory-related brain activation increased after cognitive training in individuals with mild cognitive impairment and that synaptic growth and repair might occur.^49,50 Some psychosocial interventions had a small effect on cognition or verbal learning-related memory in individuals with mild cognitive impairment.⁵¹ Although similar positive results have been reported in transcranial and transcutaneous stimulation studies, the principles and techniques of intervention, and even the mechanism, vary widely.^52,53 As studies have reported, short-term effects of transcranial direct current stimulation, which is a commonly used transcranial stimulation, occur via nonsynaptic mechanisms of resting membrane potential depolarization, whereas long-term effects might act on NMDA-dependent mechanisms and seem to be parallel to synaptic plasticity.^54,55

Home-based training is valuable in delivering rehabilitation, especially for chronic diseases that require long-term rehabilitation, and helps eliminate the barriers of insufficient time, distance, financial costs, and transportation.^56–58 Additionally, motivation and training adherence rates contribute to better outcomes following home-based exercise training.^57,59 Overall, better outcomes are associated with greater intensity, stronger motivation, greater independence and more self-monitoring,⁶⁰ which further promotes performance at home.

Clinical implications

In conclusion, moderate to high evidence shows that home-based interventions can significantly improve the cognitive performance of dementia patients, especially their comprehensive cognitive function, compared with home-based education, counseling, and regular clinic visits and that improvements in cognitive function will last for a period of time. However, the available evidence is still uncertain about which home-based interventions are most effective. Therefore, in clinical practice, the form of home-based rehabilitation methods can be considered in the long-term management of dementia. It is also an effective, alternative intervention that breaks the constraints of time, space and transportation and gains improvements in functional maintenance at a lower economic cost, which is a cost-effective intervention. Clinical professionals can design suitable home-based rehabilitation plans and programs for patients on the basis of their basic condition through detailed and comprehensive evaluation, summary and analysis and provide a theoretical basis for home-based training. The company of family members or caregivers can use new, high-tech or intelligent devices, such as remote training, intelligent programs to control devices, or mobile phones, to monitor and improve patient engagement.

Limitations

This systematic review was conducted in accordance with PRISMA standards and PICOS principles, but some limitations are unavoidable. One important limitation is the diversity of home-based interventions. In addition, there is no specific compliance with exercise prescription and safety monitoring under expert supervision;⁵⁸ therefore, there are differences in intervention intensity, frequency, duration, monitoring methods, follow-up, and internal and external motivations among the included studies,^61,62 which may cause high heterogeneity in the results of the studies. We also conducted subgroup analysis of the included studies, but the results of the subgroup analysis could not fully explain the sources of heterogeneity. A wide variety of tools have been used to measure cognitive performance in various studies, resulting in fragmentary data analysis. The inclusion criterion of this study is that the included research is English, so studies in other languages may be omitted; only RCT studies were included, while other types of studies were excluded, so data from unpublished research or gray literature, as well as other peer-reviewed data, are missing, which may also contribute to incomplete results. In addition, due to the particularity of the disease itself, different disease courses may present different therapeutic effects.

This study suggests that more studies need to be conducted in the future to further explore the effects of different interventions on the cognitive function of dementia patients. The specific implementation details, such as the treatment plans, intensity, duration and precautions, need to be further explored. How to analyze the intensity and duration of training effectively should also be considered. In addition, the compliance of patients and their families should be regarded as one of the key monitoring contents, which may affect the final treatment effect. The choice of assessment tools is very important because there are many cognitive assessment tools, and the content, emphasis of the evaluation, reliability and validity are quite different.

Conclusion

This systematic review and meta-analysis provides moderate to strong evidence confirming that home-based interventions can significantly improve the comprehensive cognitive function of patients with dementia, and the improvement will last for a period of time compared with home-based education, counseling, and regular clinic visits. However, it is not clear which nondrug home-based intervention is the most effective method, and the frequency and intensity also cannot be determined. Multicenter, large-sample, high-quality studies are needed in the future to determine the best intervention method, proper frequency and intensity that can improve or maintain cognitive function in patients with dementia. Therefore, we suggest that patients with dementia who are limited in time, space and economy can choose home-based rehabilitation interventions to promote or maintain their cognitive function to delay the decline of the disease itself and, to a certain extent, improve their quality of life.

Supplemental Material

sj-docx-1-alz-10.1177_13872877241301456 - Supplemental material for Effects of home-based interventions on cognitive performance in patients with dementia: A systematic review and meta-analysis

Supplemental material, sj-docx-1-alz-10.1177_13872877241301456 for Effects of home-based interventions on cognitive performance in patients with dementia: A systematic review and meta-analysis by Xichao Ma, Yu Wang, Xinxin Chen, Shijie Zhu, Yang Lin, Shaxin Liu and Yonghong Yang in Journal of Alzheimer's Disease

Footnotes

Acknowledgments

The authors have no acknowledgments to report.

ORCID iDs

Xichao Ma

Yu Wang

Shijie Zhu

Shaxin Liu

Yonghong Yang

Author contributions

Xichao Ma (Writing – original draft); Yu Wang (Data curation); Xinxin Chen (Conceptualization); Shijie Zhu (Formal analysis); Yang Lin (Formal analysis); Shaxin Liu (Methodology; Supervision); Yonghong Yang (Methodology; Supervision).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Key R&D Program of China (Grant No.2023YFC3603800, 2023YFC3603802) and Sichuan Science and Technology Program (2024NSFSC0539).

Declaration of confliction interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

The data supporting the findings of this study are available on request from the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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